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§ Dr. Evan Harris (Oxford, West and Abingdon)
I am particularly pleased to be able to introduce this debate, which I understand will be the last one-and-a-half-hour Back-Bench debate to take place in the Chamber before we begin holding debates in Westminster Hall in the new Session. There can be no more important issue for many Back Benchers than the workings of the National Institute for Clinical Excellence, and the implications of its workings for rationing in the health service.
I am pleased to see that the Minister of State, Department of Health, the hon. Member for Southampton, Itchen (Mr. Denham), is to respond. When I was a Liberal Democrat health spokesman, I spent many long hours discussing this and other issues with him, during the Committee and Report stages of the Health Bill, and in a Statutory Instrument Committee considering the orders setting up NICE. I am pleased that we shall be able to continue those discussions today.
Let me declare some interests. I am a fellow-elect of the Industry and Parliament Trust, which was established to give parliamentarians such as myself, who have no private-sector experience, experience of industry. My fellowship is with Glaxo Wellcome, with which—among other pharmaceutical companies—I have discussed the debate. I also went on a three-day study trip to an oncological conference in the United States, along with NHS clinicians and purchasers. The travel, which took place earlier this year, was funded by the pharmaceutical company Rhone-Poulenc Rorer.
Part of the subject of this debate is rationing, a word that the Government do not like using. Perhaps if I now define what I understand by it, we can talk in approximately the same terms, even if the Government do not accept my definition. Rationing of health care is caused by a mismatch between demand, or need, and the provision of services for which resources allow—and, indeed, the efficiency with which those services can be provided. When we talk of rationing in this context, we do not mean the system that operated during the war. We do not mean that everyone in the country receives a set ration of treatment that, once exhausted, cannot be used any more.
The Government have attempted to define away the problem by claiming that the Liberal Democrats—and, following a Damascene conversion in this Parliament, the Conservatives—are referring to rationing in that other sense, and that therefore it does not exist. When we speak of rationing, we mean that sometimes some treatments are not available when they would benefit patients or populations, because there simply are not the resources to provide all those treatments on the NHS.
§ Dr. Harris
I will in a moment.
Liberal Democrats believe that this kind of rationing is inevitable. To say that there cannot be rationing in any public-health sector is like saying that the earth is flat. There will always be pressures on the health service, and decisions will have to be made. Our point is that the existence of rationing should be recognised by the 1067 population and admitted by the Government, so that the population can debate whether it wants to vote for more resources to reduce—not obliterate—the rationing that now exists. Clearly, more resources mean that more treatments would be affordable.
The hon. Member for Broxtowe (Dr. Palmer) now does not wish to intervene. Presumably I have answered his question.
The Government have a responsibility to conduct a public debate about rationing. Liberal Democrats would like nothing more than a discussion—at election times generally, but in particular at the next election, as no such discussion was held at the last election—about whether we should be putting significantly more money into the health service. Should we put in more—yea, if I may speak in biblical terms, even more than the Government say that they are putting in and will put in, in real terms—so that we can reduce the amount of rationing to the levels found in countries that spend a significantly higher proportion of their gross domestic product on health services generally, and the public-health sector in particular?
§ Dr. Stephen Ladyman (South Thanet)
May I tease the hon. Gentleman slightly? When I checked the Liberal Democrat manifesto yesterday, I found that it identified not one penny of extra funds for medicines. There was a substantial list of items of additional spending on the health service, fully costed—to be paid for by the closing of a loophole involving national insurance contributions—but there was not a penny extra for drugs. As the Liberal Democrats also proposed to freeze prescription charges, there might have been even less money for drugs had they won the election.
§ Dr. Harris
There are two fallacies in that argument. The first is that the Liberal Democrats proposed to put in less money than Labour. We were clear about the fact that those were specific commitments over and above the Conservatives' spending plans, which also included an uplifting for inflation that was not included in the Government's calculations.
The hon. Gentleman's primary error, however, is that it is not, currently, for politicians to say, "This money is ring fenced for drugs." I shall be interested to see whether the Minister backs up his hon. Friend the Member for South Thanet (Dr. Ladyman) by suggesting that the money from prescription charges is in a ring-fenced budget for spending on drugs, or that the Government allocate any funds specifically for that purpose. I think that we and the Government agree that health service spending in that sense should take place in a primary and secondary care setting, and that a clinical judgment should be made about whether to spend money on drugs, bed stay, operative intervention, aids or counselling. I hope that the hon. Gentleman's comments do not mean that he is in a drug-obsessed frame of mind.
As I have said, we need to hold a public debate on whether to spend more on the health service—the NHS, rather than private care. We need an honest debate about whether there should be tax cuts or more public spending. If the Conservative party—or the other Conservative party, in this context, the Labour party—wins that fair 1068 debate and wins an election on that basis, our position will clearly be more difficult to sustain, although we will still hold and express our present views. The point is that such a debate never took place at the last election. The Government said, "We will save the NHS, there is and will be no rationing, and well-off people can have tax cuts."
In yesterday's pre-Budget statement, a huge opportunity was missed to invest even more in the health service at a time when in my county, Oxfordshire, community hospitals are threatened with closure. We have been waiting for a decision from the Government for more than a year. Those hospitals are closing not because the beds are in the wrong place, or because no one needs them; they are closing because the community trust is short of £1.5 million. The closure proposal is a financial proposal, and, three years into their regime, the Government must take responsibility either by saying that they were wrong, or by saying that there will be health service cuts because they do not spend enough.
The Government set up NICE following a discussion paper called "Faster Access to Modern Treatment". That follows the trend of giving Government papers titles whose contents belie them: another example is an education paper called "Fair Funding", which has prompted more humour than any other such title that I have encountered. In their paper, the Government said that the big geographical variations in the provision of treatments or drugs were unacceptable. We agree wholeheartedly; indeed, we would go further, and point out that many such unacceptable variations—postcode prescribing—are a function of the fact that there is rationing in the health service due to underfunding.
Some health authorities may well fund proper treatment for multiple sclerosis sufferers with beta interferon, but not fund medium-secure mental health beds. Other authorities may choose to spend what little they have on the provision of better mental health beds, but cut their drug budget for neurological disease. There is a patchwork of such inequalities throughout the country. The Government must recognise that the underlying cause is pressure on the health service budget. They do not have to take the blame, but they should at least recognise the fact.
NICE was set up to deal with that problem, but it cannot do so unless it deals with the underlying problem of shortage of resources in the health service and the unacceptable rationing of useful treatments. It was set up first to examine the clinical effectiveness of drugs, and then to examine their cost effectiveness. There was widespread support, including from me. We believed that, if that was as far as NICE went, giving its advice to the Government based on those two criteria, with certain concerns, that would be good. It would help to even out variations, and encourage clinicians to use new treatments more quickly and, just as important, to stop using old treatments earlier that were reckoned to be no good.
We had concerns on a number of things. Would NICE look just at new drugs, and not at old drugs? There were concerns that that would affect investment in research and patients' access to modern treatments. There has to be a balance between looking at old treatments, finding that those are not effective and releasing resources for their use, and looking at new treatments that the Government are interested in.
1069 Would clinical effectiveness work just repeat what the licensing authorities had done based on phase-three clinical trials, which show whether a treatment works, or would some new measure of effectiveness—which the Government would not specify—have to be met? I fear that some of those concerns have proved to be correct.
The other concerns centred around cost-effectiveness. What measurements would NICE, at the Government's behest, use to measure cost-effectiveness? Clearly, relative cost-effectiveness of a new treatment as against an existing treatment for the same problem is reasonable. There is no way that the health service should pay for treatment A if it is more expensive, but no more effective than existing treatment B, so there is a clear role for NICE to issue some clear guidelines about relative cost-effectiveness.
Overall cost-effectiveness is much more difficult to get to grips with. It is harder to measure cost-effectiveness of treatments that are not curative. There is much debate about whether quality-adjusted life years are a fair way of measuring that, or in fact discriminate against the elderly, something that the Government should be concerned about, given this week's news about the prevalence of age discrimination in the NHS. There is concern about whether there is enough data in this country, or even in other countries where health economics are more advanced, to look at cost-effectiveness in very clear and explicit terms.
Another concern is that the Government would ask for data from the pharmaceutical industry on new drugs under new rules since the setting up of NICE, where the trials for licensing purposes of the drug had been started years ago and it was far too late for a pharmaceutical company to redesign its international trials to meet the demands.
Those were genuine concerns, which I hope the Minister accepts, but if they could be dealt with and were not too severe, people would say that the gain of ironing out unacceptable variation would be worth it. However, time and again, we have pressed the Government to say whether affordability would be a criterion on which NICE would judge matters. One would not imagine it from looking at the order setting up NICE, which was laid before Parliament in February 1999 and which we debated in Standing Committee following a call for such a debate by the Opposition. Article 3 says in terms of the functions of the institute:Subject to and in accordance with such directions as the Secretary of State may give (b), the Institute shall perform such functions in connection with the promotion of clinical excellence in the health service as the Secretary of State may direct.There is no way I understand clinical excellence to relate to issues—important issues—of affordability. They are two different things. I think that it is argued uniformly in the NHS that affordability is a matter for the Government to decide. The Government set the budget. They make announcements saying that they are not spending this money on the health service, but spending it on something else, or that they are spending so much on the health service, even though it may be counted several times, as the Government tend to do.
§ Dr. Palmer
Before my intervention, I should mention that I advise Novartis; it could conceivably be relevant.
The hon. Gentleman appears to say that it is reasonable for NICE to compare the cost-effectiveness of one treatment against another to guide local health authorities, 1070 primary care groups and so on, but that NICE should not look at the cost-effectiveness of treatments if there is no comparable treatment. I do not quite see why he makes that prime distinction, especially as he admits that what he calls rationing—what I would call prioritisation—is inevitable in any health care system. I would have thought that primary care trusts and others would welcome guidance on that point.
§ Dr. Harris
There are two points there. The hon. Gentleman talks about prioritisation. That is a bit of a spin statement in itself because prioritisation implies "posteriorisation." No one ever talks of the procedures that we are going to posteriorise—that we are not going to fund when we fund specific treatments that we wish to prioritise. I think that he will accept that it is important that we recognise that the patients at the sharp end who get the posteriorised non-treatment do not see the prioritisation—they just see that the treatment is not available to them.
The point I am making is that it is difficult to look at cost-effectiveness when there is no existing treatment. For example, beta interferon is the only treatment that interferes with the disease process in multiple sclerosis and can, for certain patients, give benefits, so comparing that with something else is difficult. The cost of that is £10,000 per year, which is deemed to be too much by health authorities, yet the annual cost of dialysing a 30-year-old to keep that person alive is £30,000. On that basis, the hon. Gentleman is suggesting that we should divert all funds from dialysis, which is perhaps the most expensive treatment in terms of life years saved, to things that currently are not funded per life year saved and where the amount is lower; for example, Riluzole for motor neurone disease, or beta interferon for multiple sclerosis.
Some of the new taxane drugs for chemotherapy do not cure. The argument is about their indications in metastatic cancer, which is effectively incurable, and whether they should be first line. There is strong evidence—it is used overseas for the purpose—that first-line treatment with taxane can add years to life at a cost of about £10,000 per year. Again, that is not funded by some health authorities. The question is: if we ask health authorities all to fund it within the same cash envelope, what will they not fund? That choice has to be recognised.
If the things that the health authorities then do not fund are not acceptable to the electorate, the electorate might support a party that calls for higher funding, the things that are not funded being less unacceptable. If they think that, in the round, it is acceptable—that degree of rationing is the level that they want and they want their tax cuts—then we can have that argument. That is all that I call for.
That is not an issue on which the Government should hide behind NICE. They should start a debate on it. We have said on at least 15 occasions in debate that we will not oppose the Government if we have a public conference to debate those issues outside the party political arena, so that we can have a proper debate.
In July 1998, the Minister's predecessor, who is now the Secretary of State for Health, answered an oral question from me on the issue. He said in response to a supplementary question from the hon. Member for Walthamstow (Mr. Gerrard):we get lots of advice from economists and others who say that we need to bear down on the NHS drugs bill, as though drugs were a bad thing, which is a naive assumption. If drugs mean easier, better 1071 and quicker treatment for the patient instead of going to hospital, that is a good thing and if it means growth in the NHS drugs bill, we should welcome it … we want a more rigorous assessment of what is cost effective and clinically effective, particularly when drugs come on to the market."—[Official Report, 28 July 1998; Vol. 317, c. 158.]Those were all welcome comments, but there was no mention of affordability, particularly in all the talk about the cost of new drugs and the drugs bill—no mention that affordability would be an issue.
When Professor Michael Rawlins took on the job, he was clearly under the impression that he would not be asked to talk about the affordability of treatments. In answer to a question in the Select Committee on Health from the hon. Member for Preston (Audrey Wise), he said:Yes, but I am also conscious that NICE does not have a responsibility for the total allocation of financial resources with the National Health Service. NICE ultimately has to temper its advice in relationship to the people's elected representatives in Parliament and in Government.It is clear that his view was that affordability is an issue for elected politicians. He says:Absolutely. I have no doubt at all that where NICE believes that a new technology or new guideline, even if it is expensive, has a real health gain it will be an advocate with the Department. like there has not been before, it will be robust, it will be given by clinicians and if necessary we will, as it were, bully the Department into seeing things our way.It will be quite clear that we regard treatment: with Taxol"—I think that that was being used as a hypothetical example—in ovarian cancer as clinically effective and the most clinically effective agent around.
Immediately, the hon. Member for Halifax (Mrs. Mahon) asked Professor Sir Michael Rawlins to confirm that that was the separation in roles that he envisaged between the national institute and Ministers, and he replied "exactly". Liberal Democrat Members would like that separation to be maintained.
In Standing Committee, and during consideration of the Health Act 1999, the Minister made it quite clear that the national institute should not use an affordability criterion. On 6 August 1999, the Government issued a press release describing NICE's national programme, but made no mention of an affordability criterion. In the first note for editors, it states:The National Institute for Clinical Excellence (NICE) will give clinical guidance to the NHS in England and Wales including guidance on the clinical and cost effectiveness of new and existing clinical interventions. Proposals for NICE were first set out in the White Paper The New NHS: Modern and Dependable and further elaborated in a consultation paper A First Class service".In pages and pages, that press release mentions various treatments and the unacceptability of postcode prescribing, but it makes not one mention of affordability. That was peculiar.
On 6 August—the day that all that spin on NICE's programme was issued, and in the depths of the recess—an order was introduced, to insert in article 3, from which I quoted a moment ago, after the words "promotion of clinical excellence" the wordsand of the effective use of available resources".That was a huge change. Liberal Democrat Members argue not only against that change in policy, but against the surreptitious way in which it was made. We also asked the Minister to appear before a Standing Committee to justify the change and the way in which it was made.
1072 Subsequently, there has been some progress, with the national institute's first evaluation of a drug—the anti-flu drug Relenza. It is unfortunate, to say the least, that the institute's first decision has confirmed all the fears expressed over many months by United Kingdom pharmaceutical companies that the national institute would effectively create a fourth, affordability hurdle for new medicines.
I do not want to deal with the details of the Relenza case—although I should be more than happy to do so if the Minister wishes to—but there were several problems with the decision. The first one is that the drug has been licensed and is effective in ameliorating the symptoms of flue and in shortening its course by, on average, one and a half days. I would like to have a drug that, for £24, would save me one and a half days off work because of flu, and think that, in principle, the health service should be prepared to buy such a drug. Moreover, the drug would probably be cost effective in work lost, even if there was no evidence that it saves lives.
NICE seems to be saying that, on the basis of affordability, it and the health service would not be interested in flu as a disease until there was a drug that is proved to save lives among the elderly. However, that is a separate issue.
§ Mr. Paul Marsden (Shrewsbury and Atcham)
Does the hon. Gentleman think that a £5 flu vaccination is more cost effective than a £24 five-day course of Relenza?
§ Dr. Harris
I know that we cannot have a direct exchange now, but I wonder whether the hon. Gentleman knows the effectiveness of the flu vaccination—is it 100 per cent? It is 30 per cent. Therefore, even with universal flu vaccination—currently, only risk groups are receiving it—effectiveness would be only 30 per cent. Other treatments, such as Amantadine, are available in the NHS for some strains of flu. Therefore, a new principle has not been established that the NHS is not interested in flu.
When we talk about rationing NHS treatments, or the unavailability of treatments on the NHS, we are not saying that no one in the United Kingdom will receive those treatments, but that the treatments will not be available to poor people. The rich and others who can afford the treatments will be able to receive Viagra, Relenza and other treatments, such as new chemotherapy, that are not available from health authorities.
Yesterday, the Daily Mail made it clear that some doctors—including some oncologists to whom I have spoken—tell their wealthier patients that they cannot provide the drug on the NHS, but that they would prescribe it if they visited as a private patient. Doctors are not funded to provide some of the new chemotherapeutic agents to everyone. I think that that is immoral, and that the Government have to recognise that NHS rationing entails depriving treatments to poor people.
§ Dr. Ladyman
NICE's judgment on Relenza was only an interim one, based on current evidence, and was based not on the treatment's cost, but on the difficulty of ensuring that patients present at the right time to ensure that the treatment is effective. Other than Glaxo, 1073 Relenza's manufacturer, pharmaceutical companies—at least the ones that I have spoken to—think that NICE got the decision right.
§ Dr. Harris
I have not heard that view expressed before by the industry, but shall deal with that later.
Other treatments may be affected by the affordability criterion, but are seen by Ministers and Labour Members as more desirable—and less as low-hanging fruit—than flu treatments. If NICE said that, on the basis of affordability, beta interferon should not be prescribed or that taxanes should not be used as a first-line treatment, I would bet that Labour Members would find it much more difficult to dismiss Relenza as simply a flu treatment and to insist on vaccination.
In "Faster Access to Modern Treatment", we were promised transitional arrangements for companies. The paper stated:Transitional arrangements will be needed over the next few years, in particular for medicines, since any clinical research needed to satisfy the licensing requirements will already be underway. Under these circumstances it would be unreasonable to require information which was not obtainable from the research already underway, since that would imply new research and might delay, perhaps by several years, the launch of the product. We believe that this would be unrealistic for many companies, especially those with international markets.
It would be incredibly unfair if a company spent up to 12 years on developing a drug—including years in clinical trials, to reach phase 3—but the Government subsequently said, "You should have got this data on cost effectiveness". The transitional arrangements were therefore crucial. However, those arrangements were ignored in the Relenza decision—they were not heeded.
A drug that has been judged to be clinically effective should be innocent until proven guilty. Particularly in the transitional phase, drug companies—which invest hugely in the United Kingdom—should be treated fairly and should not be asked, after the fact, to provide cost-effectiveness data.
I think that Ministers will find that a consequence of decisions based on affordability—such as the one on Relenza, but also future ones—is that products are not launched first in Britain. Britain is an important market, and other countries watch to see what we do. There has been grave concern in the pharmaceutical industry that decisions made by the national institute will be emulated by other countries.
Drugs may also not be launched early in Britain. Therefore, British patients may have slower, rather than faster access to modern treatment. It is well recognised that, in NHS clinical trials, some data even on clinical effectiveness, but especially on cost effectiveness, are extremely difficult to obtain and may be obtained only after the drug is in use in the NHS. The Government have to allow drugs to be used in the NHS. If they do not allow them to be used on the basis of affordability, Ministers should clearly say that and not seek to hide behind NICE.
I fear that clinical trials will not be performed in the United Kingdom, as companies will not plan an early launch here for the treatments. Currently, many new treatments in my health authority are being provided cheaply in ethical clinical trials.
The Government have to recognise that sneaking in the affordability criterion, not applying the transitional arrangements, and giving responsibility for affordability 1074 decisions to a non-elected body will damage not only investment by the pharmaceutical industry in the United Kingdom, but NHS patients' access to modern treatments. When we talk about the access of NHS patients, in these senses we are often talking about elderly and poor patients. That policy undermines everything that the Government say about the need to tackle health inequality.
§ Mr. Paul Marsden (Shrewsbury and Atcham)
I am grateful for the opportunity to contribute to this important debate and I congratulate the hon. Member for Oxford, West and Abingdon (Dr. Harris) on securing it. I have the utmost respect for the hon. Gentleman and must confess that we have spent many a night together. Before the media start to ring my wife, I hasten to add that that was during the long debates in the Standing Committee that considered the Health Bill.
I pay tribute to my hon. Friend the Minister of State and the ministerial team for making the National Institute for Clinical Excellence a reality. No more of the rhetoric or excuses for unfair treatment, no more the spiral of decline of our much-loved national health service, and no more one patient receiving a treatment and another being declined—in short, no more Tory Government.
Instead, we have a national institute that provides access to a single source of quality information for health professionals. It assists them to make complex decisions about patient care and ends the current state of confusion over treatment. Among other things, NICE' s programme of work includes beta interferon for multiple sclerosis, taxanes for ovarian and breast cancer and inhalers for childhood asthma. Patients will receive greater consistency in the availability and quality of NHS services. NICE guidance covers all aspects of management of a condition, from self-care to care by the family doctor, the hospital and specialist services.
First, on the constant and rather sad argument that comes from the Tories and Liberal Democrats, who mention the "R" word rationing. In spite of what the hon. Member for Oxford, West and Abingdon said, they try to paint a picture of people holding ration books, counting their coupons, terrified of not being treated when those run out. They fear they will be told, "Sorry, Madam, we can't prescribe any more painkillers because you've exceeded your quota. Come back next year when your ration starts again", or, "No, Sir, we can't admit you. You've already been here twice this year. I'm afraid your ration is two visits a year." The picture painted by the Opposition would be patently daft, except that it is blatant scaremongering, which frightens people, especially the elderly.
The NHS has always set priorities for treatment and worked within cash limits. The difference between this Government and previous Tory Governments is that Labour is investing £21 billion more over three years in the NHS. Just as importantly, it believes in the concept of the national health service, unlike the Tories.
NICE helps the health professionals to make judgments on treatments with thoroughly researched information—informed judgments instead of the patchwork quilt of best guesses of the previous Tory Government. The hon. Member for Runnymede and Weybridge (Mr. Hammond), 1075 who is not present—I note the acres of green space on the Tory Benches today—said on 14 June: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."—[Official Report, 14 June 1999; Vol. 333, c. 88.]There we have it, the Tories are proud of their policy of denying treatment to patients through the chronic underfunding and unfairness of the internal market.
We must put an end to the situation in which one health authority supports a treatment, but another does not because then the question of who is right and who is wrong arises. NICE is about rational thinking, not rationing treatment.
As usual, the Liberal Democrats struggle to find a single consistent argument. The hon. Member for Oxford, West and Abingdon said in 1998:It is difficult to see how we can secure the new evidence … for the National Institute of Clinical Excellence".—[Official Report, 9 July 1998; Vol. 315, c. 1315.]I took that to mean that there was no need for NICE. However, on 10 March this year, he said:NICE is necessary to iron out inequalities in health—I accept the Government's thinking on that".That was only column 10. By column 12, he said that he could give only,half a cheer for the establishment of NICE".—[Official Report, Third Standing Committee on Delegated Legislation, 10 March 1999; c. 10-12.]Up and down, round and round—that is the Liberal Democrat policy. However, it is not the Tory's policy. They are clear cut—no ambiguity, no praise for the national institute. Speaking for the Tories, the hon. Member for Runnymede and Weybridge said on 10 March:This NICE will be nasty"—[Official Report, Third Standing Committee on Delegated Legislation, 10 March 1999; c. 3.]—a nice sound bite.
Tory solutions lie in the private sector. They want to run down the national health service and force more and more people to take out private health insurance. That is rationing health care. Those who can afford private insurance get a limited health care, those who cannot have to watch a Tory NHS being reduced to ruins.
Perhaps the Tories would like this country to introduce a similar health care system to that in Germany. German workers have to sign up to an insurance company. Each worker pays 6.5 per cent. of gross pay and the employer has to match that. How about the Belgian system of patients paying up to 25 per cent. of the cost of their treatment? I am sure that the British people and British businesses would be interested in the Tory pledge to inflict a new health tax rise on the nation.
Private health care has an important role to play for some people who can afford it, but it cannot deliver the depth and quality of care that the NHS and all its staff deliver every day. NICE is an important step forward. It has been welcomed by 37 community health councils and by royal colleges. Together with other initiatives such as the modernisation programme for accident and emergency departments, NHS Direct and the largest hospital building programme in history, this Government are delivering a 1076 modern health care system for the 21st century. I asked for local views in my constituency. The Royal Shrewsbury hospital said:NICE will promote clinical and cost effectiveness through guidance and audit, to support our frontline staff.Shrewsbury health authority said of NICE that it welcomedits establishment and look forward to the role it will play. The NHS has long needed such an organisation which is able to evaluate current and new treatments including drugs … It will certainly prove extremely valuable to Shropshire … and is warmly welcomed by the Authority.Australia, Finland and the Netherlands have set up similar organisations. It seems that only Tory politicians claim to know better than clinicians which treatments are best.
The Government and the Secretary of State for Health are committed to improving cancer care with their pledge to cut deaths among those under 75 by one fifth at least in the next 10 years. NICE is appraising taxanes for ovarian and breast cancer and I understand that it will provide definitive advice next year on their clinical and cost effectiveness. Taxanes, including Taxotere, are important treatments in cancer care. I hope that NICE will support their use—even Greece uses more Taxotere treatments than this country—but that is my opinion. That is the important point. We need expert, trusted advice from NICE. In general, we need more cancer drugs with proven track records. It is up to NICE to recommend which drugs are cost effective and clinically effective.
In summary, I support the national institute wholeheartedly. It will raise the quality of care in the NHS. It empowers clinicians and commissioners to make informed decisions on best advice. Patients will receive greater consistency in the availability and quality of NHS services. The Liberal Democrats offer half a cheer and the Tories offer health care in chaos. It is this Labour Government, through NICE's advice and by investing in staff, technology and new treatments, who are to deliver the quality health care that we need in the NHS for the 21st century.
§ Mrs. Virginia Bottomley (South-West Surrey)
I congratulate the hon. Member for Oxford, West and Abingdon (Dr. Harris) on securing this important debate. I declare my interests, as set out in the register, particularly with Wyeth, the firm involved in the meningitis C vaccine campaign.
NICE's recent announcement on Relenza will have greater long-term implications for science in the NHS and for the pharmaceutical industry than the Government may yet realise. I have no financial relationship with Glaxo Wellcome, but I am indebted to Sir Richard Sykes because five years ago we launched a campaign to win for Britain the European Medicines Evaluation Agency. This is not the time to set out why our pharmaceutical industry is such a leader among the creative industries. We are low prescribers per head, and overwhelmingly the industry invests in research in Britain and uses this country as a springboard for exports. It would be dangerous to put the long-standing partnership between the industry and the NHS in jeopardy.
When we launched the campaign for the European Medicines Evaluation Agency, it was to be a magnet for inward investment. Britain was advanced as a location for 1077 the agency because of our record for integrity and probity and our commanding position in pharmaceutical research, with four out of the top 10 medicines prescribed having been discovered in the UK.
Above all, our drug regulation agency, the Medicines Control Agency, deals with more drug applications more quickly than any other European licensing agency. A Department of Health press release of 29 October 1993 said:London offers precisely the right conditions for the Agency: the UK's record for probity, integrity and swiftness in medicines regulation is second to none. The EMEA will be crucial to the development of safe and innovatory medicines for all EC citizens.That success was followed by a major campaign entitled "Prescribe UK", which involved the pharmaceutical industries, led by Sir Richard Sykes, the Department of Trade and Industry and the Invest in Britain Bureau. It was an attempt to encourage more Japanese, American and other pharmaceutical companies to invest in Britain. The Government declare themselves to be champions of the pharmaceutical industry and to want to promote inward investment. It is a shame that there is no representative here today from the Department of Trade and Industry or the other Departments which, in the age of so-called joined-up government, should be watching the situation carefully.
If a product has been licensed by the Medicines Control Agency or the EMEA, it has been approved for safety, quality and efficacy. The message that has gone to the industry from the announcements on Relenza is that there is a mysterious new delaying tactic that will prevent new products from reaching the market. The industry has just faced a 4.5 per cent. price cut and is often sceptical about the pharmaceutical price regulation scheme. I support the PPRS, with all its difficulties. However, the Minister should be aware of what is being said in the industry, particularly by those from overseas, about the new, unaccountable way of delaying new products reaching the market.
I was prompted to speak today partly by the concern expressed by the industry and the real danger of the withdrawal of inward investment. I know, for example, what major pharmaceutical inward investment means to people in Thanet, in Scotland and throughout the United Kingdom. It is essential that the Government understand the message that is being taken from the announcement on Relenza. However, the main factor that has prompted me to speak is the growing concern in the scientific community, particularly among those whom I most respected when I was Secretary of State for Health. They have no political partisan commitment. They work in the health service because they are fascinated by medical research and they argue that the contribution of the industry to science in the NHS has been formidable.
The Government do not have a proud track record. The first thing that they did in their first year was cut the NHS research budget. Research is all too easily too low a priority. My concern is that the implications of what has been happening at NICE may threaten not only a successful industry but, even more important, the nature of research in the NHS.
It is fashionable for politicians on both sides to condemn postcode prescribing. It was an attempt to allow different health authorities to set their own priorities and make different decisions. That allows diversity, which, 1078 when different areas are compared, becomes a springboard for innovation. It is hard to explain and to justify, but the effect was to create diversity. It is as old as the NHS.
§ Mr. James Gray (North Wiltshire)
I apologise to my right hon. Friend for not necessarily agreeing with what she says about postcode prescribing. I was not here earlier in the debate, but I know that we have talked about beta interferon. Does she agree that the situation is a terrible tragedy for constituents such as mine, who could be prescribed beta interferon if they lived in Bath or Oxford, but not in Wiltshire?
§ Mrs. Bottomley
All Members of Parliament have been affected by the campaign on beta interferon, and sufferers of multiple sclerosis feel understandably anxious and alarmed about the availability of new products and the best products for their condition.
The problem is that NICE is seeking to make premature decisions. It is well established that many new technologies or drugs end up being used for conditions and in circumstances that were not previously anticipated. The danger is that NICE will clamp down on innovation too soon.
As my hon. Friend the Member for North Wiltshire (Mr. Gray) made clear, there is mounting anxiety that new products are not being made available. We have first-class people working in a second-class service. The hon. Member for Shrewsbury and Atcham (Mr. Marsden) spoke euphorically about changes in the health service. I ask him to come to west Surrey, which has not had a ministerial visit in two and a half years. The news is very bad, and there has never been a time of greater despair and concern about the ability to provide treatment and care for a range of patient needs.
My concern is to promote evidence-based medicine. I support the concept of NICE. I share the concern of the hon. Member for Oxford, West and Abingdon that forcing the issue of cost-effectiveness and affordability onto NICE at the last minute, in a way that the distinguished Professor Michael Rawlins initially denied, will give the institute a task that will make it increasingly incredible. I ask the Minister to meet leaders in medical research in the NHS in an open-minded way and to talk more widely with people in the industry before a good idea turns out to be deplorably destructive to medical research, to science and to an extremely successful British industry.
§ Dr. Stephen Ladyman (South Thanet)
I seldom congratulate the previous Government on anything, but, picking up on the comments of the right hon. Member for South—West Surrey (Mrs. Bottomley), I congratulate them on her successful campaign to win the European Medicines Evaluation Agency for the United Kingdom. In many ways, the agency was given to the United Kingdom as a second prize, because we did not get the European Bank. In the long term, it may well turn out to be the first prize and will probably make more money for the United Kingdom, one way or another, than the European Bank would have done. To that extent, I agree with the right hon. Lady.
However, when the right hon. Lady talks about prescribing guidelines and the way in which the NHS decides which drugs to buy, she forgets that the NHS is 1079 not the Government or the marketplace—it is only a purchaser. In the United States, where there is a private marketplace, the equivalent to the NHS is the health management organisation with which one's insurer happens to be tied up. The United States may not have a National Institute for Clinical Excellence, but I bet my life that each health management organisation has an internal group that makes decisions about prescribing guidelines and drug purchase. For it, cost and cost-effectiveness are not tangential but direct matters. It must decide whether the health management organisation will prescribe a particular drug in a particular way.
The health service must have something equivalent to that and, in setting up NICE, the Government have taken a logical step which they are perfectly entitled to take. With some refinements and improvements it will have nothing like the impact on the United Kingdom's pharmaceutical industry that the right hon. Lady fears.
I congratulate the hon. Member for Oxford, West and Abingdon (Dr. Harris) on securing this debate. I agree with a number of points that he made, but I cannot let his speech go without noting once again, as I did in my intervention, that the Liberal Democrats' manifesto contains not a word about medicines. I have read it thoroughly, and if the hon. Gentleman has forgotten what is in it I shall gladly give him my copy. It contains not one extra penny for the drugs budget.
The hon. Gentleman says that prescription charges are not ring-fenced for the drugs budget, and he is right. They were in the supplementary costings document that went with the Liberal Democrat manifesto. Of the £570 million extra for the NHS this year identified in that manifesto, £200 million was to go to the Treasury to freeze the cost of prescription charges, and only £370 million was additional money for the NHS and was identified for hospitals, an additional carers allowance and dentistry. There was not a penny extra for drugs. Had the hon. Gentleman been the Minister replying to today's debate, he would have been trying to justify a Liberal Democratic Government's plans for limiting the availability of drugs on a smaller budget than the Government have currently made available. Liberal Democrats need to be a little more honest about that.
There is a serious debate. Liberal Democrats talk about rationing and the Government talk about prioritising. Like the line in the song,I say tomato, you say 'tamater'",it is a matter of semantics, which I do not want to get into. What the Government have done, and on which they should be congratulated, is to pool the community health service moneys, the hospital expenditure moneys and the drugs budget moneys, making them available to the health authorities in their entirety so that health authorities can prioritise locally as they wish. Such local prioritising must be right. However, that has probably highlighted the differences in prescribing guidelines throughout Britain.
In an Adjournment debate on 13 April, I highlighted the cases of two constituents who were not at that time receiving beta interferon—Ms Lesley Jordan and Mrs. Noreen Heffer. The first of those two ladies is now receiving beta interferon, but the second still is not, and I continue to campaign for her to receive it as soon as possible. But in east Kent the amount of money allocated 1080 to beta interferon is much greater than in equivalent sized health authorities elsewhere, yet we have a long waiting list.
The hon. Member for North Wiltshire (Mr. Gray) said that in some areas there is not a waiting list, but that is because the prescribing guidelines there are different. The money might be available and there might be no waiting list, but a person might not be put on the waiting list because the doctors there might not consider that beta interferon was a suitable treatment. On that basis, creating NICE must be right. It is the right organisation with the right task, and its guidelines will be invaluable in solving such problems.
I said earlier that NICE requires some refinements. One thing that NICE has not publicly said that it will do, but which I hope that it will, is to look at the regulatory process and advise the Government and the EU on how it is working. Hon. Members may not realise it, but in America the Food and Drug Administration takes raw data from pharmaceutical companies and carries out its own expert analysis. In the United Kingdom, the pharmaceutical companies analyse the data and produce their own expert reports on efficacy, toxicology and so on. Our drugs agencies assess those expert reports to see whether the analysis is correct and whether the appropriate conclusions have been drawn. It is a different process.
NICE should be looking at that process and asking whether there is a point at which it should intervene or enter into negotiations with the pharmaceutical companies at an earlier stage in order to influence what goes into the expert efficacy report so that decisions can be made more effectively and rapidly once licensing approval has been given. Could NICE perhaps write an additional expert report, requesting the raw data in order rapidly to produce such a report? Discussions between NICE and the pharmaceutical industry could resolve many of the problems that have been highlighted today, and I encourage NICE to continue with such discussions.
At the end of the day, however, even with common prescribing guidelines across the country—here I am on common ground with the hon. Member for Oxford, West and Abingdon—there will still be pressures on the budget. We cannot fund everything. Therefore, decisions have to be made about what will not be spent. I have said publicly on many occasions, not least in the Adjournment debate on 13 April, that we can make those decisions relatively easily because, within the drugs budget, there is a huge amount of money that does not need to be spent.
A list of products for non-life-threatening illnesses includes dermatological products, anti-ulcerants, laxatives and topical non-steroidal anti-inflammatories. Such illnesses might be uncomfortable, but they are not debilitating, disabling or life-threatening, and spending on them amounts to £1.075 billion. Even if 50 per cent. of that spending was for uncomfortable illnesses that we decided to fund, if one added to the list medicines such as antibiotics, which doctors prescribe for colds, despite knowing that it will make no difference whatever, at least £500 million of spending on medicines in Britain at the moment could be cut tomorrow without seriously affecting anyone. We would then have our cancer drugs and our beta interferon, and all the problems that we want to be resolved would be resolved, at least in the short term. That is where we need to be putting in extra effort.
1081 To help us make such decisions, NHS legislation should define exactly what we wish to treat. The 1945 NHS White Paper which preceded the 1948 legislation declared that, irrespective of means, age, sex or occupation, everyone shall have equal opportunity to benefit from the best and most up-to-date medical and allied services available. The 1977 legislation referred to a comprehensive health service designed to secure improvement in the physical and mental health of people in the prevention, diagnosis and treatment of illness. We should be moving towards adding a definition of the services provided by the NHS, which specifies that the health service will treat without charge, irrespective of income, all those who suffer from life-threatening, disabling or debilitating illnesses.
§ Mrs. Bottomley
Essentially, the hon. Gentleman has just defined rationing. That is what the hon. Member for Oxford, West and Abingdon has been saying.
§ Dr. Ladyman
I have not defined rationing—I have defined prioritising. I said that, on this matter, I am on common ground with the hon. Member for Oxford, West and Abingdon. There are things that the NHS currently funds which it should not be funding. If NICE can help us to resolve that problem, it will have performed a great benefit, and the hon. Gentleman will have to congratulate it.
§ Dr. Harris
May I dissociate myself from your proposal not to fund certain treatments that you think—
§ Mr. Deputy Speaker (Mr. Michael Lord)
Order. The hon. Gentleman must use the correct parliamentary language.
§ Dr. Harris
May I dissociate myself from the hon. Gentleman's suggestion that certain treatments should not be funded because he feels that the conditions are not debilitating? That puts a whole new complexion on the seriousness of some skin diseases.
§ Dr. Ladyman
I made it clear that I was referring to non-serious uses of drugs. I said that even if we eliminated half of the budget, we would save £500 million. I accept that there are many uncomfortable and serious skin conditions which need treatment. However, if the hon. Gentleman can sit tell me with his hand on his heart that, as a GP, he never wasted a penny of his drugs budget or gave antibiotics to someone with a sore throat or a cold, I will congratulate him on being the only GP of his kind.
I congratulate the Government on setting up NICE which, with a little more refinement, will have a beneficial effect on the NHS and the pharmaceutical industry in this country.
§ 12.1 pm
§ Mr. Paul Burstow (Sutton and Cheam)
I congratulate my hon. Friend the Member for Oxford, West and Abingdon (Dr. Harris) on securing a debate that he has been seeking for some time. The debate has demonstrated 1082 the importance of the issue, and more time is needed to allow more hon. Members to have a say.
The crux of the debate is whether NICE is to be a vehicle to enable the Government to pass off their responsibility for decisions on prioritising or rationing health care, or whether it is to be a vehicle for making decisions about the efficacy and clinical effectiveness of various treatments. Until the agency starts its work seriously and we see the product of its labours, the jury is out.
My hon. Friend the Member for Oxford, West and Abingdon is right to draw attention to the order introduced in this House on 6 August, which made it clear that the question of affordability will be at the heart of NICE' s work. In Committee in May, we pressed the Government on whether they would use their powers of direction and their order-making powers in this respect. We were left with the impression that they would not go down that path on affordability.
I hope that the Minister will state that when NICE comes to a crunch decision about the availability of a particular treatment or drug—and if it comes down to resource availability—the decision and the announcement will come from the Minister, and that the Minister will be seen clearly in this House and outside as the person who has taken that decision. It must not be a matter that the Minister can distance himself from, using NICE as a shield behind which he, the Department and his colleagues can hide.
The independence of NICE is crucial to its effectiveness. It is crucial also to its standing and to whether clinicians will comply with its guidance. If clinicians do not believe that NICE is acting independently, how can we expect them to respect and follow what it says? It is essential that Ministers make it clear from the outset that they are not intending to use NICE as a vehicle to deny a range of treatments on grounds of affordability.
In August, the Department set out, in terms, that beta interferonis a controversial treatment for a patient group with poor prognosis. Many clinicians continue to have doubts over the cost-effectiveness of this treatment".However, there was no balance in the Department's comments. There was no reflection of the fact that the Association of British Neurologists had issued guidance which suggested that the efficacy of the drug was sound. It makes no reference to the extensive research, published in The Lancet and elsewhere, which demonstrates that, particularly in terms of the relapsing and remitting forms—and the secondary progressive forms—of multiple sclerosis, the evidence is becoming overwhelming in terms of the drug's efficacy. The evidence from such a survey suggested that there was a "highly statistically significant benefit". I hope that the Minister will say more about that today.
There is much ambiguity about the definition of clinical and cost-effectiveness. There is no clear definition. Could the Minister begin to put one on the record so we all know where we stand? On savings, we are unclear as to whether the Government will allow NICE to look at the wider picture of the costs to UK plc.
1083 In a letter that I received a few days ago, in response to correspondence that I initiated with the Department in March, I was told:In relation to clinical and cost effectiveness, NICE's task is to assess the evidence of all the clinical and other health-related benefits of an intervention in a wide sense, and to reach a judgment on whether on balance this intervention can be recommended as a cost-effective use of NHS and Personal Social Services resources.That was music to my ears, and a step in the right direction. I hope that the Minister will confirm that social services and social security resources, and the cost to the economy as a whole, can be taken into account by NICE.
My constituent, Mrs. Josephine Timms—I raised her case with the Minister in March—is still waiting for beta interferon treatment. She is still being told that she is a perfect candidate, and that there is no waiting list. However, she is waiting, and I am waiting for an answer from the Minister. What is being done to ensure that Mrs. Timms gets the treatment she deserves?
In conclusion, many patients groups are concerned about NICE. The Multiple Sclerosis Society has said:Both the statutory instrument on NICE tabled in August and the Institute's appraisal framework give a worrying indication that the Government may allow information about NHS resources to distort the Institute's conclusions about clinical and cost effectiveness.Decisions about the effectiveness of a treatment should be entirely separate from the consideration of whether funds exist to pay for it. NICE should decide whether a drug is effective and good value for money compared with other forms of care available to patients. The Secretary of State should then decide whether the NHS can fund the treatment.I agree with that—it is a sound basis to go forward. NICE does not appear to be allowed to do that as of now. Can the Minister confirm that it will be allowed to do that?
§ 12.8 pm
§ Dr. Phyllis Starkey (Milton Keynes, South-West)
According to the hon. Member for Oxford, West and Abingdon (Dr. Harris), the Liberal Democrats' view of NICE seems to be that it is primarily a device for limiting access to health care. I want to argue that the opposite is the case. It is a mechanism for ensuring that the maximum number of people have access to the most effective health care.
I wish to allude to the issue of postcode rationing, which is, essentially, an aspect of the inequity of access to health care. The greatest cause of inequity of access to health care is not at the level of hospital services—it is a public health debate. If one is poor, lives in poor housing and experiences air pollution, one is likely to have much poorer health than someone rich who lives in decent housing and clean air. The Government's White Paper on public health will address that agenda and will make the most difference to health inequalities in this country.
The second contributor to health inequality is the variation in the quality of treatment that individuals receive for the same condition, depending on their GP and local hospital. That variation has nothing to do with drugs budgets or the limitation on the drugs being prescribed. It will be addressed partly by NICE and partly by the Commission for Health Improvement, which will make a huge contribution to reducing health inequalities.
1084 So-called postcode rationing is only the third contributor to health inequalities. The right hon. Member for South-West Surrey (Mrs. Bottomley) alluded to the contradiction in opposing different health authorities having different spending priorities if we believe that the role of a health authority is to react to the needs of its region. Either we want to get rid of that and have national uniformity, with decisions taken nationally that do not take account of regional variation, or we have to stop talking about postcode rationing necessarily being evil. In a given area, it may be right that greater priority is given to one service rather than another, while a different decision is taken in another area.
I shall explain how NICE will increase access for the maximum number of people to effective health care. For many conditions, a large range of potential treatments is available and new treatments continuously emerge. It is difficult for doctors in the health service, whether general practitioners or hospital doctors, to keep abreast of all the research and all the evaluation of existing treatments.
The doctors whom I know tend to stick to what they know works, or are rabid innovators and try the latest idea without necessarily being aware of the full evaluation or the basis of the treatment. There has been much talk about pharmaceuticals, but NICE also evaluates treatment protocols and other procedures. For example, hip replacement operations are fairly low technology and very important to the individuals who receive them. They give enormous pain relief and improve hugely the quality of life of the people who need them. About 40,000 are done a year. I understand that, on average, the procedure costs £4,000. Some 60 different implants are available to NHS doctors, their cost varying from £200 to £2,000. A recent study showed that, in terms of benefit to patients, there is almost no difference between the most and least expensive implants. If all doctors used that advice and went for the cheapest implant, there would be no diminution of the quality of service given to patients but many more operations could be done and more patients would receive a hip replacement sooner.
That is an excellent example of the way in which NICE will be able to get such information quickly and easily to those in the health service who need to take such decisions and ensure that the best possible use is made of public resources. NICE will effectively provide a single source of advice on the evaluation of existing treatments and the best guidelines and protocols to be used in various clinical circumstances. That will help to drive up quality in the NHS.
For example, protocols are drawn up on the criteria for out-patient referrals. One of the commitments that the Government have rightly made is that women who are believed to be exhibiting the symptoms of breast cancer will be referred to a consultant within two weeks. It is important that GPs have a clear protocol for deciding when patients present to them what indicates that the patient is at likely risk of breast cancer and the signs that mean that they are highly likely to have breast cancer but may have some other breast condition that needs to be seen by a consultant but not within two weeks. It is important that the protocols are clear and that GPs stick to them or it will be impossible to meet the Government's targets because consultants will get clogged up with referrals that need attention but not within two weeks.
1085 There are similar issues in respect of the protocols drawn up and disseminated on the appropriate use of drug regimes in treating cancer patients. It is not simply a question of having unlimited budgets so that the most expensive drugs can be used, but of the correct drug regime being designed for the individual patient.
The other way in which NICE will help ensure that people get the most effective treatment is that it will help avoid unnecessary treatment. I want to consider glue ear, which hon. Members will remember occasioned a heated debate in the general election before last. I have had direct experience of it through my daughters. In many cases, the condition resolves itself, and operations have a pretty limited efficacy. Most protocols on glue ear suggest that it is best when the child first presents for the GP to wait before referring the child to hospital to avoid the risk of a child having to undergo a general anaesthetic. In talking about the efficacy of drug treatments, we must remember that every drug and clinical procedure has a risk attached. It is important that people are aware of that and are not exposed to treatment that is unnecessary or that has only a low probability of bringing an improvement.
It is now widely understood in the pharmaceutical industry and the health service that not all drugs are equally effective on all patients. There is enormous hope that improved knowledge of genomics and human genetics will enable doctors to identify from people's genetic make-up which drugs will be most effective for the individual patient in an individual condition, thereby much more effectively targeting the drug on those patients who would benefit and ensuring that the money is spent in the most effective way.
With several drugs, including beta interferon and proton pump inhibitors, it is already clear that only a relatively small proportion of patients with a given condition will necessarily benefit from them. Again, NICE will be able to ensure that all doctors are aware of such information and constantly updated on how to identify the patients who will most benefit from the drugs. That will avoid the more expensive drugs being sprayed around on all the patients who might benefit, and allow targeting on those who will benefit.
I strongly believe that NICE has the capacity hugely to improve the quality of health care, reduce regional variations and allow effective use of resources. I hope that all parties will recognise that that is its main object and will support that.
Finally, I want to consider the pharmaceutical industry, which was mentioned by the right hon. Member for South-West Surrey, and relate it to what I said about the importance of genomics and the future of health care. Many different factors contribute to making this country a good environment for the pharmaceutical industry to operate in. One that we are not properly exploiting is the fact that the existence of the NHS and the primary care network means that we have a fantastic database of patient information that would be incredibly useful in informing the sort of research that pharmaceutical companies need to do to link drug development to human genetics. If we find a way that continues to protect patient confidentiality but can make those records available for use in such research, it will do much to ensure that we continue to provide an environment in which the pharmaceutical industry can operate for the benefit of the industry but also for the benefit of the quality of our health care.
§ Mrs. Caroline Spelman (Meriden)
The quality of many of the speeches in this debate on the National Institute for Clinical Excellence was wholly consistent with the quality of debate that we have come to expect on Wednesday mornings. We hope that debates of such quality will continue in the new surroundings.
I congratulate the hon. Member for Oxford, West and Abingdon (Dr. Harris) on securing the debate which, at times, almost raised the blood pressure. The subject needs to be debated in Parliament openly and honestly. We think that there is no dispute that rationing occurs in the national health service. There were moments during the debate when I got quite excited, particularly during the contribution of the hon. Member for South Thanet (Dr. Ladyman) who made perhaps the first such effort. He spoke of the money wasted through the unnecessary prescribing of drugs. That is a topical issue: primary care groups have overspent to the tune of the half a billion pounds that the hon. Gentleman says could be saved. Perhaps there is room for debate on that subject.
Our real purpose this morning is to focus on the role of NICE. I have read carefully the Standing Committee reports on the Health Bill, and the goalposts appear to have been moved since then. On several occasions in Committee, Opposition amendments sought to tease out whether NICE would use affordability as a criterion. The Government response on a number of occasions was that that would not be the case. Yet, as the hon. Member for Oxford, West and Abingdon pointed out, an order was laid before Parliament on 6 August which explicitly changed the constitution of NICE, amending it to take into account the effective use of available resources. That criterion would justify the Opposition's concerns that the institute would be brought in to shield the Government from the very difficult decisions that have to be taken, given that the Government have finite resources at their disposal with which to treat the health of the nation. The institute's original aims—to promote faster access and more effective treatments—might well have to compete with the extra constraint of affordability.
I endorse the concerns expressed by various hon. Members about how such cost-effectiveness will be defined. A definition will be important for all those working in the health service and the research organisations that help it do its job better. Cost-effectiveness will be particularly difficult to determine where new medicines are concerned, as it involves comparison or relativity between treatments, and a new medicine or treatment may have nothing with which to be compared. We look forward to hearing the Minister of State's definition. I endorse the view that it should be wide enough to take account of savings in other Departments. Surely that is consistent with joined-up government. I hope that the Minister will provide confirmation.
One of my greatest concerns about the Government introducing the new criterion will be in the treatment of chronic conditions. Savings could be made if treatments for chronic conditions allowed patients to stay in work longer or reduced their need for social care. That may not always be the case, and it should never be a condition of treatment on the NHS that a treatment can necessarily demonstrate a concomitant economic benefit. That has to be wrong for a publicly provided health service.
1087 If we assume that a financial cost will be incurred from caring for patients with chronic conditions, we must ensure that they enjoy the best possible quality of life. The Minister of State said on 10 March that NICE would look at priority setting, but we believe that that must remain a decision for the Government who can be held to account by Parliament. Making NICE responsible for such decisions would undermine its credibility and make its implementation by the clinicians extremely difficult.
§ The Minister of State, Department of Health (Mr. John Denham)
I congratulate the hon. Member for Oxford, West and Abingdon (Dr. Harris) on obtaining this debate. If he is right that this is the last debate of one and a half hours that will take place in the Chamber on a Wednesday morning, I am glad that it has been spent discussing something so critical to the Government's programme for modernising the national health service.
Inevitably, I will not be able to answer all the points that have been raised in this debate. It has been extremely constructive and well informed which, as the hon. Member for Meriden (Mrs. Spelman) said, is so often the case with Wednesday morning debates. However, I shall pick up a few of the major issues and, if the Liberal Democrats pursue their prayer, we may be discussing them in more detail in Committee.
I think that I should welcome the fact that the hon. Member for Oxford, West and Abingdon now feels that he needs to spend about five minutes distancing himself from the official Opposition before he uses the word "rationing". I think that he has begun to understand—although it was not much in evidence this morning—that the official Opposition's loose throwing around of that term in recent months has more to do with attempts to undermine public confidence in the national health service and to promote a private alternative than with the way in which the health service sets priorities. As we have always acknowledged, any system that does not have infinite resources has to set priorities. I realise that that is almost a meaningless statement. It is my belief that the national health service and the principles on which it is based provide us with the fairest, most equitable and efficient way of taking the necessary decisions. It is certainly better than the options that are promoted. I welcome the hon. Gentleman's shift in position.
We have made it clear that we want to tackle what we see as the unacceptable variations in the quality of, and access to, treatment and care in different parts of the 1088 country. The right hon. Member for South-West Surrey (Mrs. Bottomley) suggested that those variations were a good part of the system—she referred to it as diversity. I do not agree. The hon. Member for Oxford, West and Abingdon said that it was all to do with funding. I do not agree. As my hon. Friend the Member for South Thanet (Dr. Ladyman) made clear, differences in the provision and quality of care and treatment arise from different approaches to the same decision based on different interpretations of the evidence, different approaches to best clinical practice, slower spread of the best treatment and slower spread of the best ways to approach different issues.
Several strands in the Government's programme have come together to tackle the unacceptable variations in quality of care and treatment. That is one of the reasons that we are introducing clinical governance; it is one of the reasons that we have set out a programme of national health service frameworks; and it is one of the reasons that we are establishing the Commission for Health Improvement.
NICE will provide guidance on the clinical effectiveness and cost-effectiveness of treatments and protocols. We are implementing all the elements of that important agenda in the national health service, and I think that they will enable us to tackle unacceptable variations in treatment and care. As my hon. Friend the Member for Shrewsbury and Atcham (Mr. Marsden) said, the approach has been widely welcomed across the health service.
My hon. Friend the Member for Milton Keynes, South-West (Dr. Starkey) reinforced the point. She said that for general practitioners to keep up with all the new research evidence currently produced, they would need to read about 17 scientific papers each day, 365 days a year. That is not realistic. NICE will provide a single source of authoritative guidance and advice on clinical effectiveness and cost-effectiveness that is necessary to inform health professionals' decisions. It will not override decisions made by clinicians with their patients in the consulting room.
If Ministers decide that something needs to be banned entirely from the national health service, there are procedures to do so. In pre-NICE days, that happened with Viagra, and the decision was properly debated in the House. The truth is that, overwhelmingly, health professionals—