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8.47 pm
Dr. Vincent Cable (Twickenham): I want to draw together two strands from the opening speeches. The Secretary of State made passing reference to the fact that the Government were embarking on an NHS-wide standard-setting exercise focused specifically on the needs of the elderly and the treatment of old people within the health service, and the right hon. Member for Maidstone and The Weald (Miss Widdecombe) spoke on the theme of rationing. The right hon. Lady, as we would expect, made her point in a polemical way, but it would help the debate if we treated the idea of rationing not in a polemical or a pejorative way, but as a simple factual statement of what happens when there is a gap between supply and demand.
Rationing can be done well or badly, fairly or unfairly, and on the basis either of clinical judgments or of arbitrary bureaucratic judgments. I shall pursue that issue, especially in relation to the treatment of the elderly, and the way in which the Government-inspired exercise that the Secretary of State mentioned might work. Clearly, the question is about more than how rationing works. There is a resource issue, too. The gap between supply and demand will vary depending on the resources available, which is why the Liberal Democrats consistently draw attention to the under-resourcing of the system.
Some Labour Members seemed wholly blind to that problem. The hon. Member for Brighton, Kemptown (Dr. Turner), who has now left the Chamber, presented himself as an expert on cancer treatment. I am sure that he is, but he seemed wholly unaware that British funding of cancer services is seriously deficient in relation to that
of comparable western countries. That deficiency is reflected in the fact that key chemotherapy drugs are not available to British women in the same way that they are to women overseas.
There is a resources issue, but there is also a deeper question about how rationing is carried out. I shall focus specifically on how it is applied to older patients in the NHS. In principle, care is allocated on a wholly idealistic basis. The codes of conduct of the professions make it clear that clinicians should not discriminate on the ground of age or on any other basis. However, there is a growing concern among elderly people and the organisations that represent them that age is becoming a basis for rationing, often quite explicitly. To some extent, elderly people are bound to feel the adverse effects of the shortage of resources in the NHS because they use it more frequently than others--40 per cent. of the users of the NHS are retired people. However, there is growing concrete evidence of age being used as a rationing criterion.
I gave several examples of that when I introduced a ten-minute Bill some months ago, and it is worth repeating some of them because they are highly relevant to the debate. Rehabilitation programmes for people who have had strokes do not involve a great deal of resources, but a lot of research shows that many health districts and trusts use a specific age cut-off to limit the availability of the service.
Another more understandable example is kidney dialysis. The treatment is very costly and it is widely known that elderly people have great difficulty in getting on to the programmes, although all the medical evidence that I have seen suggests that they are just as likely to benefit as younger patients.
Cancer screening also arouses strong feelings. Active efforts are made to ensure that younger women are screened, but less effort is made for older women, even though the evidence suggests that they benefit just as much from early detection. That is a specific, and probably rather absent-minded example, of age-based rationing.
Drug rationing is at the heart of much of the debate. My final example relates to the drugs available for people suffering from senile dementia. There is controversy about the benefits of some of the new drugs becoming available and clinical trials are continuing, but the balance of evidence that I have seen suggests that if the drugs were widely available they would considerably reduce the damage, inconvenience and great humiliation that people suffer as a result of Alzheimer's. The drugs are severely rationed and there are enormous disparities between different areas.
The process should be more open. I hope that the Government will address the problem. I should like to hear more about what the Secretary of State meant when he said that the Government were embarking on a process of standard setting, experiment and research into the treatment of elderly people in the NHS. Part of the problem is that not enough research has been done.
Ms Julia Drown (South Swindon):
I welcome the duty of co-operation that will be placed on health authorities and others. The Labour Government are already making a difference in my constituency on that issue. Health trusts and my local social services have made it clear to me that the encouragement that they have been given since the election to get together and work in the interests of local people has made a difference to the services that they provide. I have been pleased to see the good work that is being done locally. I also very much welcome the abolition of fundholding, which not only created a two-tier service, but was incredibly expensive to administer. It is outrageous for the NHS to spend so much money on administering the scheme.
The Conservatives have claimed that GPs became fundholders by choice. I saw the performance objectives of regional health service managers when GPs were being encouraged to take up fundholding. Those objectives, presumably from the Department of Health, clearly stated that the proportion of fundholders in the area had to be increased.
That was a funny way of creating a simple, open and rational choice for all GPs. If one really wanted a fair choice for GPs, one would not give preferential grants to one group--GPs were told that if they became fundholders they would get extra money for computers--and one would not tell health authority managers that they must increase the number of fundholders in their area.
The Labour Government's approach, creating primary care groups instead, strikes me as far more sensible and rational. To reduce the number of commissioning groups from 3,000 to about 500 is obviously a way of reducing bureaucracy, yet ensuring that a much wider group of people in each area can have an influence on the health care that is provided. I congratulate the Government on not limiting the system to GPs. Community nurses and other lay members can have an influence, and that is much better than the narrow focus instituted by the Tories in the fundholding scheme.
I welcome the Bill's emphasis on quality of care and the introduction of the Commission for Health Improvement, but I seek clarification on several points. Users, carers and patient groups want to be sure that their views will be included in discussions on their local health services in the new NHS. I agree with that aim, but will it be best achieved by creating a legal duty or by providing guidance and spreading best practice?
Under the National Health Service and Community Care Act 1990, there is a legal duty to consult various people, but that has given rise to some bureaucratic exercises in which a glossy 200-page brochure has been sent to every single voluntary organisation in an area, many of which simply do not know what to do with it and certainly do not have the time to examine it in any detail. That is not necessarily the best way of achieving real consultation. We must find out what works and ensure that the views of users, carers and patient groups are properly taken into account.
I seek clarification about the membership of primary care groups and trusts. The NHS is much more than doctors and nurses, and one of its great strengths is
teamwork, with the input of all the different professions, giving the best patient care to everyone. It is important, if all the needs of all the different areas of the country are to be met, that the membership of the groups and trusts should not be set in stone, but should be able to change and be fluid over time.
Physiotherapists, pharmacists, health visitors, occupational therapists and midwives all have much to add and can greatly influence and improve primary care services. I am not asking for guaranteed places for members of each of those professions, as what works in one place or time may not work so well in another, but we need fluidity to get the best out of primary care.
I seek clarification on the duty of trusts to be responsible for the quality of care that they provide. For me, quality of care is not about producing glossy documents to match the glossy annual accounts that many trusts now produce; it is about listening seriously to patients and users views on the services provided by their local trust and about seriously challenging the results of clinical audit in every single trust.
I hope that the responsibility for providing quality of care will be extended in time to all aspects of the NHS and to the private sector, but I am not convinced that now is the right time to put the details of that implementation into law. It is the right time for the Government to make a commitment to ensure quality of care across the board, whether by the NHS or by the private sector.
Other hon. Members have said that regulation of quality of care should be applied in the same way to the private sector as the Bill would apply it to the public sector. The Health Committee is considering this issue at the moment and I still have an open mind as to the best way forward. There are attractions in having the same body to regulate both the public and the private sector, and some people have suggested that CHIMP should be the organisation that reviews all health facilities. However, significant difficulties would need to be overcome. First, part of the private sector is already monitored by a separate body, and it is proposed that it will be monitored by regional commissions for care standards. Secondly, the private sector does not work in the same way as the NHS. In the private sector, a lead consultant will book a session in a theatre and does not work in a team with junior doctors. That alone suggests that the arrangements should be separate. Thirdly, many patients go to the private sector because they want something different. We would need to think about those issues carefully before we apply the same rules to both sectors.
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