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Mr. Bercow: There is a respectable argument for the view that my hon. Friend is expressing. I think that, essentially, his thesis is that, if there is competition and local flexibility, the best will tend to drive out the worst, or, at least, that the better will tend to drive out the worse. Is that what he is suggesting?
Mr. Brady: That would tend to be the case, but, more fundamentally, it is appropriate for local communities to have some input into the decision-making process, and for a health authority to be able to set priorities different from those of a neighbouring health authority if the population that it serves wishes.
Mr. Bercow: There is an argument for that. However, it is important that, if such arrangements are to be instituted, the forum in which such decisions are taken does not become dominated by the activist who is willing to attend most regularly. There must be a check on the idea that, simply by packing a particular meeting, for example, one view can hold sway, even if the validity of that view turns out, on later inspection, to be outweighed by that of another. I am not averse to what my hon. Friend is suggesting, but I think that we could get into difficulty unless we very carefully consider the constraints within which such local discretion is operated.
Mr. Swayne: Will my hon. Friend bring his precise use of language and analysis to bear on the problem in the way that I suggest it is defined now? The easy bit is to decide, on the basis of positive science, whether a treatment is clinically effective. The question whether it can be afforded is a normative question, requiring a normative judgment, and our difficulty is finding the forum in which that normative judgment can be made. In putting together the Bill, the Government have run those two functions together into NICE, and it is entirely inappropriate for that one body to try to fulfil both the positive and the normative role.
Mr. Bercow: My hon. Friend makes a powerful point. There is no sense in which we can honestly say that a specific treatment cannot be afforded. In fact, although we might not realise it, it constitutes bad faith so to argue. In practice, the Government do not go bankrupt any more than local authorities, the creations of statute, do, so it follows that, in the final analysis, the judgment is about whether we want to afford a specific treatment or whether we prefer resources to be directed to the provision of an
alternative treatment for the same condition or for an entirely different one. Therefore, I accept the thrust of what my hon. Friend is saying.9.45 pm
I have spoken about a situation in which there is unanimity of clinical judgment that is ignored or, worse, scorned by administrators or politicians. However, the argument can be taken a stage further. I have made the point to the Minister before. I do not recall that he had an effective response to it, which rather suggests to me that he did not. If he had, I think that I would remember it. I do not, so I do not think that he possessed such an answer.
What about a situation in which there is no unanimity of view, but individual clinicians are advising what they think is right for their particular patients? In the debate on 14 May, in which I raised the problems of multiple sclerosis sufferers in Buckinghamshire, the Minister said quite reasonably to me and to the House that he recalled that the four neurologists in Buckinghamshire who were consulted about the efficacy of beta interferon disagreed. He said that given the difference of opinion among the four consultants, it was not surprising that a decision to fund on a significant scale by the Buckinghamshire health authority had not yet been made.
I see the hon. Gentleman's point, but I hope that he will not use the fact of differences of opinion among respected consultant neurologists as a justification for the denial of funding. In short, just because one neurologist does not think that the treatment is generally effective, or concludes from his analysis that it would not be efficacious for his particular patient, that does not mean that it should be denied to others.
If another neurologist, readily accepting the drug's inappropriateness for other patients, said, "Ah, yes, I accept that, Minister, but beta interferon will be efficacious for my patient", does the hon. Gentleman accept that that judgment should be respected? Does he agree with the proposition that where the neurologist judges that the provision of beta interferon will be clinically effective, it should ordinarily be prescribed? The hon. Gentleman does not answer. He is mute. The position is fixed. The head does not move. There is no flicker of emotion or indication of stance from the hon. Gentleman. I shall wait patiently for his winding-up speech.
I have on previous occasions worried that at a late hour, Ministers might inadvertently neglect to respond to the points that my hon. Friends have made.
Mr. Eric Forth (Bromley and Chislehurst):
No. Surely not.
Mr. Bercow:
My right hon. Friend cavils at the suggestion that a Minister might inadvertently fail to respond to a point. I have the highest regard and affection for my right hon. Friend. Not every hon. Member or every current Minister can match his high standards. Just because he has instant recall, never forgets a point that is put to him, and is unfailingly effective and courteous in his response to any challenge, does not mean that he can demand or expect the same high standards of members of the new Government. My right hon. Friend had a number of years experience--[Interruption.]
My right hon. and learned Friend the Member for Sleaford and North Hykeham (Mr. Hogg) says from a sedentary position that my right hon. Friend the Member for Bromley and Chislehurst (Mr. Forth) may expect such high standards. He might expect them, as my right hon. and learned Friend points out, but he assuredly will not get them. It is possible that Ministers will neglect to respond to particular points.
I challenge the Minister, when he replies to the debate, to give me an answer to this question: does he agree that where a consultant neurologist believes that the provision of a treatment is clinically appropriate, it should ordinarily be prescribed? If he does agree, the hon. Gentleman will have made an important admission. The fact of differences of opinion does not mean that the judgment of an individual consultant neurologist in respect of a particular patient at a given time, possibly for a limited period, should not be respected. Rather, it tends to imply that that judgment should be respected and translated into practice.
I challenged the Minister on 14 May to make it clear beyond peradventure that the period between now and the issue of new guidance by NICE should on no account be used by any health authority to justify the reduction, still less the withdrawal, of funding of beta interferon. That goes to the heart of the issues raised by the hon. Member for Oxford, West and Abingdon.
I believe that the Minister gave a categorical assurance on that point, saying that until the new guidance comes forward the November 1995 guidance in the Government's circular should be honoured. I was grateful for that. So we assume that, for the time being, on the basis of a judgment about clinical effectiveness, neurologists should be free to prescribe and the drug should be available.
We now come to the question of the National Institute for Clinical Excellence and how it will operate. I should like to think that the institute will be absolutely independent, free to make judgments about clinical appropriateness and not subject to public or private pressure of any sort from Ministers or officials in the Department of Health.
It was because I wished to establish the status of NICE and the freedom that it would have to make recommendations and to issue guidance that I challenged the Minister on this point on 14 May. I asked whether NICE would be genuinely independent. I was not encouraged by the hon. Gentleman's reply. He told me that NICE would operate on the basis of a framework agreement with the Department.
I am a new Member and, on the whole, I am inclined to give people the benefit of the doubt. I have not yet been afflicted by the world-weary cynicism that characterises my right hon. Friend the Member for Bromley and Chislehurst. However, I smelt a rat. I detected a desire by Ministers to ensure that the institute would not be fully independent. I did not like the talk of a framework agreement. It seemed to me that the Department of Health would be saying to the institute, "You will volunteer to agree with the Government", with the proverbial gun being held to its head.
Mr. Forth:
Will my hon. Friend give way?
Mr. Bercow:
I shall readily give way to my right hon. Friend, who is wearing a particularly fetching tie.
Mr. Forth:
If a word from the very old to the very new would be helpful, may I point out to my hon. Friend--he seems uncharacteristically to have missed this opportunity--that any Minister must have regard to the financial aspects of his policies? Therefore, it must be inevitable that real financial constraints must be placed on the policy that we are discussing from the outset. My hon. Friend seems to be suggesting that "framework" is being used to disguise real financial constraints, which will inevitably operate on the apparent clinical neutrality of the new organisation.
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