Examination of witnesses (Questions 1280
- 1299)
WEDNESDAY 9 FEBRUARY 2000
RT HON
ALAN MILBURN
and MS YVETTE
COOPER
1280. A final question: have you any assessment
of what the costs are going to be of what you are currently proposing,
that is the one week free for people on free prescriptions, and
what it would cost were you to make it available to everybody
for a week on the NHS? Do you have any figures?
(Mr Milburn) The rough figure is our smoking cessation
budget, as I remember it, is £60 million over the course
of these three years. An element of that is for free NRT and I
think it is about £12 to £15 million of free NRT. Our
estimates suggest that if we are to make NRT available for everybody
then we could be talking—purely for the NRT, never mind
the support services that would need to go with it—of somewhere
between £80 and 100 million before you start providing the
comprehensive support services that you need to go with it to
make sure that it is properly effective.
Chairman
1281. That is for how long?
(Mr Milburn) A year.
Dr Stoate
1282. Do you envisage that being part of the
programme in the future?
(Mr Milburn) I think the important thing to remember
is that as we understand it, and the information that we have
from the drugs companies who manufacture NRT, there is no health
care system in the world—we have been informed—which
provides NRT for free at the moment. We are well ahead of the
game here. We are world leaders. I am proud of that. I think it
is the right thing to do but there is always a danger in being
world leaders and that is you have to make sure that actually
what you are doing is based on very firm evidence. I want to assess
very carefully how effective this is being and I think that is
the right thing to do.
Chairman
1283. The point you made about costs for a year
for free NRT, can you be specific about whether that is continuing
the one week free or is that over a period of a year free?
(Mr Milburn) No, no. I think the figures that we have
suggest that if we make NRT widely available for everybody on
prescription—
1284. Without a limit of a week?
(Mr Milburn) Without the limit.
(Yvette Cooper) At full cost.
(Mr Milburn) For a full cost which is on average,
as Yvette rightly says, around eight weeks.
Dr Stoate
1285. Three months actually.
(Mr Milburn) Is it three months. We would be talking
about £80 to £100 million. Frankly, I would not want
to be held to that particularly.
(Yvette Cooper) It depends on all kinds of assumptions
about how many people take it up.
Chairman
1286. If you want to come back in writing on
that we would be very happy. It is obviously important.
(Mr Milburn) We can give you some assumptions about
that.
(Yvette Cooper) We cannot predict confidently on this.
(Mr Milburn) We cannot assume behavioral changes,
for example.
Audrey Wise
1287. Ms Cooper has mentioned the monitoring
of the smoking cessation schemes in the Health Action Zones. You,
Secretary of State, have talked about solid evidence.
(Mr Milburn) Yes.
1288. Can you tell me, will you be monitoring
what is done in the rest of the country, the effectiveness of
what is done in the rest of the country, from April? Will you
be collecting information? Have you told health authorities they
have a duty to supply you with information, and, if so, what kind?
In a year's time, if we start asking parliamentary questions will
we be told "This information is not collected centrally"
or will you be able to tell us how things are going?
(Yvette Cooper) The tightest monitoring, obviously,
is about what is happening in the Health Action Zones, partly
because they are ahead of the game and partly because we are putting
additional resources in. As part of the Health Improvement Programmes
in general we are asking for a lot more, for local areas themselves
to monitor their own progress and to work out what is effective.
Also, as well as the Health Development Agency at a national level,
we are putting in place public health observatories at a local
level to monitor local public health problems. The answer is we
are extending the monitoring and evaluating in general. I think
the best figures in terms of what is working that we will be able
to provide in a year's time will be based on the Health Action
Zones.
1289. But you will be collecting the information
from places like Preston and other places?
(Mr Milburn) To be honest, I do not know in what form
we will collect the information so perhaps I can come back to
you. I think it is important, as you rightly say, Mrs Wise, that
we are able to assess the effectiveness of the programme right
across the country in HAZ and non HAZ areas. Perhaps I can come
back to you. I do not want you to be in a position where your
questions are not answered.
1290. I appreciate the emphasis on evidence
but from where you are now do either of you have any assumptions
about what at the moment, if pressed, you would say were the likely
most useful tools? There is a whole range of things: price, manipulation,
etc., etc.. Not holding you to this if evidence contradicts later
but as you are now, what do you think each of you would say are
a couple of most important things?
(Mr Milburn) In terms of reducing smoking?
1291. Yes?
(Mr Milburn) Price. There is no doubt that price does
have an effect on consumption, as you are aware. We have been
putting up the price of cigarettes. In some quarters we have been
criticised for doing so.
1292. We have noticed.
(Mr Milburn) There is a relationship between price
and consumption, so that is true. Also, I think that the more
informed the public is and the more information that smokers and
potential smokers have about the hazards of cigarettes, and indeed
about the ingredients of cigarettes, the better we will be in
a position to achieve what we and the overwhelming majority of
smokers want and that is for smokers to stop. 70 per cent of smokers
say that they want to give up. Why do they not give up? They do
not give up because it is difficult to do so because cigarettes
are addictive, tobacco is addictive, nicotine is addictive. We
have to have the appropriate programmes in place to help and support
people.
Mr Burns
1293. Can I just go back to the information
that you gave concerning NRT and the costs because, as I have
understood it, you said if you went to Boots, for example, in
Victoria, you could get a course or supply for £15 and the
NHS will supply for Income Support recipients one week's course.
I do not know if you have ever given up smoking or not in your
life but one week certainly is not enough time to give up smoking.
It is a question of taste but certainly some people have shown
that patches are the most effective way, as long as you do not
peel them off to have a cigarette. The point is that no way if
you are addicted to cigarettes, and I agree with your analysis
that it is an addiction and that makes it all the more difficult
to kick that addiction, can you do it in a week. So what you are
going to have if you are not careful is that people will benefit
for a week, and that will have helped them on their way, but given
it is an addiction I suspect if you monitor the results thereafter
there will be a large proportion of people who after the week
then become personally financially responsible for buying the
patches or the other form of therapy and they will not be able
to on the level of Income Support that they receive each week
because of the other financial commitments they have on either
themselves or their household, if they are married or if they
have children. Surely it will be counter-productive, will it not,
given that you are making a step forward to help people, to limit
it only to one week because the financial cost of the course they
are after will almost certainly have a disproportionately high
number of people who will then drop out and make the whole thing
a waste of money?
(Mr Milburn) Remember, nicotine replacement therapy
only works if you give up the cigarettes.
1294. Absolutely.
(Mr Milburn) It only works if you give up the cigarettes.
The way that the therapy works, as you know, is it reduces over
time physically your craving for the nicotine. Okay.
Mr Burns: Hang on. I have used it, you I suspect
have not.
Chairman
1295. We have an expert here.
(Mr Milburn) Let me just finish the point and you
can tell me why I am wrong. You start out with a fairly heavy
dosage and gradually you are weaned off to a level your body can
tolerate. The theory of this is basically it will only work if
you start giving up the cigarettes, it is pointless taking it
if you are still smoking, it has no effect. The idea behind this
is pretty straight forward, that as you give up the smoking as
a consequence of taking the nicotine replacement therapy, you
then have whatever it is in terms of personal disposable income
that otherwise you would have been using on cigarettes. I do not
doubt for a moment in the short term physically it is difficult,
it is hard to give up, but financially there is a cost to bear
in the short term. In the long term the health benefits and financial
benefits, it seems to me, are overwhelming. Now why am I wrong?
Mr Burns
1296. In one way you may not be. The logic of
your argument is 100 per cent accurate and right.
(Mr Milburn) Right.
1297. But in reality one week even with the
heaviest level of patch for an addicted smoker smoking, say, a
packet of cigarettes a day or more, is just not long enough. By
the end of that week you will still be on the highest level concentration
of nicotine. Then, if they are on Income Support, after that week,
to then have to finance it themselves on the limited income they
are getting, people will peel off the scheme like nine pins because
they will not be able to afford it and the craving for a cigarette
will still be so great that they need more patches. The only point
I am making is if you want to get really good value for money
for the NHS and for this scheme to work effectively for people
who do not have the money to continue a course in the short term,
but the short term cannot be governed in weeks per se because
it depends on the level of addiction of the individual and their
willpower, then I just think one week is too short and you will
cost the health service more overall because too many people will
drop out.
(Mr Milburn) You are obviously speaking as a disenchanted
consumer. Did it not work for you?
1298. No. I am speaking from my own personal
experience but the fact is I am not on Income Support and I can
take the patch off and have a cigarette if I want, which is stupid.
(Yvette Cooper) It is worth saying we are certainly
not saying one week's NRT is the answer. NRT, for lots of people,
will be something that they will want to take for a long period
of time for it to make a difference. Plus, to go back to what
you were saying before, what happens at the end of that first
week, actually that is why the smoking cessation service is so
important as well, to have that additional support, another week
later to have somebody to talk to a week later as part of the
cessation support as well. The financial arguments are that after
that week of not smoking you will not have been buying cigarettes
for a week. The health inequalities issue is something that we
feel very strongly about. We know that people who are on low incomes
are both more likely to start smoking in the first place and also
less likely to give up. This is an area that we will keep evaluating
and monitoring. We feel very strongly about the inequalities aspect.
I do not want you to feel that we are misunderstanding the purpose
of NRT because we are not at all.
1299. No, I do not feel that, I just think that
you have put forward a very good scheme, from the very best of
intentions, but possibly because you do not smoke or never have
smoked you do not understand the hill that has to be climbed.
The trouble is we have had people telling us in this Committee
and elsewhere that nicotine addiction is greater to overcome than
heroin or cocaine. Now I am not qualified to judge on that but,
if that is true, the National Health Service also provides extremely
good help for heroin and other drug abusers who are addicted.
It may be patchy or not, I am not getting into that argument.
If you are provided with a course to wean you off those hard drugs
it is a very good course, but it is not one week. A health authority
will send patients to specialist centres to try and get them off,
they could be there six weeks, eight weeks, 12 weeks, because
you recognise that in those areas they have got to be there until
they have gone through cold turkey, and everything else, and got
off their addiction. It just seems odd if you accept that nicotine
addiction is much greater and much more difficult to get off,
that it is just simply a week of paid help for those people who
are the most vulnerable people to carry it on because of the level
of their Income Support. This is simply a plea to ask you to make
it really successful and not to possibly ruin the efforts you
are making by only restricting it to a week.
(Mr Milburn) I think these are all reasonable points.
As Yvette said earlier, what the Committee will recognise is that
no-one in the world is doing this. We are way, way, way ahead
of anywhere else in the world. If you like, we are engaged in
an enormous public trial. That is what is happening, affecting
tens of thousands, and maybe beyond that, of people who are smoking
and want to give up. Yes, we will continue to assess its effectiveness,
absolutely, that is why we have precisely these tight monitoring
arrangements in place. What I do say from the evidence that we
already know about in the published literature, that the effectiveness
of NRT is immeasurably increased if not only people are getting
access to NRT but they are getting access to NRT services as well,
certainly the evidence that was published by the British Thoracic
Society suggests that in terms of an increase in the percentage
of smokers stopping for six months or more, if you get very brief
advice from your clinician, from your GP and you get NRT then
there is a two per cent increase in the number of people giving
up. If you get intensive support in the way that we are providing
in the Health Action Zones and once they are all out across the
whole country from April of this year that dramatically increases
to eight per cent, so it quadruples. Yes, it is right to ask these
questions about NRT, of course. We will continue to keep that
under very close supervision. We will continue to monitor but
the provision of NRT is not just the be all and end all, it is
very important that there are a whole set of services that are
available to help people through what is pretty difficult. It
is not easy.
Chairman: I hate to break up this counselling
session with Mr Burns. John Gunnell has a question.
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