§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Hill.]
10.26 pm§ Dr. Stephen Ladyman (South Thanet)I do not know whether it is a good or a bad thing that the Adjournment immediately follows the Second Reading of the Health Bill. My hon. Friend the Minister has had to work doubly hard tonight, but at least he has not had to break up two evenings. As I was in Committee this evening, I was unable to listen to the Second Reading; I hope not to cover the same ground but if I do so, I apologise to the House.
The national health service drugs bill is rising; in my opinion, it is rising inexorably, but, also in my opinion, that is not a bad thing. Drugs can be extremely cost effective. A drug that keeps someone out of hospital can make a saving for the NHS. A medicine that gets someone back to work quickly can have a beneficial effect on the economy. New drugs are becoming more efficient all the time and are starting to deal with conditions that we were previously unable to treat. The pharmaceutical industry is a big contributor to the national economy and is an industry that we should be trying to support. My purpose tonight is try to convince my hon. Friend—if he needed to be convinced—of those matters and to suggest some ways in which we could try to think about meeting the rising drugs bill that we shall face in coming years.
The Government have already made a huge start: an extra £19 billion will be available for the NHS in the next three years. That money will help to modernise the service. It will make more services available, and some of it will go towards meeting the cost of the rising drugs budget. However, in my view, it will be insufficient.
In recent weeks we have engaged in debates on this subject; we have increasingly heard the Conservatives start to answer some of the questions that perhaps they did not fully address during their 18 years in government. Unfortunately, the answers that they have given to those questions tend to be right-wing ones that advocate more private practice and more private medicine. I do not believe that those answers are in line with the principles of the NHS. The Liberal Democrats have also acknowledged the rising drugs bill, but yet again they seem to think that their magic penny on income tax will address all the problems.
I am loth to suggest that what I offer tonight is a third way, because the boss—my right hon. Friend the Prime Minister—has already copyrighted that particular phrase. I will, however, offer a basis for debate that is in line with the principles of the NHS and that will help us to address the issues.
My constituency includes Pfizer, a large and successful pharmaceutical company that employs 3,500 people there. When its current building programme is complete, it will employ 1,000 more. My right hon. Friend the Secretary of State for Trade and Industry and I are working hard to encourage the company to make further investments, and we are hopeful that it will do so. However, the company, like other pharmaceutical firms, is beginning to feel underappreciated.
Some reasons for that have been inherited by the Labour Government, including the limited prescribing list and the problems of parallel importing that still have not
130 been fully dealt with. Equally, however, Pfizer feels underappreciated because it is difficult to see effects such as the outcome generated by a medicine taken into consideration when pricing is considered. The company also fears that the National Institute for Clinical Excellence will focus on driving down the drugs bill rather than on outcomes and cost effectiveness.
The industry is also worried about changes in the pharmaceutical price regulation scheme, although it has been reassured by recent statements that the new agreement would be introduced after full discussion and, as far as possible, on a voluntary basis.
I reject some of the fears that have been expressed, but I must recognise that those fears exist, and, as a constituency Member, I must reflect them fairly. Of even more concern, however, are the needs of individual constituents such as Mrs. Noreen Heffer of Ramsgate and Ms Lesley Jordan of Sandwich, who have been diagnosed as suffering from multiple sclerosis and who would benefit from beta interferon treatment, which they currently cannot receive.
The reason for that is complex. As best as I can piece the story together, there was an accord in east Kent on who could appropriately receive the drug and who could not. The accord broke down, and too many people were put on the treatment, for some of whom it was not suitable. Once the health authority recognised that there was a problem, consultants got together to agree new prescribing guidelines and to start to review the cases of people on beta interferon. While the list is being reviewed, and while people for whom the treatment is not appropriate are weaned off it, Mrs. Heffer and Ms Jordan have to wait.
The health authority has increased its budget to £325,000, which is large for an authority of its size. Although I can give my two constituents a good explanation for what has happened, all they want to hear is that beta interferon is available so that they can begin their treatment. How can we make such treatments available?
We must remember that if expensive drugs are made available, there will be an impact on drugs budgets.
Another constituent's wife was diagnosed as suitable for Aricept treatment at a time when it was not available in my constituency. By the time it became available, her condition had deteriorated to the point at which the treatment was no longer appropriate. An opportunity was missed for that patient.
Many constituents have also come to me because they have erectile dysfunction and wish to receive Viagra. which they cannot receive under current guidelines. They are concerned that they will not receive it either if the preliminary guidelines on which the Government are consulting remain unchanged.
§ Dr. Evan Harris (Oxford, West and Abingdon)I thank the hon. Gentleman for letting me intervene on his thoughtful and remarkably independent-minded speech. Does he agree that the Government's proposal on Viagra, which has just been out to consultation, is a rather irrational way to go about rationing a drug? The proposal would restrict the drug's prescription on the basis of the causes of dysfunction rather than the likely benefit, meaning that many people, particularly older people, simply will not have access to it because the Government
131 are choosing to limit it. It is welcome that the Government are taking responsibility for rationing, but that is an irrational way to do it.
§ Dr. LadymanI largely agree with the hon. Gentleman; I have concerns about the rationality of the drug's availability being limited by the cause of the underlying condition. But even on that basis the principle behind the guidelines appears to be that erectile dysfunction has an underlying psychological cause, whereas it is now clear that there is usually an organic condition behind it—for example, diabetes, hypertension, post myocardial infarction, arteriosclerosis, stroke, renal disease, multiple sclerosis, spinal cord injury, pelvic injury, prostate resection, radical prostatectomy and pelvic radiotherapy are all major causes of erectile dysfunction.
Erectile dysfunction is an extremely distressing condition, and I think that men who suffer from it are entitled to have the entirety of their condition treated. If one is treating renal disease, surely one should also treat the conditions that renal disease causes, which might include impotence. The prescribing guidelines should reflect that.
In fairness, I should state that Viagra is a Pfizer drug, so that is another constituency concern. I should also point out to the Minister that Pfizer has estimated that Viagra would cost only about £50 million if it were freely available on the NHS. That is far less than some of the figures that were put about a year ago when the debate first took off. Viagra is actually quite a cost-effective treatment. It would cost only about £19 a month under the current pricing guidelines, which is far less than the monthly cost of an antacid treatment.
If the Minister feels that he needs to limit the availability of Viagra in case the bill gets out of control, I suggest that he challenges Pfizer to cap the cost of Viagra at £50 million; if more than £50 million worth is required, he should suggest that Pfizer should provide it for free. I think that Pfizer might enter negotiations on that basis. The Minister might be pleasantly surprised—he should at least have a go. If he does not think that he has the power to do so, today's Second Reading of the Health Bill revealed that clauses 30 and 31 give him the power, even if he does not have it at the moment.
Finally on behalf of my constituents, I have a further concern that men's health issues are generally downgraded and not given the consideration that they should be. With Lord Jopling, I recently helped to host a meeting in the Houses of Parliament with Senator Bob Dole. I do not share Senator Dole's political philosophy, but he has been campaigning in America for increased prostate cancer treatment and screening. We should be taking up that issue in this country, but I accept that if we did, it would also greatly increase the drugs budget.
I am asking the Minister for fair treatment for pharmaceutical companies, for novel treatments such as Viagra and Aricept to become freely available, and for expensive drugs like beta interferon to become freely available. All these will increase the pressure on the drugs bill. Although the National Institute for Clinical Excellence is a very good start and will clearly consider cost-effectiveness, it alone will not hold back the flood waters of increased drug prices.
132 Therefore the Minister might care to give some thought to my following suggestions. He could switch as many drugs as possible to over-the-counter availability. If he then changed the way in which pharmacists were remunerated to encourage them to have private rooms where they could advise customers on over-the-counter drugs, and if the Government and pharmacists together raised awareness of the benefits of home health care, many of the treatments that currently have to be prescribed by GPs could be sold over the counter. That would also keep people out of GPs' surgeries, thus reducing another burden on the NHS.
The Minister should change the way in which drugs are priced to reflect outcomes, and do so in such a way that the saving made by a medicine keeping somebody out of a hospital bed is reflected in the drugs budget. The drugs budget can then be allocated the resources needed to exploit to the full the potential of medicines.
Even those things would not be sufficient for the increase in the drugs bill for which we must gear ourselves up. So, I shall make one further slightly more radical suggestion for the Minister to consider. Currently, the NHS prescription bill—based on an answer that his predecessor, my hon Friend the Member for Brent, South (Mr. Boateng), gave me in April last year—is £4.5 billion a year, of which we raise only £300 million through prescription charges. We can either fund the increased drugs budget through the money made available under the comprehensive spending review or in some way increase prescription charges—the money which comes directly from the patients. That is where the Minister should be looking.
The Government have said in the debate on Viagra that the principle behind the NHS is that it should make freely available treatments for life-threatening, painful or disabling conditions. I agree; drugs for such treatment should be freely available to everybody irrespective of income. But, those represent only half of the current drugs budget. The other half need not necessarily be freely available to everybody. Drugs that deal with trivial conditions and conditions which get better on their own should be charged at the market rate to everybody, also irrespective of income.
In the middle, there is a group of drugs which deal with serious conditions—I would include Viagra in that category—and should be freely available only to people who are on low incomes. Others should pay for them at the market rate. By doing that, we would create a market in such drugs; competition might force the price down. We would also generate private medical insurance schemes to help people who want to take such an option. Such an approach would be true to the principle of the NHS that life-threatening and disabling illnesses would be freely treated and that pain relief would be freely available to all.
In case the Minister doubts whether there is room in the budget for such an approach, I shall give him a few examples of drugs in the middle category. Dermatological products cost £246 million, non-serious use of antiulcerants costs £300 million, anti-diarrhoeals cost £67 million, laxatives £71 million, tropical non-steroidal anti-inflammatory drugs £35 million, drugs for hay fever £34 million, contraceptive pills—slightly more controversial in such a category—£58 million, hormone 133 replacement therapy £138 million, oral nutrition drugs £85 million, food for special diets £29 million and vitamins £12 million.
That is a list of £1,075 million-worth of drugs that do not deal with life-threatening, disabling or painful conditions. If the NHS were not paying for just a fraction of, say, non-serious use of anti-ulcerants, my constituents could get their beta interferon and Aricept. Those drugs should be freely available to people who need them.
Does the Minister agree that the drugs bill will inevitably rise over the next few years? How will he stem or meet that rise? Will he consider my suggestions? When will the Viagra consultation process be reported on? Will he give thought to increasing the availability of drugs over the counter and through home health care measures? If he will give those suggestions some serious consideration, this debate will have been well worth while.
§ The Minister of State, Department of Health (Mr. John Denham)I congratulate my hon. Friend the Member for South Thanet (Dr. Ladyman) on his success in securing the debate. I understand the importance of the topic to his constituents, many of whom are employed by Pfizer, which is of course the manufacturer of Viagra, among many other important products. That drug has produced more comment and opinion than perhaps any new drug in living memory. I shall return to it in a moment.
As a Government, we do fully accept the importance of the United Kingdom pharmaceutical industry to this country. Only last week, at the Association of the British Pharmaceutical Industry annual dinner, my right hon. Friend the Secretary of State described the industry as "quite brilliant". The Government unequivocally support the industry.
The Department of Health is responsible within Government for policy in relation to NHS purchase and the use of pharmaceuticals, and for policies designed to create the right competitive environment in which the UK pharmaceutical industry can continue to flourish and compete in the global market. Those two aims are not at odds. We recognise that the industry's present success was hard won. In the face of globalisation and increased competition, the industry must be at the forefront of innovation and competitiveness if that success is to be sustained. Nothing that we are doing threatens that success—rather the opposite.
The principal objective of recent developments, such as the National Institute for Clinical Excellence, is to enable faster and more equitable access to innovation, and to ensure that resources are used cost-effectively. Clinicians encounter more and more new products—the pace of change is quickening. The setting up of NICE recognises the need for machinery to provide authoritative guidance, and the industry has expressed support for the broad objectives of NICE. The Association of British Pharmaceutical Industry and the Association of the British Health Care Industry will be represented on the partners' council, which will oversee NICE' s work programme and ensure fair play in its working methods.
We have made it clear that if medicines are shown to be more clinically and cost effective than other treatments, that is how the money should be spent. Unified budgets will facilitate that. There is no cap on the drugs budget. The introduction of unified budgets creates a single 134 funding stream for three components of expenditure—hospital and community health services, prescribing, and GP practice infrastructure—which were previously managed separately, under differing rules, by different parts of the NHS.
§ Mr. Philip Hammond (Runnymede and Weybridge)Will the Minister give way?
§ Mr. DenhamIn fairness to my hon. Friend the Member for South Thanet, I think I should try to answer as many of his points as possible.
Those three components have been combined into a single pot at health authority and primary care group level. That level will depend on the clinical priorities that health authorities and primary care groups set themselves. Unified budgets will create a flexible environment, which will help to ensure that patients get the most appropriate treatment for their condition.
It is not true to say that the Government are unwilling to allow for the full cost of treatment when assessing the price of medicines. Under the NICE appraisal system, companies will be free to submit any relevant data, with the core of NICE' s appraisal focusing on the health benefits achievable from NHS budgets—including hospital beds and staff, not just the cost of drugs.
We continue to work closely with industry. For example, the industry strategy group, which includes senior industry representatives and Department of Health, Department of Trade and Industry and Treasury officials, meets every quarter to discuss a range of issues. The industry has praised Government for their handling of the debate on the development of the single market in pharmaceuticals during our presidency last year, and subsequently the ISG and other bilateral contacts provide forums for discussion of NHS policies as they affect the pharmaceutical industry and other relevant Government policies. One of these is the parallel import of pharmaceuticals into the UK. Government has an on-going and constructive dialogue with the industry on that issue. Internationally, the ISG is seen as a unique forum for Government-industry debate.
As a discerning home customer, the Government are determined to secure value for money for the national health service. The clinically and cost effective use of pharmaceuticals helps to stimulate UK industrial competitiveness; it does not undermine it.
We do want to reach a voluntary agreement on the pharmaceutical price regulation scheme, but the Health Bill will enable us to back it by statute if necessary. Above all, the PPRS—voluntary or backed by statute—has, and will continue to have, the joint aims of fair prices for the NHS which represent good value for money, and fair prices or profits on NHS sales for the industry which represent a reasonable return on the enormous investment that goes into pharmaceutical research and development and of course helps to fund future R and D.
This remains a very good country in which to invest in pharmaceuticals: it has lower costs, labour flexibility, good industrial relations, a strong science and skills base, a strong cluster of existing industry, low corporation tax, political and social stability and an excellent regulatory regime.
I said that I would return to the topic of Viagra. Impotence is in itself not life-threatening and does not cause physical pain. It can, in exceptional circumstances,
135 cause psychological distress. Until the advent of Viagra, NHS expenditure on this condition has been limited because of the nature of the treatments available. Now that treatment is available in tablet form, the cost of treating impotence could escalate. To limit that impact, we propose controls that reflect the priority given to treatment for impotence and reflect current expenditure on it.
Briefly, it is proposed that Viagra and other drug treatments for impotence would be available on prescription from GPs for the following groups of men: those who have had radical pelvic surgery or their prostate removed; those suffering from spinal cord injury; diabetics; multiple sclerosis sufferers and those who have single gene neurological disease. Treatment would also be available for other men adjudged by a hospital specialist to be suffering from severe distress. General practitioners would be able to prescribe privately to impotent men not suffering from one of the named conditions.
The period of consultation ended on 25 March and work is now under way to collate the responses. That is likely to be a considerable task as there are about 850 of them. Even at this initial stage, it is clear that the widest possible range of views has been expressed to us. I should make it clear that no final decisions will be taken until we have had the opportunity to consider the range of responses sent in. We will carefully consider all comments that have been received during the consultation period before reaching a final decision. We shall also keep the issue under review once final policies are in place. We have to find a sensible balance between treating men with a distressing condition and protecting the resources of the NHS to deal with other patients with, for example, cancer, heart disease and mental health problems.
All health authorities were issued in 1995 with guidance that covered the use of beta interferon for the treatment of multiple sclerosis. It recommended that prescribing should be initiated by hospital specialists where clinically appropriate. The costs of prescribing are expected to be met within health authority allocations, taking account of local priorities.
However, we should be clear that there are continuing questions about the clinical effectiveness and cost-effectiveness of beta interferon, the benefits achieved, which patients will benefit and for how long, and how the benefits compare with those of supporting patients through, for example, specialist nursing care. Health authorities and clinicians rightly take these and other factors into account when they set local priorities.
We must ensure that clinical and cost-effective treatments are spread through the NHS as quickly as possible, and that is one of the roles of the National Institute for Clinical Excellence, which will provide clear and authoritative advice on key treatments and procedures. Subject to the outcome of consultation on the discussion document and appraisal by NICE, we are minded to refer beta interferon to the institute.
I should like to take the opportunity to address some of the other specific issues and suggestions that have been 136 raised and made by my hon. Friend. My hon. Friend suggests that we should switch as many drugs from prescription only to over-the-counter status as can be accommodated safely. The Government encourage wider availability of medicines as soon as there is adequate evidence of safety in use. We have tried and effective mechanisms for processing such switches; indeed, they have formed the model for European-wide switching.
My hon. Friend suggests that greater emphasis should be given to the benefits of home health care. The Government are already doing a great deal to promote self-care. Most significantly, we have set up NHS Direct, the 24-hour nurse-led helpline, which has been a big success, with the first three pilot projects achieving a 97 per cent. satisfaction rating. NHS Direct is helping patients to make better use of the NHS. Many of the callers change their course of behaviour as a result of their calls.
Drawing on the experience of NHS Direct, my right hon. Friend the Prime Minister announced today plans for extending its role in a number of new areas of activity. Among these is the development of NHS Direct as a health promotional tool, and NHS Direct nurses in west Yorkshire are planning to phone people to remind them of their hospital appointments.
We will also be piloting arrangements under which nurses will be able to call older people who come out of hospital to check that they are all right, or work will be done with family health service teams to help to improve the management of chronic diseases such as asthma and diabetes. NHS Direct will go on the internet as NHS Direct On-Line, so that the public can consult an interactive guide covering common minor ailments to help them decide when they can look after themselves and when they need to seek professional advice.
National health service direct information points may be placed in surgeries, libraries, pharmacies, post offices, supermarkets, accident and emergency departments and healthy living centres. They will be able to provide internet access to NHS Direct On-Line and phone access to a NHS Direct nurse and information on local health services. We shall publish a NHS Direct health guide to help people care for themselves. These are important developments.
My hon. Friend was right to refer to the role that pharmacists can play in encouraging the effective use of medicines. We are working on a strategy for community pharmacy that will take into account the expertise that pharmacists can bring to the use of medicines.
My hon. Friend made some radical suggestions about prescription charges, including the proposal that they should bring in about three times as much revenue as they do at present. In opposition, we promised to review prescription charges, and that we have done. The current prescription charge exemption arrangements were examined as part of the comprehensive spending review, which reported last year. We looked at a range of options for this Parliament, but concluded that the present charging arrangements should continue: all current prescription charge exemptions would be protected for the rest of this Parliament and existing patient charges would rise by no more than the rate of inflation over the next three years.
137 I am afraid that nothing my hon. Friend has said tonight has persuaded me that that conclusion was wrong.
There are systems such as my hon. Friend proposes in other parts of Europe. I should say that, where they apply, it is almost always the case that Viagra has been placed not in the intermediate category, as he proposes, but in the category of medicines for which patients have to meet the full cost themselves.
138 This has been an interesting debate and I am aware that, in the time available, I have not been able to respond—
§ The motion having been made 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 at four minutes to Eleven o'clock.