Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 220-239)


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 treatment.

  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 treatment?

  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 series—I do not want to run through the whole list because it is about a page of people who qualify under different categories—such 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 risk.

  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 a year.

  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 liability?

  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 free—of 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 or not.

  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 opportunity?

  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.

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