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Dr. Palmer: Before my intervention, I should mention that I advise Novartis; it could conceivably be relevant.

The hon. Gentleman appears to say that it is reasonable for NICE to compare the cost-effectiveness of one treatment against another to guide local health authorities,

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primary care groups and so on, but that NICE should not look at the cost-effectiveness of treatments if there is no comparable treatment. I do not quite see why he makes that prime distinction, especially as he admits that what he calls rationing--what I would call prioritisation--is inevitable in any health care system. I would have thought that primary care trusts and others would welcome guidance on that point.

Dr. Harris: There are two points there. The hon. Gentleman talks about prioritisation. That is a bit of a spin statement in itself because prioritisation implies "posteriorisation." No one ever talks of the procedures that we are going to posteriorise--that we are not going to fund when we fund specific treatments that we wish to prioritise. I think that he will accept that it is important that we recognise that the patients at the sharp end who get the posteriorised non-treatment do not see the prioritisation--they just see that the treatment is not available to them.

The point I am making is that it is difficult to look at cost-effectiveness when there is no existing treatment. For example, beta interferon is the only treatment that interferes with the disease process in multiple sclerosis and can, for certain patients, give benefits, so comparing that with something else is difficult. The cost of that is £10,000 per year, which is deemed to be too much by health authorities, yet the annual cost of dialysing a 30-year-old to keep that person alive is £30,000. On that basis, the hon. Gentleman is suggesting that we should divert all funds from dialysis, which is perhaps the most expensive treatment in terms of life years saved, to things that currently are not funded per life year saved and where the amount is lower; for example, Riluzole for motor neurone disease, or beta interferon for multiple sclerosis.

Some of the new taxane drugs for chemotherapy do not cure. The argument is about their indications in metastatic cancer, which is effectively incurable, and whether they should be first line. There is strong evidence--it is used overseas for the purpose--that first-line treatment with taxane can add years to life at a cost of about £10,000 per year. Again, that is not funded by some health authorities. The question is: if we ask health authorities all to fund it within the same cash envelope, what will they not fund? That choice has to be recognised.

If the things that the health authorities then do not fund are not acceptable to the electorate, the electorate might support a party that calls for higher funding, the things that are not funded being less unacceptable. If they think that, in the round, it is acceptable--that degree of rationing is the level that they want and they want their tax cuts--then we can have that argument. That is all that I call for.

That is not an issue on which the Government should hide behind NICE. They should start a debate on it. We have said on at least 15 occasions in debate that we will not oppose the Government if we have a public conference to debate those issues outside the party political arena, so that we can have a proper debate.

In July 1998, the Minister's predecessor, who is now the Secretary of State for Health, answered an oral question from me on the issue. He said in response to a supplementary question from the hon. Member for Walthamstow (Mr. Gerrard):


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    and quicker treatment for the patient instead of going to hospital, that is a good thing and if it means growth in the NHS drugs bill, we should welcome it . . . we want a more rigorous assessment of what is cost effective and clinically effective, particularly when drugs come on to the market."--[Official Report, 28 July 1998; Vol. 317, c. 158.]

Those were all welcome comments, but there was no mention of affordability, particularly in all the talk about the cost of new drugs and the drugs bill--no mention that affordability would be an issue.

When Professor Michael Rawlins took on the job, he was clearly under the impression that he would not be asked to talk about the affordability of treatments. In answer to a question in the Select Committee on Health from the hon. Member for Preston (Audrey Wise), he said:


It is clear that his view was that affordability is an issue for elected politicians. He says:


    "Absolutely. I have no doubt at all that where NICE believes that a new technology or new guideline, even if it is expensive, has a real health gain it will be an advocate with the Department, like there has not been before, it will be robust, it will be given by clinicians and if necessary we will, as it were, bully the Department into seeing things our way.


    It will be quite clear that we regard treatment: with Taxol"--

I think that that was being used as a hypothetical example--


    "in ovarian cancer as clinically effective and the most clinically effective agent around."

Immediately, the hon. Member for Halifax (Mrs. Mahon) asked Professor Sir Michael Rawlins to confirm that that was the separation in roles that he envisaged between the national institute and Ministers, and he replied "exactly". Liberal Democrat Members would like that separation to be maintained.

In Standing Committee, and during consideration of the Health Act 1999, the Minister made it quite clear that the national institute should not use an affordability criterion. On 6 August 1999, the Government issued a press release describing NICE's national programme, but made no mention of an affordability criterion. In the first note for editors, it states:


In pages and pages, that press release mentionsvarious treatments and the unacceptability of postcode prescribing, but it makes not one mention of affordability. That was peculiar.

On 6 August--the day that all that spin on NICE's programme was issued, and in the depths of the recess--an order was introduced, to insert in article 3, from which I quoted a moment ago, after the words "promotion of clinical excellence" the words


That was a huge change. Liberal Democrat Members argue not only against that change in policy, but against the surreptitious way in which it was made. We also asked the Minister to appear before a Standing Committee to justify the change and the way in which it was made.

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Subsequently, there has been some progress, with the national institute's first evaluation of a drug--the anti-flu drug Relenza. It is unfortunate, to say the least, that the institute's first decision has confirmed all the fears expressed over many months by United Kingdom pharmaceutical companies that the national institute would effectively create a fourth, affordability hurdle for new medicines.

I do not want to deal with the details of the Relenza case--although I should be more than happy to do so if the Minister wishes to--but there were several problems with the decision. The first one is that the drug has been licensed and is effective in ameliorating the symptoms of flue and in shortening its course by, on average, one and a half days. I would like to have a drug that, for £24, would save me one and a half days off work because of flu, and think that, in principle, the health service should be prepared to buy such a drug. Moreover, the drug would probably be cost effective in work lost, even if there was no evidence that it saves lives.

NICE seems to be saying that, on the basis of affordability, it and the health service would not be interested in flu as a disease until there was a drug that is proved to save lives among the elderly. However, that is a separate issue.

Mr. Paul Marsden (Shrewsbury and Atcham): Does the hon. Gentleman think that a £5 flu vaccination is more cost effective than a £24 five-day course of Relenza?

Dr. Harris: I know that we cannot have a direct exchange now, but I wonder whether the hon. Gentleman knows the effectiveness of the flu vaccination--is it 100 per cent? It is 30 per cent. Therefore, even with universal flu vaccination--currently, only risk groups are receiving it--effectiveness would be only 30 per cent. Other treatments, such as Amantadine, are available in the NHS for some strains of flu. Therefore, a new principle has not been established that the NHS is not interested in flu.

When we talk about rationing NHS treatments, or the unavailability of treatments on the NHS, we are not saying that no one in the United Kingdom will receive those treatments, but that the treatments will not be available to poor people. The rich and others who can afford the treatments will be able to receive Viagra, Relenza and other treatments, such as new chemotherapy, that are not available from health authorities.

Yesterday, the Daily Mail made it clear that some doctors--including some oncologists to whom I have spoken--tell their wealthier patients that they cannot provide the drug on the NHS, but that they would prescribe it if they visited as a private patient. Doctors are not funded to provide some of the new chemotherapeutic agents to everyone. I think that that is immoral, and that the Government have to recognise that NHS rationing entails depriving treatments to poor people.


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