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Mr. Fabricant: Does the hon. Gentleman not consider that there are parallels with a cost-benefit analysis that the Government should undertake regarding the free provision of nicotine replacement therapies in order to reduce the cost to the national health service of treatments for cancer and pulmonary and other dysfunctions caused by tobacco smoking?
Dr. Harris: I agree with the hon. Gentleman. My point is reinforced by Stephen Thornton, who is quoted in an excellent booklet produced by the Association of the British Pharmaceutical Industry and authored by Chris Mihill, a well-regarded former medical correspondent on The Guardian. Stephen Thornton, the chief executive of the NHS Confederation, is reported as saying that he
- "doesn't think the savings from other budgets, such as social services or social security, will revert to the health service, even if they could be fully quantifiable."
- "If patients go back to work and pay taxes, the money goes to the Treasury, and when does the health service see that? It's an argument the Health Department must have with the Treasury,
- that investment in the health service produces economic benefit. But at the moment, from a GP and trust point of view"--
- "if it's outside the health sector, it's money which we can't have."
7.45 pm
Mr. Bercow: The hon. Gentleman has largely dealt with the point that I proposed to raise. Does he agree that, on the basis of ministerial pronouncements thus far, it would appear that Ministers intend to adopt a very narrow interpretation of cost-effectiveness? Although they have not excluded the consideration of social factors, the Minister has attempted to play them down on several occasions. That is a worrying portent for the future.
Dr. Harris: I have read the Minister's responses to Adjournment debates about multiple sclerosis, and I have listened carefully to his comments in previous debates. I remain optimistic that he will recognise the concerns that we have highlighted and will confirm now that, in their response to the consultation on NICE, the Government will give the institute adequate resources so that it may undertake true cost-effectiveness work. Narrow cost-effectiveness measures will not be fair to patients or to those seeking to develop new treatments.
Regardless of how the Minister deals with the problem of cost-effectiveness, I hope that it is clear to all--I trust the Minister will agree--that it cannot be right for NICE to set out guidelines preventing or advising against use by the NHS of a drug or other treatment when it is effective and cost-effective but when the take-up of that treatment would adversely affect the NHS budget. That is a consideration for Ministers, but NICE would be abusing its power if it were to restrict the use of cholesterol-reducing drugs, for example, that would prove both effective and cost-effective in the long run by reducing cardiovascular mortality and morbidity simply because it would have significant cost implications for the NHS.
If such restrictions must be made, the Government should say that the NHS cannot afford to provide the treatments out of current resources. We could then debate publicly how much the Government should spend on the NHS or, as the Conservatives would have it, how much use those who can afford to should make of the private sector in order to create more space in the NHS. We believe equity dictates that there should be much more funding for the NHS, but that is a matter for another debate. The key point is that the public have a right to consider that issue. Even if new clause 14--to which I shall turn in a moment--is agreed to, I do not think the public will have much of an idea about the pronouncements of academics and others from NICE.
I believe that the Government adopted the correct position on Viagra. That was a pure case of rationing on the grounds of affordability, and the Government were right not to impose restrictions through a covert health service circular or through some quango, although there were some problems. I seek the Minister's assurance--we
have not received such an assurance from the chairman of NICE--that the institute will not apply the criterion of affordability when considering effective and relatively cost-effective drugs. I will be happy if the Minister will provide that assurance. I know that many, if not all, clinicians, as well as those who take a sensible and mature approach to the difficult question of prioritisation and deprioritisation, will be relieved to hear that the Government are taking a responsible view of where political accountability lies.
We discussed proposed new clause 14 in the Third Standing Committee on Delegated Legislation on 10 March this year, when I asked the Minister whether meetings of NICE would be open to the public. He said that I was
Subsections (3) and (4) of new clause 14 set out a way in which the public can be involved in decisions relating to NICE. It is important that the public have a say in the issues that the institute should consider because we have to find a way to involve the public in decisions on rationing.
Mr. Bercow:
The hon. Gentleman is making a powerful point about public involvement and the need for accountability. Does he agree that the machinery of consultation and public involvement is likely to be effective only in so far as there is a guarantee from the Government that there will not be private words between Ministers and NICE, the purpose and effect of which will be to disregard the outcome of the consultation and, in other words, to make it a sham? Do we not need to be reassured that under no circumstances will that happen?
Dr. Harris:
That is a very important point. The decisions about which treatments, processes and drugs the institute should consider should be made openly. There should not be seen to be collusion between what is supposed to be a semi-independent health service body--a special health authority--and Ministers. If Ministers are to give directions, which they may feel is their right, they should do so openly and in consultation with the public.
Many people have called for the public to be more involved in such decisions. In the Standing Committee that considered the statutory instrument, to which I have already referred, the Minister said:
Mr. Hayes:
The hon. Gentleman is making a good case for a wider debate about this matter, and he is right to do so because some of the institute's judgments will not be clinical but ethical or moral in a broad sense. Is that open and public debate helped by Ministers' continual denials that those restrictions are not already operating? The truth is that there is already rationing. One can euphemistically call it strict management of resources, as the hon. Gentleman has done--I understand why he has done so--but continual denials that those choices are already being made does not help the process of public, open and honest debate that the hon. Gentleman is advocating.
Dr. Harris:
I agree with the hon. Gentleman, and both Opposition parties have initiated debates on that. There is scope for a separate debate on the workings of the national institute, but I am keen to make progress now. I hope that by making points that hon. Members agree with, I shall enable them to restrict their comments so that we can make quicker progress.
On public accountability, the Consumers Association's magazine Health Which? pointed out that, in its survey, three quarters of the people who were interviewed felt that the public should have a say in which services were available on the NHS, but only a third of the 35 health authorities surveyed made any mention of public consultation in their material.
Oxfordshire has a priorities forum that is open to the public, and I attend that forum to find out exactly what is happening in health service rationing. I can assure the Minister that the word "rationing" is used by all the people in that forum, whether they are professionals or lay people. I know that Buckinghamshire and other health authorities try to involve the public. However, that is not sufficient public involvement. There should be a national scheme to mirror those local arrangements. We support the Consumers Association's call for wider public involvement.
I press on now to new clauses 16 and 17, which relate to the way in which the Government have used the scheduling procedure in the National Health Service (General Medical Services) Regulations 1992 to restrict the availability of drugs on the NHS, particularly Viagra. I make two criticisms of the Government in speaking to those new clauses. My reasons for tabling new clause 17 echo my arguments about the Government using affordability as a criterion for using schedule 10 or11 of those regulations on the basis of cost or affordability.
"right to say that the regulation as drafted does not require public access to meetings of the institute's board. There is a case for that in the climate of openness and transparency, as he said, although he also acknowledged that issues of confidentiality would need to be protected."
He continued:
"If the matter proved in practice to be a problem, it could be dealt with by further regulation."
I say to the Minister that it is not a question of whether there is a problem in practice, but making public access subject to matters of commercial confidentiality should be a default principle. The Government should ensure that meetings are held in public unless there is a reason why they should not be. I look to the Minister to reassure us that the public will normally be admitted to the board's meetings and that the Government will introduce regulations to ensure that, so that I will not need to press that part of new clause 14.
"I confirm that it is important that patients' interests are represented in all NICE's work. From a patient's point of view, quality has sometimes been neglected in the drawing up of
14 Jun 1999 : Column 82professional guidelines in the past."--[Official Report, Third Standing Committee on Delegated Legislation, 10 March 1999; c. 18-19.]
By having not only lay representatives on the institute's board but a public consultative committee for the authority, we shall ensure that the institute's deliberations are seen to be publicly accountable in a way that, with the best will in the world, one could not guarantee if there were only a cosy arrangement between the Minister and the institute.
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