| National Institute for Clinical Excellence (Establishment and and Constitution) Order 1999
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The Minister of State, Department of Health (Mr. John Denham) rose—
Dr. Evan Harris (Oxford, West and Abingdon) rose—
5 pmMr. Denham: I am happy to give way to the hon. Member for Oxford, West and Abingdon (Dr. Harris). Dr. Harris: I am grateful to the Minister. We agreed earlier that because I had some substantive questions, I would table them early to allow him to compose his replies. I was grateful for that opportunity. I shall deal with my questions on the text of the orders and then make a few general comments, some of which have been provoked by the Conservative spokesman, the hon. Member for Runnymede and Weybridge (Mr. Hammond). I agree that paragraph 3 of order No. 220 is grossly inadequate as an overt way of saying what the institute will do. Even if the matter did not involve rationing and was all of the worthy things that the Government talk about, while not using the R word, it is such an important issue for the health service that it is right and proper that it should be discussed openly and subject to scrutiny. I plead with the Minister for time for a substantial debate, preferably on the Floor. It does not have to be partisan, although that may be inevitable, given the importance of the NHS. Beneath the party political point scoring, there are important issues to discuss. One of the most important matters for the future of the health service is how this issue is handled. It deserves parliamentary time, which is difficult to achieve without a framework set out in orders or regulations—or, preferably, primary legislation. The Liberal Democrats would co-operate on a Bill that would allow an informed debate in Committee or on Report. The error pointed out in order No. 260 by the hon. Member for Runnymede and Weybridge is there for all to see. We noted it, too. My specific questions refer to paragraphs 2 and 3. We note that seven members, a chairman and four officers will be appointed by the Secretary of State. We have seen draft consultation papers on who might be appointed, but we are anxious to ensure that there is patient input into such a body. It would be welcome if that could be specified at a senior level. Perhaps the vice-chairman could be from one of the patient groups. Representing the diverse interests of various patient bodies is a large responsibility for one person, or even for two people on a partners council. We want to ensure that seniority is given to such a patient voice, and I shall be interested to hear the Minister's comments. Another matter that concerns us is whether the meetings will be in public. In the appraisal committee, some issues may involve commercial confidence in respect of pharmaceutical companies or bodies that produce treatments, interventions, mechanical or medical devices for use in the health service. As such matters are a horizon-scanning exercise, such substances will not have been marketed. Some of the information may be share-sensitive. I accept that some of the evidence should not be available in the public arena. I shall discuss the drawbacks later, but because of the way in which the Government are handling rationing, it is important that such meetings of the main body are held in public and that there are papers available to inform public discussion. Commercially sensitive data may have to be expurgated from those documents, but the people looking at the functions of this important body, which will deal with details of cost effectiveness, should have access to them. Liberal Democrats want clear reassurances from the Minister that there will be freedom of information—I am sad to say that legislation to that effect has not yet been enacted—about the national institute, and that details of it will be open and explicit. We are also concerned about the
which is the title of regulation 12. That relates to how it would be possible to bring in the expertise of clinicians, given that it may be felt that their research, staff and time are funded by pharmaceutical companies that have an interest in the national institute's findings. Two extreme approaches could be taken. One is that someone with a financial interest should immediately leave the room after declaring that interest when any matter that might relate to a pharmaceutical company is raised for discussion. The alternative, which I prefer, is to veer towards the other extreme and recognise that the state of basic science in universities and in the NHS is such that it would be in direr straits without the input of pharmaceutical companies. It should also be recognised that it is unlikely that the national institute will get the best advice if it shuns people who have engaged independent or other research for such companies. It is important that their expertise is used. Clearly, any such interests should be declared. However, if post-doctoral students, half a day of whose time might be funded for research by a pharmaceutical company, had to leave the room, they would be incapable of providing much-needed input. We will look for a rational approach. We shall not point fingers at interests that exist, provided that they are declared and registered and exist from the outset. We live in a world where much of the clinical expertise is rightly sought not only by the NHS and Ministers, but by pharmaceutical companies. Mr. Hammond: I would like to associate the official Opposition with the hon. Gentleman's remarks. I read carefully the provisions on interests, and came to the same conclusion as he did. Therefore, I decided not to mention it. We also think it very important that people with relevant information and knowledge are included. Dr. Harris: The main issue is the nature of such decisions. The contribution of the hon. Member for Runnymead and Weybridge was interesting, and his points are valid, but Conservative Members must recognise that those points were equally valid ones, two, four or six years ago. To conservative Members' credit, they recognise that the issue is not new under this Government, and that they might have been more explicit about it. Liberal Democrats were concerned about the issue under the previous Government, and we raised it early in this Parliament. Our questions have been taken up by Conservative Front Benchers. We aim to be constructive. We do not see the rationing issue as a way to beat the Government over the head. Instead, we argue that recognising the situation would save the health service from the clutches of privatisation. If people do not understand that they will not receive some treatments until those treatments have been denied them—despite the fact that they have paid their taxes—they will be disillusioned. If they can afford to go private, or make sacrifices to do so, they will resent paying for private health care in addition to their taxes. They will be more unwilling to pay the taxation needed for the health service. Although the Government's intentions towards the health service are honourable, they may be killing it with kindness by denying that rationing takes place. They do not allow the public to express the view that more money should be spent on the health service—not only through the cumulative £21 billion of the comprehensive spending review, but through incremental increases that would raise the share of gross domestic product spent on health. Such increased funding would mean that any rationing decisions would be on minor issues, not fundamental issues of effective treatment that the NHS cannot afford. If the Government acknowledged that rationing exists and said that if people agree to pay only a certain amount of taxation, they will get only a certain amount of NHS services, there may be—I would hope—a clamour for fairer taxation and spending on the NHS so that we would not have the sort of rationing decisions on vital treatment that we currently face. An alternative view, proposed by the Conservatives, is that we should abandon public funding of the NHS and collect extra money from private sources. That is a rational view although I do not agree with it; it threatens the NHS. It would require rationing to be made explicit so that people could plan their private provision. I do not believe that asking people not to use the NHS solves its problems, but perhaps the hon. Gentleman will clarify his party's position? Mr. Hammond: While that is a view, it is not the view of the Conservative party. My right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) who has unfortunately had to leave the Committee, has already said that a future Conservative Government would commit themselves to year-on-year increases in tax-funded spending in the national health service. Dr. Harris: As the hon. Gentleman knows, the Government promised year-on-year increases in spending in real terms. They could be met by a 1p above inflation rise in spending. Mr. Ronnie Campbell (Blyth Valley): Is that the penny? Dr. Harris: It is not the penny on income tax that my party proposed and which is ever-needed in my constituency. If the hon. Member for Blyth Valley (Mr. Campbell) had community hospitals threatened with closure and patients being denied treatment that is clinically necessary and cost-effective, he would not pour scorn on the idea that we need more funding for our public services. However, I shall not stray on to that issue. The Conservative party has said that rationing should be recognised and that it will offer year-on-year increases in public spending, which is not much when a 3 per cent. increase in real terms is needed for the NHS to stand still in terms of wage rises, the price of new drugs and demographic changes. The proposed real terms increases are no comfort to the NHS. If we are to have an honest debate, we must recognise that. Before deciding how to fund an NHS that no longer has to ration such treatments, we must recognise that the pot is not big enough to deliver universal and equitable health care that is free at the point of delivery. Anyone having to pay prescription charges who is just outside the catchment net will know that the NHS is anything but free at the point of delivery. I have made the case for recognising that rationing exists so that we can have a debate of it. The Liberal Democrats have made an offer to the Government to take the debate out of the party political arena into a standing conference, with other sources of input, so that it is not used as an opportunity to score points over whether promises have been kept. If we do not have that debate, the NHS will be threatened by increasing Americanisation—the better-off going private and refusing to pay twice. That brings us to the order, because given that NICE is necessary to iron out inequalities in health—I accept the Government's thinking on that—there are two ways in which it could make recommendations. It could say that new or existing treatment is not efficacious or not safe—although in that case it is unlikely to have been given a licence—and is not clinically effective because it adds nothing to the range of treatments available to GPs. There is provision in the NHS for drugs to be blacklisted on grounds other than costs. Traditionally, schedule 10 has not been solely cost-based. We believe that NICE can be a useful source of such information. As the chairman of the institute pointed out, it is peculiar that there are 167 guidelines for the treatment of asthma and that various health authorities are having to re-invent the wheel. With regard to clinical effectiveness, the proposal is a valuable step. NICE was originally to be set up as the national institute for clinical effectiveness. On 9 December, when the NHS White Paper was published, a press release from the Department of Health stated:
That body later became NICE. Was it originally called the national institute for cost-effectiveness, and was a clinical aspect added to it? Clearly, Government Departments have been considering the matter. With regard to clinical effectiveness, the relevant proposals could work if the decisions are made public. Policitians need not get involved in decisions about clinical effectiveness. It would be harmful if the Secretary of State defended rationing by referring to clinical effectiveness rather than to cost-effectiveness, or if he tried to hide behind clinical effectiveness by announcing, for example, that a treatment for impotence was effective in relation to diabetes but not in relation to cardiovascular disease—the evidence suggests that the reverse is the case. Politicians should not get involved in questions of efficacy—those issues are best dealt in an open debate that is clinically led but in which patients have an input. The issue should be dealt with in an holistic manner—it should not be based purely on pharmacology. NICE could also offer advice by arguing that the cost-effectiveness of a drug could not be assessed. That does not mean that the drug does not work; it suggests that NHS resources should be used on another treatment for the same condition—which may or may not be better tolerated but which was more cost effective—or that such resources should be used in another treatment area. Ministers should formally recognise the fact that the clinicians who take such decisions cannot put more resources into the system to change the variable. The democratic body that is charged with funding the health service should say, ``Experts have advised us that with the current funding envelope for the NHS, a particular treatment cannot be justified on the ground of cost-effectiveness.'' Limited drug budgets and the fact that health authorities have to balance their books mean that such steps are already being taken, although political accountability is not involved. If the Government were to introduce political accountability in this context, we should welcome it. We therefore give half a cheer for the Government's approach to sildenafil—Viagra—which is a treatment for impotence. The Government took responsibility for saying that we should not spend more in that context. However, we are concerned about the fact that they cloaked their decision in an inequitable system for establishing who should receive treatment. That system cannot be defended on the grounds of ethics, equity or efficiency. However, the fact that the Government took responsibility was welcome, and I hope that the matter will be further debated. The guidelines that are produced should inform NICE and its constituent bodies that any advice that is based on cost-effectiveness should be subject to a ministerial announcement and to the Minister's taking responsibility for the fact that cost is a factor. Politicians should not normally interfere in questions of clinical effectiveness. Could that proposal be included in the documentation? I should be happy to write to the Minister about it. Rationing, the inequities of service provision and the fact that certain provisions cannot be made for reasons of cost-effectiveness must be seen to be politicians' responsibility. Their responsibility should not be hidden behind other bodies, such as health authorities, GPs or clinically-led bodies, including NICE. On that basis, we give half a cheer for the establishment of NICE, but we hope that the Minister will take on board our valid concerns not only for those concerned solely with party politics but for professionals and patient groups.
5.19 pm
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| ©Parliamentary copyright 1999 | Prepared 11 March 1999 |
