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Mr. Bercow: My hon. Friend is making an important point and I should like to clarify one aspect of it before he moves on. Does he agree that the only way in which the Government can refute the charge that he has made about their reasoning in creating NICE is to confirm this evening that there will be no private discussions between Ministers and the chairman of NICE and that their content will be disclosed publicly?
Mr. Hammond: My hon. Friend is right. That would be one way in which the Government could provide some reassurance about their intentions for NICE, but I say again that NICE, despite its rather overblown title, was conceived as a vehicle for assessing clinical and cost effectiveness, which was a sensible idea. However, what happens with that information afterwards might become dangerous. That is essentially a matter for the politicians and it is extremely important that we keep the distinction between what they decide and what information the
technical experts and advisers can bring to us, better to inform our debate about the way in which to use the limited resources available to the NHS.
Mr. Swayne: On the suggestion of the chairman of the national institute that it might have to recommend that a treatment is too expensive, the current situation is that many health authorities have made such a decision, which has given us the horror of treatment by post code. By transferring that responsibility to the national institute, we are in effect ensuring that such treatments will be available within no post code whatever.
Mr. Hammond: My hon. Friend is exactly right. The Government have said that they want to reduce regional disparities, but they are unable to put forward a convincing argument that the advice of NICE, properly implemented, will not inevitably mean a levelling down of services.
The Government have not said that they will make funds available--they have been given plenty of opportunities to give us that assurance--to enable best practice on every drug to be followed nationally as a result of the initiative to eliminate regional disparities. If the budget is not to be expanded, and if the service is to be increased in other areas, it is logical that the availability of some treatments will inevitably be reduced. The Government cannot have it both ways: they cannot eliminate regional disparities and also assure us that the purpose of their reforms is a levelling up of service.
I accept new clause 4 for what it is, and I think that NICE works well in that role. However, my criticism of new clause 4 is that it begs the question whether we should assess treatments, interventions or drugs that are available for a condition if there are no alternative treatments against which they can be appraised for clinical and cost effectiveness.
That brings us right back to the original question of how we are to make rational rationing decisions in the NHS, recognising the overall resource constraint. Beyond the role that new clause 4 would cast for NICE--that of assessing the relative clinical and cost effectiveness of different solutions to the same problem--we would need to debate the question of how we go about assessing which areas should or should not be prioritised if there is only one solution to a problem and it is very costly and there are a number of such problems and not enough resources to allow all the demands for treatment to be met. There may be many answers to that question, but the position is pretty clear to anyone who has considered the scale of the problem and the funding gap were there to be--as Ministers would like to believe--no rationing in the NHS. The problem could certainly not be solved with the product of 1p on income tax, which is the standard Liberal Democrat response to these difficult questions.
The technical input of NICE would be extremely welcome and useful in that debate if we could solve the political questions of how the total budget should be divided up and how we should deal with the overall resource limitations. If we had a good mechanism for doing that, it would presuppose that the Government recognised that there was an issue to be addressed. Politicians should not shunt decisions on to NICE. We must set the framework, and then let the experts deal with the technical questions.
I cannot be quite so complimentary about new clause 14. New clause 4 is worth while, but its provisions would be unravelled by new clause 14. The first two subsections are unexceptional. They require NICE to meet in public and to publish a report annually. Both themes were pursued in Committee, with the objective of making the processes by which difficult decisions are made more transparent and understandable to the public, who feel the impact of those decisions.
Subsection (3) of new clause 14 proposes:
Mr. Hayes:
As well as compromising the empiricism of that professional body, might not the notion of public consultation that my hon. Friend describes be interpreted by the Government--but no one else--as an alternative to a proper, full and open public debate? Is not the proposal a sop to public consultation rather than the proper debate that should be taking place in the wider community and in this place about the key priorities that my hon. Friend identified earlier?
Mr. Hammond:
My hon. Friend is right. We must never be trapped into believing that, because NICE exists and will examine the issues objectively, there is no need for a wider debate on the rationing of resources in the NHS.
The experience of public consultation in prioritising health care is not particularly happy. Most people who are interested in the subject will think immediately of the Oregon experiment. I suspect that none of us was impressed by the priorities that the public in Oregon gave for publicly funded health care. A straw poll of Members of Parliament would probably put cosmetic breast surgery a lot further down the list than the citizens of Oregon did. I caution the hon. Member for Oxford, West and Abingdon about the usefulness of a crude public consultation exercise.
New clauses 4 and 14 appear to contradict each other. New clause 4 rightly emphasises that NICE should stay out of the political debate, but new clause 14 would send it straight to centre stage.
Mr. Bercow:
My hon. Friend is invariably courteous in exchanges in the House. Perhaps I can try to decipher what he is saying. Is he telling the House, in his
Mr. Hammond:
I leave it to my hon. Friend to decide whether it is vulgar and unworthy. In fairness, the desire for public consultation at all stages and on all issues is almost a mantra with the hon. Member for Oxford, West and Abingdon. In some cases, we have disagreed with him because he has suggested taking that process too far. He has a genuine desire to have some public input into the debate and we believe that that will be required, but we also feel strongly that their input should not be to NICE but should run in parallel with its work and inform the political process.
Mr. Hayes:
Is my hon. Friend saying that although the hon. Member for Oxford, West and Abingdon is implicitly unworthy by being a Liberal Democrat, he is personally incapable of vulgarity?
Mr. Hammond:
I shall move on from that subject. I detect a certain muddle in the juxtaposition of new clauses 4 and 14. None the less, new clause 4 has served a useful purpose in allowing attention to be drawn to the gap between the role that the Government have consistently implied for NICE and the one that we fear may evolve, by design or by chance, and which its chairman has acknowledged will be a potential issue.
New clauses 16 and 17 deal with a separate issue that is another example of the working of the rationing agenda. The two new clauses, as the hon. Member for Oxford, West and Abingdon acknowledged, have been driven by the public debate over Viagra, which has raised awareness in the popular press and the public mind about some issues that might have remained obscure had they been discussed only in connection with beta interferon and the other drugs that were mentioned earlier.
By focusing the debate on Viagra, the popular press has moved forward the overall debate about rationing and the mechanisms by which rationing decisions are made. As has been mentioned, the courts have become involved in the debate about the availability of Viagra and have sent a message to the Secretary of State for Health about what he may and may not do in the exercise of his powers.
It is important for hon. Members who were not present in Committee and have not had the opportunity to consider the Bill in as much detail as the rest of us to set this issue in the context of wider concern among general practitioners about the undermining of their freedom to prescribe and threats to their independent status. As we move from GP fundholding to the new system of primary care groups and, ultimately, primary care trusts, it becomes important to maintain the confidence of GPs that the system will protect the important role that they play.
The Government have implicitly recognised the concerns and apprehensions of GPs. The first sign of that was when the former Minister of State wrote the now famous letter to the chairman of the general practitioners committee, and there have been various attempts since--not least by the Minister himself a few weeks ago--to reassure GPs about what the transition to primary care trusts would mean for them.
"The Secretary of State shall establish a public consultative committee in relation to the Authority, which shall have the duty of advising the Authority on the public's view on the priority to be accorded to different treatments and clinical interventions within the NHS."
I was disappointed to read that, because it goes against the grain of new clause 4, which would make NICE an objective and technical body that weighed up the clinical efficacy and cost effectiveness of treatments. Feeding the result of a public consultation exercise into NICE's decision-making process would be dangerous, because it would introduce an element of subjectivity that is properly the domain of politicians. It would be better for NICE to consider the relative cost and clinical effectiveness of various treatments and for another body to consult public opinion. Both those strands of information could feed into the political decision-making process. The Secretary of State must ultimately make the decisions.
8.45 pm
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