HC Deb 19 February 1997 vol 290 cc1019-26

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

10 pm

Mr. David Tredinnick (Bosworth)

In January this year, the British Society for Allergy, Environmental and Nutritional Medicine wrote to my right hon. Friend the Secretary of State for Health saying: Your ministry is planning steps which may lead to the deaths of thousands of people in the UK, and to substantial avoidable suffering for many others. That was a reference to the threat to more than 200 nutritional or vitamin supplements currently available on the national health service prescription list, which, it is alleged, the Department intends to remove.

I address the House as the long-standing treasurer of the all-party group on alternative and complementary medicine. As my hon. Friend the Minister will know, I have monitored and taken a great interest in such issues for the best part of a decade. The Department's proposal to blacklist more than 200 nutritional supplements, making it impossible for general practitioners to prescribe them on the national health service, would bring to more than 600 the total of supplements so blacklisted in the past three years.

That move would seriously damage the health of many ill people, and wastes an opportunity to reduce prescription costs and improve patient care. The proposal is the result of recommendations by the so-called Advisory Committee on Borderline Substances. In its submission, the committee stated that the products in question have more economic alternatives and have not demonstrated a therapeutic value". I hope to demonstrate to the House tonight and to persuade my hon. Friend that those contentions are completely wrong. Members of the BSAENM are doctors, and they say that many patients will suffer greatly if those vitamins and nutritional supplements are removed from the list. One estimate puts the potential savings to the NHS from improved nutrition for hospital patients alone at £266 million a year. GPs who are members of the BSAENM report similar savings in their practices. I suggest to my hon. Friend that the removal of these products is a false economy, benefiting neither the patient, the Department of Health nor taxpayers.

My hon. Friend the Minister will be aware as he travels the country how many chemists and shops now stock all kinds of vitamin supplements. My constituency contains the headquarters of Holland and Barrett, which has a massive warehouse, with all kinds of vitamins and supplements readily available. But these have to be paid for, unless they are available on the NHS. By agreeing to the proposals, my hon. Friend runs the risk of removing the opportunity for less well-off people to be treated. I am certain that many in my constituency and my county of Leicestershire will suffer if the proposals are accepted.

I gave the Minister notice of more or less exactly what I intended to say, and I have briefed him on a number of points that I was seeking to raise. On behalf of the BSAENM, I have also sent him a case study that amply demonstrates the problems that could be caused by the removal of those vitamins from the list. The case concerns Mrs. B. S., a 72-year-old retired nurse. I will not go through the whole case, but she suffered from water retention, arthritis and hypertension, and was treated using supplements.

Eventually, her doctors recommended that she came off that treatment—although it was helping her—and she was put on powerful drugs. Those drugs apparently made her much worse, and she turned to her nutritional medical adviser, who put her on a course of magnesium injections and magnesium amino acid chelate. At the moment, the supplements are provided on the NHS—and this is the point.

She responded well to treatment and, from being at death's door, she found that her weight and blood pressure dropped and she was altogether better. Without the magnesium and other supplements, I respectfully submit that this lady would probably pass away—the advice that I have been given is that she may have lived for about three months at most. This is the gravity of the situation we face, and that is why I have sought to give these important issues an airing.

There are certain specific points to which I want the Minister to respond. The first is the time that those in the field of nutritional medicine have been given to consider the proposals. According to the Department, the recommendations were published ahead of time to allow an opportunity to comment on them. But the release date of 25 November last year allowed only 45 days—including Christmas and new year—for responses to be prepared and submitted.

That may sound like a long time, but, as we are talking about 200 preparations, it works out at one hour per preparation for the submission of a proposal to retain a product on the prescription list. That is an inadequate period for consultation.

My second point is that the advisory committee has recommended that the products listed have not demonstrated a therapeutic value, or have more economic alternatives. This is a highly contentious statement, and the document does not specify which of those justifications has been applied to each item on the list. However, since it is the clear intention to blacklist most, if not all, of the readily available nutritional supplements, the suggestion that more economic alternatives are available is untenable.

In preparing its response, the society surveyed many of its members. Ninety-six per cent. considered that nutritional supplementation was essential to their method of practice. It is those practitioners who will suffer, and at a time when more and more people are turning to alternative and complementary medicines because they do not feel that the medicine available—good and proven though it is—on the national health service through conventional preparations and doctors is adequate.

People are voting with their feet. I referred to the enormous number of shops that now sell the preparations. They include high street chemists, which would not have considered selling them five or 10 years ago. My hon. Friend is in danger of undermining the use of these important supplements for those people who are unable to pay and must get them on the national health service.

Thirdly, the national health service executive says that other products will meet patients' clinical needs equally well. I have already referred to the lady who suffered from water retention and hypertension, who was put on magnesium. In that case, the magnesium was crucial, but it is one of the products listed in annex 2, along with 13 other magnesium or calcium and magnesium products. Not to coin an original phrase perhaps, but there is no alternative to that product—it is essential in the treatment of certain problems. There is no licensed multi-vitamin and mineral product with adequate potency for the treatment of those nutritional deficiencies.

The qualifications of the committees are another contentious issue—we come across this throughout the alternative and complementary medicine spectrum. The Advisory Committee on Borderline Substances has made the judgments, but it lacks the expertise to deal adequately with the issues. The practitioners with knowledge and experience of nutrition are simply not on that committee. Experts in the field need to be appointed to it. It is not good enough that committee members have some related experience. I suggest that the management of the committee should be modified to include medical practitioners with knowledge and experience of nutritional medicine.

My next and perhaps final point is that the Department contends that the selected list scheme has the aim of ensuring that all the real clinical needs of NHS patients can be met as economically as possible. That is such a contentious area. The national food survey in 1994 and the survey on the diets of British schoolchildren in 1986 stressed the need for certain minerals which are not necessarily readily available to the population in their diet, such as iron, zinc and magnesium. The survey of schoolchildren found that 95 per cent. of subjects had insufficient intakes of various minerals. Sometimes, it is necessary for those to be prescribed.

Doctors need that right, and it is good value, because, if people do not get them, they will become ill, and then they will become a burden on hospitals. It is a false economy to suggest that removing vitamins, which strengthen the immune system and the patients, and keep them out of expensive hospital care, is in the interests of the economy of the health service.

Another report, "Effective Nutritional Medicine", found that between 75 per cent. and 90 per cent. of cancers are attributable to environmental factors and can often be corrected—perhaps not cured—by nutritional medicines.

My final point concerns vitamin B6 and peripheral neuropathy. The issue is contentious, as my hon. Friend knows, because of the proposed removal of high doses of vitamin B6 from the list on the grounds that they are toxic. The society I mentioned submits that there is no evidence that toxicity begins at 50 mg a day for humans. Human evidence supports toxicity at 500 mg a day and upwards. There are various reports, as my hon. Friend knows, many of which date back a long time. The evidence is insufficient for the ban that is being canvassed. I encourage him to pause and reconsider this crucial issue.

I was looking at the Parliamentary Office of Science and Technology technical report in the Library on treating problem behaviour in children. Bad diet is one of the problems that causes such behavioural difficulties. Vitamins can often right that. There is an educational angle to the matter. If children have the right supplements to their diet, their behaviour improves, they become less disruptive, and they live better lives.

On the threat to 200 vitamin supplements, my hon. Friend the Minister should suspend consideration of proposals for blacklisting nutritional supplements. Many hundreds have been blacklisted already. Important supplements such as magnesium are threatened now. I ask him please to think again.

Secondly, I ask my hon. Friend to review the membership of the Advisory Committee on Borderline Substances with a view to appointing members with expertise in nutritional medicine and supplementation. The committee should at least give a fair hearing. Let us put judges in the court who understand the subject. At present, it is suspected that those who sit in judgment do not have sufficient expertise.

Thirdly, I ask my hon. Friend to consider retrospectively the position of supplements already blacklisted. Finally, I ask him further to consider the creation of a separate category of nutritional supplement that falls between those of licensed medicine and food supplement, with separate criteria and procedures, as outlined in previous correspondence. If he can respond positively to some of those points, he will improve the health and happiness of many people.

10.17 pm
The Minister for Health (Mr. Gerald Malone)

Such is the attraction of the invitation of my hon. Friend the Member for Bosworth (Mr. Tredinnick) to improve by ministerial diktat the happiness and health of the nation that I might be tempted to accept, but I am not sure that it is within ministerial gift. However, I will try to help him. He has raised several important points with which I am happy to deal. I stand in need of some sort of nutritional supplement or form of medication to deal with my cold.

It may help my hon. Friend if I first set out the system. He said at the outset that supplements were being removed from lists of items that can be prescribed by doctors. That is not so, as will become clear as I explain the system. There is no NHS prescription list that says what products general practitioners can prescribe at NHS expense. The reverse is true: GPs are free to prescribe nutritional supplements or any other preparation for their patients unless they are included in the blacklist. The blacklist scores out some items that are available generally; it does not refer back to a list on which it has been decided to incorporate certain substances.

I shall give examples, which are extreme, but which illustrate the freedom of the medical profession. When I visited the prescription pricing agency in Newcastle, it had a number of interesting examples of items that GPs had prescribed. You, Mr. Deputy Speaker, might consider it unusual if, when you next visited your GP, he prescribed you a pint of Guinness, but it has been done—and done within the letter of the rules. Another example involved a prescription for a Christmas pudding.

The difficulty is that GPs who prescribe in that way must be prepared to justify challenges to their prescribing by the health authority . If the health authority decides that such items, or any other unlicensed products—be they dietary foods, supplements or toiletries—should not be regarded as a drug for reimbursement purposes, the GP must justify the issue of the prescription. If justification cannot be given, the GP may be asked to repay the cost.

It is different when a pattern begins to emerge of a consistent habit of prescribing, at a cost to the NHS, certain specific products. That is the point on which my hon. Friend has concentrated tonight. When the spending level of such products becomes significant, it is referred to the Advisory Committee on Borderline Substances for consideration.

The issue that my hon. Friend has raised relates to the recent public consultation on the addition of further items to the list of products that may not be prescribed at NHS expense. Those products included unlicensed dietary supplements. To understand the issue, it is important to emphasise the vital nature of the word "unlicensed"—it refers to a category of products that are separate from other products that have gained a licence, and are dealt with in a different way.

The list makes an important contribution—and has done for some years—to the Government's strategy to secure best value for money from the NHS drugs bill, and to secure the greatest benefit for patients. That is the point on which my hon. Friend wanted reassurance; he wanted to know that I had an open mind about what might constitute the greatest benefit to patients. I hope to say something helpful later.

The ACBS has an important role in our strategy, through its advice to Ministers on items that it considers should no longer be prescribable at NHS expense if it has not been demonstrated that they meet a therapeutic need in the community, or if they do not meet a need as economically as possible. If therapeutic value is in doubt, it is logical that the existence of alternatives is irrelevant.

The ACBS is aware that the Department's general advice is that most nutritional problems can be treated by dietary changes—that is the scheme's history. It was the view taken by the chief medical officer in the mid-1980s, when the scheme came into play; it is a view that still holds. I am sure that my hon. Friend and the House will agree that the supply of food—the best way to treat the deficiencies—to patients in the community is not a reasonable NHS function.

Not only does the ACBS consult the company involved before offering advice to Ministers, but there is a further period of consultation with interested bodies in advance of any final decision on changes. My hon. Friend mentioned the consultation period. I was of course concerned that there should be a proper period. I am not sure that the methodology employed by those who have lobbied on the matter—dividing the amount of time by the number of products—was necessarily accurate or the right method to use. But I can assure my hon. Friend that I was extremely concerned that there should be a proper period.

In fact, a longer period was allowed in view of the Christmas and new year holiday. I would point out that this is a consultation period that has precedent in previous and similar exercises, where the consultation period was deemed to be broadly satisfactory by all those participating.

Following the most recent such consultation, which began in November and did not end until 9 January, I carefully considered the comments made—indeed, I varied four of the original proposals put before me on the basis of the evidence gleaned from the consultation evidence. I assure my hon. Friend that time was provided, and that Ministers listened to what was said, leading to the original advice being changed as a result of the consultation.

I did consider the views of the society to which my hon. Friend referred, and also took account of the opinions of a whole range of learned societies that have a knowledge of these matters. Having been specifically consulted, many of them did not object to the proposals. For example, neither the Royal College of General Practitioners, nor the general medical services committee of the British Medical Association raised objections to the recommendations.

My hon. Friend specifically pressed me about the membership of the ACBS, and passed on others' suggestions that it lacks expertise on nutritional matters. That is not true. The committee consists of several people: my hon. Friend wanted reassurance that they had some involvement in nutrition, and I can tell him that the expertise of two of the members is specifically directed towards that field. Those members are Dr. Simon Allison, who is head of the nutrition team of the Queen's Medical Centre in Nottingham; and, in a practical and more down-to-earth way, Ms Julie Fenton, who is the chief dietician at Queen Mary's university hospital, who has great insight into the sort of cases described by my hon. Friend.

Whatever the recommendations of the ACBS, it is open to the producers of high-strength multi-vitamin and mineral preparations to apply for their products to be licensed as medicines. They would have to provide evidence of the product's safety, quality and efficacy for the specified indications, and if they did so, a marketing authorisation could be granted.

That answers my hon. Friend's other point regarding a special category. There is no need to have a special category, because the way forward for those who market these products, if they think that they are of substantive therapeutic value, is simply to put them through the licensing process. If the products can be proven to be of therapeutic value, they, like all other products, will get a license,0020and will fall automatically within a category which can be prescribed by doctors.

I have some knowledge of what are commonly referred to, albeit slightly pejoratively, as alternative medicines. If there is a growing body of evidence of efficacy, which those who either market these products or claim that they have a worth are able to marshal, they will have a right—as would anyone else who claimed that their product had a therapeutic effect—to go through the licensing system so that the products could be available. I therefore issue something of a challenge to my hon. Friend: if the evidence is brought forward, it will be considered in an open way, which is the usual way in which evidence is considered on matters that may provoke a therapeutic change for the best.

I looked at the case study to which my hon. Friend referred, and I would be happy to look at further details, if he can provide them. It set out what were claimed to be the facts of the matter, but I have to say that it was based substantially not on strong evidence, but on assertion. I should be happy to see better and further evidence—if such exists—to sustain the claims made for the product referred to in the study.

My hon. Friend referred to vitamin B6. To bring him up to date, I can tell him that officials from the Ministry of Agriculture, Fisheries and Food and the Department of Health are meeting interested parties to discuss certain recommendations that have been made. Those interested parties have also been invited to submit any relevant data they might have which demonstrates that vitamin B6 is safe and of use. All such data that are received will be considered in full. That is the right way forward—there are no closed minds. I hope that my hon. Friend will find that answer helpful.

At the end of the day, I cannot give my hon. Friend specific assurances on his four points asking me to make concessions. The system we have works well, and it protects the national health service in terms of cost. It is a fair and open system, and, on this occasion, it has worked, and worked well.

Question put and agreed to.

Adjourned accordingly at half-past Ten o'clock.