Examination of Witnesses (Questions 220-239)|
JOHNSON MP, MS
10 FEBRUARY 2005
Q220 Chairman: You must have an idea
of what it would cost for a course of treatment. That is the point
we are making. We appreciate you cannot add it up and say there
are so many thousands, or whatever, but individually what would
it cost or save? If The Daily Mail rang up your office
and you had to argue with The Daily Mail, you could make
an argument that it is in the interests of this nation financially
to treat a particular person, so that it does not spread to others
and cost the NHS more money.
Miss Johnson: Yes, but people
who are here legally or who have started a course of treatment
are actually entitled to continue with that treatment free of
charge while they are here.
Q221 Chairman: I appreciate that, therefore
you must know the cost of that course of treatment.
Miss Johnson: You mean the cost
of an HIV course of treatment? It is an average of £14,000.
It is somewhere between £10,000 and £18,000, depending
on the patient, as I understand it, but the average that we use
for costing purposes is £14,000 a year.
Q222 John Austin: On the risk issue as
far as the general public health is concerned, in the evidence
in a previous session, one of the witnesses, Dr Evans, in response
to Dr Naysmith, was talking about the onward spread of HIV, and
saying that they have reasonable data showing that the spread
of HIV was strongly related to viral load, that viral load rises
with the progression of the infection, etc, etc, and therefore
saying that any delay in coming forward and being diagnosed is
therefore likely to increase the spread of infection.
Miss Johnson: But there is no
reason not to get a diagnosis, because the diagnosis is free.
Q223 John Austin: The diagnosis is free
but the treatment is not available.
Miss Johnson: The treatment is
available for all those who fit. We can have this debate but it
is a balance at the end of the day. We do have to look at how
we allocate the resources and what the balance is. To take a ridiculous
example, if we were providing free treatment for anything for
anybody, we could be providing a health service to the entire
globe out of the UK. That is clearly not a sustainable position.
Nonetheless, there is a balance to be struck on this, and the
question is where do you draw the line in the sand? We have drawn
the line on people ordinarily and legally resident in the UK,
and they have to be legal residents here, or categories that fulfil
that, such as an asylum seeker having their asylum application
determined. Everybody is entitled to free diagnosis, but everybody
in that category of legally resident is actually entitled to free
Chairman: I do not think anybody under-estimates
the difficulties of decisions in this whole area. We are not in
any way arguing that this is an easy area to address; I am sure
it is not.
Q224 Dr Taylor: Going on with this theme,
if I may, Minister, I think you said the decision to treat is
always going to be the clinician's.
Miss Johnson: At the end of the
day, yes, absolutely.
Q225 Dr Taylor: Even though the financial
aspects for some people will have to be sorted out after the treatment
has been started?
Miss Johnson: Yes, that is correct.
Q226 Dr Taylor: Have I got it straight
that it is only illegal immigrants who will not be funded for
Miss Johnson: Yes. It is people
who do not fulfil one of the legal residency requirements, and
there are a number of categories; for example, if you are working
here for a UK-based company, and there is a whole seriesI
do not want to run through the whole list because it is about
a page of people who qualify under different categoriessuch
as students here not for foreign language course purposes. There
are lots of different categories of people who are entitled to
use the NHS in this way, but what we have said is that people
who are no longer legally entitled to be here . . . Actually,
just on the point of appeal, while your appeal is being considered,
you are still entitled to the free treatment, so if you appeal
on an asylum case, for example.
Q227 Dr Taylor: But there could still
be an appreciable number of people who are potentially infectious
who are not getting treatment, and that must be a public health
Miss Johnson: Yes. That is my
point about the HIV/AIDS. People remain infectious. It does not
matter how much treatment they get.
Q228 Dr Taylor: Although as soon as you
begin to decrease the viral load, you begin to decrease the infectivity.
Our attention has been drawn to . . .
Miss Johnson: Yes, but it is not
like having another sexually transmitted infection where a course
of antibiotics will remove the infection from the body. Let us
just be clear. There is quite a difference here.
Q229 Chairman: Neither of your colleagues
are medical experts, are they?
Miss Johnson: No, they are not.
Chairman: There are quite a few heads
behind you shaking very vigorously. I do not think it is fair
to press you on that. It is a very specific medical point.
Q230 Dr Taylor: I was only going to draw
the Minister's attention to the paper we have been shown from
Taiwan, which showed that the government policy of providing HIV-positive
people with free treatment reduced the rate of HIV transmission
by 53 per cent. That was in the Journal of Infectious Diseases.
That is a fairly powerful bit of evidence that if there is an
appreciable number of people around who are not being treated,
there is a public health risk.
Miss Johnson: We obviously want
to treat people because it improves their life chances and their
quality of life and their life expectancy.
Q231 Dr Taylor: It protects other people.
Miss Johnson: That is not the
main reason for treating people. The main reason for treating
people is to improve their life chances and their life quality,
and the question is, how far do our responsibilities as a government
extend in this regard? I do not want to argue. I am very happy
to get the Chief Medical Officer to write to you on the question
of viral loads and all the rest of it. I have not seen this Taiwan
paper. I have no idea where the research was done or what health
service setting it was done in, nor what the circumstances of
that are. The fact remains that you do not reduce to zero someone's
infectivity by treating them when they have HIV/AIDS.
Dr Taylor: I think it is only fair to
say we would like some of the medical background for that.
Q232 John Austin: I just want to go back
to costs. You have said there is no estimate of numbers or likely
cost savings of the changes, but what we do know is that the cost
of treating someone with antiretroviral treatment is around £12,000
Miss Johnson: The average is £14,000
but I am not disagreeing with the broad, ball park figure.
Q233 John Austin: We understand that,
without antiretroviral treatment, the chances are that that person
will become seriously ill and may well need admission to hospital,
possibly presenting at A&E, where of course A&E is free,
but they may require treatment in hospital. If it is a matter
of life and death, an emergency, that person will be treated but
will presumably subsequently be billed for the services. I assume
in most cases they are likely to be destitute, so the NHS is going
to have to write that off at the end of the day. Has the Department
done its sums on this, as to whether the cost of providing treatment
might actually be a cost saving to the NHS rather than a cost
Miss Johnson: It is probably lucky
that none of us are the people actually treating the patients.
It is up to clinicians to decide the circumstances under which
they treat or continue to treat a patient. They are able to do
so, and the easement provision in the regulations allows them
to make those decisions and to continue to make those decisions.
That was a very important part of the discussion around the regulations
when they were revised.
Q234 John Austin: The clinician may admit
the patient and treat the patient, but the cost of the treatment
is likely to be twice the cost of the antiretroviral treatment
they could have been given in the first place.
Miss Johnson: No, what I am saying
is they can decide to treat the patient directly for HIV/AIDS
if they decide to do so. That is a matter for them. The A&E
attendances are freeof course, they are not free in one
sense; they need to be paid for, but they are free to the patient
and they are free whoever the patient is, under whatever circumstances.
Q235 John Austin: All I am saying is
that the cost of treatment for someone who is denied antiretroviral
treatment, who subsequently becomes seriously ill, is likely to
be a bigger cost burden on the NHS than actually providing them
with preventative treatment in the first place.
Miss Johnson: That is why it is
a matter for the clinicians at the end of the day to decide, or
it is one of the aspects why they should decide whether to treat
Q236 Mr Bradley: Can I just be clear
on this? What you are saying is that, with that clinical judgment
and the fact that it would be half the cost to give the treatment
in the first place, that is a decision that you would support
because the cost to the NHS is much less than a person becoming
ill and going into hospital through Accident & Emergency,
and then receiving the treatment?
Miss Johnson: These decisions
are made by clinicians.
Q237 Mr Bradley: You are happy for that
to be the case?
Miss Johnson: I am happy for the
clinicians to be making these decisions. I think it is right and
proper that they make these decisions because they are in the
best position to weigh these things up and to decide what the
best course, the balance, is, taking into account both the patient's
interests and wider interests in their decision-making.
Q238 Mr Bradley: And since it is cheaper
to have the treatment in the first place, you would therefore,
just in cost terms, recognise that that would be a beneficial
decision by the clinician if they had the treatment at the earliest
Miss Johnson: Every patient differs,
every circumstance differs, and every clinician's judgment is
for them to make. I cannot generalise about what is obviously
a hugely diverse set of circumstances, and I am not a clinician.
Q239 Mr Bradley: But you would want a
consistent approach to this? As the Minister, you would want to
ensure that each trust, each clinician, was dealing with people
in this situation in a similar way?
Miss Johnson: The rules set out
the overall framework and provide the arrangements under which
people are treated free of charge or not. They will be treated
with a charge whatever, but free-of-charge treatment provides
the setting in which that takes place, provides the fundamental
rules, the fundamental entitlements, and gives people advice about
how those rules are to be operated. If a clinician wants to discuss
something with the overseas patients manager in their trust, they
are obviously at liberty to do so. They can seek advice from that
person, but they are free to make their own decisions about things.
I cannot generalise any more than I can generalise about what
a GP should do for any other patient and for any other particular
condition, because it is a matter for the doctor concerned.