§ Dan Norris (Wansdyke)I am grateful for the opportunity to debate this subject. I am also grateful to my hon. Friend the Minister for Public Health for not only assisting me, but replying today.
The debate is about whether general practitioners have the right to give flu jabs on the national health service to whomever they want, or whether they are limited by other forces. It is also about whether there is a loophole whereby NHS patients can be sent to other NHS surgeries to receive private treatment.
In the latter part of last year, I was approached by a number of constituents—at my surgeries and by letter— who were greatly concerned about the fact that they had been refused flu jabs, even though they had previously received them, at the Hope House surgery in Radstock, which is in the south of my constituency. I was shown a leaflet that the surgery had produced, which strongly suggested that patients had been refused because of Government policy.
Obviously, I was concerned to hear about this. I took the matter up in the first instance with the Avon health authority, which told me that flu jabs were given at a GP's discretion, and that, although there were guidelines, the GP's decision was what finally counted.
I contacted my hon. Friend the Minister, who confirmed that it was up to GPs to decide whether to give flu jabs. She also pointed out the inaccuracies in the surgery's leaflet, which wrongly suggested that the Government had recommended that flu jabs should be given only to people in high-risk categories, and not to those at lower risk.
I wrote to the surgery with the information that I had been given by the Avon health authority and my hon. Friend the Minister. The surgery told me that it wanted to administer flu jabs to whoever requested them; it did not want to deny flu jabs to people who really wanted them. It felt strongly that flu jabs should be given on a discretionary basis, but only if that was clear to the public—the surgery was worried that it would be blamed and that there would be a public outcry if it did not give flu jabs on demand.
The surgery also told me that, when it had consulted Avon health authority, it had been told, first, that it could give flu jabs only to those people who were listed as being at high risk of developing complications if they caught flu; secondly, that it should in no circumstances give flu jabs to people who were not in a high-risk group; and thirdly, and most alarmingly, that, if it gave flu jabs to people who were not in the high-risk groups, it might face financial penalties—that applied also to other surgeries in the former Avon area.
Does my hon. Friend agree that a close working relationship between health authorities and GPs is important? Will she investigate, as a matter of urgency, the discrepancy between the accounts given by the Avon health authority and the Hope House surgery? Does she agree that, if the Hope House surgery's account is correct, Avon health authority should be called to account for its advice, which was unacceptable?
What publicity does my hon. Friend believe should be given to the issue of flu jabs in the future? To be told that one does not need a flu jab can be good—it can mean 1045 that one is healthy enough not to require immunisation— and should not be a cause of concern. Unfortunately, in Radstock and the surrounding area, such advice resulted in much disquiet and alarm.
§ Mr. David Drew (Stroud)I thank my hon. Friend for giving way, and I welcome the debate. One problem is that the people who are at risk are often not clear why they are. I should declare an interest: I suffer from asthma and am invited every year to have a flu jab, even though I do not feel myself to be particularly at risk. Does my hon. Friend agree that we need to explain to patients the whys and wherefores of flu jabs, which could help the process of deciding who should receive them?
§ Dan NorrisI share my hon. Friend's concerns; perhaps the Minister will comment on them. I hope that she will also look carefully at what seems to be a loophole. The Hope House surgery's leaflet specified two other surgeries to which its patients could go and how much an injection would cost at them—£10 and £15 respectively. It also stated that people who went to those surgeries should name the Hope House surgery and explain that they required private treatment.
Can my hon. Friend shed some light on whether that loophole could be exploited? The fear is that, if a number of surgeries came together, they could, to make money or reduce demand, refuse treatment to their own patients and refer them to another surgery at which they could receive the injection privately.
My final point is that Hope House is a fundholding surgery. Does my hon. Friend believe that the Government's introduction of a new system of commissioning will deal with the concerns that I have raised?
§ Dr. Peter Brand (Isle of Wight)May I, Mr. Deputy Speaker, make a short contribution to this valuable debate?
§ Mr. Deputy Speaker (Mr. Michael J. Martin)Does the hon. Gentleman have the permission of the hon. Member for Wansdyke (Dan Norris) and the Minister for Public Health to speak?
§ Mr. Deputy SpeakerI call the Minister.
§ The Minister for Public Health (Ms Tessa Jowell)I thank my hon. Friend the Member for Wansdyke (Dan Norris) for raising this important and timely topic. Immunisation is one of the most effective public health measures. People in their thousands now survive conditions that, even in living memory, would have killed many.
In the United Kingdom, immunisation recommendations are published in a memorandum entitled "Immunisation Against Infectious Disease", which is more usually known as the green book. The green book contains the recommendations of the independent Joint Committee on Vaccination and Immunisation—an expert 1046 and independent committee that has advised successive Governments since 1963. The green book is a highly respected source of scientific and practical advice on all aspects of immunisation.
Included in the green book is detailed advice on immunisation against influenza. I shall now deal with the highly pertinent questions asked by my hon. Friends the Members for Wansdyke and for Stroud (Mr. Drew) on that aspect of immunisation.
United Kingdom flu immunisation policy recommends that vaccines should be offered to protect people who are at most risk of serious illness or death, should they develop influenza. Annual influenza immunisation is therefore strongly recommended for adults and children with chronic respiratory disease, including asthma—in response to my hon. Friend the Member for Stroud— chronic heart disease, chronic renal failure, diabetes mellitus and immunosuppression due to disease or due to treatment. Immunisation is also recommended for those living in nursing homes, residential homes and other long-stay facilities, where rapid spread is likely to follow the introduction of flu.
However, immunisation is not recommended as routine for fit children and adults, including health care and other key workers, whatever their ages. In addition—this point is central to the concerns of my hon. Friend the Member for Wansdyke—the final decision on who should be offered immunisation is a matter for the patient's medical practitioner, and it is extremely important to emphasise that, although the Department provides advice, the decision whether to offer vaccination is a clinical judgment, made by the patient's general practitioner. The decision whether to immunise should take into account the result of flu exacerbating the underlying disease, as well as the risk of causing the individual serious illness.
The recommendations that I have described are based on the view of the Joint Committee on Vaccination and Immunisation, that not everyone in the country needs flu immunisation. As I have said, recommended groups should be offered immunisation because, in the view of the experts, they are at risk. People considered not at risk by a general practitioner should not be immunised.
For fit and healthy children and adults, of whatever age, a dose of flu is an unpleasant experience, but one which, generally speaking, mercifully does not pose a serious risk to health. Therefore, for most of the population, the advice on treating flu is well publicised by the chief medical officer and general practitioners. We are advised—as we have probably been advised several times—to stay at home, keep warm, rest, drink plenty of fluid, eat what is tolerable, and, if necessary, self-treat with paracetamol or aspirin to relieve the symptoms of flu. Obviously, if our condition does not improve, we are advised to contact our doctor.
Fit and healthy people will generally recover fully from flu and experience no serious lasting consequences. In addition, because an occasional bout of flu gives better long-term protection than a vaccination, it could be of benefit to people who are not vaccinated if they come into contact with a similar strain of flu in future, as their body's defences will be ready to react and protect.
On the other hand, influenza immunisation is only 70 to 80 per cent, effective, and provides protection only for the season in question, because of the very 1047 careful scientific matching of predicted flu strain to the vaccination for that year. As such, it is best recommended for those who might become seriously ill as a result of catching flu—those for whom the immediate, potentially serious, consequences of flu outweigh the benefits of acquiring "natural protection".
In recent years, flu vaccinations have increased substantially, and I am pleased to announce that, this winter, a record of 7.4 million doses of flu vaccine have been distributed. That figure is up from 6.2 million doses last winter, and compares with only 2 million doses 10 years ago.
However, it causes concern that only about half the people in the at-risk groups are being given the vaccines they need, and, although this percentage is improving, evidently we need to do more and to do better—and we shall.
I believe that the entirely admirable desire to improve flu immunisation uptake among those who need it, and to cut the amount of vaccine going to those who do not need it, was what led to the problems highlighted by my hon. Friend the Member for Wansdyke in the Avon health authority.
On influenza immunisation, it is the role of the Avon health authority to ensure that the United Kingdom policy is implemented locally as effectively as possible, by maximising uptake in the recommended groups. The health authority can do so only with the full co-operation of GPs and health professionals, who are, in turn, responsible for delivering the flu immunisation programme to patients.
It may help hon. Members if I clarify when influenza immunisation should be available on the national health service, and I hope that, by doing so, I shall answer one of the questions posed by my hon. Friend the Member for Wansdyke.
If an individual is in one of the Department of Health's specified at-risk groups, or their GP decides that there is a clinical need for an individual to be immunised, that immunisation is available to the individual on the NHS. The doctor should not charge the patient in that case, except where a prescription charge is applicable.
In return for giving a flu vaccine, GPs are reimbursed the list price of the vaccine, about 10 per cent, so-called "on-cost", and a personal administration fee for each vaccine. That money is paid on the understanding that the individual given the vaccine needs it in line with the national flu immunisation policy, as set out in relation to the broad at-risk categories that I have described.
Some patients outside the at-risk categories, often termed the "worried well", may be unhappy with being refused immunisation, especially if they have been immunised, albeit wrongly and against the advice, in the past. Those patients are at perfect liberty to obtain immunisations outside the national health service.
In the case that my hon. Friend the Member for Wansdyke highlighted today, the Avon health authority practice that he mentioned had identified two alternative medical organisations from which private influenza immunisations could be obtained. I can, however, assure my hon. Friend that any at-risk patient who needs flu immunisation, whether or not they fit into the broad categories describing the population at risk, will continue to receive it on the national health service.
1048 The advice that I have given today as to when influenza immunisation is available on the NHS is unaffected by fundholding or commissioning. If a GP decides that a patient needs influenza immunisation, in line with the green book guidance, based on the advice of the Joint Committee on Vaccination and Immunisation, immunisation should be provided for that patient on the national health service.
§ Dr. BrandMay I have the Minister's assurance that prescribing budgets, which are to be cash-limited for the first time, will be uprated to allow for a better take-up in the at-risk categories?
§ Ms JowellI have expressed our clear determination to increase take-up among the at-risk groups. In the light of best evidence available, we shall constantly review the scope of the at-risk groups and ensure maximum take-up. In line with that commitment, we must ensure that the budget allocated to cover the costs of immunisation allows immunisation to be made as widely available as clinical discretion permits within the framework that I have set out.
I return to the leaflet that concerned my hon. Friend. I understand that it was withdrawn in December, and that the regional director of public health for the south and west has written to the director of public health at the Avon health authority to ensure that accurate material is distributed to the public in future. I shall refer to that very helpful letter from the regional director of public health in order to make the position absolutely clear.
In writing to the director of public health at the Avon health authority, the regional director made it clear that the information distributed was inaccurate, that the leaflet had been withdrawn, and that it was extremely important that general practitioners were aware of the information provided in "Newsbrief" in September 1997, which set out the prescribing and medical protocols in relation to flu vaccination.
The regional director of public health makes it clear that the dogmatic statements relating to influenza as a vaccine were not in accordance with the policy of the Department of Health. Therefore, the chief medical officer's advice to general practitioners about the prescribing framework should be taken as the definitive framework clarifying at-risk groups and guiding the clinical judgments of individual general practitioners. The offending information has now been withdrawn. It is extremely important that we remain vigilant and ensure that accurate information is made available to guide the decisions of GPs in the future.
I hope that I have also made it clear that it is quite unacceptable for at-risk patients to be charged for influenza immunisation. The current policy necessarily allows the general practitioner—who has knowledge of his patients—to make the final clinical judgment as to who is at risk from flu. The at-risk groups are highlighted annually to the public through Department of Health flu leaflets, nearly 1 million of which have been distributed over the past two winters. The leaflets are available from GP practices, and directly through the Department's freephone health literature line.
Items on flu immunisation were also included in the Central Office of Information's "Sound Advice" audio magazine and the British sign language magazine, 1049 "Public Scene". Both magazines are distributed directly to contact organisations for sight, hearing and literacy-impaired people. The chief medical officer also writes annually to all doctors before the influenza season, reiterating the Department's immunisation policy. He stresses in particular the importance of immunisation as many at-risk patients as possible.
In addition, my Department also works closely with an organisation called AIMS, the Association for Influenza Monitoring and Surveillance, which promotes flu immunisation through the media, and offers helpful practical advice about how medical professionals can increase uptake in at-risk groups. The chief medical officer launches flu awareness week annually, accompanied by members of the scientific advisory board of AIMS. Both Help the Aged and the British Diabetic Association worked with AIMS last year to publicise the importance of immunising at-risk groups.
My Department will continue to work to improve immunisation uptake among recommended groups. We will ensure that those who need the flu vaccine receive it on the national health service. I thank my hon. Friend for raising this important subject, and for providing an opportunity for me to set the record straight following the confusion caused by the distribution of misleading information to his constituents. It is also important to reiterate the Government's determination to provide health care to the people of this country on the basis of need rather than ability to pay.
My hon. Friend expressed concern about a loophole that could technically provide an opportunity to exploit the private provision of vaccinations as opposed to their provision through the NHS to people at risk. I hope that I have reassured my hon. Friend that, if a GP recommends influenza immunisation, it will be available through the national health service.
1050 The Government's plans to build a modern and dependable national health service will in no way affect the availability of free vaccinations to patients who need them. GPs may exercise their discretion in making judgments about patients whom they consider to be at risk and who therefore require flu immunisation. The health authority in this case published misleading information, and that matter has now been set right.
My Department constantly reviews both the take-up of immunisation among at-risk groups and the definition of at-risk groups. I shall continue to seek the advice of the independent Joint Committee on Immunisation and Vaccination on that matter. I hope that the grounds for not providing blanket immunisation are well made: there must be evidence that a bout of flu would adversely affect a patient's health or well-being in order to justify vaccination.
This is an important part of the Government's approach to disease prevention. We should also take account of the substantial increase in the number of flu vaccinations that we have achieved this year. We must continue to be vigilant and ensure that flu vaccines reach those patients that are potentially at greatest risk. The chief medical officer and I will study in detail our success in targeting and vaccinating the various at-risk groups that I set out earlier.
We shall also continue to update the information provided to general practitioners about how they can act proactively to ensure that their patients who are at greatest risk from influenza receive the vaccine that will protect them throughout the winter. Again, it is always a matter of maintaining a proper balance between the protective benefits of vaccination and practical advice for avoiding flu as issued by the Chief Medical Officer, and taking care of ourselves when we do get flu.
The matters raised by my hon. Friend will have been of benefit to the many hon. Members who listened to his concerns. I hope that my response has reassured him.