HC Deb 14 June 1999 vol 333 cc73-110

'The Special Health Authority known as the National Institute for Clinical Excellence shall make its appraisals of different treatments and clinical interventions on the basis of clinical efficacy or relative cost—effectiveness compared with alternative treatments or clinical interventions for the same symptoms, but not on the basis of their affordability in relation to the funds available to the National Health Service.'.—[Dr. Harris.]

Brought up, and read the First time.

Dr. Evan Harris

I beg to move, That the clause be read a Second time.

Mr. Deputy Speaker

With this, it will be convenient to discuss the following: New clause 14—National Institute for Clinical Excellence (duties and consultation with public)

  1. '.—(1) The Special Health Authority known as the National Institute for Clinical Excellence (the "Authority") shall meet in public.
  2. (2) The Authority shall publish annually a report on its activities during the preceding calendar year which the Secretary of State shall lay before Parliament.
  3. (3) The Secretary of State shall establish a public consultative committee in relation to the Authority, which shall have the duty of advising the Authority on the public's view on the priority to be accorded to different treatments and clinical interventions within the NHS.
  4. (4) The constitution and membership of the committee mentioned in subsection (3) shall be such as the Secretary of State may determine in Regulations.'.
New clause 16—Protection of doctors' clinical freedom to prescribe appropriate drugs'.—The Secretary of State shall not exercise his powers to include a drug in schedule 11 to the National Health Service (General Medical Services) Regulations 1992 (as subsequently amended) in such a way as to restrict the circumstances in which the drug may be prescribed by reference to the different underlying causes of the symptoms for whose treatment it is clinically effective.'. New clause 17—Cost or affordability not to be criteria for restricting prescribing of drugs'.—In issuing guidance on prescribing, or in exercising his powers to include a drug in schedule 10 (drugs and other substances not to be prescribed for supply under pharmaceutical services) or schedule 11 (drugs to be prescribed under pharmaceutical services only in certain circumstances) to the National Health Service (General Medical Services) Regulations 1992 (as subsequently amended), the Secretary of State shall not base his decision on the criterion of either the cost or the affordability of the drug in question.'.

Dr. Harris

I hope to introduce the new clauses relatively quickly, but at this point it is appropriate to pay tribute to the work of the hon. Member for Runnymede and Weybridge (Mr. Hammond), who in Committee paid great attention to the detail of our proposals—as I am sure he will do to these proposals. He did so assiduously during the Bill's Committee proceedings, while simultaneously fathering a child—or rather overseeing the birth of a child—[Interruption.]—There was some confusion as to that point in Committee.

More than mere scrutiny of the Government is involved in the new clauses. Like the other groups of amendments that we shall discuss in the near future, they show that some critical issues must be decided. On this occasion, the Liberal Democrats are raising those issues—of rationing in this group of new clauses; and of the hours worked by junior doctors and discrimination in the national health service in later groups. For more than three hours, we debated the border provisions in Scotland and we shall probably have a long debate on this and future groups of new clauses. One cannot help but think that the contributions of hon. Members—I am sure that those contributions were always in order—were lengthy because of hon. Members' chagrin that they had not tabled such important new clauses as those that we are now discussing.

Mr. Bercow

Will the hon. Gentleman give way?

Dr. Harris

I shall do so in a moment.

It seems strange that, at the rate that we are carrying out our scrutiny of the Bill, we may well be discussing the hours of junior doctors in the middle of the night and spending a great deal of time discussing other matters that were covered at length in Committee. Nevertheless, although the House will want to discuss those issues, for those outside the House, it should be pointed out that something is going on—

Mr. Deputy Speaker

Order. We should not be worrying about what is to come; we need to worry only about the new clauses before us.

Dr. Harris

Thank you, Mr. Deputy Speaker. I was keen to point out that I will attempt to keep the substance of my remarks brief, because I know that Conservative Members will want to contribute—probably at length.

Mr. Hammond

I point out to the hon. Gentleman that any chagrin felt by Conservative Members is due entirely to the fact that the Government have allowed only one day for Report. We consider that to be wholly inadequate in view of the Bill's importance.

Mr. Deputy Speaker

Order. We need not go into those matters; we need only to worry about the group of new clauses before us.

Dr. Harris

The new clauses are about what the Government should and should not do in the rationing of treatment.

Mr. Bercow


Dr. Harris

I should be grateful if the hon. Gentleman would be patient so that I can get into the substance of my speech. I shall then willingly give way to him. On this Bill, we have a spirit of giving way—liberally, if he will excuse the expression.

New clause 4 provides that the National Institute for Clinical Excellence shall make its appraisals of different treatments and clinical interventions on the basis of clinical efficacy or relative cost-effectiveness compared with alternative treatments or clinical interventions for the same symptoms, but not on the basis of their affordability in relation to the funds available to the National Health Service. That is a key point and the new clause states the matter clearly. It goes to the heart of rationing, priority setting or managing the resources of the health service—whichever term we use.

New clause 14 refers to the need for openness and accountability and for public participation in whatever decisions are appropriately made through NICE.

Mr. Bercow

I welcome the fact that the hon. Gentleman is introducing this group of new clauses. He has a long-standing interest in, and some considerable knowledge of, the plight of many of our constituents throughout the country as a result of rationing. However, will he tell the House why, when he is introducing these important new clauses, he is accompanied by only two of his hon. Friends? Is that because most Liberal Democrat Members are unconcerned about the problem of rationing and do not suffer its consequences?

Mr. Deputy Speaker

Order. I certainly do not want to hear a debate about the party make-up in the Chamber at present. We must discuss the new clauses.

Dr. Harris

I was going to say that I am aware of the interest of the hon. Gentleman in rationing. As he has acknowledged, he is aware of the interest of at least two Liberal Democrat Members who have raised that matter in Adjournment debates. They will be following the proceedings carefully.

New clauses 16 and 17 consider rationing of the drug Viagra from two different approaches. We take the Government to task for what has happened, in a way that is analogous to that in which the courts and the Government, by their own admission, feel that the issue has been mishandled. We also want to help the Government by introducing a measure to ensure that those mistakes are not repeated and that such rationing decisions are made fairly and rationally, rather than irrationally.

As I did in Committee, and as is customary, I declare an interest. I have a non-declarable interest as a fellow elect to a pharmaceutical company, under the Industry and Parliament Trust scheme, which gives Members of Parliament experience of private sector companies. I am attached to Glaxo Wellcome plc for that purpose, although I receive no remuneration. In addition, my interest in rationing took me on a study trip to the United States with NHS commissioners and clinicians to study the details of the association with the American Society of Clinical Oncologists, and the trip was funded by a pharmaceutical company.

We hope not to have to press new clause 4 to a vote, important though the issues are, because we raise those issues in a spirit of constructiveness and in a workmanlike manner. We hope that the Government will be able to reassure us that our fears are unfounded. Our great concern is that NICE will be a means for the Government to ration treatments, which is the term we use, or to deprioritise treatments out of the NHS in a way that is not politically accountable. The Minister knows that I have raised these concerns before, so his answer will be well rehearsed, but I seek specific undertakings from him.

7.30 pm

I hope that the Minister recognises that my approach to the National Institute for Clinical Effectiveness is not unreasonable.

Mr. Hammond

Clinical Excellence.

Dr. Harris

Sorry, the National Institute for Clinical Excellence. When I referred to the National Institute for Clinical Effectiveness, I was thinking of the Government's original press release on the special health authority with that name, which was corrected from cost-effectiveness to clinical effectiveness, and then to clinical excellence.

The Liberal Democrats accept that treatments should be used only when they are likely to be efficacious and when they are effective. We have no time for an NHS that wastes money on prescribing drug treatments or carrying out operations that are not of clinical benefit to the patient, or where the adverse effects of the medication are likely to outweigh any clinical benefit that the patient may receive. Clearly, there is a need for national standards, not only to get rid of what the Government rightly describe as unacceptable variations in the delivery of treatment, but to ensure that treatments that are a waste of money are not carried out through best practice not being disseminated sufficiently widely.

We would go further on the issue of cost-effectiveness. We recognise that the NHS has limited funds, although we would argue that it should be better funded than even the Government have managed over the past two years. Given that funds are limited and that there is a great need for services, it would be wrong for health authorities, trusts and clinicians to prescribe drugs or offer treatments that are more expensive than other treatments for the same condition or symptoms, but no more effective. It is sensible to consider the relative cost-effectiveness of treatments and to ensure, given the NHS's limited budget, that money is not spent needlessly. I hope that that is common ground between us.

We have two concerns, however, on which the Government have yet to reassure us. The first is whether the measure of cost-effectiveness will be wide enough and, if it is sufficiently wide, whether it will be fair, especially to pharmaceutical companies and in respect of drug treatments that are relatively new. Our second concern is that, even if the test of cost-effectiveness is met, the Government will use NICE to ration on the basis of affordability drugs that are highly effective, efficacious and relatively cost-effective, but whose widespread effective and cost-effective use would have implications for NHS budgets. We acknowledge that there is a need for tough decisions to be made on those issues, but the Government must publicly announce those decisions, not shelter behind NICE.

We are concerned that, so far, the Government have not ruled out NICE making its recommendations on the basis of affordability, even in respect of treatments that are effective and cost-effective. We are also concerned that the chairman of NICE, Professor Rawlins, in his evidence to the Select Committee on Health, did not rule out the possibility that he might be forced—against his will, I am sure—to make recommendations based on affordability in respect of treatments that would otherwise pass the effectiveness and relative cost-effectiveness tests. I see that the hon. Member for Runnymede and Weybridge shares my concern.

The issue of efficacy is not all plain sailing, which is why it would be of great benefit to the House if we had a debate on NICE. However, I shall not take up time considering such matters in detail now. In respect of the efficacy of new treatments, it will be difficult for NICE to be fair to patients and to treatment providers. There are several new treatments whose efficacy dawned on the NHS rather late. For example, some of the new HIV treatments were never felt to be particularly effective on their own; but, a significant time after their introduction, they were found to be highly effective and cost-effective if used in combination. If their use on the NHS had been prevented, NHS patients would never have benefited from that combination therapy and, in this country at least, doctors might never have found out that the drugs were so useful in combination. There are significant concerns about the way in which NICE will judge the efficacy of new drugs.

Dr. Nick Palmer (Broxtowe)

I, too, should declare an interest in that, from time to time, I advise Novartis, although I am not sure that that company would agree with the question that I am about to ask. Does the hon. Gentleman agree that the approach taken today, whereby such decisions are being made by dozens of individual units around the country, is not necessarily superior to having one body deciding centrally? Does he also agree that it is difficult to consider the question of cost-effectiveness completely separately from that of clinical effectiveness, because it is only one of several factors? It is rather artificial to expect NICE completely to ignore that aspect.

Dr. Harris

I think that I have already covered the second part of the hon. Gentleman's question. As for his first point, it is not a question of centrally set guidelines versus the relatively quick or slow uptake of new treatments in various parts of the country. Clearly, having NICE lay down what should or not be prescribed and then insisting on its guidelines being followed—incidentally, the level of insistence is not clear—will mean that a treatment is either quickly introduced everywhere or not introduced anywhere. My concern is that the data on which that uniform, NHS-wide decision is based will not be complete and that the wrong decision will be made and its effect last for all time, or for a significant period of time until the decision is re-examined. Such an approach might well have held back the introduction and use of the HIV drugs to which I referred.

Although we support the idea that NICE should examine efficacy, costs and prescribing practices in respect of new drugs and treatments, we recognise the difficulties with data on efficacy. Another example of that is ACE—angiotension converting enzyme—inhibitors. They were felt to be of limited clinical use when they were first introduced, and certainly when I was a medical student, but were later found to be highly effective for conditions other than those for which they were originally used. That discovery would not have been made had they not been prescribable on the NHS on the basis of more limited evidence.

There is concern that the way in which NICE will consider cost-effectiveness will be too pure—that it will not consider "relative cost-effectiveness", which is the wording in the new clause, but will use some pure measure of cost-effectiveness without stating how that measure should be arrived at. There are many measures of cost-effectiveness, such as the numbers it is necessary to treat in order to achieve a valuable clinical effect in one patient, or the cost of a treatment, perhaps combined with the costs per life-year saved or per quality adjusted life-year. There is a series of such measures, but the NHS is not experienced in assessing them.

Patients, patient groups and the pharmaceutical industry are concerned that NICE will seek large amounts of data that are not readily available. The new clause makes it clear that we should be considering "relative cost-effectiveness", where it is measurable, against existing treatments. When the data are poor, the new treatments should be given the benefit of the doubt.

An example is the drug erythropoetin, which is used to stimulate the production of red blood cells in patients who are anaemic and suffering from renal failure. That treatment was very expensive when it was first introduced. It was believed not to be cost-effective, and its availability was extremely limited. However, it proved to be relatively cost-effective in preventing hospital re-admissions and negated other costs associated with chronic renal failure. The early prevention of that drug's prescription may have hidden its relatively high cost-effectiveness.

Our main concern is which budgets NICE will examine when measuring cost and benefit. For example, the new anti-psychotics—the so-called atypical anti-psychotics—used to treat schizophrenia are much more expensive than the old reliables, such as haloperidol. There is no justification, on a purely cost basis, for prescribing the atypical anti-psychotics. However, it is now well recognised that the side-effects of the older drugs are so great that compliance is poor. Patients do not take them; they then suffer acute relapses and require hospitalisation, which generates more costs. The new drugs are tolerated better, and should therefore be prescribed.

We are concerned that the cost-effectiveness data will comprise only NHS drug budgets, not broader NHS treatment budgets. In the case of Alzheimer's disease, we are concerned that the measure will be NHS budgets rather than the wider social care budgets. Even if wider budgets across the health and social care fields were examined and the data were available—it may be difficult to obtain without investment in research and development, which the Government have cut in the first few years of this Parliament—there is concern that NICE will not take account of social security budgets and the benefits to the nation of having healthy people working and paying taxes.

Mr. Fabricant

Does the hon. Gentleman not consider that there are parallels with a cost-benefit analysis that the Government should undertake regarding the free provision of nicotine replacement therapies in order to reduce the cost to the national health service of treatments for cancer and pulmonary and other dysfunctions caused by tobacco smoking?

Dr. Harris

I agree with the hon. Gentleman. My point is reinforced by Stephen Thornton, who is quoted in an excellent booklet produced by the Association of the British Pharmaceutical Industry and authored by Chris Mihill, a well-regarded former medical correspondent on The Guardian. Stephen Thornton, the chief executive of the NHS Confederation, is reported as saying that he doesn't think the savings from other budgets, such as social services or social security, will revert to the health service, even if they could be fully quantifiable. The booklet quotes him as follows: If patients go back to work and pay taxes, the money goes to the Treasury, and when does the health service see that? It's an argument the Health Department must have with the Treasury, that investment in the health service produces economic benefit. But at the moment, from a GP and trust point of view"— I think he also means from a commissioning point of view— if it's outside the health sector, it's money which we can't have. Mr. Thornton argues that that cost-effectiveness calculation should not be made, or is not currently being made. I fear that the wider arguments that would prevent false economies will not be made unless the Government pay particular attention to the workings of NICE.

7.45 pm
Mr. Bercow

The hon. Gentleman has largely dealt with the point that I proposed to raise. Does he agree that, on the basis of ministerial pronouncements thus far, it would appear that Ministers intend to adopt a very narrow interpretation of cost-effectiveness? Although they have not excluded the consideration of social factors, the Minister has attempted to play them down on several occasions. That is a worrying portent for the future.

Dr. Harris

I have read the Minister's responses to Adjournment debates about multiple sclerosis, and I have listened carefully to his comments in previous debates. I remain optimistic that he will recognise the concerns that we have highlighted and will confirm now that, in their response to the consultation on NICE, the Government will give the institute adequate resources so that it may undertake true cost-effectiveness work. Narrow cost-effectiveness measures will not be fair to patients or to those seeking to develop new treatments.

Regardless of how the Minister deals with the problem of cost-effectiveness, I hope that it is clear to all—I trust the Minister will agree—that it cannot be right for NICE to set out guidelines preventing or advising against use by the NHS of a drug or other treatment when it is effective and cost-effective but when the take-up of that treatment would adversely affect the NHS budget. That is a consideration for Ministers, but NICE would be abusing its power if it were to restrict the use of cholesterol-reducing drugs, for example, that would prove both effective and cost-effective in the long run by reducing cardiovascular mortality and morbidity simply because it would have significant cost implications for the NHS.

If such restrictions must be made, the Government should say that the NHS cannot afford to provide the treatments out of current resources. We could then debate publicly how much the Government should spend on the NHS or, as the Conservatives would have it, how much use those who can afford to should make of the private sector in order to create more space in the NHS. We believe equity dictates that there should be much more funding for the NHS, but that is a matter for another debate. The key point is that the public have a right to consider that issue. Even if new clause 14—to which I shall turn in a moment—is agreed to, I do not think the public will have much of an idea about the pronouncements of academics and others from NICE.

I believe that the Government adopted the correct position on Viagra. That was a pure case of rationing on the grounds of affordability, and the Government were right not to impose restrictions through a covert health service circular or through some quango, although there were some problems. I seek the Minister's assurance—we have not received such an assurance from the chairman of NICE—that the institute will not apply the criterion of affordability when considering effective and relatively cost-effective drugs. I will be happy if the Minister will provide that assurance. I know that many, if not all, clinicians, as well as those who take a sensible and mature approach to the difficult question of prioritisation and deprioritisation, will be relieved to hear that the Government are taking a responsible view of where political accountability lies.

We discussed proposed new clause 14 in the Third Standing Committee on Delegated Legislation on 10 March this year, when I asked the Minister whether meetings of NICE would be open to the public. He said that I was right to say that the regulation as drafted does not require public acc ess to meetings of the institute's board. There is a case for that in the climate of openness and transparency, as he said, although he also acknowledged that issues of confidentiality would need to be protected. He continued: If the matter proved in practice to be a problem, it could be dealt with by further regulation. I say to the Minister that it is not a question of whether there is a problem in practice, but making public access subject to matters of commercial confidentiality should be a default principle. The Government should ensure that meetings are held in public unless there is a reason why they should not be. I look to the Minister to reassure us that the public will normally be admitted to the board's meetings and that the Government will introduce regulations to ensure that, so that I will not need to press that part of new clause 14.

Subsections (3) and (4) of new clause 14 set out a way in which the public can be involved in decisions relating to NICE. It is important that the public have a say in the issues that the institute should consider because we have to find a way to involve the public in decisions on rationing.

Mr. Bercow

The hon. Gentleman is making a powerful point about public involvement and the need for accountability. Does he agree that the machinery of consultation and public involvement is likely to be effective only in so far as there is a guarantee from the Government that there will not be private words between Ministers and NICE, the purpose and effect of which will be to disregard the outcome of the consultation and, in other words, to make it a sham? Do we not need to be reassured that under no circumstances will that happen?

Dr. Harris

That is a very important point. The decisions about which treatments, processes and drugs the institute should consider should be made openly. There should not be seen to be collusion between what is supposed to be a semi-independent health service body—a special health authority—and Ministers. If Ministers are to give directions, which they may feel is their right, they should do so openly and in consultation with the public.

Many people have called for the public to be more involved in such decisions. In the Standing Committee that considered the statutory instrument, to which I have already referred, the Minister said: I confirm that it is important that patients' interests are represented in all NICE's work. From a patient's point of view, quality has sometimes been neglected in the drawing up of professional guidelines in the past."—[Official Report, Third Standing Committee on Delegated Legislation, 10 March 1999; c. 18–19.] By having not only lay representatives on the institute's board but a public consultative committee for the authority, we shall ensure that the institute's deliberations are seen to be publicly accountable in a way that, with the best will in the world, one could not guarantee if there were only a cosy arrangement between the Minister and the institute.

Mr. Hayes

The hon. Gentleman is making a good case for a wider debate about this matter, and he is right to do so because some of the institute's judgments will not be clinical but ethical or moral in a broad sense. Is that open and public debate helped by Ministers' continual denials that those restrictions are not already operating? The truth is that there is already rationing. One can euphemistically call it strict management of resources, as the hon. Gentleman has done—I understand why he has done so—but continual denials that those choices are already being made does not help the process of public, open and honest debate that the hon. Gentleman is advocating.

Dr. Harris

I agree with the hon. Gentleman, and both Opposition parties have initiated debates on that. There is scope for a separate debate on the workings of the national institute, but I am keen to make progress now. I hope that by making points that hon. Members agree with, I shall enable them to restrict their comments so that we can make quicker progress.

On public accountability, the Consumers Association's magazine Health Which? pointed out that, in its survey, three quarters of the people who were interviewed felt that the public should have a say in which services were available on the NHS, but only a third of the 35 health authorities surveyed made any mention of public consultation in their material.

Oxfordshire has a priorities forum that is open to the public, and I attend that forum to find out exactly what is happening in health service rationing. I can assure the Minister that the word "rationing" is used by all the people in that forum, whether they are professionals or lay people. I know that Buckinghamshire and other health authorities try to involve the public. However, that is not sufficient public involvement. There should be a national scheme to mirror those local arrangements. We support the Consumers Association's call for wider public involvement.

I press on now to new clauses 16 and 17, which relate to the way in which the Government have used the scheduling procedure in the National Health Service (General Medical Services) Regulations 1992 to restrict the availability of drugs on the NHS, particularly Viagra. I make two criticisms of the Government in speaking to those new clauses. My reasons for tabling new clause 17 echo my arguments about the Government using affordability as a criterion for using schedule 10 or 11 of those regulations on the basis of cost or affordability.

Schedule 10 relates to drugs that are not available on the NHS, and schedule 11 relates to drugs that are available only under limited conditions. Since their introduction, those procedures have traditionally been used, in the case of schedule 10, for drugs that are not efficacious, or are no more efficacious, than cheap alternatives and, in the case of schedule 11, for drugs that are effective only in treating certain conditions. It is not the case that certain conditions are specified to control cost. The use of those schedules has been based on effectiveness and, even if drugs are effective, on strict relative cost-effectiveness.

Mr. Fabricant

Does the hon. Gentleman have a view, as his party's spokesman or as a former houseman in a hospital, on the effect of prescribing generic drugs that may be cheaper but have side effects very different from those of the main drug for which they are a substitute?

Dr. Harris

I do have views on that, but I shall not express them in this debate. If the hon. Gentleman sees me afterwards, I will be happy to go over those issues. There are issues of generic substitution but they do not relate to these new clauses.

Mr. Fabricant

They do.

Dr. Harris

No, they are different, and controversial, issues, although I understand the point that the hon. Gentleman is trying to make.

Dr. Stoate

I seek clarification from the hon. Gentleman. He seems to be telling us that drugs that are proscribed from being used for certain conditions under schedule 11 are simply not effective in treating those conditions, but that is not the case and it is not borne out by my knowledge of medicine. For example, a severe case of sunburn may be due to overexposure to the sun or to photosensitivity. Sunblock will work in both conditions, but schedule 11 specifies that sunblock should be prescribed only in clear cases of photosensitivity and should not be prescribed as a cosmetic treatment to allow people to spend more time in the sun. Another example is scaly scalp condition—

Mr. Deputy Speaker

Order. The hon. Gentleman should know that interventions should be brief, so perhaps he will allow the hon. Member for Oxford, West and Abingdon (Dr. Harris) to respond to that point.

Dr. Harris

The hon. Gentleman is making the same point as I am. The scheduling of drugs for certain conditions is based on their effectiveness and cost-effectiveness. I agree with the examples that he has given. Those schedules do not include drugs that are effective and relatively cost-effective for a recognised clinical condition and have never been used for that purpose. However, that is exactly what the Government plan to do from 1 July for Viagra. There is no doubt that the Government accept that Viagra is effective and also relatively cost-effective, but the increased demand for an acceptable and cost-effective treatment creates problems of affordability for the NHS. The Government are misusing schedules 10 and 11 for such a drug.

As I have said before, if the Government suspect budget implications as a result of increased need for a drug, it is right that they make an announcement. Our concern is not that the Government made such an announcement, but that they did so irrationally. Part of that irrationality was the misuse of schedules 10 and 11. The criteria should have been based on effectiveness and relative cost-effectiveness, not on pure cost or affordability. That is why we have tabled new clause 17. My criticism of the Government on that matter has been shared by many clinical authorities.

8 pm

Mr. Fabricant

I do not like to press the hon. Gentleman—he is very reasonable—but surely the very new clause that he has tabled relates to generic substitution. The Government would argue at times that cost-effectiveness could be secured by prescribing a substitute for a drug at the expense of clinical side effects that may be detrimental to the patient.

Dr. Harris

I do not want to be drawn into the question of generic substitution simply because it is controversial whether the differing availability of generic drugs and patented drugs causes side effects. That is a drug-specific matter. Regardless of the details of generic substitution, I am talking about the general principle—I hope that the hon. Gentleman will accept this—of the Government's misuse of schedules on effectiveness and cost-effectiveness in order to get themselves off a hook.

As the Government may know, new clause 16 is a direct criticism of the way in which they chose to ration Viagra. If accepted, it would prevent the Secretary of State from doing what he did with respect to Viagra. I think that the NHS, lawyers and the Department of Health would be grateful for such legislation, since the Government would be prevented from breaching what I consider to be a doctor's ethical duty: to prescribe a drug that he or she considers to be effective, regardless of the origin of the complaint from which the patient suffers, if, in each situation, the drug is equally effective.

The Minister will know that there was a court case concerning the interim guidance and that the final guidance that the Government are producing under schedule 11 almost certainly cannot be challenged legally. New clause 16 is not about the legal judgment but about whether the Government are rational in saying to a group of patients, "However effective and cost-effective this drug may be in treating your recognised condition, you will not be given it because your condition stemmed from"—for example—"cardiovascular or psychiatric causes." As a result of the Government's creating two lists and direct discrimination, a diabetic, for whom the drug may be less effective and cost-effective, may well qualify for the drug.

We shall come in due course to another group of new clauses that address discrimination. The Government have said that they do not believe that the NHS should be discriminating irrationally. We have agreed, I hope, that where such rationing occurs, there should be a clinical basis for it. In the case of Viagra, the basis was cost. The Government wanted to ensure that only 15 per cent. of potential patients were treatable, and therefore chose conditions that accounted for only 15 per cent. of patients.

It would have been more rational to give hospitals, primary care groups or individual GPs a budget, enabling them to use their clinical judgment to treat the 15 per cent. of patients who would benefit most from such treatment. The Government should not lay down rules. To give them credit, they did say that only 15 per cent. of potential patients would be treated; that is part of the openness and accountability in rationing decisions about which we talked earlier. It was entirely wrong, unfair, inequitable and discriminatory for the Government to do what they did over Viagra.

In Committee, I pressed the Minister on this point and asked whether, if such a situation arose again, he or his right hon. Friend the Secretary of State would use the same technique in order to ration. He reassured me partially that he thought that unlikely—I think we were still awaiting the outcome of the legal matter at that point. I should be grateful if the Minister confirmed that discrimination on the basis of cause of condition rather than effectiveness of treatment will not be the basis on which future rationing decisions are made. If that reassurance cannot be given, we shall press new clause 16 to a Division.

Mr. Fabricant

Does the hon. Gentleman accept that the Minister, just like his boss the Secretary of State, will not allow the word "rationing" to cross his lips? They will not even admit the existence of rationing in the health service, so any reassurance that the hon. Gentleman may have been given would have certainly omitted that word.

Dr. Harris

The hon. Gentleman knows that I agree with those sentiments, which have been expressed before by other hon. Members. I hope that we shall not have a long discussion on the Government's refusal to use the dreaded "R" word, although I fear we will. Despite the fact that the Government refuse to call a ration a ration, I am trying to make a constructive point. I very much look forward to the Minister giving an assurance that prioritisation or deprioritisation or resource management, or whatever he calls it, will not be conducted on such an irrational basis again, and to his accepting the principle of new clause 16.

The new clauses go to the heart of the rationing issue. They identify many of the key points that the Government have not yet clarified, despite hours of debate both in Committee and on the Floor of the House. I know that the Minister has a deep understanding of these issues, so I look forward to his offering considered reassurances. The matter is set out clearly on the amendment paper. He will be judged by the health profession and those involved in the NHS on the satisfactory nature of his answers.

Mr. Hammond

It is very appropriate that the hon. Member for Oxford, West and Abingdon (Dr. Harris) ended on an explicit discussion of rationing and whether we should call it by its name, because this debate on Report is on the question of rationing. Many hon. Members present will regard the question of rationing and the attempts to rationalise rationing without ever admitting that it exists as one of the most important issues to address in considering this Bill.

Mr. Fabricant

I am sorry to interrupt my hon. Friend so very soon in his peroration, but does he not find it ironic that it took a High Court judge to tell the Secretary of State that rationing—in that case of Viagra—was wrong, but that the Secretary of State still cannot bring himself to use the word?

Mr. Hammond

My hon. Friend is entirely right. I shall return to that matter in a moment.

I thank the hon. Member for Oxford, West and Abingdon for acknowledging the role that the Conservative Opposition played in Committee in seeking to widen the debate on this Bill to embrace the very important issue of rationing. It was not as easy as one might have expected. Although the clauses before us deal specifically with the National Institute for Clinical Excellence, which is indeed a key part of the Government's machinery for rationing service delivery in the NHS, many hon. Members who have not had the privilege of serving on the Committee that considered the Bill, and perhaps may not have studied the Bill in great detail, might be rather surprised to discover that NICE is not a child of the Bill. It was introduced by the Government by means of a statutory instrument. Therefore, it is only by means of new clauses such as new clause 4, which seeks to restrict the scope of NICE' s operation, that we can use this Bill in any way to bear on those very important issues.

Mr. Bercow

Given my hon. Friend's deserved reputation as an intellectual giant in the House, I wonder whether he can clarify a matter that has puzzled me for some time, upon which I feel sure that he has dwelt in reflecting on the Bill. In his judgment, what is the difference between rationing, which the Government disavow, and prioritisation of resources within a finite budget, of which they apparently approve?

Mr. Hammond

My hon. Friend asks a very good question—one which I put to the Minister of State—

Mr. Fabricant

Another intellectual giant.

Mr. Hammond

Indeed, as another intellectual giant. My hon. Friend asks a question which I put to the Minister in the Committee on the statutory instruments that introduced NICE. I feel a little sorry for Ministers who have to deal with this question time and again, because they are intelligent people who well understand the situation in which the NHS operates. They understand as well as we do, as well as the BMA, as well as the royal colleges, as well as the Patients Association, that of course there is rationing in the national health service. That is nothing to be ashamed of. We should accept and acknowledge that, and then we might have a sensible debate about how best to ensure that that rationing occurs in a way that is fair, transparent and rational.

The absurd situation that we all find ourselves in this evening is that the Government have created, in NICE, a mechanism that will make more rational the imposition of rationing in the national health service, but they cannot proclaim that success because they will not admit that there is any rationing in the NHS. Indeed, my right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe), after an exchange at the Dispatch Box a few months ago, asked the Minister for Public Health outright the question, Is there rationing or is there not? and the answer came, No."—[Official Report, 15 December 1998; Vol. 322, c. 746.] We cannot have a more explicit statement of Government policy from a Minister at the Dispatch Box than that, and yet, absurdly, although every commentator—qualified or not—recognises that there is rationing in the NHS, the only party that does not is Her Majesty's Government.

In defence of the Minister of State, I am certain that he and his colleagues—the Minister for Public Health and the Under-Secretary—privately recognise, in their own intellectual analysis of the situation, that of course there is rationing, and find having to keep denying it publicly deeply embarrassing.

Miss Widdecombe

In case my hon. Friend was prepared to be generous and felt that the Minister for Public Health was put on the spot by my question and said no by accident, would he now like to consult written answers in which he will find that the Secretary of State has said that there is no rationing in the health service?

Mr. Hammond

I was not suggesting for a moment that the Minister for Public Health might have answered no through inadvertence or for some other reason. I am saying that, having dealt with the Minister of State for several months on many issues and having had a chance to appreciate his rational and analytical approach, I cannot believe for a moment that he really believes that there is no rationing in the NHS. I was merely pointing out that I find it deeply embarrassing that Ministers have to keep repeating the nonsense that there is no rationing—but not so deeply embarrassing that I shall not ask them that question again in due course.

Mr. Bercow

On the "pedantry pays" principle, I am anxious that we should be accurate as regards the record of oral questions. Am I right in thinking—my right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) will probably correct me if I am wrong—that the Minister for Public Health insisted that there was no rationing, not once in answer to one question, but on no fewer than three occasions in answer to three questions from my right hon. Friend? My photographic memory is not serving me on this occasion.

Mr. Hammond

My hon. Friend is right, and that assurance that there is no rationing has been repeated by the Minister of State and the Secretary of State. However, I have not yet come across any other body—I mean that in the literal sense—that shares that view. Almost everyone else that I have come across accepts and acknowledges that there is rationing and believes that we should be discussing how to deal with that rationing.

8.15 pm
Mr. Fabricant

Will my hon. Friend give way?

Mr. Hammond

If I may, I should like to pay tribute to the hon. Member for Oxford, West and Abingdon for raising those issues tonight. He has done us a service in doing so. They are important issues, and the hon. Gentleman is well qualified to raise them. Apart from being instantly recognisable as the only member of the Liberal Democrat party not yet to have declared himself in the leadership race, he is a former junior doctor so he speaks with some authority on such matters.

Opposition Members have noticed that the Bill is about separating power and responsibility: about moving power upwards to the Secretary of State through an ever more centralised system of directions and determinations, so that the Secretary of State has more and more power at his fingertips to control every minute part of the operation of the NHS, while at the same time delegating down responsibility for the results of actions over which the bodies held responsible have a decreasing amount of power or influence.

We have been very focused on the issue of rationing. The new clauses that the hon. Member for Oxford, West and Abingdon has introduced tonight focus us on the wider issue of rationing. In that context, he has picked two specific examples of rationing as it currently exists and is proposed to exist—the role of NICE and the use by the Government, in dubious circumstances, of schedules 10 and 11. I shall disappoint some of my hon. Friends by pronouncing "schedule" as the hon. Member for Oxford, West and Abingdon did—with a hard c—but it is a habit that I, too, find difficult to drop.

It might be useful if we look at that bogey word, "rationing", because it is not really as awful as Ministers' constant denials of it might have us believe. Conservative Members believe that there is no shame in acknowledging that there is rationing within the NHS. There has always been rationing within it. For the record, there was rationing within the NHS during the period of the previous Conservative Government. We do not deny it, and have not sought to deny it.

Mr. Denham

I wonder whether the hon. Gentleman would explain a question that has been worrying me, which is why, for 18 years under Conservative Governments, not a single Conservative Minister—or, as far as I know, Conservative Member of Parliament—said that there was rationing in the health service.

Miss Widdecombe

I did.

Mr. Hammond

My right hon. Friend says from a sedentary position that she did. Perhaps the hon. Gentleman did not ask the right questions. I regret that I was not here at that time to observe what was going on.

Those of my hon. Friends who happened to be watching last night's television coverage of the results of the Euro-elections may have seen Peter Snow conjure up a rather whizzy little graphic that showed the change of the Government's popularity rating on various different issues, and the issue on which the Government's confidence rating among the British population had declined the most since May 1997 was health. The graphic showed that very neatly.

The Minister might reflect upon the extent to which reiterating a statement that the vast majority of the British public know from experience to be untrue, and which the vast majority of the professions involved know to be untrue, may have, in no small part, led to the significant decline in the British public's confidence in the Government's health agenda.

Rationing is an undeniable fact. Professor Sikora of the World Health Organisation stated that terminally ill cancer patients have to pay thousands of pounds for life prolonging drugs because of lack of cash. It has long been the case that doctors prioritise cancer cases on the chances of an effective cure or a lengthy prolongation of life, but the Government still deny that cancer services are rationed.

Breast cancer patients are paying £12,000 for a six-month course of Taxol. Many hon. Members have examples from their constituency correspondence of constituents who have had to go to extreme lengths, in some cases having to sell houses, to pay for life chance-enhancing drugs that are not available from the health authority where they live.

Patients with cancer of the colon are paying £8,000 for a course of Ironotecan. One of the hazards of engaging in a debate on rationing with people who have a specialist knowledge, such as the hon. Members for Oxford, West and Abingdon and for Dartford (Dr. Stoate) is that one must wrestle with the pronunciation of such unpronounceable words. Lung cancer victims must find £6,000 for a course of Gemcitabine.

Professor Thomas from the university of Surrey, which is close to my constituency, and a specialist cancer referral centre that serves cancer patients from my constituency, states that she has cash disputes with the NHS on behalf of patients every two or three weeks.

The concerns that have been voiced regarding drugs for the treatment of people with psychotic illnesses, as we heard, are even more notable. In many cases, drugs developed in the 1950s are preferred not only over the latest atypical anti-psychotics, but even over drugs developed in the 1970s, such as Clozapine.

Mr. Hayes

That highlights the issues raised by my hon. Friend the Member for Lichfield (Mr. Fabricant) in his intervention—the definitions of efficacy and of effectiveness. When we speak about effectiveness, we may be speaking of a cure, but we should also consider the route to the cure, and the effect on the patient during treatment. In measuring effectiveness, we must take such aspects into consideration, and the Government are simply not doing so.

Mr. Hammond

My hon. Friend raises an interesting question, which could take us still wider on the issue of rationing: what are we measuring when we look at the outcomes? What are we measuring as a benefit—extension of life, or extension of life with a certain quality attached to it, as the hon. Member for Oxford, West and Abingdon said? It is legitimate to ask such questions, and it would be legitimate for us all to engage in a sensible debate about them, but we cannot do so while the Government insist that no rationing exists.

Mr. Fabricant

May I ask my hon. Friend a philosophical or historical question? Does he recall that in the 19th century, many great medical schools were unable to offer cures for certain dysfunctions, but they thought it important to diagnose a dysfunction such as diabetes, for which no cure was known until the 1920s? Without being able to identify a problem, one cannot seek a solution. Until the Government identify the fact that rationing exists, there cannot be a sensible debate about how we solve that problem.

Mr. Hammond

My hon. Friend's suggestion of using an evidence-based medical approach to the Government's problem of acknowledging rationing is interesting, but, as I said, I imagine that the Government have already identified the problem, but have boxed themselves into a corner. They cannot acknowledge it and engage in a sensible debate. I expect that, to their credit, many Ministers greatly regret that they are in that position. When they could be addressing the issues, they must instead deny the fact that rationing exists at all.

Beta interferon is a favourite example in the House whenever rationing is debated. Many hon. Members have harrowing tales of availability that is often limited by crude numbers, so that patients who need treatment with beta interferon may have to wait for someone else to die before they can get on to a course of that treatment.

Rationing has manifested itself in many other ways throughout the NHS. Operations for many minor procedures in many health authorities have ceased to be available. Operations on lipomas, sebaceous cysts and non-acute varicose veins are unlikely to be available in many health authorities across the country. West Hertfordshire health authority has a list of 32 operations and treatments that it will not provide other than in exceptional circumstances.

The waiting list is a form of rationing—rationing by inconvenience. Reducing the convenience of the service provided and making people wait for the provision of a treatment constitutes an additional form of rationing.

In the NHS that the Government are seeking to create through changes in primary care, increasing pressure will be directed at general practitioners to restrict their prescribing practices to meet the budgetary needs of the primary care trusts or primary care groups of which they are members, or to fall into line with prescriptive guidance from mechanisms such as NICE.

Mr. Bercow

Does my hon. Friend agree that because Ministers are not prepared to acknowledge the indubitable fact that rationing exists, that has led them down the dark alley of making invidious comparisons of relative cost-effectiveness? Does he agree that even at this, the 59th minute after the 11th hour, it would be helpful if they would abandon that pretence so that a genuine and meaningful debate, rather than a bogus one, about the relative cost-effectiveness of different treatments could take place?

Mr. Hammond

My hon. Friend raises an interesting point. There is a place for the important debate on relative cost-effectiveness. Although we need to examine the overall resource constraint under which the NHS labours, we all have a duty to ensure that the money available in the NHS, whatever the amount is, is spent in the most effective way.

Where there are different treatment approaches to the same symptoms, and one of them can be shown to be more cost-effective than another, that is precisely the sort of issue that a dispassionate, apolitical, technical institute should consider and report on. That is quite different from allowing that institute to recommend that a treatment should not be available at all because it is too expensive to the NHS and cannot be afforded.

The new clause specifically draws that distinction between what I think of as the technical function of assessing the relative cost effectiveness of different alternative treatments or clinical interventions for the same symptoms and assessing the affordability of a given treatment or intervention in relation to the overall total funds available to the national health service. I would characterise that as a political rather than a technical function.

That is what I had in mind when I mentioned that there is a trend or a tendency within the Bill to devolve power upwards to the Secretary of State and responsibility downwards to other NHS bodies. The technical process of evaluating the relative cost-effectiveness—I emphasise relative—of different treatments or clinical interventions is properly something that the Secretary of State can devolve to a body such as NICE. In an environment where the Secretary of State acknowledged that there was overall rationing and that there was a resource constraint that limited the amount of treatment available, the input from the institute would be vital information in moving to the next stage, which is to ask who gets what within the overall resource constraint.

8.30 pm

We are concerned because, given the Government's refusal to acknowledge that there is an overall resource constraint, the role of NICE, which should be a technical, dispassionate and apolitical one, exactly as the new clause suggests, risks becoming politicised, with the institute being encouraged or forced to make judgments about what should or should not be available on an absolute basis, in the context of assessing treatments and drugs against the overall budget that the NHS has available to it.

Mr. Hayes

The dilemma that my hon. Friend is describing—the contradiction in the structure—coupled with the lack of clarity or openness in the debate, will encourage the public to blame NICE or, more likely, the local hospital or the local GP, rather than taking a view that the Government should have made wider strategic judgments. The Government are not simply setting up something that is contradictory and paradoxical. Instead, they are passing the political buck. People will be angry and they will direct that anger at professionals rather than at politicians. My hon. Friend is putting the case in an informed way, but I will put it rather more bluntly when dealing with my constituents in my case work.

Mr. Hammond

My hon. Friend is right. If he reads the medical press, he will see that general practitioners have rightly recognised that they are being lined up to take responsibility for rationing decisions and to bear the brunt of the complaints and criticisms that he anticipates his constituents will raise with him. My hon. Friend is right to identify the issue.

Power resides with the Secretary of State throughout the Bill, but it is someone else's responsibility to answer for the delivery of the service. That is the antithesis of transparency and openness in government, where power and responsibility should be seen clearly to reside together. The overall issue of rationing and how the available resources within the NHS are to be allocated is intrinsically a political decision. There is no shame in making it, but it is not a decision that can be shunted off on to an institute that has been set up to make evaluations and to report on the relative merits of one thing or another.

Neither is it a decision that can be made by doctors on the basis of clinical priorities without a political framework being placed around them so that they know the context in which they are required to make that clinical prioritisation. It is relatively simple to ask doctors to place in order of priority a group of patients in terms of who is the most needy or deserving of treatment in a particular circumstance. However, it is not reasonable to ask doctors to determine where the cut-off point should come in allocating the available resources. The amount of the available resources is, of course, a political decision. The determination of the level of those resources must reside with the Government. There responsibility must also reside for deciding how the impact of rationing will fall.

The new clause correctly defines the role of NICE if we take the Government entirely at face value and if we take their assertions that the institute will spread best practice and will examine the relative cost-effectiveness and clinical effectiveness of different treatments and interventions so that the NHS can operate in a more logical and rational way, so that it does not waste money on things that are relatively ineffective or expensive for a given outcome.

If the Government are to be believed, and if their assertions about their intentions for NICE are to be taken at face value, they should have no difficulty in accepting new clause 4, but we have long believed that they have another agenda for NICE. They intend to create through NICE a quasi-clinical respectability for the rationing decisions which increasingly will have to be made.

As the hon. Member for Oxford, West and Abingdon has already pointed out, we have to consider not only Viagra and other well-known drugs that are already available, at least in the technical sense, but drugs that we all know are coming along, although they are not yet even theoretically available on the market. Such drugs will be very expensive, but they could change quite radically the outcomes for people in certain disease groups or with certain conditions.

The chairman of NICE, Professor Michael Rawlins, has already openly admitted that the institute may have to recommend that a treatment or a drug should not be available on the NHS because of the overall constraint on resources and the impact that such a product or treatment would have on the NHS budget.

Mr. Bercow

My hon. Friend is making an important point and I should like to clarify one aspect of it before he moves on. Does he agree that the only way in which the Government can refute the charge that he has made about their reasoning in creating NICE is to confirm this evening that there will be no private discussions between Ministers and the chairman of NICE and that their content will be disclosed publicly?

Mr. Hammond

My hon. Friend is right. That would be one way in which the Government could provide some reassurance about their intentions for NICE, but I say again that NICE, despite its rather overblown title, was conceived as a vehicle for assessing clinical and cost effectiveness, which was a sensible idea. However, what happens with that information afterwards might become dangerous. That is essentially a matter for the politicians and it is extremely important that we keep the distinction between what they decide and what information the technical experts and advisers can bring to us, better to inform our debate about the way in which to use the limited resources available to the NHS.

Mr. Swayne

On the suggestion of the chairman of the national institute that it might have to recommend that a treatment is too expensive, the current situation is that many health authorities have made such a decision, which has given us the horror of treatment by post code. By transferring that responsibility to the national institute, we are in effect ensuring that such treatments will be available within no post code whatever.

Mr. Hammond

My hon. Friend is exactly right. The Government have said that they want to reduce regional disparities, but they are unable to put forward a convincing argument that the advice of NICE, properly implemented, will not inevitably mean a levelling down of services.

The Government have not said that they will make funds available—they have been given plenty of opportunities to give us that assurance—to enable best practice on every drug to be followed nationally as a result of the initiative to eliminate regional disparities. If the budget is not to be expanded, and if the service is to be increased in other areas, it is logical that the availability of some treatments will inevitably be reduced. The Government cannot have it both ways: they cannot eliminate regional disparities and also assure us that the purpose of their reforms is a levelling up of service.

I accept new clause 4 for what it is, and I think that NICE works well in that role. However, my criticism of new clause 4 is that it begs the question whether we should assess treatments, interventions or drugs that are available for a condition if there are no alternative treatments against which they can be appraised for clinical and cost effectiveness.

That brings us right back to the original question of how we are to make rational rationing decisions in the NHS, recognising the overall resource constraint. Beyond the role that new clause 4 would cast for NICE—that of assessing the relative clinical and cost effectiveness of different solutions to the same problem—we would need to debate the question of how we go about assessing which areas should or should not be prioritised if there is only one solution to a problem and it is very costly and there are a number of such problems and not enough resources to allow all the demands for treatment to be met. There may be many answers to that question, but the position is pretty clear to anyone who has considered the scale of the problem and the funding gap were there to be—as Ministers would like to believe—no rationing in the NHS. The problem could certainly not be solved with the product of 1p on income tax, which is the standard Liberal Democrat response to these difficult questions.

The technical input of NICE would be extremely welcome and useful in that debate if we could solve the political questions of how the total budget should be divided up and how we should deal with the overall resource limitations. If we had a good mechanism for doing that, it would presuppose that the Government recognised that there was an issue to be addressed. Politicians should not shunt decisions on to NICE. We must set the framework, and then let the experts deal with the technical questions.

I cannot be quite so complimentary about new clause 14. New clause 4 is worth while, but its provisions would be unravelled by new clause 14. The first two subsections are unexceptional. They require NICE to meet in public and to publish a report annually. Both themes were pursued in Committee, with the objective of making the processes by which difficult decisions are made more transparent and understandable to the public, who feel the impact of those decisions.

Subsection (3) of new clause 14 proposes: The Secretary of State shall establish a public consultative committee in relation to the Authority, which shall have the duty of advising the Authority on the public's view on the priority to be accorded to different treatments and clinical interventions within the NHS. I was disappointed to read that, because it goes against the grain of new clause 4, which would make NICE an objective and technical body that weighed up the clinical efficacy and cost effectiveness of treatments. Feeding the result of a public consultation exercise into NICE's decision-making process would be dangerous, because it would introduce an element of subjectivity that is properly the domain of politicians. It would be better for NICE to consider the relative cost and clinical effectiveness of various treatments and for another body to consult public opinion. Both those strands of information could feed into the political decision-making process. The Secretary of State must ultimately make the decisions.

8.45 pm
Mr. Hayes

As well as compromising the empiricism of that professional body, might not the notion of public consultation that my hon. Friend describes be interpreted by the Government—but no one else—as an alternative to a proper, full and open public debate? Is not the proposal a sop to public consultation rather than the proper debate that should be taking place in the wider community and in this place about the key priorities that my hon. Friend identified earlier?

Mr. Hammond

My hon. Friend is right. We must never be trapped into believing that, because NICE exists and will examine the issues objectively, there is no need for a wider debate on the rationing of resources in the NHS.

The experience of public consultation in prioritising health care is not particularly happy. Most people who are interested in the subject will think immediately of the Oregon experiment. I suspect that none of us was impressed by the priorities that the public in Oregon gave for publicly funded health care. A straw poll of Members of Parliament would probably put cosmetic breast surgery a lot further down the list than the citizens of Oregon did. I caution the hon. Member for Oxford, West and Abingdon about the usefulness of a crude public consultation exercise.

New clauses 4 and 14 appear to contradict each other. New clause 4 rightly emphasises that NICE should stay out of the political debate, but new clause 14 would send it straight to centre stage.

Mr. Bercow

My hon. Friend is invariably courteous in exchanges in the House. Perhaps I can try to decipher what he is saying. Is he telling the House, in his extraordinarily polite fashion, that the hon. Member for Oxford, West and Abingdon is guilty, in new clause 14, of vulgar and unworthy populism?

Mr. Hammond

I leave it to my hon. Friend to decide whether it is vulgar and unworthy. In fairness, the desire for public consultation at all stages and on all issues is almost a mantra with the hon. Member for Oxford, West and Abingdon. In some cases, we have disagreed with him because he has suggested taking that process too far. He has a genuine desire to have some public input into the debate and we believe that that will be required, but we also feel strongly that their input should not be to NICE but should run in parallel with its work and inform the political process.

Mr. Hayes

Is my hon. Friend saying that although the hon. Member for Oxford, West and Abingdon is implicitly unworthy by being a Liberal Democrat, he is personally incapable of vulgarity?

Mr. Hammond

I shall move on from that subject. I detect a certain muddle in the juxtaposition of new clauses 4 and 14. None the less, new clause 4 has served a useful purpose in allowing attention to be drawn to the gap between the role that the Government have consistently implied for NICE and the one that we fear may evolve, by design or by chance, and which its chairman has acknowledged will be a potential issue.

New clauses 16 and 17 deal with a separate issue that is another example of the working of the rationing agenda. The two new clauses, as the hon. Member for Oxford, West and Abingdon acknowledged, have been driven by the public debate over Viagra, which has raised awareness in the popular press and the public mind about some issues that might have remained obscure had they been discussed only in connection with beta interferon and the other drugs that were mentioned earlier.

By focusing the debate on Viagra, the popular press has moved forward the overall debate about rationing and the mechanisms by which rationing decisions are made. As has been mentioned, the courts have become involved in the debate about the availability of Viagra and have sent a message to the Secretary of State for Health about what he may and may not do in the exercise of his powers.

It is important for hon. Members who were not present in Committee and have not had the opportunity to consider the Bill in as much detail as the rest of us to set this issue in the context of wider concern among general practitioners about the undermining of their freedom to prescribe and threats to their independent status. As we move from GP fundholding to the new system of primary care groups and, ultimately, primary care trusts, it becomes important to maintain the confidence of GPs that the system will protect the important role that they play.

The Government have implicitly recognised the concerns and apprehensions of GPs. The first sign of that was when the former Minister of State wrote the now famous letter to the chairman of the general practitioners committee, and there have been various attempts since—not least by the Minister himself a few weeks ago—to reassure GPs about what the transition to primary care trusts would mean for them.

GPs have never before come up against such an explicit act of rationing as the Secretary of State implemented with his decisions on Viagra. He may have chosen Viagra deliberately as the ground on which to hold the debate, because it is not a drug which has a life-saving effect. However, I should say immediately that it deals with a condition that can be distressing and costs the NHS a lot of money to treat in other ways. If I did not say that, the hon. Member for Oxford, West and Abingdon would jump up and say it for me.

The Secretary of State has moved the debate on rationing forward another notch. A couple of weeks ago, Doctor magazine ran the headline "Rationing: it's official". The Secretary of State may not have used the word "rationing", but everyone in the medical profession knows that a Rubicon has been crossed. For the first time, he has proposed making a drug or treatment available to some people only, on a basis other than need. That is a significant change. It may not touch many lives as long as it is limited to Viagra, but we, and most commentators, would expect that, as other innovative drugs become available, the methodology tested with Viagra will be more and more widely employed.

Mr. Bercow

I am confused about the stances of different members of the Government. How does my hon. Friend reconcile—if it is possible—the stated position of the Secretary of State in respect of Viagra and the oft quoted remark of the Minister for Tourism, Film and Broadcasting that there would be more and better sex under Labour?

Mr. Hammond


Mr. Denham

He is embarrassed.

Mr. Hammond

I am somewhat at a loss. I thought that my hon. Friend was going to challenge me to reconcile the actions of the Secretary of State with the remarks of the Minister for Public Health; I am afraid that he has thrown me a little. I must confess that I cannot reconcile the Secretary of State's actions with that rather unwise promise.

This is a matter of significance and not merely something for the tabloid press to titter at. Until September 1998, when the Government introduced their interim guidance on Viagra, treatment for erectile dysfunction was fully funded throughout the NHS. The Government may have been panicked by media stories exaggerating the likely demand for Viagra when it became available in the United States; the Secretary of State has said that the stories were material considerations in formulating the policy. It has subsequently appeared that such stories were exaggerated both here and in the United States.

The Government issued interim guidance advising general practitioners that they should not prescribe Viagra other than in exceptional circumstances—which were not properly defined. The High Court recently found that guidance to be illegal on the grounds that it contravenes both the doctor's professional duty to treat his patient and the requirements of European Union law. You see, Mr. Deputy Speaker, that I was not being facetious when I mentioned Brussels earlier.

There have been attempts to suggest that erectile dysfunction is different—that it is somehow less worthy than other conditions and so automatically of lower priority. However, the Secretary of State has admitted that it is a distressing condition, that it has serious medical consequences for sufferers and their partners and, interestingly, that 85 per cent. of cases result from underlying organic disease rather than from psychological problems.

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Mr. Fabricant

Does not my hon. Friend find it worrying that several Labour Members have said that the problem is a life style issue? Is not it far from being that?

Mr. Hammond

That is right, and some of the early scaremongering in the popular press focused on that. However, in fairness to the Secretary of State, he has made it clear that erectile dysfunction is a serious medical condition with serious consequences. Until recently, its treatment was fully funded under the national health service, but an arbitrary decision has been made to cease that funding for all patients. The result will be discrimination between groups of patients.

I suspect that the medical profession's outrage at the Secretary of State's decision to use schedule 11 to the 1992 regulations to limit the prescription of treatments for erectile dysfunction is what has caused the hon. Member for Oxford, West and Abingdon to take action. The British Medical Association said that the Secretary of State's action was arbitrary and that it would exclude people with genuine clinical need. It is important to recognise the significance of that: for the first time, official policy has acknowledged that people in genuine clinical need will be denied a treatment. That is a change in the ethos of the national health service, and deserves serious exploration.

New clauses 16 and 17 would make it impossible for the Secretary of State to resort to the mechanism that he has used previously to limit the availability of such a drug. If the Minister could bring himself to recognise the rationing that exists, he might say that the proposal from the hon. Member for Oxford, West and Abingdon is not the best way to deal with the matter. He might admit that a mechanism is needed to resolve the problem posed when a clinically effective but increasingly expensive drug is available for use but cannot be afforded within the national health service's resource constraints. Both I and my right hon. Friend the Member for Maidstone and The Weald has been saying that for the past year, but there cannot be a sensible debate until the Government acknowledge that rationing exists.

The real objection, which we share with many clinicians, is to the fact that the Government make rationing decisions on grounds of costs—and it is clear that the decision about the availability of Viagra is one such—but then try to justify them on pseudo-medical grounds that are quickly disowned by authoritative medical opinion. One of the important issues to flow from the recent decision is the question of discrimination in the NHS, a matter to which we shall come in a later debate. However, that discrimination will not be for reasons of gender, race, sexual orientation or age. People with a given condition will suffer discrimination based on how they came to have the condition.

That is equivalent to accident and emergency departments being asked to treat people with broken arms differently depending on whether the limb was broken in the course of work or leisure. Instinctively, we find that inappropriate, and new clauses 16 and 17 would make it impossible in the future.

The Government's approach to the treatment of male erectile dysfunction has shown the reality of the existence of rationing. There are, however, numerous examples of so-called post code rationing, when health authorities themselves have decided that they will or will not fund something. That is incompatible with the Government's expressed desire for universality in the NHS and their commitment that doctors should be free to treat patients according to clinical need. Given the resource constraints of the NHS, the Government must explain how they will square their desire to eliminate unjustifiable regional variations—a form of discrimination—with the lack of any significant additional resources to enable levelling up.

We would have been delighted if the Government had accompanied the introduction of the National Institute for Clinical Excellence with an announcement that it would provide a levelling-up process so that the best and most clinically effective practice would be made universally available. That would have been good news for many patients, but it would have raised questions of how the improvement would be paid for and how the wider debate over rationing would be dealt with.

Rationing is one of the most serious problems faced by the NHS, and the Government and Parliament, rather than institutions with powers and responsibilities devolved by the Secretary of State, must confront it. It is, and must remain, intrinsically a political issue. As new clause 4 implies, NICE must remain an advisory body, and Ministers must take the hard decisions.

Although new clause 4 usefully highlights the rationalisation potential of NICE and the Government's unwritten agenda of using it as a rationing device, it does not fully answer the problem of rationing. With the greatest respect to the hon. Member for Oxford, West and Abingdon, that is not compatible with new clause 14.

New clauses 16 and 17, by contrast, go to the heart of rationing, demanding a coherent response from the Government and something more than the mantra that rationing does not exist—a denial which does not move the debate a millimetre forward. Despite the Minister's consistent assurances that he is anxious to engage in constructive debate, the denial that rationing happens continues to prevent sensible debates that would benefit our constituents and the people of the UK. Instead, the Government have condemned themselves to continual stonewalling and have boxed themselves into an absurd position.

Mr. Bercow

I congratulate the hon. Member for Oxford, West and Abingdon (Dr. Harris) on the presentation of his argument. As my hon. Friend the hon. Member for Runnymede and Weybridge (Mr. Hammond) observed, there are flaws in his position and in that of his party. There is not a complete identity of view between the stance of the Liberal Democrats and that of the official Opposition. However, I respect the hon. Gentleman's medical experience, in spite of the occasional eccentricity of his political viewpoint. A good deal of the rationale behind his arguments will have commended itself to hon. Members and to people outside the House. In so far as it attempts to flush out the Government's position and to deny them the opportunity of continued obfuscation, it is welcome.

The contribution of my hon. Friend the Member for Runnymede and Weybridge was typically succinct. It was a remarkable performance for my hon. Friend to confine his remarks to one hour in the interests of the progress of the debate. His lucidity and eloquence are such that we should have been happy to listen to a continued exposition of the arguments for considerably longer. I can only assume that his natural concern that others should get in on the debate caused him to relent and resume his seat.

At the heart of this debate and essential to any meaningful discussion of new clause 4, and certainly to discussion of new clauses 14, 16 and 17, is the concept of rationing. We come back to that central issue time and again.

Without giving him any advanced warning, I asked my hon. Friend the Member for Runnymede and Weybridge what he considered to be the difference between rationing and the prioritisation of resources, or at least the allocation of resources, within a finite budget. My hon. Friend legitimately chose not to answer directly. He cannot be expected to surmise exactly what Ministers are thinking. Much of the time their thoughts are impenetrable and their expression of whatever thoughts they have, still more so. It is not reasonable for my hon. Friend to be expected to decipher exactly what Ministers—in their statements or lack of them—intend us to infer. However, the Minister has the opportunity to tell us tonight his understanding of the difference.

For the avoidance of doubt, the challenge is simple. What is the difference between rationing and the prioritisation of the allocation of resources within a finite budget in the national health service? I cannot conceive of a way in which the question and the challenge could be more simply put. I appeal to the hon. Gentleman to answer that question tonight.

Also, I ask the Minister to confirm that he is content absolutely with the reply on rationing offered by his right hon. Friend the Minister for Public Health on 15 December 1998 at Health Question Time, which is in Hansard, column 746—it is important to be precise about these matters. My right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) challenged the right hon. Lady as to whether there was rationing in the NHS. On that occasion, the Minister for Public Health looked like a rabbit caught in front of the headlights. I say that with no disrespect to the right hon. Lady. Her predicament was understandable. My right hon. Friend the Member for Maidstone and The Weald scares the living daylights out of me and she is my right hon. Friend, so it is perfectly imaginable that she would have caused terror in the heart and mind of the Minister for Public Health. Nevertheless, the right hon. Lady was obviously frit. She did not know what to say and thought that the shortest possible answer was probably the best escape route. She unwisely replied to the challenge of whether there was rationing in the NHS, "No." Moreover, she did not content herself with giving that answer once. Working on the assumption, I think, that having said it once it was best to stick to it and say it as many times as necessary, she repeated that answer on two further occasions in response to challenges from my right hon. Friend.

That begs the question that if there is not rationing in the NHS, what does the Minister believe is happening daily in our health service when, because of a lack of funds, the availability of treatment is limited and people are either denied it altogether because of the absence of funds or are told that they will have to wait longer than they otherwise would for that treatment, until further funds are available? If that is not rationing, the Minister must explain the intellectual distinction between rationing, which he disavows and claims is not occurring, and the denial of treatment because of an insufficiency of resources, which he cannot disavow and that he knows is occurring.

9.15 pm

I am sure that the Minister will be interested to hear the official definition. I have taken the trouble to find out that, on page 2482 of "The New Shorter Oxford English Dictionary"—copies of which are available for consultation in the Library during the drier parts of my speech—the verb "to ration" is defined as follows: to limit to a fixed allowance. The dictionary helpfully continues with another definition of the verb: to share out in fixed quantities. I am grateful to my hon. Friend the Member for Boston and Skegness (Sir R. Body) for suggesting that ratios are involved in this matter. To ration implies the existence of ratios. I hope that, at least on that point, there can be unanimity among the parties in the Chamber. Does the Minister accept those meanings of the word "ration", or is this new Labour Government so arrogant that they believe that they know the definition of words better than the distinguished sources who compiled the "New Shorter Oxford English Dictionary". We know not. Perhaps we shall be told. I hope that we shall hear about that before the conclusion of the debate.

Mr. Swayne

Is not the attitude and the new-speak of the Labour Government made manifest in the Bill by NICE, CHIMP and PRODIGY?

Mr. Bercow

I am grateful to my hon. Friend for making that point. In previous reflections on these matters, I have challenged the Government as to the profusion of those new bodies and the peculiarly inelegant titles that Ministers have conferred on them. Indeed, on one occasion I regarded it as a particular pleasure to reel off no fewer than six such bodies during a question to the former Minister of State at the Department of Health, the right hon. Member for Darlington (Mr. Milburn), now the Chief Secretary to the Treasury. I should like to trouble my hon. Friend for further details, but fear that I should try your patience, Mr. Deputy Speaker, if I did so tonight.

I should be happy to give way to the Minister at any point in my remarks, if he feels inclined to answer this central question: if there is no rationing, what is happening now? If there is no rationing, why does almost everyone in the United Kingdom—intelligent, unintelligent or of varying degrees of intelligence—believe that there is? Why is it that the Government are right about this question, even though they are in a tiny minority and are disbelieved, but that everyone else is wrong?

Sir Richard Body (Boston and Skegness)

Surely, the origin of rationing was to give to five people what was normally available for four—hence the word "ratio". In relation to the health service, in most of our constituencies, although five people are lining up for operations, there is time to carry out only four operations. Resources are available only for four operations, but five people want an operation.

Mr. Bercow

Rationing can take a variety of different forms. It is not in dispute that, because of the constraint of insufficient resources, if people cannot receive treatment, or cannot receive it until a certain period has elapsed, that constitutes a form of rationing. My hon. Friend is right to describe another form of rationing, but if people cannot have treatment now because there is no money to pay for it—or there is money to pay for treatment for only four people, rather than for five—manifestly, in ordinary, everyday parlance, we must conclude that that constitutes a rationing of the available treatment.

I hope that the Minister will agree with that. I look to him, with beads of sweat upon my brow, in eager anticipation of a straightforward answer to a straightforward challenge. He sits there, he cogitates, he looks down at his notes—

Mr. Brady

He sweats.

Mr. Bercow

I am not in a position to confirm the accuracy or otherwise of that observation. I simply ask the Minister to confirm that he accepts—so far, because I want to take him step by step through this issue—the validity of what I have said. Does he accept the definition of rationing that I have given?

Mr. Deputy Speaker (Mr. Michael Lord)

Order. I am sure the House will agree that we have now dealt adequately with the definition of rationing. Perhaps the hon. Gentleman will now move on.

Mr. Bercow

I am happy always to be guided by you, Mr. Deputy Speaker. Although I immediately accept your ruling that we have adequately debated the definition of rationing for tonight and that to avoid tedious repetition and defiance of the rules of order we cannot continue to have that debate on this occasion, there will be ample opportunities in the course of this Parliament for debate to be rejoined.

I say to the Minister of State in the friendliest spirit, he should not imagine that he can get away with avoiding an answer to my question tonight, because we shall be back. We shall be back before breakfast, before lunch, before tea, before dinner and before we consume the bedtime Ovaltine to harangue him on this issue. He knows that all of those present in the Chamber are assiduous attenders of parliamentary debate, as is my hon. Friend the Member for Boston and Skegness, and we shall pursue the issue at every opportunity.

New clause 4, moved by the hon. Member for Oxford, West and Abingdon, specifies that clinical efficacy or relative cost effectiveness should be the criterion on which treatments are prescribed. He suggests that overall cost or the possibility of additional cost to the NHS should, of itself, not be a criterion. However, I agree with my hon. Friend the Member for Runnymede and Weybridge that there have to be limits to total expenditure. We would argue an absurdity if we were to suggest that there could be limitless expenditure.

I have reflected carefully on this issue. I have reflected carefully on the unpopularity of rationing: it is almost the inadmissible sin of the operation of the NHS. It is to the great credit of my hon. Friend the Member for Runnymede and Weybridge and my right hon. Friend the Member for Maidstone and The Weald that they have tried to cut the Gordian knot of that debate. They acknowledge that there are, of course, limitations of resources within which judgments have to be made, but that ordinarily clinical judgments should be respected and once there is a budget known, Ministers should not retreat into arguments about resources when to do so negates the power and clinical freedom of, for example, in the field of multiple sclerosis, neurologists.

The hon. Member for Oxford, West and Abingdon referred to the debate about beta interferon. He and I are currently engaged in a correspondence on this important matter, and I know that hon. Members on both sides of the House with genuine concern about multiple sclerosis sufferers have raised with Ministers the question of the funding of beta interferon and its continuing provision.

My concern is that the Government are not being up front and saying that resources are of the essence and that it is a lack of resources that is causing them to think about ways in which to restrict the availability of the drug. Even though to make that admission would give rise to some hostility and considerable debate, the admission would be honest. I would go so far as to wager—and I believe that my right hon. Friend the Member for Maidstone and The Weald would concur with me on this—that the Government would win respect for candour and openness. In respect of beta interferon, it is their pretence that factors other than limitations on resources are uppermost in their minds that leads sufferers from that chronic neurological disease to distrust them.

I would go so far as to say that there are some who despise the attitude of the Government because it is not frank, candid or open. The Government treat the people of this country and the sufferers of the disease who know about it and feel it in a way that none of us can emulate as stupid: they simply consider that they cannot grasp the issue. That is unfair.

Let us take the particular case of the provision of beta interferon to sufferers of multiple sclerosis. The House will be aware that there are four forms of multiple sclerosis, of which the two most commonly debated in the Chamber are the relapsing-remitting and the secondary progressive forms of the disease. There is a limited number of manufacturers of the drug beta interferon, of which perhaps the most notable is Schering Health Care plc. It currently supplies beta interferon to those who suffer from the relapsing-remitting form of the disease, but it has recently been granted a licence—I believe I am correct in saying that it is currently the only manufacturer to have been granted such a licence—to supply that version of the product that treats the secondary progressive form of the disease.

Ministers have acknowledged that there has been some testing of the efficacy of the drug, but, either deliberately or inadvertently, they have sought to convey an impression of ambiguity. The Minister will acknowledge that he does not have medical expertise—if I am mistaken, he can correct me. I am not trying to score a point against the hon. Gentleman because I do not have medical expertise either. However, consultant neurologists have such expertise, as do those who undertake the trials of this drug, and of others. I hope that the Minister will accept—I have made this point before—that there have been so far no fewer than four independent and separate trials of the clinical effectiveness of beta interferon. I shall come to the question of cost in due course.

I suggest that those separate, independent trials have proved conclusive. They have shown—the Minister acknowledged this recently in reply to an Adjournment debate introduced by me on 14 May this year—that treatment for the relapsing-remitting form of multiple sclerosis with beta interferon can reduce the rate of relapse by up to 30 per cent. as well as the severity of the relapses. Treatment with the drug over a period of three years can reduce the speed of deterioration in the condition by up to one year.

Mr. Fabricant

I am sure that my hon. Friend would not want the House to think that it is only beta interferon that the Government claim has clinical deficiencies. Is my hon. Friend aware that the Government also claim that Taxol, an excellent drug used in the treatment of certain cancers and in the reduction of certain malignant tumours, should be restricted not because of its cost but because of its efficacy? However, clinical oncologists argue that Taxol is an effective means of treating certain forms of cancer.

Mr. Bercow

I am grateful to my hon. Friend. I was not aware of that point. My hon. Friend has now enlightened me and, in so doing, he underlines the fact testified to by my hon. Friend the Member for Runnymede and Weybridge that this problem applies across the board.

If there were just one disease to which the Government's rather curious attitude applied, our argument might not be conclusive. It is a fact that for many diseases there is a drug that clinicians believe will be effective but over which Ministers hesitate, and that is a serious problem. Ministers claim that their decisions are based on the fact that the efficacy of the drug is unproven. We suspect, and patients are convinced, that a reluctance to fund is at the root of the Government's constant prevarication.

9.30 pm
Mr. Fabricant

Would my hon. Friend care to speculate that the Government would earn respect not only among parliamentarians but among those in the medical profession if they came clean and said, "Yes, there is rationing. That is not surprising. There ought to be rationing because, whether we like it or not, there are limited resources. Given that there is rationing, let us approach the problem logistically, logically and systematically and try to find a solution"? The fact that they deny that rationing takes place and that they try to deceive the electorate and patients means that they earn the disrespect of this House and those who know that the NHS is not safe in Labour's hands.

Mr. Bercow

I agree entirely with my hon. Friend. That lack of candour applies across the board. I appeal to the Minister to abandon his nescience and to admit that the Government are trying to present the issue in a way that clouds the facts instead of clarifying them. [Interruption.] I am sorry if the Minister is uncertain about the word "nescience". The late parliamentarian of 37 years' standing, the right hon. Member for Down, South—and, before that, the Member for Wolverhampton, South-West—once said to the Member for Harrow, East, who was so unwise as to claim that Mr. Powell had used a word that did not exist, that if, during the drier parts of his speech, the hon. Gentleman would like to avail himself of a copy of the Oxford English Dictionary in the Members' Library, he might look up the word "transfretation", and he would find it all right. I say to the Minister that if he looks up "nescience" in the dictionary, he will certainly find it. I shall not help him because he should learn by discovery and the effort required to consult the dictionary. He will benefit from that.

The Minister acknowledges that there is a patchwork of provision of beta interferon throughout the country. That point is common ground between us. In the debate on 14 May, he reiterated what he had said at health questions some 10 days earlier. He said that there are great disparities between what health authorities in different parts of the country provide. We agree on that.

Dr. Dennis Briley, consultant neurologist at Stoke Mandeville hospital, which serves many thousands of my constituents, has described that situation as treatment by postcode. He disapproves of that, I disapprove of it and the Opposition disapprove of it. The Minister of State implies that he disapproves of it and contends that the Government's proposals for the National Institute for Clinical Excellence will lead to increasing provision and greater equality of provision throughout the country. I am not sure that their proposals will deliver anything of the sort because I subscribe to the view of my hon. Friend the Member for Runnymede and Weybridge that NICE is being set up in a way that will give the Government an excuse to ration while avoiding the blame for its effects. They intend NICE to carry the can.

I am concerned, and my concern is reinforced because the Minister of State has on several occasions given a bogus reason for the disparities in treatment. I will not accuse him of bad faith.

By the standards of a Labour Minister, and at the risk of causing grave embarrassment and damage to his future, I shall go so far as to say that I have always thought the hon. Gentleman the closest approximation to a normal human being on the Government Benches whom I have encountered since 1 May 1997. I do not think that he is advancing such a reason deliberately. I think that he genuinely believes that difference of opinion among consultant neurologists is the reason for the disparity in provision of beta interferon across the country.

On 4 May, in answer to a question from me, the Minister suggested that differences of opinion among consultant neurologists explained the variations in the amount of treatment provided by different health authorities.

Mr. Denham

I am grateful for the hon. Gentleman giving way on this very important point. I believe that the record will show that I indicated that it was one of the factors that influenced the differences in prescribing. To my recollection, I certainly did not indicate that it was the only explanation of differences in prescribing policy in different parts of the country.

Mr. Bercow

I am grateful for that assurance. The Minister is edging his way towards a more satisfactory position. He will forgive me for saying so, but when he made that point before, he did so with some emphasis. The impression which many of us gained, including my constituents who suffer from the relapsing, remitting form of multiple sclerosis, was that he was taking refuge behind clinical differences of opinion. I do not say that unkindly to the Minister, but my constituents, Caroline Cripps, who is 28 years old and from Westcott, and 31-year-old Mr. Marc Smith from Buckingham, both believed that the Minister was trying to use that point as an excuse for the variations in provision. If he is assuring me now that it is but one of the factors and that it is by no means the major factor, I am very grateful. The debate has already advanced if he is prepared to make that admission.

I should like to take the debate a stage further. If the Minister is to advance difference of opinion among consultant neurologists as an explanation—not necessarily a justification—for the disparities in treatment, he is duty bound to consider the position when no such disagreement exists, but, rather unanimity of view.

I cannot expect the Minister, much as I would like him to do so, to recall word for word the exchanges between us during an Adjournment debate on 14 May. He may recall that I reminded him of the position in the south-west of England, where all 18 consultant neurologists had decided that the provision of beta interferon for particular multiple sclerosis sufferers would be clinically effective. Despite that unanimity of view, such treatment was for long periods not made available. Therefore, it is simply not good enough for the Minister to talk about differences of opinion as an explanation for the provision of treatment.

When there is unanimity of view among the people whom we all accept are the experts, and still the funding is not made available, we must conclude that other factors are at work. Either a political decision has been made or financial factors explain the unwillingness to fund.

Mr. Swayne

Is not the very purpose of new clause 4 to ensure that the national institute takes a considered view on the basis of positive science as to the efficacy of a treatment such as beta interferon? The danger, as evidenced by the statements of the chairman of the national institute, is that NICE may well decide that such treatment should not be available simply on the ground of cost.

Mr. Bercow

That possibility does exist. I am sure that my hon. Friend will agree that it emphasises the importance of having the maximum discussion in public of what the priorities should be, the criteria upon which judgments are made, and the mechanisms to review those judgments.

There is no shame, even for a commission, in making an honest mistake. There is only shame in failing to acknowledge the possibility of having done so. It is precisely because we can get it wrong from time to time, and clinicians can make mistakes, that there must be review mechanisms. The magnifying glass of publicity, which the hon. Member for Oxford, West and Abingdon mentioned in different terms, is important in that process. The more private discussion and confidentiality there is, the less confidence there will be. The more public discussion and openness there is, the greater confidence there will be in the propriety of the decision-making process.

Mr. Brady

Does my hon. Friend agree that it is a matter of concern that, in the pursuit of cost saving through the activities of the National Institute for Clinical Excellence, there may be a reduction in communities' ability to have an input into the priorities for health care, and that, in pursuing uniformity, NICE may be the enemy of good provision because, at the moment, some communities may set different priorities from others?

Mr. Bercow

There is a respectable argument for the view that my hon. Friend is expressing. I think that, essentially, his thesis is that, if there is competition and local flexibility, the best will tend to drive out the worst, or, at least, that the better will tend to drive out the worse. Is that what he is suggesting?

Mr. Brady

That would tend to be the case, but, more fundamentally, it is appropriate for local communities to have some input into the decision-making process, and for a health authority to be able to set priorities different from those of a neighbouring health authority if the population that it serves wishes.

Mr. Bercow

There is an argument for that. However, it is important that, if such arrangements are to be instituted, the forum in which such decisions are taken does not become dominated by the activist who is willing to attend most regularly. There must be a check on the idea that, simply by packing a particular meeting, for example, one view can hold sway, even if the validity of that view turns out, on later inspection, to be outweighed by that of another. I am not averse to what my hon. Friend is suggesting, but I think that we could get into difficulty unless we very carefully consider the constraints within which such local discretion is operated.

Mr. Swayne

Will my hon. Friend bring his precise use of language and analysis to bear on the problem in the way that I suggest it is defined now? The easy bit is to decide, on the basis of positive science, whether a treatment is clinically effective. The question whether it can be afforded is a normative question, requiring a normative judgment, and our difficulty is finding the forum in which that normative judgment can be made. In putting together the Bill, the Government have run those two functions together into NICE, and it is entirely inappropriate for that one body to try to fulfil both the positive and the normative role.

Mr. Bercow

My hon. Friend makes a powerful point. There is no sense in which we can honestly say that a specific treatment cannot be afforded. In fact, although we might not realise it, it constitutes bad faith so to argue. In practice, the Government do not go bankrupt any more than local authorities, the creations of statute, do, so it follows that, in the final analysis, the judgment is about whether we want to afford a specific treatment or whether we prefer resources to be directed to the provision of an alternative treatment for the same condition or for an entirely different one. Therefore, I accept the thrust of what my hon. Friend is saying.

9.45 pm

I have spoken about a situation in which there is unanimity of clinical judgment that is ignored or, worse, scorned by administrators or politicians. However, the argument can be taken a stage further. I have made the point to the Minister before. I do not recall that he had an effective response to it, which rather suggests to me that he did not. If he had, I think that I would remember it. I do not, so I do not think that he possessed such an answer.

What about a situation in which there is no unanimity of view, but individual clinicians are advising what they think is right for their particular patients? In the debate on 14 May, in which I raised the problems of multiple sclerosis sufferers in Buckinghamshire, the Minister said quite reasonably to me and to the House that he recalled that the four neurologists in Buckinghamshire who were consulted about the efficacy of beta interferon disagreed. He said that given the difference of opinion among the four consultants, it was not surprising that a decision to fund on a significant scale by the Buckinghamshire health authority had not yet been made.

I see the hon. Gentleman's point, but I hope that he will not use the fact of differences of opinion among respected consultant neurologists as a justification for the denial of funding. In short, just because one neurologist does not think that the treatment is generally effective, or concludes from his analysis that it would not be efficacious for his particular patient, that does not mean that it should be denied to others.

If another neurologist, readily accepting the drug's inappropriateness for other patients, said, "Ah, yes, I accept that, Minister, but beta interferon will be efficacious for my patient", does the hon. Gentleman accept that that judgment should be respected? Does he agree with the proposition that where the neurologist judges that the provision of beta interferon will be clinically effective, it should ordinarily be prescribed? The hon. Gentleman does not answer. He is mute. The position is fixed. The head does not move. There is no flicker of emotion or indication of stance from the hon. Gentleman. I shall wait patiently for his winding-up speech.

I have on previous occasions worried that at a late hour, Ministers might inadvertently neglect to respond to the points that my hon. Friends have made.

Mr. Eric Forth (Bromley and Chislehurst)

No. Surely not.

Mr. Bercow

My right hon. Friend cavils at the suggestion that a Minister might inadvertently fail to respond to a point. I have the highest regard and affection for my right hon. Friend. Not every hon. Member or every current Minister can match his high standards. Just because he has instant recall, never forgets a point that is put to him, and is unfailingly effective and courteous in his response to any challenge, does not mean that he can demand or expect the same high standards of members of the new Government. My right hon. Friend had a number of years experience—[Interruption.]

My right hon. and learned Friend the Member for Sleaford and North Hykeham (Mr. Hogg) says from a sedentary position that my right hon. Friend the Member for Bromley and Chislehurst (Mr. Forth) may expect such high standards. He might expect them, as my right hon. and learned Friend points out, but he assuredly will not get them. It is possible that Ministers will neglect to respond to particular points.

I challenge the Minister, when he replies to the debate, to give me an answer to this question: does he agree that where a consultant neurologist believes that the provision of a treatment is clinically appropriate, it should ordinarily be prescribed? If he does agree, the hon. Gentleman will have made an important admission. The fact of differences of opinion does not mean that the judgment of an individual consultant neurologist in respect of a particular patient at a given time, possibly for a limited period, should not be respected. Rather, it tends to imply that that judgment should be respected and translated into practice.

I challenged the Minister on 14 May to make it clear beyond peradventure that the period between now and the issue of new guidance by NICE should on no account be used by any health authority to justify the reduction, still less the withdrawal, of funding of beta interferon. That goes to the heart of the issues raised by the hon. Member for Oxford, West and Abingdon.

I believe that the Minister gave a categorical assurance on that point, saying that until the new guidance comes forward the November 1995 guidance in the Government's circular should be honoured. I was grateful for that. So we assume that, for the time being, on the basis of a judgment about clinical effectiveness, neurologists should be free to prescribe and the drug should be available.

We now come to the question of the National Institute for Clinical Excellence and how it will operate. I should like to think that the institute will be absolutely independent, free to make judgments about clinical appropriateness and not subject to public or private pressure of any sort from Ministers or officials in the Department of Health.

It was because I wished to establish the status of NICE and the freedom that it would have to make recommendations and to issue guidance that I challenged the Minister on this point on 14 May. I asked whether NICE would be genuinely independent. I was not encouraged by the hon. Gentleman's reply. He told me that NICE would operate on the basis of a framework agreement with the Department.

I am a new Member and, on the whole, I am inclined to give people the benefit of the doubt. I have not yet been afflicted by the world-weary cynicism that characterises my right hon. Friend the Member for Bromley and Chislehurst. However, I smelt a rat. I detected a desire by Ministers to ensure that the institute would not be fully independent. I did not like the talk of a framework agreement. It seemed to me that the Department of Health would be saying to the institute, "You will volunteer to agree with the Government", with the proverbial gun being held to its head.

Mr. Forth

Will my hon. Friend give way?

Mr. Bercow

I shall readily give way to my right hon. Friend, who is wearing a particularly fetching tie.

Mr. Forth

If a word from the very old to the very new would be helpful, may I point out to my hon. Friend—he seems uncharacteristically to have missed this opportunity—that any Minister must have regard to the financial aspects of his policies? Therefore, it must be inevitable that real financial constraints must be placed on the policy that we are discussing from the outset. My hon. Friend seems to be suggesting that "framework" is being used to disguise real financial constraints, which will inevitably operate on the apparent clinical neutrality of the new organisation.

Mr. Bercow

This evening, there have been competing attractions. There has been the opportunity to enjoy a congenial dinner. There has been the option, which I admit is much the lesser of the two, of listening to my oration. My right hon. Friend was absent during the earlier part of my speech in which I said that it would be welcome if the Government would be candid, if they would say, "Yes, financial factors are at stake. Monetary judgments have to be made. There is not enough money and we cannot afford everything. We shall restrict the supply of some treatments because of cost limitations."

I pay tribute to the candour of my right hon. Friend the Member for Maidstone and The Weald and my hon. Friend the Member for Runnymede and Weybridge. They have acknowledged the existence of rationing and they are not afraid of it. They are principled conviction politicians. They are not scurrying around and retreating into the dark, afraid to admit the inevitable. The great British public are not stupid. They know that there is not a bottomless pit. They know also that there is a limit to what the public purse can afford. They know that judgments about what can be managed have to be made. It is a case of demand always exceeding supply. With a service that is free at the point of consumption, that will always be the position.

So, my right hon. Friend the Member for Bromley and Chislehurst is right: if Ministers would only say that there will be financial restrictions on what NICE can do, we would know that they were being honest. They could say, "The chairman of the institute takes one view. We, who have to apply the cash limits throughout the public sector, take another. We will insist that our view holds sway and the chairman of NICE will be shown the door if he does not like it." However, they are simply not prepared to do that.

Ministers want to give the impression that an independent body will make the judgments. If that independent body—knowing of the framework agreement and of the limitation on resources—declines to provide a particular treatment or reduces the quantity of that treatment in a given year, Ministers will retreat behind the fiction that that is an independent judgment decided by the national institute. Why do not they say, "There is a lack of funds. We politicians have to balance the books and we are restricting the freedom of NICE to do as it wishes"? As my right hon. Friend the Member for Bromley and Chislehurst said, there is nothing dishonourable in imposing some constraints on the freedom of NICE, but there is something dishonourable about denying the intention to do so.

Mr. Forth

Perhaps I can help my hon. Friend. Is it not at least possible that, in framing the terms of reference for that body, the Government could arrive at some compromise in which they would charge it with investigating clinical excellence while having regard to the availability of resources? Perhaps they could use another term of art, something with which we are all too familiar. Does he accept that that would at least be a way forward for the Government, even though it would effectively reduce the independence of the body that is being set up?

Mr. Bercow

That would reduce the independence of the body that is being set up and it would of course entail an acknowledgement by the Government that they hold the purse strings.

The absurdity of the present position is that, although we all know that Governments fund the NHS, Ministers would like to give the impression that responsibility for funding will in future lie with NICE. We know that to be a monstrous fiction; it is such an absurd proposition that, as the late and great parliamentarian Enoch Powell would have said, only an extraordinarily clever person could fail to see the point.

Mr. Brady

I fear that, for once, my hon. Friend is missing the point. The Government do not want NICE to be seen as controlling funding. They want to be seen as providing funding, but they want NICE to be seen as restricting the treatments available.

Mr. Bercow

That would be a tortuous position for the Government to adopt. I do not rule out the possibility that that is what lurks in the inner recesses of what passes for the mind of a Minister in the new Labour Administration, but that does not make it a satisfactory position. Such a position is wholly unacceptable—it is dishonourable, it lacks candour and it flatters to deceive.

The hon. Member for Oxford, West and Abingdon, in addition to a number of other important points that he flagged up in this brief debate, raised the issue of the appraisal of treatments. [Interruption.] We are delighted at this stage of our proceedings to be joined by the right hon. Member for Holborn and St. Pancras (Mr. Dobson)—the Secretary of State for Health himself. As Lord Archer of Weston-super-Mare, when Member of Parliament for Louth, said to Prime Minister Harold Wilson, "Good of him to drop in."

We are delighted to see the right hon. Gentleman, but it is a pity that he has not attended the debate. I would like to say that it has been left in good hands, but I fear that that would not be correct. The Minister is a genial fellow, but he is finding it all a bit too much to take. We do not know whether a response from his lips will be forthcoming, but I hope that he will confirm in the short time that remains that the appraisal of the efficacy of a treatment will consider not only clinical costs, which have been referred to, but the wider costs entailed such as loss of tax revenues because of unemployment and help with adaptations to the home—for sufferers from extreme conditions such as multiple sclerosis, for example. All those factors must be considered in the equation and I would welcome an unequivocal assurance from the Minister that they will always be taken into account.

This is a debate of the utmost importance. Before the Bill creeps on to the statute book, we need to know what Ministers really intend for NICE.

It being Ten o'clock, the debate stood adjourned.

Debate to be resumed tomorrow.