Westminster Hall Sitting of 10 April 2003

Preamble
[SIR ALAN HASELHURST in the Chair]

Urban Renewal
2.30 pm
Mr. Deputy Speaker: As this is the third cross-cutting question session in Westminster Hall, I hope that hon. Members will not require me to explain the procedure in detail again. Hon. Members who have tabled questions will be called in the same way as in the House and, likewise, will be allowed a supplementary question. Other hon. Members and Opposition spokesmen who rise in their places will be called as appropriate and as time permits. A small number of second supplementary questions may also be granted, depending on the pace of events.
I remind hon. Members of the obvious: that this is a question-and-answer session and not a series of mini-debates, so I would appreciate brevity in both questions and answers.
Finally, I stress that this remains an experimental procedure and feedback from all those participating is most welcome, preferably in private notes to me.

Oral Answers to Questions
The Government were asked—

Estates (Improvements)
Ms Oona King: What extra funds are being made available for environmental improvements to, and redesign of, estates to discourage vandalism and drug abuse. [107466]
The Parliamentary Under-Secretary of State for the Home Department (Mr. Michael Wills): Although no specific funding is available for environmental improvements to estates, a number of funding streams can be tapped to redesign estates, discourage vandalism and tackle drug abuse. Home Office funding over and above the £9.6 billion allocated in 2003–04 to the police service includes £72.3 million for crime and disorder reduction partnerships and £50 million for police basic command units.
In addition, the Office of the Deputy Prime Minister has allocated £2 billion over 10 years to the new deal for communities; £400 million has been allocated in 2003–04 to the neighbourhood renewal fund; and £250 million has been committed over three years to improve the quality of public parks and spaces.
Ms King: The Minister will agree that design is a way of minimising the problems of antisocial behaviour, vandalism and drug abuse. Bearing in mind the cleaner, safer, greener spaces initiative, will he ensure that the design of estates is taken into account when seeking to
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improve urban areas and will he consider greater coordination with all the various agencies involved in that work?
Mr. Wills: I am happy to give that assurance. I pay tribute to my hon. Friend's work. She has been a doughty campaigner for her constituency. All Ministers are aware of the needs of Tower Hamlets, and it is partly as a result of that and her sterling efforts on its behalf that it is benefiting from the streams of Government funding—£10.6 million in 2003 from the neighbourhood renewal fund and £56.6 million from the new deal for communities.
I know that the Under-Secretary of State, Office of the Deputy Prime Minister, my hon. Friend the Member for Harrow, East (Mr. McNulty) would like to say a few words as a large part of the responsibility falls to his Department.
The Parliamentary Under-Secretary of State, Office of the Deputy Prime Minister (Mr. Tony McNulty): The document to which my hon. Friend the Member for Bethnal Green and Bow (Ms King) refers, "Living Places—Cleaner, Safer, Greener", was extended subsequently by the communities plan, "Sustainable communities: building for the future". At the core of that document is a real commitment to ensure that designs are central to all that we do in growth areas, low-demand housing areas, neighbourhood renewal areas and, indeed, everywhere across the piece of the Office of the Deputy Prime Minister. We are reviewing planning policy guidance and working closely with colleagues in the Home Office to update our documents on designing out crime rather than designing in crime, which has happened too often in the past when architects seem to have gone out of their way to do that.
Mr. David Heath: I support the comments of the hon. Member for Bethnal Green and Bow (Ms King), but does the Under-Secretary agree that the problem affects not just inner-city urban areas but all urban spaces, including even those in rural constituencies, and not just estates but all common places in urban areas? Does he also agree that maintenance of the built environment, as well as the improvement of the general environment, is useful? Put together, would the measures not have at least as much effect as some of those in the Anti-social Behaviour Bill that we discussed earlier this week?
Mr. McNulty: I certainly agree with that, which is why I emphasise that design is at the core of all that we do in the Office of the Deputy Prime Minister. That applies not only 10 deprived areas and to neighbourhood renewal areas but across the piece in urban and rural areas in the north, the south and the midlands. That is especially true of new build, which is surrounded by low-maintenance but high-quality public spaces, small green spaces and parks. I therefore entirely agree with the hon. Gentleman.
Mr. Dominic Grieve: Does the Under-Secretary for the Home Department agree that the experience in the United States in reducing problems, such as broken windows, and in providing policing to address urban disorder and crime shows conclusively

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that how an area is policed is as important as the amount of money invested to regenerate or to change it? If policing does not take place, we end up with examples such as the north Peckham estate in which a lot of money is invested in the immediate aftermath of a murder or tragedy. However, when policing levels are reduced, the same problems of disorder manifest themselves. What are the Government doing to link regeneration schemes to changing police practices to ensure that there are lower levels of crime and disorder?
Mr. Wills: Because the hon. Gentleman has cogently outlined the case for Government policies, I assume that we are assured of his support for the Anti-social Behaviour Bill and other measures that we are driving forward. He is, of course, right. Since we came to office in 1997, we have adopted holistic, joined-up approaches to solving those problems. We agree that we must not let any antisocial or disorderly behaviour go unchallenged and unpoliced. That requires investment by the Government, which is why we are investing in record numbers of police. Police numbers are now at the record level of more than 131,000, and I am sure that the hon. Gentleman will welcome that. It is impossible to achieve such a level of policing without investing sufficient money, and it would be impossible to achieve that if public spending were cut by 20 per cent.
The hon. Gentleman's second point that money alone is not sufficient is right. We need to see more police on the beat, which is why we have driven forward reforms through the Police Reform Act 2002 and the taskforce chaired by Sir David O'Dowd to cut the burden of bureaucracy on the police force to ensure that more police are on the streets. We are giving them the necessary tools to tackle the antisocial behaviour that makes so many people's lives a misery in all areas of the country. Given the hon. Gentleman's remarks, I hope that we can look forward to his support for the Anti-social Behaviour Bill, which will tackle many of those issues.
Mr. Grieve: The Minister will know that we do not view the Anti-social Behaviour Bill with disfavour, but many of its provisions already exist—for example, aggressive beggars can already be dealt with under the Vagrancy Act 1966, and there are numerous other examples. The Government are reinventing the wheel. The powers are already there; the question is whether there are sufficient police to deliver new practices to ensure that provisions, whether they are in the Government's Bill or in earlier legislation, are enforced. There is ample evidence that there are not.
Mr. Wills: Everyone accepts that there is a great deal still to do. I refer the hon. Gentleman to the provisions of the Anti-social Behaviour Bill. He will find that the measures are necessary and will be invaluable tools for the police. It is true that the provisions are not all that the police need: we must ensure that they spend more time on the beat, that they are given the resources that they need and that the courts are equipped properly to process the various measures quickly enough. The problem is complex and requires action across the whole criminal justice system and in government, but we are tackling it with the necessary resources.

Suburban and Urban Regeneration
Dr. Andrew Murrison: What environmental factors are taken into account in the regeneration of (a) suburban and (b) urban areas. [107467]
Mr. Henry Bellingham: What environmental factors are taken into account in the regeneration of (a) suburban and (b) urban areas. [107469]
Mr. Mark Francois: What environmental factors are being taken into account in the regeneration of (a) suburban and (b) urban areas. [107470]
The Parliamentary Under-Secretary of State, Office of the Deputy Prime Minister (Mr. Tony McNulty): Regardless of area—be it urban, suburban or rural—the Government recognise that environmental factors play a critical role in successful regeneration and improving the quality of life for those who live and work in our towns, cities and communities.
Dr. Murrison: I thank the Minister for that comprehensive answer. There are 120 local air quality management areas in this country. Some of them are in surprising places, and two of them are in my constituency. What assessment have Ministers made of the likely increase in the number of local air quality management areas as a result of the building in the south of England upon which they have embarked? Would they agree that air quality is a principal consideration in planning consent for such building?
Mr. McNulty: I agree that air quality is an important factor in environmental matters. I do not know off the top of my head whether it is a material planning gain in all circumstances, which is slightly distinct from whether it is an important factor to be taken into account. I understand that both the Office of the Deputy Prime Minister and the Department for Environment, Food and Rural Affairs consider the matter seriously. My right hon. Friend the Minister for Rural Affairs and Urban Quality of Life may add something in the spirit of harmony and parliamentary pluralism.
The Minister for Rural Affairs and Urban Quality of Life (Alun Michael): The hon. Member for Westbury (Dr. Murrison) is right to say that air quality is sometimes bad in surprising areas. That is one reason why the mapping of air quality and the co-operation that is taking place with local authorities is very important. We wish to address the issue and improve not just the quality of air, but the quality of information.
Mr. Bellingham: Is the Under-Secretary aware of the Nar-Ouse regeneration scheme in my constituency, which has a huge amount of local support? It has the support of the local borough council, and it also has the support of the Deputy Prime Minister who came down during the last election to a tremendous fanfare. He came down to support me, which was very kind of him, and said that he was announcing the scheme. He also announced that it was to be a millennium community scheme.

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Obviously, the scheme takes into account the point about regeneration because it deals with the regeneration of derelict land. Part of the site is a former fertiliser factory, and everyone wants the scheme to get the final go-ahead; there is a huge amount of local support for it. Will the Under-Secretary examine that scheme and do all that he can to support residents in my constituency to ensure that it gets off the ground?
Mr. McNulty: I am pleased to hear about the level of support that the hon. Gentleman has, not in relation to the election campaign, but for the millennium community scheme. I shall do all that I can to ensure that—it and the other millennium community schemes throughout the country at various stages of development—delivers for the people in the area.
Mr. Francois: One of the largest regeneration projects in Europe is the Thames gateway area, which touches on the borders of my constituency of Rayleigh. As I understand it, the Government are due to outline their detailed plans for the gateway next month. In advance of that, can I ask Ministers, when there is a controversial planning application anywhere within the Thames gateway area, what the planning authority will be for the purposes of that application? Will it be the local district council in the normal way, the Thames gateway, or some other body?
Mr. McNulty: The short answer is that it depends where in the gateway area the controversial or otherwise planned application is. The hon. Gentleman will know that we made announcements in the communities plan about particular configurations and mechanisms for delivery in various parts of the gateway. The specific answer to his question is that, if development took place in parts of London or Thurrock, many of the planning powers would rest with urban development corporations.
If the development were in south Essex, which I suspect is more relevant to the hon. Gentleman, it would be a matter for the local planning authority, because south Essex and many parts of north Kent have gone for a more partnership-driven approach rather than something specific in relation to planning power.
Andrew Bennett: May I remind Ministers considering regeneration just how much local people cherish allotments, parks, cemeteries and public open spaces? They very much welcome the extra money that the Government are making available for them, but they find it a little puzzling that other political parties are keen to cut the resources available for such facilities. Specifically, will my hon. Friend the Under-Secretary of State for the Home Department tell me what point we have reached on the question of the reuse of graves and the generation of income from that, which will ensure that cemeteries are looked after and are attractive, safe places where people can go to grieve?
The Parliamentary Under-Secretary of State for the Home Department (Mr. Michael Wills): I shall write to my hon. Friend, because I cannot give him a precise answer. From my own experience, I know how
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incredibly important the matter is, and I echo his thoughts about it. I shall write to him with a detailed answer.
Andy Burnham: I wish to bring to Ministers' attention the Leigh sports village, which is a pioneering regeneration scheme in my constituency. It will provide sorely needed, high-quality sports and education facilities in a deprived community, and it is due to be submitted for planning approval within days.
People in Leigh live in fear that a spotted toad or a great rare newt will be found on the site in the next few weeks. In some cases, environmental factors are not just taken into account, but are given too much weight in the overall calculation. I ask Ministers to advise Government offices, particularly the Government office for the north-west, to ensure that such schemes, which will improve the quality of life and have huge public support, are not derailed by what are, in some cases, marginal environmental considerations.
Mr. McNulty: In the broadest sense, environmental factors are weighed in the balance with many other factors in deciding on planning permission. I would not underestimate the love or affection in which the spotted toad or whatever else is held. I shall not answer the question in its strictest sense, not least because I am the planning Minister for the north-west, and the matter may cross my desk. However, in general, we exhort Government offices to follow best practice when dealing with planning applications, to consider matters in the round and to include in the balance specific policy planning guidance for the area and the region, as well as other material planning matters such as the environment.
Lawrie Quinn: May I direct my question to the Minister for Sport, who represents a Sheffield constituency? In the context of urban renaissance, he will be aware that Yorkshire Forward has seven community schemes in our region, one of which is the Scarborough urban renaissance project. Fundamental to any environmental consideration is the fact that we have the sea at our front door, so we are tightly drawn on where we can go. An excellent aspect of the scheme is the partnerships that have developed between communities and individuals. Central to them have been cultural, tourism and sporting considerations. What is my right hon. Friend doing to ensure that that type of approach—fundamentally, a people approach—is used in urban renaissance projects not only in Yorkshire but across the country?
The Minister for Sport (Mr. Richard Caborn): Working with the Office of the Deputy Prime Minister, we changed PPG 17, which had been a real problem. It had not been revised for 10 or 15 years, but we changed it last year from a reactive to a proactive piece of planning guidance. It asks every local authority to examine its sporting needs in terms of open spaces and planning and to report to the Government.
If my hon. Friend remembers, the Government inherited a problem when they came to office in 1997. The previous Administration allowed 40 playing fields to be sold off each month. We curtailed that and now

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have a proactive piece of legislation that ensures that every local authority carries out a needs assessment. The stick is that the Secretary of State will reject any planning application to close any playing field or other sporting venue until the needs assessment is done. The ODPM and the Department for Culture, Media and Sport have worked together creatively to ensure that the two things come together for sports facilities. We have also taken a view on greenfield sites and sports facilities. Again, it is proactive. I hope that it will lead to a much more sensible approach to sports facilities, which are badly needed throughout the country.
We are dealing with tourism through the regional development agencies. We have given them the powers and resources to address that very important industry, which has been the subject of under-investment and for which there has not been a strategic approach in the recent past. There are major economic drivers in relation to tourism and, in that sense, the RDAs are making it a major part of their plans for the economic renewal of many regions.
Mr. John Greenway: This is an opportune moment to raise a point that I was hoping to make if I caught your eye, Mr. Deputy Speaker, on Question 6. I remind hon. Members that I am a trustee of the National Playing Fields Association.
I am sure that the Minister for Sport is not seeking to mislead, but the fact remains that the Government have not produced a single statistic to back up what he just said about 40 playing fields per month being sold off under the Conservative Government. We know from the Government's figures that 202 playing fields have been sold since the School Standards and Framework Act 1998. Perhaps the Under-Secretary of State, Office of the Deputy Prime Minister can confirm that the PPG17 guidance sets no test of need for recreation, but only a test of need for education.
Why is no account taken of the need or demand for other types of open space? That is in direct conflict with what the Under-Secretary said. Is there not a conflict of interest when a planning authority and a local education authority are parts of the same council? If the Minister for Sport and the Under-Secretary, to whom I am addressing my questions, disagree with my contention, would they happily meet me and other trustees of the NPFA? We believe that what I have said is exactly correct.
Mr. McNulty: The hon. Gentleman's comments are not accurate. PPG17 puts a burden on all local authorities to do a full strategic assessment of the recreational open spaces used for education and other purposes in each and every area. It is in that context that such planning applications have to be determined. I recently met my hon. Friend the Member for Vauxhall (Kate Hoey) to discuss PPG 17 and how it will be bedded in. At some stage in the near future, I will be more than happy to meet the NPFA again, with or without the hon. Gentleman in tow. However, he would, of course, be extremely welcome.

Social Housing
Mr. Andrew Robathan: Whether Government targets for social housing in urban areas have been met. [107468]
Mr. Desmond Swayne: What targets the Government have set for social housing in urban areas. [107474]
The Parliamentary Under-Secretary of State, Office of the Deputy Prime Minister (Mr. Tony McNulty): The 2002 spending review reaffirmed our commitment to delivering decent social housing by 2010. The sustainable communities plan sets out the resources and the policy changes that would put us on track to meet the 2010 target. The target applies equally to all areas of England, rather than simply to urban areas.
We are on track, according to local authority plans, to meet the 2004 interim milestone of reducing by one third the number of non-decent homes in the social sector. This will bring the total down from 1.6 million in 2001 to 1.1 million in 2004.
Mr. Robathan: The question was quite specific. I asked whether Government targets have been met, but I did not notice an answer. I understand that the number of new-built social houses has fallen by one third since 1997, which is quite extraordinary. What confidence does the Under-Secretary think that the House, or the public, should have that the Government will increase their social housing build? Indeed, what confidence can one have when such announcements are made by the Deputy Prime Minister—as with the announcement in February this year—whose housing interests were so vividly exposed by the previous Parliamentary Commissioner for Standards, who found that he had been acting against the Orders of the House?
Mr. McNulty: On the hon. Gentleman's latter point, I have already remonstrated with him for continuing to bore the House with irrelevancies.
In the first part of the hon. Gentleman's question, he suffers from the same delusion as the hon. Member for Buckingham (Mr. Bercow), who, in a written parliamentary question, asked me the same thing, but inserted the word "new". There is no target for new social housing in terms of our decent homes target and there is no target in terms of build for social housing—that is a matter for local plans, regional plans and everything that will follow when Royal Assent is given to the Planning and Compulsory Purchase Bill.
Our one target for social housing is to bring all housing up to the decency level by 2010. The hon. Member for Blaby (Mr. Robathan) asked whether we have achieved that target. Short of using H.G. Wells's time travel machine, he will have to wait until 2010.
Paul Clark: My right hon. and hon. Friends on the Front Bench will be well aware of the review that my right hon. Friend the Prime Minister is leading on the delivery of development in the Thames gateway and of his intention to make a statement in May 2003. I am especially interested to know if my hon. Friend the Under-Secretary can say whether that statement is still on target to be made in May 2003, bearing other events in mind, and if he expects the

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statement on the level of development to lead the way and set the scene for the various delivery vehicles to make a serious contribution to social and affordable housing in the Thames gateway.
Mr. McNulty: My hon. Friend will know that my right hon. Friend the Prime Minister, as well as engaging in a range of other activities, is chairing a Cabinet Sub-Committee called "MISC 22", for no other reason than 22 was the next number. The number 21 had been taken.
I understand that that body is still on schedule to report by the end of May on a range of issues, not least on the scope for detailed delivery of housing—affordable and otherwise—in the gateway. Other issues include a range of mechanisms and policy changes that may be needed in that context, such as value capture, review of planned obligations, and how, with a mixture of public and private funding, we will secure the necessary infrastructure to make all the developments in the gateway vibrant and sustainable communities rather than simply creating urban sprawl and add-ons to existing communities.
Simon Hughes: Are the Government prepared to consider a target in housing that would allow need to be met before demand? As the Under-Secretary will know, the borough, of which I represent part, has the largest local authority housing stock in London. Sites that become available could often be used for social housing if they were not bought by the private sector to provide much more expensive housing or second and third homes for people who are already housed.
Mr. McNulty: I fully understand the nature and context of the hon. Gentleman's question for the reason, among others, that I have responsibility for the new deal for communities. I know Aylesbury intimately, but sadly not Southwark. Buckinghamshire has different problems, but I must say to him that the development of Southwark's new deal development plan and its subsequent local delivery documents is, in the first instance, a matter for Southwark.
In the coming months, however, we will be reviewing circular 6/98 as a matter of urgency. The review will take on board the needs assessment process and a range of others that may or may not he included in the end. There are some very good, sometimes radical, ideas about a new use class order for social housing that would capture a social model, but leave the home in a social sector without necessarily preventing people from rising up the elevator to private home ownership. That will be considered in the mix, but it is a matter for Southwark and its unitary development plan and local development framework, albeit in the context of the Mayor's London plan, which, as the hon. Gentleman will know, is being examined in public in full detail.
Mr. Edward Davey: The Under-Secretary talks about targets, but has conveniently forgotten to mention the target from the spending review 2000; namely, that the Government were going to help to build 100,000 new affordable homes by the end of 2004. Will he tell us what has happened to that target and what progress has been made? Does he realise that constituencies such as mine
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desperately need new, affordable homes, yet the Government's policies to date—the starter home initiative, for example —have failed to deliver on what they promised. Fewer than 70 per cent. of the homes promised under the starter home initiative have been built. Moreover, the Government have failed to support councils and realise the potential supply from empty homes. When will the Government deliver on their old targets?
Mr. McNulty: I know that it is a common feature of the Liberal Democrats to flip flop on almost every issue, but I did not realise that that had a temporal dimension. They are now asking me to comment on targets that are, in one sense, a year away from fruition and that, in another sense, are two years away. I hope that the hon. Gentleman endorses our sustainable communities plan, which includes £22 billion of public expenditure, some £5 billion of which will specifically be for affordable housing, and up to £1 billion of which will be for key worker housing. I certainly eschew the notion that the starter home initiative has failed. I have spent much of my time in the past few months going up and down the country, and certainly around London and the southeast, seeing firefighters, teachers and nurses who are in fire stations, classrooms and with patients only because of the starter homes initiative. If Kingston has not got its whack from the initiative, it needs to pull its finger out.
Mr. Swayne: Will the Minister alter the rules so that those local authorities that have established a good record of maintaining their existing housing stock can be allowed much greater freedom to dispose of their budgets by building additional units?
Mr. McNulty: It is extremely unlikely that we will change the rules, given that the ink is barely dry on the rule changes that we made on 5 February, when the sustainable communities document was announced.
Mr. Swayne: The rules are a product of a time when many authorities were not maintaining their stock, so much so that it became uninhabitable. Now, good authorities can no longer be held back by bad ones. However, New Forest district council now has to rip out perfectly good kitchens from its existing stock and put in new ones, rather than building new houses, simply to comply with the rules imposed by Whitehall. It must be horses for courses. Will the Minister reconsider his answer?
Mr. McNulty: All local authorities need to produce housing stock plans by 2006. The hon. Gentleman may be referring to decent home standards. I imagine that constituents of the New Forest, East or New Forest, West require those decency standards as much as anyone else. He exhorts me to travel back in time to a land of milk and honey under the Conservatives that never existed, and the Liberal Democrats exhort me to travel forward in time. I would rather stay where I am.

Open Land and Parkland
Dr. Vincent Cable: What action the Government are taking to safeguard metropolitan open land against the pressures for urban and suburban development. [107471]
Miss Anne McIntosh: What plans the Government have for the safeguarding of parkland in suburban areas. [107473]
The Parliamentary Under-Secretary of State, Office of the Deputy Prime Minister (Mr. Tony McNulty): In planning terms, metropolitan open land is afforded the same protection as designated green belt. Government policy on the green belt, as set out in planning policy guidance 2, has not changed.
Dr. Cable: If the policy is unchanged, can the Minister explain the circumstances in which my local council, which happens to be Conservative-controlled, could proceed with proposals to lift metropolitan open land protection of large areas of parkland, allotments and playing fields? Is it true, as the council claims, that the Government have threatened that, unless it does that and builds on green land specifically to meet housing targets, it will incur financial penalties from the Government?
Mr. McNulty: It would be remiss of me to comment on second-hand hearsay, not least from a Tory council. As I said, the policy protection afforded to MOL is the same as that for green belt, as outlined in PPG2. That has not changed. [Interruption.] If the hon. Gentleman, by his wiggling, is signalling that I should leave for my time travel or write to him, I am happy to write to him on the specifics but, as I said, I will not comment on second-hand hearsay from a Tory council.
Miss McIntosh: Perhaps the Minister will consider the practice of the flagship Labour-controlled City of York council, which seems to build, or want to build, on every inch of parkland, green belt and greenfield site in its area. What reassurance can he give those of my constituents in Vale of York who live within the parameters of City of York council that their green belt, greenfield sites and green space in totality will be protected from such growth schemes as the northern gateway scheme?
Mr. McNulty: I have no comment on the specifics of that. If the hon. Lady wants to write to me, I will look into the matter, but I respond to her point by mentioning the same planning protection for the designated typologies of land as is in legislation; it was inherited from the Conservatives. I am referring to PPG3, which talks about brownfield first, then urban edge, then greenfield and, in the final instance, green belt or MOL.
It is for each local planning authority, whatever its political make-up, to submit its plan in an orderly fashion. Plenty have not done that, which is why we are reviewing the entire planning system. I exhort all constituents, no matter to which party their MP belongs, seriously to engage in the development of those plans.

Urban Parks
Mr. Gareth Thomas (Harrow, West): What action the Government are taking to increase funding to refurbish (a) sports and (b) general facilities in urban parks in London. [107472]
The Minister for Sport (Mr. Richard Caborn): A number of funding streams are available to improve
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sports facilities, including those located in parks. They include the lottery sports fund and the community capital development programme. It is not possible to give accurate figures covering funding just for facilities in parks. However, to give hon. Members some idea of the scale of funding, more than £180 million from the fund has been spent to date on improving sports facilities across London. The community capital development programme will provide £60 million between 2003 and 2006 for the provision of sports facilities in deprived areas.
On the issue of parks in general, the Government have committed £201 million over three years to improve the quality of parks and public spaces throughout England. That will include a new "liveability" fund of £89 million to help local authorities to improve their public spaces.
In addition, and in recognition of the importance of urban parks and public spaces, the Government have asked the Commission for Architecture and the Built Environment to set up CABE Space to champion the vital role of parks and public spaces in improving quality of life and delivering sustainable communities. CABE Space will be launched next month and a new director of CABE Space has just been appointed.
The Government also provide funding to the Urban Parks Forum, which has been instrumental in setting up the London Parks and Green Space Forum.
Mr. Thomas: I am grateful to my right hon. Friend for his answer. Is he aware of reports from CABE that almost 50 per cent. of local authorities in London and elsewhere have no strategy for their green urban spaces? Is he aware, too, of the suggestion that almost a third of people are deterred from using parks because of the fear of crime? Although the sums of money that the Minister announced today are excellent news, is he confident that he has enough money to provide the necessary incentives to all local authorities in London and elsewhere to get sports and other facilities in parks up to scratch?
Mr. Caborn: I referred earlier to PPG17. For the first time we have been able to bring sports facilities, open spaces and recreational space together in the planning guidance. Local authorities are now under instructions through PPG17 to carry out a needs assessment across the range of those facilities and open spaces and to bring it into their planning regimes. I hope that if they do not do so and alterations are wanted, the matter will come to the Office of the Deputy Prime Minister, and there will thus be a prerequisite for them to carry out that assessment.
My hon. Friend spoke about having a strategy. The strategy will have to be in the needs assessment. We hope for a quantum change in the way we look at open spaces and sports facilities. The Under-Secretary of State, Office of the Deputy Prime Minister, my hon. Friend the Member for Harrow, East (Mr. McNulty), is deeply involved in the matter, too.
The Parliamentary Under-Secretary of State, Office of the Deputy Prime Minister (Mr. McNulty): Building on the "Living Places" document, the communities plan launched on 5 February included a commitment to spend £250 million in the next three years in precisely

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those areas. We will shortly be launching CABE Space, to which my right hon. Friend the Minister for Sport referred, a strategic community enablers scheme, a revamp of the green flag awards and a "liveability" fund, all of which focus on an acceptance that parks, green spaces and the public realm in general are as crucial to urban townscapes as they are to areas on the periphery. For the reasons suggested earlier, the work of the police and others is important in the maintenance of those spaces.
Simon Hughes: I am well aware of the Government's commitment to these issues. Can the Minister for Sport help me in relation to matters that arise frequently in the borough of Southwark, where there is a significant deficit of football and cricket pitches? The Heritage Lottery Fund has made some good investments. Southwark park has been re-opened and is very well used. I hope that between the beginning of May and the summer the Minister will accompany me to talk to leading people in the local authority and some of the users of the facilities to discuss how to lever in the maximum public and other funds to provide cricket, football and other facilities, as demand for them definitely exists. However, at present, no funding is available to turn the spaces in the big parks in Southwark to such uses. I am willing to give the Minister relevant material beforehand. It is exactly the sort of profitable use of underused spaces for young people that would help to deal with social disorder on the estates and to improve sporting interests and abilities in our communities, which are waiting for the space.
Mr. Caborn: I will answer about the hon. Gentleman's constituency, but I should first explain that there are two bodies into which we are putting significant funding. The first is the New Opportunities Fund. About £500 million is going through local education authorities in the next three years. That is starting to come on stream, and there will be just over 2,000 developments. That money is going into sports facilities, both new and upgraded. Even though the money is going through the LEAs, the prerequisite is that the money is used for the community. I have seen some innovatory schemes among those 2,000. do not know what is in the hon. Gentleman's constituency, but we can find that out.
The second body is the Football Foundation, through which £60 million is being spent specifically on grass-roots football. I have asked the Football Foundation to develop partnerships and to start using synthetic pitches more effectively. Although one is always happy to see the upgrading of traditional football pitches, in inner cities the pitches used most effectively are synthetic. They can be played on 24 hours a day, seven days a week, and many are floodlit.
We must also explore the work being done by the private sector, for example, by JJB Sports. In Trafford park, there are 24 indoor five-a-side football pitches. Every day from about 4 to 10 o'clock at night, including Saturdays and Sundays, those pitches are booked one year in advance by football teams. Dave Whelan, the managing director of JJB Sports, allows those pitches to be used by schools for nothing between 9 and 4 o'clock during the day. That is a real marriage between the public and private sector. There are complexes in Wigan and Trafford, and the company is rolling out others.
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We can explore public-private partnerships and should examine indoor facilities more effectively than we have in the past. Using synthetic surfaces is important for sustainability and usability. I apologise Mr. Deputy Speaker—I am almost making a speech rather than answering a question.
Mr. John Greenway: Although I welcome the Minister for Sport's answers, do he and his colleague in the Office of the Deputy Prime Minister recognise that pitches in our parks play a crucial role in providing sports facilities for many local schools and grass-roots sports clubs—particularly for soccer and cricket, but also for rugby and hockey—where the schools and clubs have no pitches or land of their own?
Will the Minister for Sport, who is responsible for the lottery, examine how the NOF money is being spent by the LEAs to ensure that it is not focused only on schools that have the land and therefore the ability to improve and create new pitches? It should also be available to LEAs and local authorities to improve their facilities that are used by schools that do not have land of their own. I am thinking particularly of the kids who play on the pitches at Wandsworth, whom I see occasionally when I walk my dog.
Will the Under-Secretary of State, Office of the Deputy Prime Minister say whether the Government have looked at local authorities' ability to maintain the pitches that already exist, given the severe pressure on local authority budgets in the current spending round?
Mr. Caborn: With sports facilities, whether they are football or cricket pitches or tennis courts, one problem is that there has never been an audit of our facilities. We have spoken about PPG17 and conducting a needs assessment of facilities in certain areas. We are in the process of putting together a domesday book of all sports facilities, both public and private, and I hope that we will complete the first part of that project by the middle of this year. We hope to add to it month by month, and once we have the full survey, we can make a realistic assessment of what we need to invest in, whether that is for schools or the community. I am sure that organisations such as Football Foundation will join us in that project, as will the private sector. We will have a comprehensive picture of the sports facilities throughout the country in about a year from now, and we can then work out in a realistic and informed way where new investment should go. It is amazing that that has not been done before.
Mr. McNulty: I realise that pitches and playing areas outside schools are important, not least in some of our most deprived communities. I also understand that there are constant calls on local government funding, even though we have increased by well over £1 billion the local environmental, protective and cultural services block, the old standard spending assessment and the formula spending share.
The point made by the hon. Member for Ryedale (Mr. Greenway) is important. PPG17 is part of the process, but I should also pay tribute to organisations such as Groundwork, which is a serious player in recapturing many parks and open spaces that have gone into disrepair. Schools are then able to use them for the reasons that he suggested.

Empty Homes
Chris Grayling: If the Government will make a statement on empty homes in England. [107475]
The Parliamentary Under-Secretary of State, Office of the Deputy Prime Minister (Mr. Tony McNulty): With permission, Mr. Deputy Speaker, I shall answer question 10 on its own. [Laughter.]
We are determined to deal with the wide-ranging impact of empty homes by pursuing policies to reduce the number that remain empty for long periods. It is unacceptable for homes to be left to rot. They impact widely on the surrounding community and deny housing opportunities.
Chris Grayling: Last year I was on the Select Committee that looked at the serious problem of empty houses, particularly in areas in the north of England where there is no obvious role for the housing. The Deputy Prime Minister has said that he plans to reduce significantly the number of empty houses and return the areas to open land. Will the Minister explain what stage that process has reached, how the different Departments will work together in establishing how the areas can be cleared and what use the land will be put to?
Mr. McNulty: The hon. Gentleman will know that, in the communities plan, my right hon. Friend the Deputy Prime Minister earmarked £500 million for nine designated low-demand pathfinder areas where the problems are particularly acute and there is abandonment or low demand. I was happy to be in a position last week to announce that six of the pathfinders would receive a further £4 million for the coming year, building on the £3 million that they received last year to start early-win schemes. Those moneys were drawn down from the capital modernisation fund. There are serious negotiations between the ODPM and the three other pathfinder areas for more progress in the plans and serious delivery this year. However, the hon. Gentleman should understand that it is about not simply clearing houses and putting grass seeds down, but re-engineering and refocusing the communities and the housing market so that people are served properly.
Andrew Bennett: I welcome what the Government are doing with the pathfinder schemes, but will the Minister give some of them a kick up the backside so that they get on a little more quickly? Does he recognise that there are places where the market has totally failed and properties cannot be sold, and that there are areas of significant housing weakness surrounding those areas? Should we not be looking at those areas as well as those that have seen total failure?
Will the Minister seriously consider, when a house is fit and of good standard, putting, a floor in the market, so that people can be sure that if they buy the property at a certain price, they will be able to sell it in five years at least at that price? As soon as confidence is put back, particularly in some areas in which the market is fragile, the market will take off again.
Mr. McNulty: There is a range of different problems in each of the nine pathfinder areas. Some reflect
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different manifestations of the difficulties of low demand and abandonment. We are keen to work with each of the nine to sort out the problems locally for that community, and we have exhorted them all, when they have drawn up their visions for their communities, to be fully aware of the ramifications in next-door areas of what they are doing. We also exhorted areas that are close to the nine pathfinder areas that have experienced some of the difficulties, but clearly not to the same extent, to learn some of the lessons from their neighbours.
Mr. Edward Davey: May I welcome the Government's commitment to consult on empty home management orders? When will that consultation be published, and when will legislation follow? While we are waiting for that, will the Government do more in promoting and encouraging best practice among local authorities to tackle the problem of empty homes? Will the Government consult the Local Government Association on that? Will they consider promoting voluntary leasing schemes, information and advice to local authorities, and even grants to ensure that we can tackle the problem? The use of empty homes can do a lot in the short term to tackle the problem of the chronic shortage of affordable housing.
Mr. McNulty: I agree with much of what the hon. Gentleman says. He will know that Hammersmith and Fulham is one of the lead authorities in terms of voluntary leasing schemes. It works with the individual who, for whatever reason, owns the empty home but cannot do much with it. In the near future, we will consult on turning best practice on those schemes into a more compulsory system by means of home management orders. That is not the appropriation of private property, as one or two Opposition Members suggested when we announced it, in a sort of reversal of Proudhon's axiom.
On the whole, it is a matter of working with those who own empty properties. Those properties will be empty for a range of reasons. It is not necessarily simply a case of some nasty landlord letting it become run down for some nefarious reason.

Planning Policies
Angela Watkinson: What the Government's policy is on balancing urban infill against new settlements. [107476]
The Parliamentary Under-Secretary of State, Office of the Deputy Prime Minister (Mr. Tony McNulty): Our policies in PPG3 set out a sequential approach that expects urban brownfield sites to be considered for housing before green fields in the countryside. Where development has to take place outside urban areas, we want to see the most sustainable option. Normally, that means urban extensions; urban extensions are likely to be more sustainable. We are working with local planning authorities very closely as they determine their plans.
Angela Watkinson: What advice would the Minister give to authorities such as the London borough of Havering when it is considering planning applications

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for infill or back garden development that it feels under pressure to approve, perhaps in the face of many objections from local residents, partly because of the Government's high housebuilding targets in the south-east and partly because the council is in financial difficulties and does not want to risk facing the high appeal costs associated with refusal?
Mr. McNulty: My advice to Havering and any other local planning authority considering a plan is, if it is in full accordance with the national planning policy framework, grant it. If it is not, do not. I speak as someone who was on a planning committee for 11 years. We do not have planning by plebiscite. One does not weigh petitions objecting to a plan. If it is within the framework go with it, and if it is not, refuse it.
Angela Watkinson: The problem is that the council feels under pressure to approve applications that it would rather not allow because of the rules that are in place. That means that Government are imposing decisions rather than allowing them to be made by the local council in line with local circumstances.
Mr. McNulty: With the best will in the world, as I said in one of the Committee sittings on the Planning and Compulsory Purchase Bill, I have no wish to design local plans for each and every local planning authority, and that is not the Government's position. We are not imposing any targets or plans on the London borough of Havering that are outwith our statutory planning policy guidance, or the unitary development plan that Havering is currently operating.
Another thing that the hon. Lady said troubled me—that Havering is making such decisions because it is financially constrained in some way. If it is looking to let through planning applications that should not be let through under the current planning policy framework purely to make a few bob, it should not be.

Flooding
Mr. David Atkinson: What discussions have taken place between the Department for Environment, Food and Rural Affairs and the Office of the Deputy Prime Minister on using the planning process to reduce the threat of flooding in urban areas. [107477]
The Minister for Rural Affairs and Urban Quality of Life (Alun Michael): Regular discussions have taken place between Department for Environment, Food and Rural Affairs and the Office of the Deputy Prime Minister on flooding issues, for example on new planning policy guidance on development in flood risk areas issued in July 2001, and recently in relation to the Thames gateway proposals.
Mr. Atkinson: Does the Minister agree that people who intend to move into areas that are at risk of flooding should be made aware of that risk before committing themselves to such an investment? Is he aware that the CON29 local search form, which is used by solicitors for those seeking to purchase property, does not include a question concerning flooding and erosion? It should include such a question. Does he agree that the home information packs, which will include key information
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on a property for sale and which are proposed in the forthcoming housing Bill, should include any history of a risk of flooding?
Alun Michael: The hon. Gentleman asks several questions that are outside my direct responsibilities. The Government's policy is to discourage inappropriate development on flood plains and to examine plans when they are being developed. PPG25 stresses the need for local planning authorities to examine in consultation with the Environment Agency how flood risk can be taken into account as part of the planning and development control process. There is good cooperation between Government Departments on trying to anticipate where problems will arise and ensuring that the planning process takes account of them. As for searches, I am intrigued by the hon. Gentleman's comment but it falls outwith my portfolio of responsibilities.
Mr. David Heath: Is it not the case that planning policy should discourage new development in areas of unsustainable flood risk without blighting existing properties? Does the Minister not agree that the key to protecting urban areas from flood is whole river catchment area management dealing with land use, compaction of subsoil, aquifers and deforestation? That is the way forward and his Department should pursue it.
Alun Michael: The hon. Gentleman is right that there are implications for land use upriver from settlements. Measures can be taken within land management and farming practice to affect the management of flood risk. We try to look at the problem in a joined-up way. The Government's policy is to discourage inappropriate development on flood plains. Whether a particular development is inappropriate depends on the quality of flood protection in an area. From the way in which he asked his question, I assume that he agrees that we should not have a blanket ban on development, which should be examined in its context. I agree that looking at the wider implications of land use is important in understanding the specific issues in particular locations.
Mr. James Gray: May I apologise for not having been here for the whole of this crosscutting question and answer session? I was upstairs participating in a debate on a statutory instrument, which the Minister delegated to his deputy. Sadly, I have no deputy to whom to delegate.
The Minister says that the Government do what they can to avoid inappropriate developments, which we welcome. There are currently 2 million houses built on flood plains across England. Perhaps the Minister can explain why the Government forced through agreement on 288 of the 758 planning applications to which the Environment Agency objected last year. Not all those applications involved building on flood plains, but a substantial proportion did.
Equally, can the Minister tell us why the Deputy Prime Minister has chosen to allow the building of substantial numbers of houses on greenfield sites in the south-east of England, which will unquestionably add to the flooding problems?
Alun Michael: I indicated earlier that we work closely with the Office of the Deputy Prime Minister in

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considering the implications of planning for flood plains. It is neither practical nor desirable to stop all development. The Environment Agency is now required annually to report to DEFRA and the Office of the Deputy Prime Minister on planning applications that are determined against the agency's advice. We can see from the report that local planning authorities are taking flood risk more seriously, which is a welcome change that reflects the issue's increased profile.
The Parliamentary Under-Secretary of State, Office of the Deputy Prime Minister (Mr. McNulty): With the best will in the world, the hon. Member for North Wiltshire (Mr. Gray) suffers from the casual empiricism of aggregates. We cannot put all these referrals from the Environment Agency together and leave the impression that those that were granted against the advice of the Environment Agency were problematic. That would be deeply irresponsible, as it is to suggest that because the Thames gateway means the Thames and therefore a river and river banks, it is all prow, to flooding, and that we built anywhere regardless of flood risks. That was not the case. Everything that we did in early developments and identification of sites in the Thames gateway was in full cognisance of the facts. We worked with all local authorities in the gateway, whatever their hue, in the context of full and frank consultation with the Environment Agency. Casual empiricism does not sit gently on the hon. Gentleman's shoulders.
Mr. Deputy Speaker: I apologise if I have been unable to fit in every intervention that was sought, but, by and large, the session has dovetailed fairly well.
A norm of around 12 questions is becoming established, but I shall give instructions that 15 questions should be published on the Order Paper in future to provide a little more flexibility and we shall see how we get on from there. I repeat what I said at the beginning: any observations from any hon. Members, be they Front Benchers or Back Benchers, would be extremely welcome.

National Institute for Clinical Excellence
[Relevant documents: Second Report from the Health Committee Session 2001—02 HC 515 and the Government's response thereto, Cm 5611.]
Motion made and Question proposed, That the sitting be now adjourned.—[Mr. Woolas.]
3.31 pm
Mr. David Hinchliffe: May I begin by expressing my appreciation for the opportunity to debate the Health Committee's report on the National Institute for Clinical Excellence? It may be Thursday afternoon and some of us are subject to a one-line Whip, but it is always a pleasure to have the company of the Under-Secretary of State for Health, my hon. Friend the Member for Salford (Ms Blears), for two hours.
I begin with the usual formal expressions of gratitude to all who co-operated with the inquiry and those who submitted detailed written evidence, which was extremely helpful and informative. I particularly want to thank the oral witnesses whom we heard during the inquiry. It is appropriate to thank the representatives of NICE who co-operated fully with our inquiry, and I want to place on the record my thanks to the chief executive of NICE for his letter to me and other hon. Members earlier this week giving an update on the developments since our report was published and the Government responded.
It is also appropriate to place on the record my thanks and those of the Committee to Lord Hunt, who was the Minister responsible when the inquiry was undertaken. It is a matter of personal regret that he is no longer in the Government; I have known him for a very long time and have the highest regard for his integrity and for his knowledge of health and social care matters. In view of recent events, I hope that there may be a possibility of his returning to office in the near future.
I also want to place on the record the Committee's thanks to our two advisers during the inquiry: Professor Joe Collier of St. George's hospital medical school and Dr. Hilary Pickles, director of public health policy at the Public Health Laboratory Service.
It is particularly important to put on the record my thanks and those of my colleagues on the Committee to our excellent Committee staff. We have been very fortunate in being served by a first-class team on this inquiry and many others. We owe them a great debt of gratitude. In the current environment, in which Members spend a great deal of time together trying to agree a report on a certain subject that I will not go into, it is also appropriate to thank my Committee colleagues for their patience and work. That comment is addressed to members of all the parties that are represented on the Health Committee.
Let me turn now to the detail of our inquiry. It is fair to say that it was the first independent evaluation of NICE since NICE was established in 1999 to tackle the inequities of what has been called postcode prescribing in the national health service. All Members who were involved found that the inquiry proved to be complex but fascinating. It raised many questions about the process of prioritising health care spending, which strikes at the heart of many key debates about today's NHS.

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From the outset, the Committee was clear about its support for the principle that informed the establishment of NICE: a desire to eliminate postcode prescribing by providing clear guidance on the supply of sometimes controversial treatments that would be applied uniformly across the country so that NHS patients, whether in my area of Yorkshire or in Bristol, London or elsewhere, could expect access to the same high standards of care. That was to be achieved through a central body that would provide independent, evidence-based analyses of treatments to inform the decisions of prescribing committees and clinicians. Treatments were to be assessed in terms of their clinical effectiveness but also their cost-effectiveness, so that clinicians would not be able to prescribe overly expensive treatments at the behest of pharmaceutical companies if cheaper, equally effective treatments existed.
As we took evidence, however, it emerged that the reality of the system was far from straightforward. Several key concerns emerged. The first task for any new NHS organisation is to establish credibility within the service and to work collaboratively with others in the field. We heard widespread concern that lack of communication between NICE and other established sources of pharmaceutical guidance already being used by the NHS, such as the British National Fortnulary and the Drug and Therapeutics Bulletin, was causing confusion among clinicians, who were suddenly faced with conflicting guidance from different sources. We were very pleased to hear from the Government's response that NICE now formally invites the editors of other relevant publications to comment on its guidance in draft form. A letter that I received recently from NICE goes into much more detail about how it is addressing the problem. I believe that we all welcome that.
The Committee also heard from several witnesses working in the NHS that NICE was not engaging sufficiently with NHS staff. NICE now has a representative from an NHS trust and from a health authority as formal consultees in its process. In addition, the Government welcomed the Committee's suggestion of creating a network of NHS clinicians and commissioners to maintain dialogue between NICE and the NHS and to promote the implementation of NICE guidance. We strongly welcome such developments.
NICE is charged with making difficult decisions on issues that are often highly emotive. Its decisions may have a profound impact on the lives of individuals. For that reason, it is absolutely vital that the process of establishing clinical and cost-effectiveness is, and is seen to be, entirely independent of intervention from Government or the pharmaceutical industry, and that the processes are completely transparent and open. As a result of the Committee's report, NICE is introducing further measures to improve the transparency of its decision-making process. It has also changed its arrangements for hearing appeals against its decisions, as they have attracted considerable criticism for a perceived lack of impartiality.
Dr. Evan Harris: I was interested to see that the report recommended not removing the selection of topics from the Government's control. If NICE at least had a say in that, the process
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would be seen as more independent and open. Is it not a problem, therefore, given the consequences of selection for appraisal, that that fundamental step is not subject to the independence that many would like?
Mr. Hinchliffe: I will touch on that issue and a number of wider questions in the course of my remarks, because the more one looks at some of the issues raised by the role of NICE, the more one has to address the kind of point that the hon. Gentleman has just made.
I was talking about the independence of NICE. I welcome the steps that have been taken subsequent to the inquiry to address that issue, particularly in respect of the appeals mechanism, which was causing concern to many of the witnesses who gave evidence to the Select Committee.
As our inquiry progressed, we were continually struck by the complexity arid breadth of the guidance that NICE was expected to produce, and also by the tight time scale to which it was expected to produce it. It was therefore perhaps unsurprising that its work had attracted criticism from people who felt that the quality of its analysis was not: sufficiently robust. Although we were obviously not sufficiently qualified to assess those claims ourselves, we recognised in our report the huge importance of maintaining credibility among the clinicians at whom the guidance is aimed, and we were very pleased to hear that NICE is now working with the World Health Organisation to arrange an independent review of the technical quality of a sample of its guidance, as we recommended.
During the inquiry, we were faced with a multitude of technical concerns about NICE's very complex processes, and we attempted to address those as fully as possible. However, we felt it was important that our inquiry was not entirely consumed by those technicalities at the expense of the broader issues.
Perhaps most importantly, we considered what effect NICE was having on the NHS. At the time of our inquiry, we received a great many submissions, from both sides of the fence as it were—from patients and pharmaceutical companies—arguing that despite the existence of NICE guidance, patients were still being systematically refused treatments endorsed by NICE. Given the plethora of new initiatives, guidance and must-dos that have begin issued to the NHS over the past few years, it is perhaps unsurprising that guidance takes a while to filter down to ground level and does not translate into improvements overnight. However, more worrying was the apparent lack of any form of systematic assessment of the implementation of NICE's guidance. Our report recommended that appropriate monitoring of the implementation of guidance should be undertaken as a matter of urgency, and we are heartened to learn that the Government's Modernisation Agency is now taking a key role in driving that forward.
In December 2001, the Government issued a directive to the NHS making the implementation of all NICE guidance mandatory. Although the move may have been made partly in response to concerns about the implementation of NICE's recommendations, it has thrown the contentious issue of the prioritisation of health care spending into sharp relief. We received compelling evidence about that from many NHS

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managers, who told us that because NICE recommendations are mandatory but do not have ring-fenced funding, managers find themselves having to cut back on other services to fund NICE-endorsed drugs and treatments. We were told, for example, that for the cost of four implantable cardiac defibrillators of the type recommended by NICE, an NHS hospital could fund four extra nurses in the accident and emergency department.
The increasing use of technology in medicine will only compound those problems. Our inquiry into NICE persuaded us that, with so many competing interests vying for attention and funding in an area in which resources are finite, it is not sufficient to have prioritisation of health care services carried out, effectively through the backdoor, by an organisation such as NICE. That is why our report called for a more open debate on the issue, and recommended that the Government should work to achieve a comprehensive framework for health care prioritisation, underpinned by an explicit set of ethical and rational values.
Prioritisation of health care spending is an issue that lies at the heart of almost every debate on health care policy, because for each aspect of health care provision that is given priority on the NHS agenda, another aspect is deprioritised. We saw a graphic illustration of that during our recent inquiry into sexual health. The chair and chief executive of an NHS hospital told us that its sexual health clinic, which was turning away more than 300 patients a week and operating out of premises which had been condemned, could not be developed or improved because the trust's spending priorities had to be centred on meeting Government waiting list targets for elective surgery and routine out-patient appointments.
Those are tough decisions to make. However, I would find it hard to justify such a decision if it meant not being able to offer prompt treatment to a young person with a potentially life-threatening sexually transmitted infection who, once turned away from a service, would probably be lost to follow-up. Moreover, that young person would probably go back into the community and continue to have unprotected sex, further endangering himself or herself and others.
However, in its response to our report into NICE, the Government made it clear that they had already established their key priorities at a broad level through the planning and priorities framework and the national service framework programme. It is well accepted that once everything becomes a priority then nothing is, and we are already in a situation where that is a risk. The planning and priorities framework for primary care trusts covers nine key areas: reducing waiting times for A and E, out-patient appointments and surgery; improving services in cancer, coronary heart disease, mental health and services for older people, and improving life chances for children; improving the overall experience of patients; reducing health inequalities; and contributing to the Government's drive to reduce drug misuse.
In addition, national service frameworks now exist in six clinical areas and are about to be published in four more. That is a huge sweep of diverse concerns, and there is already widespread anxiety that primary care
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trusts, which are relatively new organisations, will struggle to meet such a broad range of targets. The mandatory implementation of NICE guidance, which is often not linked explicitly to any of those priority areas, will add to the list of must-dos that restrict the amount that primary care trusts can invest in so-called low priority services such as sexual health.
A glance at NICE's website shows that recent NICE guidance has covered a bewildering array of subjects, including obvious priority areas such as cancer and coronary heart disease, but also hip replacements, wisdom teeth extraction, the treatment of influenza and stress incontinence, the use of growth hormones, and the treatment of eczema. NICE is currently working on guidance on IVF fertility treatment, to be published in November this year. If it recommends that couples experiencing difficulty conceiving are routinely offered a certain number of cycles, at an average of £1,200 per cycle, that will have a considerable impact on prescribing budgets.
I do not want to pass judgment on what degree of priority should be afforded to any of those issues, but none of those areas appears to feature either in national service frameworks or in the primary care trust planning and priorities framework. If sexual health, or other services, must be cut to fund new technology recommended by NICE, such as implantable defibrillators or IVF treatment, there should be an open and rational framework for systematically addressing those trade-offs.
I will raise one further point about the local implementation of national guidelines, an issue that does not arise specifically from our report, but arises from my experiences in various parts of the country. Could the Minister comment, for example, on whether the Government believe that the strict numbers-based guidelines contained in the NICE cancer guidance have sufficient research justification for the current reconfiguration of services being proposed in some cancer networks? It is not clear to what extent they are factoring into their requirements the impact of the proposals on district general hospital services, when specialist skills are centralised to cancer centres.
The Committee's view, which I hope is shared by others, is that the inquiry was useful. It was certainly interesting and we learned a great deal from the experience. As I said to the hon. Member for Oxford, West and Abingdon (Dr. Harris), the issues raised in the inquiry took us to a range of other, more difficult issues which will not go away, whatever Government are in power.
I welcome the Government's positive and helpful response to the points that were raised. I want to place on the record my thanks and those of the Committee for NICE's constructive response to our recommendations.
3.50 pm
Sandra Gidley: I apologise in advance as I have another engagement in my constituency, so I shall not be able to stay for the Minister's winding-up speech. However, I assure her that I will read it avidly in Hansard when I return on Monday.
I shall refer to three matters: first, the access to NICE medicines. The Committee was aware of something called NICE blight, a problem that has not gone away.

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NICE admits that, in an ideal, world a drug would be examined and appraised to coincide with its launch, and that would avoid the current time gap between the launch and the drug receiving NICE approval. However, that is a fudge, because there is nothing to stop anyone who can do so prescribing any drug, even if it has not been through the NICE process. However, when there is pressure on budgets, that process is often used an excuse by administrators, those who set the budgets and even doctors for not prescribing a drug or making it available. It would be useful if the Minister would say how that problem will be addressed and how she plans to speed up the process.
NICE has been disappointing because its work is incredibly slow. An appraisal takes a long time from start to finish and the rate at which drugs are examined is slow. The process needs to be speeded up—perhaps by increasing the resources available—if medicines are to be considered and decisions taken in good time.
I imagine that the matter also exercises the pharmaceutical industry, although I have not been lobbied about it. However, when it takes an ever-decreasing length of time for drug companies to take out a patent on a drug to recoup some of their investment, it must be worrying that both ends of the process are being squeezed. There are generic pressures at one end of the market and the delay in NICE approval at the other. In the middle are the patients, who suffer, first, because they do not get the drugs in the first place and, secondly, because the process makes supplying the drugs less cost-effective for the industry.
The process is particularly slow if there is an appeal. It is often frustrating for all concerned—most of us have been lobbied about visidyne and beta interferon; there are numerous examples—that the guidance is so slow in coming. I appreciate that that is because of the desire to try to get things right but, in the meantime, the patient's condition gets worse and their chance slips away.
I want now to put something else into the equation: I think that the first NICE determination was for the anti-flu preparation—I forget its name. [HON. MEMBERS: "Relenza."] That is the one. NICE lost a little early credibility when it produced interim guidance that did not seem to be very workable and that it reviewed a year or so later. Although a review process is built into the NICE appraisal calendar, it strikes me that, if new evidence proves that a drug is effective or ineffective, there does not seem to be an easy mechanism by which there can be a quick review and, accordingly, a review of any NICE guidance. It is important to work such a mechanism into the system somehow. I shall talk a little more about the process later.
The other hot potato is the implementation of NICE guidance and how it is monitored. Committee members raised the concern that there was no baseline other than drug industry sales figures. Although NICE is producing guidance on a drug, no figures are collected to show what the baseline for prescribing it is during that time. That causes a problem, because NICE issues a guesstimate of what it believes the take-up will be. That is not always accurate—the take-up has sometimes been greater than NICE said that it would be—and we have no easy way of looking back and asking if PCTs and hospitals are doing what they promised to do.
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Our recommendation (p) suggested that practical systems and structures should be put in place. The Government's response was that they agreed in principle, which is good news. On page 9, they state:
"CHAI should be the principal external inspector of the implementation of NICE guidance, and the details of this inspection will be agreed between the Commission and the Department of Health."
They also mention the Modernisation Agency, which will work with NHS bodies, and the board development programme, with which I admit I am not entirely familiar. The response continues:
"NHS Boards are asked to check how NICE guidance is implemented".
It notes:
"The Institute has commissioned through the NHS Research and Development Programme an independent evaluation of the impact of the Institute's technical appraisal guidance."
I would welcome any indication from the Minister about how all that was progressing. Patients and the industry will be much happier if they are convinced that there is a robust monitoring system, although I hate to use the word "robust"—it is one that we tried to keep out of the report.
Much has also been said about the postcode lottery, although I am not sure whether that was why NICE was set up. As an Opposition politician, it is easy to jump on the bandwagon and decry the whole issue. However, I will not do that, because if we are devolving decision taking down to local areas, there will inevitably be some difference in the way in which PCTs in different parts of the country decide to implement guidelines. Any Government mechanism must ensure that such flexibility is still available to local decision makers. We cannot have our cake and eat it. We cannot have blanket NICE guidance that is implemented in exactly the same way everywhere and still say that local people will take local decisions. The two things do not square. There needs to be a loose framework in which both are taken into account.
Secondly, are we monitoring drugs in the right way? I ask that because I was especially struck by much of the evidence that we received that was very complimentary about the Scottish system called SIGN, which tends to examine a drug in the context of the wider disease, condition or whatever it is used for. That was coupled with alarming evidence from, for example, the Drug and Therapeutics Bulletin and the British National Formulary that there were discrepancies between the guidance issued by them and the guidance issued by NICE. Most people in the medical profession regard the British National Formulary as a bible. It is probably the first work that one looks at to get an initial picture of something. The Drug and Therapeutics Bulletin is also held in very high regard. There are moves for more consultation between bodies but, at some stage, we need to ask whether there is enough consultation and whether they are all singing from the same song sheet.
We consider drugs in isolation. That is the biggest problem with the way in which NICE tackles things. I do not mean that as an attack on NICE, because it was set up to work in that way. However, doctors are using outdated medicines for many conditions. On the face of it, they may look like the cheapest option, but if we factor in the costs of prescribing drugs for side effects

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and quality-of-life issues, the picture can suddenly change quite considerably. I should like more emphasis to be placed on a wider appraisal that considers new drugs alongside existing therapies and that comes to a balanced view about the relative merits of both.
That is linked to the argument about cost-effectiveness and affordability. I admit that I was sometimes confused by the conflicting evidence that the Committee received. NICE considers cost-effectiveness. There was significant concern that there was an arbitrary cut-off rate in relation to quality-adjusted life years. It became apparent that this is an inexact science. Often, a medical model is examined. The quality-adjusted life year often does not take into account other factors, such as a person's ability to carry on working, not to have to claim certain benefits and even to live at home unaided. Such factors are important, but are not taken into account adequately in the process.
Recommendation (w), which is on page 12 of the Government response, was about greater clarity. However, it will be difficult for the Government and NICE to provide that until clearer guidelines are accepted by all. There was confusion about whether NICE decided on affordability, or whether that was a political decision. The consensus at the end was that it was a political decision, because clearly the Government fund the NHS and it is up to them to decide what is affordable. I sometimes think that NICE crosses the border between deciding cost-effectiveness and deciding affordability. Greater clarity as to who makes which decision would be welcome.
It is easy to pick on the negatives and on the things that are going wrong but, on the whole, NICE serves a useful purpose. If sufficient notice is taken of the Committee's concerns and some of the concerns raised today, and if there is a will to change, we can come up with a system that benefits patients and politicians alike.
4.4 pm
Dr. Richard Taylor: As our Chairman, the hon. Member for Wakefield (Mr. Hinchliffe), was kind enough to compliment the members of the Committee, I should like to compliment our Chairman on his incredible patience and sense of humour. His patience was tried excessively this morning, but it remained intact. I also want to compliment the Minister and say how pleased I am to see her. I know that she spent as much time working out the answers as I did working out the questions. I saw her in the Library yesterday, and I tipped her off about one of my questions—but only one.
I want to speak on three topics. I want first to welcome events that have happened since our inquiry, although I will not say whether they are a result of the inquiry or not. I will then raise a few matters that I am still concerned about, before speaking briefly about the future.
My first welcome concerns the "British National Formulary". As has already been pointed out, we were staggered at the lack of collusion between the BNF, the "Drug and Therapeutics Bulletin" and the National Institute for Clinical Excellence, even to the extent that the BNF at that stage was not a formal consultee. I had
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a word with the chairman of the BNF earlier today, and I am glad to report that he feels that satisfactory communication is now taking place between NICE and the BNF, so much so that the BNF now includes summaries of NICE recommendations in up-to-date issues.
The only disappointment is that the BNF is having trouble with its computers, just as every other organisation seems to do, which means that the current BNF is not out until the end of April and I have not been able to check it. The executive editor of the BNF said that they were almost overwhelmed with information from NICE, but I do not want that to detract from the fact that NICE is sending it all that information. The situation is improving with the "Drug and Therapeutics Bulletin" as well, although perhaps a little more slowly.
My second welcome concerns paragraph 104, in which we noted that NICE had plans to establish a citizens council. We know from the press that something like 30 people from all walks of life have been enrolled into the council. From the NICE response, we know that one meeting has taken place already. I regret that I have not had time to check on the web what happened at the meeting, but I am sure that the Minister will be able to tell us how those ordinary citizens are coping—I do not mean to talk down people when I say "ordinary". During the inquiry, one or two witnesses said that going up before the academics at the NICE inquiries was scary, and I want to know how the ordinary people are standing up to it. Are they finding it friendly or intimidating?
Paragraph 94 has been superseded because the citizens council has been appointed before the Commission for Patient and Public Involvement in Health has really got off the ground. Could the citizens council be affiliated to the commission in some way, because that would give it more strength and bring NICE into the same fold? The NICE response mentioned the feasibility study on the patient impact assessment, and I want to know how that is going.
My third welcome concerns paragraph 99, which mentioned the need for an independent, detailed peer review. The NICE response says that the World Health Organisation is being asked to review the work of NICE, which is a tremendous step. However, I am slightly worried by the wording, because the NICE response says that the WHO will carry out a review of the technology appraisal programme for 2003. Is that the same as our recommendation that the review should be of a random selection of actual guidance?
Those are my three points of welcome, and next are my three points that still concern me, the first of which is funding. We are told repeatedly that the Government's welcome huge increase in funding to the NHS is enough to cover the cost of NICE recommendations and many other proposed developments. I have never been convinced that that is absolutely realistic. PCTs are overspent already, and a vast amount of extra money will go into the overspend. The three PCTs in the county in my constituency are overspent to the tune of £14 million, and that will swallow up a vast amount of their extra money. That is emphasised by the health bulletin produced by the Audit Commission, "Primary Care Prescribing", which shows that on average PCTs have increased their drug budgets by about 10 per cent. Drug

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costs are forecast to rise by about 12 per cent., so 2 per cent. of the figure is not actually accounted for, and it is a puzzle where that extra 2 per cent. will come from.
Others have already mentioned implementation of NICE recommendations and it is a worry. If a 2 per cent. rise is not accounted for in PCT budgeting and the implementation is not full, something of a black hole will be exposed. The charity Schizophrenia First has done a lot of work on implementation of the guidance, particularly the use of atypical anti-psychotic drugs. Its work does seem to show a clear gap between the issue of guidance and the actual implementation. The health bulletin states that the increase in spending on the atypical anti-psychotic drugs is £39 million, or 32 per cent., and if implementation is incomplete there will be a swingeing total increase that may not be covered. I wonder whether full implementation is affordable.
Dr. Evan Harris: What does the hon. Gentleman think of the Government's response to that point in recommendation (o) on page 10 of their response? The report raises concerns about not only the affordability of the NICE recommendations, but the distorting effects that they might have on privatisation for those treatments that are not NICE-approved. The Government simply state:
"The NHS does have sufficient funding to meet the cost of NICE recommendations."
If only inquiries were so straightforward that bald assertions could be made and weeks of work and evidence considered could just be dismissed by the stroke of an assertive ministerial pen.
Dr. Taylor: That is exactly my next point.
My next point, which has been touched on, is the impact of NICE guidelines on service delivery. If one examines the health bulletin, one finds some extraordinarily interesting figures. It analyses the £540 million increase in spending on drugs from 2001—02 to this year. A figure of £250 million is spent on drugs recommended by national service frameworks or by NICE guidelines. That includes a vast amount of money spent on the statins that improve the health and prognosis for many patients with heart disease. It includes money for anti-hypertensives, diabetic drugs, and atypical anti-psychotic drugs. Nearly half of that £250 million goes on drugs that have the support of NSFs and NICE guidelines, and the other £290 million—just over half— covers the vast bulk of medicines that are not supported by NICE guidelines. There is a worry that there will be a skewing of prescribing in the initial phase in favour of the drugs that have NSFs or NICE guidelines behind them.
Finally, I shall mention briefly three aspects on which I would like clarification for the future. Paragraph 68 addresses the issue of legal status:
"We recommend that the Government and NICE should clarify the legal status of NICE guidance in relation to the other legal duties incumbent upon clinicians and commissioners of health care."
I understand that NICE, working with the Department of Health and the Welsh Assembly, is trying to make sure that the service is clear about the priority that should be accorded to the guidance. However, I still have worries. Clinicians have legal duties of care to their
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patients and the PCTs have a duty to remain within their budgets. Somewhere, there will be a clash between those duties. If treatments that do not have the NICE guidelines or the national service frameworks behind them are squeezed out, where does the clinician who wants to use something that is no longer funded stand?
Secondly—this point was mentioned by the hon. Member for Romsey (Sandra Gidley)—we should bite the bullet and spend now to save money in the future. Obviously, expenditure on statins is improving the outlook and will reduce the number of patients who are admitted. Thinking again about anti-psychotics, full implementation of those recommendations would almost certainly reduce the need to admit schizophrenics to hospital, which is the sort of economy that it is so difficult for PCTs to make. They have got the money now, but they cannot use it to make savings in the future.
Thirdly—this was mentioned by the hon. Member for Wakefield—paragraphs 134 and 135 raise the wider issue of prioritisation. We have to welcome NICE as the first brave attempt at prioritisation or even health care rationing. Paragraph 135 of its response states that
"NICE agrees that this is a key issue and it is a debate in which the Institute wishes to contribute. NICE's experience so far, as well as imminent developments (especially the formation of the Citizens Council) gives the Institute a special perspective."
Speaking personally and not on behalf of the Committee, I would welcome a more wide-ranging, open debate on rationing, which is what prioritisation really means—although "rationing" is easier to say. I look forward to hearing the Minister's comments.
4.18 pm
Dr. Evan Harris: Of course, I join those who have already spoken in applauding the Select Committee, and in particular its Chairman, the hon. Member for Wakefield (Mr. Hinchliffe), for not only choosing to open the inquiry but conducting it so deliberately. Reading the report, looking at the amount of evidence taken and how it was weighed, I find that it has covered the issues very well. There are some areas or the report with which I disagree, but there are broad areas with which I agree. Even in those areas of disagreement, it is clear that the Committee has done the work, taken the evidence and reached a view, which it sets out and defends.
At the outset, it is important to say that the Liberal Democrats supported the broad purposes for which NICE was set up. They were to provide clear guidance to the NHS about the evidence on the clinical effectiveness and efficacy of a drug and its cost-effectiveness, not only in absolute terms but more important in relative terms compared with other treatments, and to allow decisions to be made on a consistent basis, as far as possible, across the country.
Dr. Doug Naysmith: Does the hon. Gentleman agree that there were other reasons for setting up NICE? It was not simply to deal with postcode prescribing. People have argued for a body to consider clinical effectiveness, and perhaps cost-effectiveness, for many years. Does he welcome the body being set up, as I do?
Dr. Harris: I did not mention postcode prescribing. I was making the point that the hon. Gentleman made.

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There were reasons for setting up NICE other than abolishing the so-called postcode lottery. In that respect, I entirely agree with him. The rationale that I set out for setting up NICE has little to do with so-called postcode lottery. As my hon. Friend the Member for Romsey (Sandra Gidley) explained, there are difficulties in saying that one wants to devolve decision making to the front line, to local bodies, and then saying that there will be no geographical variation in the provision of services—that is a much better way of putting it than "postcode lottery".
Using the term "postcode lottery" is insulting to people who have to make tough decisions. In my area, the commissioners in Oxfordshire have painful decisions to make about what treatments they can afford to fund, and what treatments and quantities of those treatments they cannot afford to fund. They have no way of raising funds, so they have the blame and responsibility without the power to raise extra money and be accountable for it. Their decision may have a bad impact on some of my constituents, who will feel hard done by. Those who benefit from the money being used in other services will appreciate it. Different decisions are made in Berkshire and Buckinghamshire.
To call that difficult decision making a lottery is an insult to the work being done. For example, in Oxfordshire, there is a priorities forum in which community health councils and patient groups are represented. Academics and clinicians are present, consider the evidence on effectiveness and cost-effectiveness and make decisions.
Rationing is rightly touched on in the report. Rationing is a natural consequence of the need for health care being greater than the general ability of resources—whether we are talking about funds, beds, doctors, nurses, or accessibility in terms of geographically appropriate services—to provide for that need. That is what causes rationing. By rationing I mean the lack of provision of certain treatments that would benefit patients, but which cannot be accessed on the NHS.
I hope that the Minister will use the "R" word, now that it has been defined in that way, because it is not a bad thing. The NHS has always rationed health care. The question is not whether there is rationing; there should be no sudden realisation of the existence of rationing. There are two fundamental questions. First, how much rationing is taking place—in other words, how many effective treatments cannot be afforded in terms of the resources available? Secondly, how explicit is that rationing, and, therefore, how accountable is the system? The British public have been failed in relation not to the existence of rationing but to the lack of explicitness.
One of the tests for NICE, therefore, is whether, since it cannot increase resources, it can specify that certain treatments are not beneficial. That is rarely done, because NICE considers treatments that have licences, presumably for an efficacious use. However, NICE has helped in making certain rationing more explicit, which is important. For that reason, NICE has been a welcome innovation over the past few years—it seems like it has been with us for decades.
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As I have said, the fact that NICE is an authoritative national body that reaches its recommendations in an open, transparent and detailed way will make it easier to understand why certain treatments are not available and why there is more pressure for certain treatments to be available. As far as it goes, the Select Committee report makes those points as well, and I welcome that.
Liberal Democrats have some concerns about NICE. One is the question of affordability and the politicisation of NICE decisions, which occurs in various ways. The decision about what technologies to appraise is not independent but a political decision made by the Government. When NICE says that the NHS will fund a certain drug or will not provide certain treatments, it gets the blame from patient groups or, on the other side, pharmaceutical companies. The Minister, who is the person who is ultimately responsible for providing resources to the NHS and for deciding which technologies are appraised, does not.
To that extent, I worry that NICE is the fall guy for decisions for which accountability should lie with the Minister. I have always been clear that if the Government were explicit about rationing decisions, there would be no criticism from us about them, although we could have a debate about the level of the resources. There is less of a debate now between the Government and Liberal Democrats, but there certainly was debate in the five years before the new resources were allocated.
Mr. Hinchliffe: I have listened carefully to the hon. Gentleman's thoughtful contribution. I am interested in some of the wider points arising from the experience of NICE. Bearing in mind the commitment of the hon. Gentleman's party to devolving decision making in the NHS, which I and, I believe, hon. Members from all parties share, I wonder how he squares the process with his concerns about who chooses the interventions that are analysed by an organisation such as NICE?
Dr. Harris: That is a very good question. I would be happy to send the hon. Gentleman more details about that matter.
Mr. Hinchliffe: Not too much.
Dr. Harris: I do not think that any detail would be too much for the hon. Gentleman.
It is a very important question, because simply devolving to the front line is not adequate. Those on the front line would take more blame for decisions that they are making without any get-out. Under our approach, commissioning decisions would be made locally, but the local commissioning bodies would be dramatically different in two ways.First, they would be democratically accountable. We propose to do that in the same way called for by the hon. Gentleman, which is by merging health commissioning directly with local authority-based social services commissioning and by having a health and social care board, social services committee or local authority executive with a strengthened and unfragmented public health function.
Andy Burnham: Will the hon. Gentleman give way?
Dr. Harris: I will when I have finished answering the question of the hon. Member for Wakefield.

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Secondly, those bodies would be able to raise resources locally in a fair and progressive way to add to the pot that comes from central Government. Clearly, equity is a key issue, and there would have to be redistribution of the resources raised locally to poorer areas. However, one can have a rational system of democratically accountable, locally based decision making on commissioning—it is the commissioning that is critical, not the provision—only if one ensures that there is an ability to raise or reduce the resources that go into the pot. I hope that hon. Members accept that that is a rational way to do it.
There would still be national guidelines, but they would be agreed by the regions. Under our system, the national service framework guidance and standards would be accepted, because they are clinically based. They are not political. Nor are they like some of the performance targets that are wholly unclinical and that work against patient interests. I hope that I am not provoked into that debate. Our proposal would involve a mixture of national standards and local decision making.
Andy Burnham: The hon. Gentleman spoke a great deal about political purity and health decisions, but I just heard him say that he would like local authorities to control spending decisions in the NHS democratically. Will he be absolutely clear whether it is Liberal Democrat health policy that local authorities should control commissioning decisions in the NHS?
Dr. Harris: Yes. It is set out in a paper that is available on our website. I am sure that the hon. Gentleman knows how to use the internet and will be able to access it to reassure himself even more completely. It is our policy that local authorities should control commissioning decisions in the NHS, which we have been saying for some time.
Dr. Naysmith: Judging by what the hon. Gentleman has said, he will agree that it might be a good idea if NICE were encouraged to consider some existing treatments and discontinue them—I believe that he used the word "discontinue"—rather than being forced by political interests or patient groups to consider the latest, most exciting product. I know that NICE wants to do so, because it said so when it gave evidence to the Select Committee. Does he believe that local decision taking would make that easier to achieve? Would there be more local pressure to make that happen?
Dr. Harris: I stress that I am keen to discuss the Health Committee's report, but, again, the paper that I just described says that we want NICE to be significantly expanded so that it can consider existing treatments. Some treatments have been shown to be less effective over time when used outside the purity of clinical trials, and have been superseded by newer treatments that may appear to be more expensive but that are cheaper in the long run because eventually one has to use them anyway. We therefore want the work of NICE to be expanded. I suspect that NICE would want it to be expanded if it could choose its subjects, which it cannot, to cover some existing treatments that, I am ashamed to say, are not rational. The "Drug and
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Therapeutics Bulletin' exposes that very well, and I know that the Select Committee carefully considered the work that it does.
Under the sort of scheme that I described, decisions would be made locally and in a democratically accountable way. Every local voter, patient and member of the public would receive a leaflet saying what services were not available, so rationing would be explicit, and if they objected to that they could apply for more funding through the usual democratic process. An obvious consequence of what I have said is that NICE decisions should be advisory, not binding.
We had two reasons for objecting to the fact that NICE guidance is made mandatory without earmarked funding being made available. First, it makes it very difficult for there to be local prioritisation, especially when there is a suspicion that the treatments chosen for appraisal by NICE are chosen for political reasons because they are imposed on NICE by the Department of Health. Secondly, while that situation pertains, as the Select Committee said in its report, treatments that are not appraised are likely to have their funding cut to fund a mixture of NICE must-dos and less worthy Government must-dos. That is what I have described as a tyranny of the appraised over the non-appraised. The more things that NICE covers, the greater that tyranny will be. The treatment areas that remain are not subject to compulsory funding in that way. The Government's response has completely failed to deal with that distortion of resource allocation from the must-dos, but the Government must deal with it. I hope that the Minister will do better than the response set out in her report.
I was interested in the Select Committee's discussion of affordability. When NICE was established, the statutory instrument made no mention of affordability when it described its functions. In the summer of 1998, the Government snuck out an additional statutory instrument that said something to the effect that NICE would take account of the resources available to the NHS when it took its decisions. That was asking NICE to factor in affordability.
Of course affordability is important. My objection is that those who control the amount of resources available on one side of the equation that I described should be the ones who take the blame or get the credit for recommending the use or prescribing of a treatment or drug. However, if NICE decided that there was a very effective drug that was also cost-effective but that allowing the drug to be widely used on the NHS would have an impact on NHS budgets, that drug could not be recommended. That may be the right decision, but it is a decision for Ministers to make.
Perhaps the only good thing about the decision made on Sildenafil, or Viagra, by the Government is that they made that decision in pre-NICE days. It was, and remains, wholly unethical that a drug should be rationed according to the disease process behind the disability or condition, rather than according to the ability to benefit. That is not the sort of thing that we should be seeing from those with the responsibility for making decisions.
In long conversations that I have had with the chairman and chief executive of NICE, they have said that they do not make decisions based on affordability, so why that statutory instrument was introduced,

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debated and passed, I do not understand. I know that the Select Committee has withheld its judgment on whether that is the case, because it is hard to find examples. I hope that the Minister will make it clear that it is the job of NICE to discuss effectiveness and cost-effectiveness.
The question of cost-effectiveness is interesting because of the other issue raised about NICE—whether it has set a ration for the health service in terms of an amount of money per quality-adjusted life year. In the old days, when we discussed rationing, Ministers refused to accept that there was rationing. Notoriously, in the first half of the previous Parliament, Ministers would say at the Dispatch Box, "If you mean by rationing that there is a certain ration of treatment that everyone has, as with wartime food rationing, then there is no rationing in the health service." However, that was not what most people understand by rationing in the NHS. Curiously, the process of NICE's evaluation has tended to create, by iteration, a limit of cost per QALY, which it will judge to be cost-effective enough to recommend.
I am not saying that that is a bad thing—it is rational, understandable and a rule that can be followed. It allows a standard to be set and decisions to appear less perverse. Clearly, if something costs £80,000 per quality-adjusted life year, and it is rejected, and something costs £20,000 per quality-adjusted life year, and is recommended, people can see the reasons. It is important that, despite the difficulty of getting good data, some attempt is made to cost such decisions. It allows vigorous debates about whether the right studies have been used and whether the right time scales, particularly in respect of QALY, have been used.
However, in its evidence to the Committee, NICE still denies that there is a threshold, and I am not sure that it does not deny that what is involved is the process by which it says that it will recommend a treatment that costs £20,000 but will not recommend one that costs £200,000. I would expect that it would do that, and why should it deny that that is the case? I would be interested in the Minister's view. Does she expect to see decisions understood in that way?
As I said in my intervention on the hon. Member for Wyre Forest (Dr. Taylor), the Government have said that they think that there is no problem about the affordability to local health economies of positive recommendations from NICE. However, they just state that baldly, without providing any evidence, on either a national or a local level, about the overall cost of the funding, and how that can be afforded together with everything else. I tabled some parliamentary questions and, in the end, got some figures about the Government's estimate of the cost to the NHS of NICE guidance. When that is added to the cost of meeting the clinically correct standards in NHS frameworks, which I endorse, that creates a new figure. When that is added to the cost of implementing some of the political targets that the Government impose on local health economies, it is clear, as we can see by the enormous deficits in health economies, that it simply cannot be done, even out of the growth money that, in the last year only, has been at the sort of level that we would have liked to see some years ago.
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The Government must recognise that that is the case and say that they will not be able to achieve everything very quickly because if money is going on cancelling deficits on health economies, it cannot be spent on investing in new services. That is just a fact of arithmetic, and if the Government accepted that, we would have some common ground. In fact, the Government do hint that there may be a problem here. In response to recommendation (k), where the Committee calls for
"an increase in NICE's capacity"
to look at treatments as whole rather than at individual drugs—a wise recommendation—the Government say:
"As the Government made clear in its response to the Kennedy Report, it agrees that over time NICE guidelines should cover all major conditions".
Again, I worry about what happens to minor conditions under the tyranny of the appraised. They continue:
"However, the pace at which guidelines are produced must take account not of NICE's capacity but the ability of the NHS to act on them."
Is that finally a little honesty about the impact of making NICE recommendations that are expensive to provide?
Those are some of the key issues in the Select Committee report. One final point concerns the setting up of the NICE citizens council. Although it looks as if that is a sensible move that makes decisions more accountable, I believe it to be the opposite. When I asked NICE how it could defend making decisions about whether QALYs should be used—in a sense, they are age-discriminatory—and allocating decisions on that to 30 people who are in no way democratically accountable, or indeed accountable at all, rather than expecting Parliament to make a decision, its response was, "It's in the NHS plan."
If what NICE does is subject to what the Government decide in the NHS plan, and that does not come before the House in the shape of regulation or even primary legislation so that we can debate it and vote on it, NICE is not truly independent. It was not NICE that set up the so—called citizens council—the Government forced it to do so.
There is a question that we have to answer about QALYs. Is it right that a seven-year-old should have treatment, but not a 70-year-old when they could both benefit equally? Logically, more quality-adjusted life years are saved by treating the seven-year-old rather than the 70-year-old. The question about whether that is discriminatory or appropriate is a decision for which the House must be responsible. We must debate it and we must be accountable, and there must be a full public debate. Using 20 or 30 people, however interested they are in the subject and however varied their background, as a barrier behind which to hide when such decisions and judgments are made means that there is less accountability for such decisions—it is a sham.
I should be grateful if the Minister told us whether she feels that QALYs are satisfactory as the basis for making key decisions on cost-effectiveness and therefore recommending whether treatments are available or not—it is a binary decision once NICE makes the decision. If she feels that that is so, can she tell us when that has been debated in the House and the Government have been responsible for that decision?
The report is an excellent start on probing NICE, health economists and the Government on some of the issues but, without the Government engaging in debate, it can be only part of what needs to be a wider process.
4.43 pm
Mr. Simon Burns: I join the Chairman of the Committee, the hon. Member for Wakefield (Mr. Hinchliffe), in his generous and appropriate comments about Lord Hunt, who was associated with the Committee, as he conducted our inquiry.
The hon. Member for Wakefield has a justified reputation for being able to talk the talk fluently, but in his bluff Yorkshire manner he also has a reputation, to which the Secretary of State would certainly testify, for walking the walk.
In the light of the hon. Gentleman's comments on Lord Hunt, I may be able to help him. I draw to his attention early-day motion 935, which says:
"That this House recognises the personal commitment made by Lord Hunt of King's Heath to the NHS over many years and fully accepts that his decision to resign over the issue of Iraq is one entirely of personal conscience."
In the light of the hon. Gentleman's comments, he might like to join seven of his hon. Friends, not all of whom are the usual suspects, in adding his name to that early-day motion that I and my hon. Friend the Member for Woodspring (Dr. Fox) tabled. Moreover, if he is tempted by that, he may want to walk the walk a step further and turn the knife and sign early-day motion 936, which says:
"That this House deplores the derogatory comments by the Deputy Prime Minister in relation to the resignation of Lord Hunt."
I hope that—
Mr. Deputy Speaker (Mr. Edward O'Hara): Order. I hope that we are coming to the subject of NICE, eventually.
Mr. Burns: We are indeed, Mr. Deputy Speaker, but it seemed appropriate to go down that cul-de-sac to start with, because the Chairman of the Health Committee was so eloquent and appropriate in his comments about the loss to the Government of Lord Hunt, given the tremendous work that he did in assisting the Committee during its investigation of NICE.
I listened to the speeches today with great interest, and two things struck me as unusual. I listened carefully to the hon. Member for Romsey (Sandra Gidley), who said, in connection with one of the issues that she raised, that she would not jump on a bandwagon. I commend her for that. She is the first Liberal Democrat that I have encountered who has not jumped on a bandwagon when appropriate, or even sometimes on two different bandwagons at completely opposite points.
I listened with incredulity to the hon. Member for Oxford, West and Abingdon (Dr. Harris) because, if I understood him correctly, he said that to use the term "postcode lottery" is insulting. I took that to mean the general use of the term, as well as its use in connection with the report. I find that staggering, because although I would agree with him that it is an insulting misnomer, I suspect that that has not stopped most of his colleagues, and probably the hon. Gentleman himself when he was a parliamentary candidate, from using it ad nauseam in the mid-1990s.
Dr. Evan Harris: I should be grateful if the hon. Gentleman could find an early-day motion that I signed
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that includes the term "postcode lottery" or any leaflet of mine that uses the term, because I have been reasonably consistent. If the hon. Gentleman finds it an unreasonable term because it is too simplistic, he should look at how often he has used it and not try to have it both ways.
Mr. Burns: I do not want to go too far down that cul-de-sac, but I do not think that the hon. Gentleman was listening. I said that his colleagues were likely to have used the term, and that he is likely to have used it when he was a parliamentary candidate in the 1990s. It defies belief for a Liberal Democrat politician to claim that he or his colleagues have not used the term "postcode lottery" during their political careers. He knows as well as I do that they have, and have done so with a vengeance, but "on the one hand or on the other" is the Liberal Democrats' position.
The report by the Select Committee on NICE is welcome, because, as you will be aware, Mr. Deputy Speaker, NICE is a new body. It is therefore important that an in-depth assessment is made of its operation in the initial stages after its establishment. That is why I think it was appropriate that we, as a Committee, examined the organisation at that stage. We were able to see it working through some of its teething problems at the beginning of its existence, and to examine some of the controversy associated with it in certain areas because of the statutory instrument on affordability, and the whole area of cost-effectiveness to which the hon. Member for Oxford, West and Abingdon referred.
This is in no way a criticism, but it is fair to say that setting up such a body, a move that the official Opposition welcomed and supported, raises expectations, sometimes unrealistically, because of the nature of its work. It is certainly not the fault of Government that expectations were raised, and by definition it would be unfair to make criticisms because those expectations have not been met. I suspect that some if not many people thought that a body of this nature would in some respects be a blank cheque, but of course that was never going to be the case, and nor should it be, because that is just not realistic.
I should like to deal with two issues arising from the report that to me, as a member of the Select Committee on Health, were of particular concern during our investigations. The first issue is the length of time that it takes for an appraisal to be carried out. In some cases, that has led to what has become known as NICE blight. In paragraph 63 of the report, NICE states:
"We have been playing a lot of catch-up at NICE. We have been looking at anti-cancer drugs that were first launched in 1994. This is not a tolerable situation. What we do need to do…is to be proactive. We need to be starting the appraisal process a year before a drug is licensed. It is perfectly feasible to do it."
That is a very valid point. The Minister may argue, with some justification, that at the beginning of its life, a body cannot play by those rules because of the heavy work load of a new body. I would accept that, but I hope that, as time progresses, NICE's comment can be acted on more speedily.
An early problem has been that NICE has had to carry out two different roles: the catch-up role and carrying out appraisals of new drugs. It has not been easy for NICE to combine both roles in the early life of the organization, because of the sheer scale of the catch-

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up involved. That is no one's fault, but an inevitability of creating such an organisation. However, that situation has caused serious problems and, in some cases, possibly avoidable suffering to patients who could have benefited from drugs that were being appraised.
During our hearings, we took important evidence on that problem from Mr. Campbell-Morrison from the Campaign for Effective and Rational Treatment. CERT's submission was critical of what it described as "unplanned and unexplained" delays in some appraisals. It gave in graphic terms the example of the drug Herceptin, whose appraisal had been inexplicably delayed by six months, even though the drug can have a dramatic effect on the survival chances of women who have an aggressive form of breast cancer, and can improve dramatically the quality of life of those sufferers. Such delays have adversely affected the quality of life of too many individuals who might have had an improved quality of life if they had not been victims of those delays.
I warmly endorse our recommendation in paragraph (1):
"We recommend that for all new technologies, NICE's work programme is arranged to facilitate publication of guidance at the time of launch. When this is not possible, NICE should conduct rapid "interim" appraisals of clinical and cost-effectiveness to be published at the time of a treatment's launch … Although the amount and type of information available at time of launch may be less than ideal, an 'interim' appraisal would provide useful guidance until a more detailed appraisal of the treatment is conducted as part of NICE's expanded main function of developing clinical guidelines."
In retrospect, perhaps there should have been more of an awareness of a split in NICE between dealing with existing drugs that needed appraisal, and the new drugs coming on to the market in order to minimise the problems of catch-up. Perhaps the Minister can reassure me that there was and tell me what was done to minimise the problems. I would be grateful to the Minister if she could update hon. Members on what has been happening since the Government's response on the issue was published last September.
My second point concerns recommendation (w), which talked about great clarity in the criteria for evaluating clinical and cost-effectiveness. It states:
"Whether or not Quality Adjusted Life Years are used, we"
that is the Select Committee—
"recommend that NICE should consider the wider societal costs and advantages of particular treatments and in particular the wider costs and benefits to the public purse of reduced benefit dependency and improved ability to work both for patients and their carers."
We came to that conclusion because of the numerous concerns raised about cost-effectiveness. We received criticisms from one witness in particular, Dr. Crayford of the Croydon health authority, over NICE's alleged inconsistent approach to the use of quality-adjusted life years. I know that other hon. Members have referred to that problem, but I noticed that in the Government's response that—possibly rather surprisingly—they have said:
"wider costs and benefits should be taken into account."
I welcome and agree with that, but the Government went on to say:
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"The Treasury will shortly"—
this was published last September—
"be issuing new guidance on economic appraisal which will broadly meet the Committee's point".
I would be grateful if the Minister could update us about that commitment in the Government's response.
I have not been able to find any new guidance published by the Treasury, but that may be due to an error on my part, or it may be because that there has not been sufficient time for the Treasury to publish that guidance because of the work still required on it. I would be grateful if the Minister could tell us of the current status of either the guidance or its preparation. If it has not been issued, when does the Minister expect the Treasury to issue it?
My final point returns to a point made by the hon. Members for Wyre Forest (Dr. Taylor) and for Oxford, West and Abingdon, which is the response that the Government gave to recommendation (o):
"The NHS does have sufficient funding to meet the cost of NICE recommendations."
As the hon. Member for Oxford, West and Abingdon said, that is a very bald statement. I would expect the Government to say that; I would not expect them to say anything else. It is, to my mind, a somewhat glib response, and what one would expect from the Government. If one talks to PCTs, they would not all necessarily accept the Government at face value on the matter because there are considerable budgetary problems with drug bills in PCTs. As other hon. Members have mentioned, there are problems in relation to deficits in some PCTs. If the Minister could just flesh out that statement, it would be extremely appropriate and helpful.
I welcome not only the report, but the fact that we have had the opportunity to debate it this afternoon, question the Minister and hear her response. All too often, through no fault of anyone, Select Committees produce reports to which the Government respond—within two months if we are lucky, which we usually are—but there is no opportunity to have a follow-up debate in which we can quiz the Minister following that response.
5 pm
The Parliamentary Under-Secretary of State for Health (Ms Hazel Blears): I am delighted to discuss what is an excellent report from the Select Committee on Health. We have had a thoughtful and stimulating debate, and because the National institute for Clinical Excellence plays such a pivotal role in exercising judgments about clinical and cost effectiveness and, increasingly with the introduction of the citizens council, value, we have inevitably managed to raise some fundamental and wide-ranging issues about the NHS itself, as well as those purely related to the technical operation of the institute. I hope to be able to respond to all the issues raised but, at a quick glance, there appear to be at least 30. I ask hon. Members to forgive me if I do not manage to respond to every one, but I will follow up on them in correspondence if that happens.
I want to make two preliminary points before I embark on the detail of hon. Members' contributions. The first is to note at the outset the extent to which

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NICE makes its own decisions. It works independently from the Department of Health, which was a key point for us in setting up the institute. As we said in our response to the Committee's report:
"The Government made clear from the inception of NICE that the Institute would determine its own methodology and formulate advice without interference from Ministers, subject only to its Framework Document and founding Statutory Instruments."
It was a courageous decision by the Government to embark on this dangerous territory and say clearly that the institute should be independent. It was a departure from how things were run in the past, and I believe that NICE has repaid the Government's confidence. That all means that many of the Committee's recommendations are matters for NICE, and I know that the institute's chairman has responded in detail to some Members. My replies and the Government's response will also reflect the actions taken by the institute.
The second point that is worth remembering is the report's first conclusion:
"It is clear that expectations of NICE have been high, and in addition to the challenges of its remit, NICE has also faced the same logistical and operational challenges as all nascent organisations. In this context, we welcome the support we have seen for the establishment of NICE, and we recognise that this represents an improvement on the previous situation."
All hon. Members who have contributed to today's debate have welcomed NICE and seen it as an improvement, and that conclusion reflects the complexity of the task that we have set up NICE to undertake.
I would go a little further than the Committee's conclusion and say that I believe that NICE has done a very good job. It has tackled some tough issues and has been prepared to learn from its experience and interact with a range of people both in and outside of the service. There has been some criticism, some of which has been justified, but the way in which NICE has listened, responded and learned about its future work is tremendously encouraging for the health service as a whole.
I shall now turn to Members' specific points and first to the contribution of my hon. Friend the Member for Wakefield (Mr. Hinchliffe), who is the Chairman of the Health Committee. I echo his kind remarks about Lord Hunt of Kings Heath, who was an excellent Minister and tremendous colleague. He is severely missed in the Department, not least because I am now dealing with a matter that was previously his responsibility, although I am delighted to do so.
My hon. Friend raised the issue of the institute's credibility, which is extremely important. The organisation's integrity and credibility are fundamental if the institute's recommendations are to command widespread consensus and agreement. I know that the Committee raised its concern that there was not enough interaction with outside bodies such as the "British National Formulary" and the "Drug and Therapeutics Bulletin". Those points were well made and I am delighted to tell the Committee that there have been formal meetings between NICE and those organisations, which will have opportunities to make formal comments.
On credibility, the hon. Member for Romsey (Sandra Gidley), who is not present because she has had to attend another appointment, raised the specific issue of
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the Committee's change of guidance on the drug Relenza, which was highlighted in evidence presented to it, and I should like to explain what happened. NICE issued preliminary findings in 1999 and the results of its full appraisal in 2000. NICE's task is to appraise the clinical and cost-effectiveness of treatments based on the available evidence. When it first issued its guidance in October 1999, it said twat it would review the guidance after the flu season in the following year.
The 2000 guidance was different from the 1999 guidance because new evidence had become available. At that point, NICE said that the treatment would benefit small, at-risk groups. The guidance was not that the treatment was good to use across the board, but that it might be useful for particular at-risk groups. That the experts could not agree on the precise guidance reflects the complexity of the issues. I should not want that specific, one-off issue to undermine NICE's credibility. Hon. Members are right that credibility is very important.
My hon. Friend the Member for Wakefield went on to raise the issue of inclusiveness. Trying to ensure that as broad a sweep of stakeholders as possible is involved in discussions with NICE is a fundamental tenet of the institute. There have been some improvements to try to ensure greater dialogue such as the change in the topic referral system, the widening out of the stakeholders from the NHS and the increase in stakeholders from patient and carer groups. We welcome the Committee's recommendations on involving stakeholders. In March last year, consultation, which is due to be completed in November this year, began on how NICE involves stakeholders. The review will take account of the recommendations from the Select Committee on Health. The widening of stakeholders is extremely important.
My hon. Friend raised the issue of independence, which, as I said at the outset, is extremely important. The Committee has recognised the difference, which goes to the heart of the independence debate, between what the institute decides on cost-effectiveness and what the Government decide on affordability. That demarcation needs to be extremely clear. We always intended that NICE should look at clinical and cost-effectiveness because it has the expertise and the evidence base to do so. Decisions on affordability are rightly a matter for the Government and for Ministers in setting the overall budgets for the NHS and in trying to negotiate the delicate area of priorities, a point that I shall further explore when I comment on the contribution from the hon. Member for Oxford, West and Abingdon (Dr. Harris).
Several hon. Members raised the issue of the monitoring of advice, which is an important subject. It concerns examining who takes up NICE's guidance, whether the guidance is widespread across the country and whether it is managing to ensure, as it is intended to, that there is equal access to new treatments and technologies. We want to ensure that the legal requirement on PCTs to make funding available to follow NICE guidance is implemented across the country. I should like to make the distinction, although it is perhaps a fine one, that the legal obligation on PCTs is to make funding available where clinicians decide that it is appropriate. We are not simply saying to PCTs that every clinician must implement the NICE guidance. The

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position is that once the NICE guidance is issued, clinicians must take it into account, but it is not an absolute, mandatory instruction. At the end of the day, the decision will always be for clinicians, but PCTs have to ensure that there are sufficient resources in the system to allow treatment to be made available on the indication of a clinician. The distinction is fine, but it is also important.
In terms of implementation, it is our view that the Commission for Health Audit and Inspection should be the principal external inspector of the implementation of NICE guidance. The details of that inspection will need to be agreed between the commission and the Department of Health. I expect that CHAI's work will cover clinical guidelines, as well as the appraisals that are integral to the clinical governance agenda in the organisation.
The hon. Member for Romsey raised the question of the role of the NHS Modernisation Agency in seeking to support the boards of trusts in making sure that they can also play a role in monitoring the implementation of NICE guidance. I understand that the national clinical governance support team is working with 215 NHS boards, right across the system. Executive and non-executive directors are being trained and supported in carrying out an analysis, in their organisation, of whether NICE's recommendations are being followed. So there is a mechanism at local level to try to ensure that that happens.
Mr. Hinchliffe: I thank my hon. Friend for a helpful reply. She may be coming on to the point that I raised towards the end of my speech about the mechanisms for monitoring the impact of NICE guidance where that guidance is affecting existing services, particularly in relation to requirements to reconfigure existing services that, if implemented, would threaten the future of existing services. Who would be responsible for monitoring such a development? Would it be the new CHAI body or the strategic body?
Ms Blears: I am coming on to address that point. I am sure that my hon. Friend will appreciate that I am not in a position today to give a definitive answer, and it will probably be a complex answer, as things in the NHS tend to be. Getting the position right will not be the responsibility of single body.
I wanted to deal with the points that my hon. Friend made about prioritisation—several hon. Members have raised that issue—and whether there should be a more explicit framework. The recommendation of the Committee in paragraphs (ee) and (ff) were around whether there should be a more explicit set of ethical and rational values and a framework for making decisions. Through the national service frameworks, NICE, the NHS plan and CHAI, we try to set a national framework for the national standards that should be available across the NHS.
There will inevitably be a tension between national standards and local devolution in terms of having a framework within which people can see what it is that they are entitled to expect and what the priorities are within the system. The analysis from the hon. Member
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for Oxford, West and Abingdon about the tensions between the national and local levels was simplistic. We are on a rolling programme towards having an explicit framework, through NICE work.
In his evidence to the Committee, Lord Hunt said that he envisaged, over the next five to 10 years, that the NICE work would be likely to cover the vast majority of treatments and services available within the NHS, but it had to be an incremental process. It would not be helpful to try to concertina that process by setting out the prioritisation at this point. As NICE goes on, and covers much more of the service, as it interacts more closely with the national service framework, as it produces its guidelines around treatments, we shall begin to see emerging a more detailed framework.
At the moment, it is not possible to create the kind of explicit framework of prioritisation that the Committee has asked for. I am sure that, as time goes on, that framework will become more populated by the empirical data from the individual appraisals that NICE has conducted, and we shall start to see much more of a comprehensive picture across the piece, but we are certainly not there yet, and we do not have the data to be able to do that now.
Dr. Evan Harris: Is the Minister saying that there is no role for Government in setting priorities in the health service and that there will just be an accretion of national service frameworks and NICE guidance? If the Government do not have a role that is based on ethical values, as the Committee recommends, why do they keep setting priorities and demonstrating them by earmarking central funds for them, or by earmarking a certain condition for appraisal or for a national service framework?
The Minister cannot have it both ways. Either the Government are involved, in which case they should be explicit and operate within an ethical framework, or they should leave the health service to the gradual gathering of prioritisations through standards.
Ms Blears: Clearly, the Government have a role in setting priorities. That is why we issued the NHS plan and the planning and priorities framework for the next three years to PCTs. They set out the Government's priorities and what we expect PCTs to deliver through their local delivery plans. My hon. Friend the Member for Wakefield discussed nine different aspects of the planning and priorities framework.
The hon. Gentleman's analysis is simplistic. He repeats the phrase, "You can't have it both ways," but in politics, as in life, the art of achieving a satisfactory resolution is striking the right balance between competing issues, which are not black or white, right or wrong, all of one and none of the other. It is a matter of bringing together complex factors and seeking to create from them a synthesis that meets the vast majority of the needs of the greatest number of people through the services that we provide.
That is a proper, grown-up, realistic and mature analysis of priorities in public services. The hon. Gentleman's insistence that it has to be either this or that, and that we cannot have a blend of national

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standards and local devolution of priorities is an extremely simplistic analysis and one that does not help in setting priorities.
Dr. Evan Harris: Will the Minister give way?
Ms Blears: I want to deal with the hon. Gentleman's point, but I shall give way.
Dr. Harris: The Minister says that it is important to have a blend, or synthesis, to ensure that we benefit the greatest number of people in the most effective way—I agree with her. What work are the Government doing—academically, through research or, indeed, philosophically—to demonstrate the values and rationale that underpin the strategy, which she claims to have developed through a synthesis of various factors, by which we seek to benefit the most people in the most equitable way by the most effective treatments? Is any work being done, or is "no" her answer to recommendation (ff)?
Ms Blears: An important part of our work is exactly exemplified by the work of NICE, which is going through that very process of examining clinical and cost-effectiveness. I shall later deal with the important point that was made by several hon. Members about quality-of-life years.
The hon. Member for Romsey expressed her concern about the time that it takes to carry out appraisals. Most appraisals take just over a year, which is, admittedly, an extremely long time. The hon. Member for West Chelmsford (Mr. Burns) said that the institute is trying to catch up with many existing technologies. We hope that it is possible to learn from experience and that perhaps future appraisals can be accelerated.
On NICE blight, the health service is under guidance to consider clinical effectiveness before NICE guidance has been issued. There is no bar to using drugs and services simply because they have not been appraised. I acknowledge that there are tensions in the system. PCTs sometimes say that they are reluctant to use something that has not been appraised. However, there is no technical bar to their continuing to prescribe and use products that have not been subject to a NICE appraisal.
Several hon. Members discussed the timing of guidance. Clearly, NICE would like to be able to issue its guidance at or very shortly after the launch of any new product. That would make the most sense, because people would then know exactly what the judgments were. The recommendation about interim guidance has been rejected, and rightly so. It would be dangerous to arrive at interim views that later have to be reversed because there was not enough information to make a proper decision.
We then return to the problem of the credibility of NICE if it were able to make anticipatory judgments that were later found not to be robust or to have integrity and had to be varied. We must ensure that the appraisals are carried out as early and as quickly as possible. When we can horizon-scan and anticipate new developments, the timing will coalesce much better than in the past.
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The hon. Member for Wyre Forest (Dr. Taylor) raised a number of important points and I am delighted with his welcome for NICE's work. He forewarned me of his intention to speak about the citizens council and I know that he has a particular interest in public and patient involvement in the NHS. I hope that he feels that we are making significant progress towards greater involvement of the public and patients in the design of services. I am delighted to be able to tell him that the first meeting of the citizens council was in November, when it met for three days of solid consideration, which is a lengthy commitment for the members. I am delighted that it had its first meeting in Salford, which is not quite the home of public and patient involvement but I like to think that we have a tremendous amount of experience. The panel consists of 30 people, balanced in factors such as age, gender, ethnic background and so on. I am told that there were around 5,000 applications for membership of the citizens council. Some people say that there is apathy in the community and that people do not want to come forward and take part in such bodies, but the number of applications give the lie to that.
I am told that the members took control of the first meeting and were incredibly articulate. Their agenda for the first meeting was to consider what factors should be taken into account when defining clinical need. Their views were preliminary, but they suggested that NICE should not take account of self-induced or inherited illness when deciding priorities and that voices should be prioritised, the first being that of patients and health professionals, the second being that of carers and the third being that of manufacturers. They had a clear view of the sort of priorities that should be taken into account.
Dr. Naysmith: They did not take age into account.
Ms Blears: I am unaware of that, but age may be a factor. I am sure that during subsequent discussions they will consider the difficult issues surrounding quality-of-life years and put their valued judgments to NICE.
The process is incremental. In the past, we had no such views in the system and I am sure that the citizens council is not the perfect answer to every democratic consideration, but it is a significant improvement on not having the voice of patients and the public heard at all.
Dr. Evan Harris: I am sure that it is a sophisticated focus group and the Minister referred to it making decisions, but what are the implications of its decisions? If my constituents want to object to a view that self-induced illness or any other illness should not be priority, how will they do that? Will the Minister ensure that there is democratic accountability in those important issues? In what way will that focus group be democratically accountable?
Ms Blears: I do not think that it has ever been asserted that the citizens council is a democratic body. Its purpose is to find out whether there is a way of ascertaining people's views. I do not think that a democratic element is always possible. We should work towards introducing as much democracy as possible into the national health service, but if it is not possible that is no reason for not trying to use citizens councils,

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patient forums and the other mechanisms that we have set up. I hope that the hon. Gentleman welcomes the citizens council as another step forward in trying to introduce other values into the system.
The hon. Member for Wyre Forest asked about the cost of the NICE guidance. Its appraisal guidance accounts for £521 million in recurrent costs, £21.8 million in one-off costs and in 2002–03 that represented less than 1 per cent. of annual NHS expenditure. Several hon. Members asked whether the cost of NICE guidance is included in the NHS budget. There are constraints on PCTs, which are under enormous pressure to try to meet all the standards set out, but the cost of NICE recommendations has been included in the spending review settlement that was allocated to the NHS. Hon. Members must accept that those costs are within the context of the biggest-ever increase in resources for the NHS, doubling the amount of money spent on it by 2008; which means average PCTs getting a 30 per cent. increase over the next three years. Inevitably, hon. Members will ask for even more resources, but at present the increases are in the context of a very favourable climate for the NHS.
We will not be able to do everything overnight, which is why there is a three-year forward-funding programme, within which we expect PCTs to start thinking about service redesign, about operating in a different way and about how to create more of a margin for health improvements and to start to work on that creativity. I do not know about the hon. Member for Oxford, West and Abingdon, but when I visit PCTs throughout the country, I find that they are increasingly working more creatively to find the flexibility to improve services in their local communities and I would encourage them to do so.
The hon. Gentleman raised the issue of topic selection. Some witnesses who gave evidence to the Committee argued that external organisations should be able to decide what topics go forward. The Committee rejected that. It said:
"We feel that this very high-level prioritisation is rightly the job of Government".
We believe that to be the case. However, NICE has four representatives on the new advisory committee and senior members of NICE meet as the joint planning group. NICE is free to propose topics in its own right; it has proposed atypical anti-psychotics for schizophrenia and the use of cannabis in treating MS, which it has fed into the programme. We expect NICE to continue to do so in the future.
The hon. Member for Oxford, West and Abingdon raised the issue of conflict between national standards and devolution, which I hope that we have already dealt
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with. He either wants targets and standards and the progress that goes with them or he wants a free for all at local level. I am not sure which it is.
Dr. Evan Harris: No targets.
Ms Blears: The hon. Gentleman wants no targets, but without targets there will be no mechanism to see whether the system is improving. A managed system is the way forward, to try to resolve the differences between the national standards and local devolution. Managing that process is the most sensible way to get the most benefit from our investment for citizens throughout the country.
I shall turn briefly to the matters raised by the hon. Member for West Chelmsford. He thought that NICE might raise unrealistic expectations because of its work. I can tell him that the Government are tremendously ambitious for the health service.
Mr. Burns: I do not think that the Minister understood; what I said was that at the time of NICE's creation, some unrealistically high expectations were established in the community.
Ms Blears: The public now have extremely high expectations of all public services, and rightly so. NICE is helping us to meet those expectations and to manage them properly.
The hon. Gentleman expressed concern about the length of time taken to carry out appraisals. As the programme progresses, I hope that the time taken will come down, although that will depend upon the complexity of the appraisals and the amount of evidence available.
Several hon. Members mentioned the need to consider issues such as the wider societal costs and the benefits of NICE, and it is right to do so. The Treasury will be issuing guidance on a new and improved way of carrying out an economic appraisal. The guidance was published on 16 January and has just been received by the NHS. It will be discussed with NICE to discover whether there is a better and more appropriate way to measure the wider costs and benefits involved. The Treasury will be concerned to ensure that we do not do any double counting; it wants a fairly rigorous appraisal and we shall ensure that it is.
NICE decisions are not based just on QALYs. It pays full attention to all the evidence that is presented to it by patient and carer groups, too. It is not a mechanistic process in which an appraisal has to get over a QALY threshold. It is more complex than that; there are more judgments to be made in the process and NICE does an excellent job of bringing all the issues together.
I thank the Select Committee for an extensive and extremely constructive report. Many of its recommendations have been helpful to the Government and to NICE. I thank all hon. Members who took part in the debate and managed to improve the Government's policy by their cautious and careful deliberations.
It being half-past Five o'clock, the motion for the Adjournment of the sitting lapsed, without Question put.