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22 Jun 2005 : Column 269WH—continued
National Institute for Health and Clinical Excellence
2.30 pm
Mr. Dai Havard (Merthyr Tydfil and Rhymney) (Lab): First, I know that other hon. Members are interested in the debate, which I am pleased to have secured. I know also that my hon. Friends the Members for Norwich, North (Dr. Gibson), for Bristol, North-West (Dr. Naysmith) and for Brighton, Kemptown (Dr. Turner) want to talk about their experiences with the National Institute for Health and Clinical Excellence.
I want to do four things: review the current situation; talk about and give examples of technology and different types of treatments and how they are dealt with; talk about related relationships within the United Kingdom, because NICE has an interesting relationship with the rest of the UK beyond England—there are organisations in Wales and Scotland that do similar work—and say something about how all that affects commissioners and delivery agencies; and assess how such issues affect financial efficiency, the making of changes and the improvement of standards.
Running through the subject is a second aim because two things are involved. One aim is to consider efficiency, process and practice when making changes, but that has to be done for a particular reason, because relative to all that are the human tragedies and journeys. Patients and families are people, so the second aim is to drive up the quality of their care by the efficiency changes, as well as efficiency being gained simply for its own sake.
I have had three Westminster Hall debates on the subject, and you will know from those, Mr. Cook, because you chaired one of them, of my interest in it. I became involved because there was, at that time, a huge incidence of cancer in my constituency and I had been looking at how to improve standards of cancer care. One thing that came to my attention was people's treatment in relation to anaemia and blood. As a consequence of that, I looked at how standards were applied for alternative technologies to blood transfusion, for example. That led me to NICE and the process of rationing in the NHS. Since then, I have asked 50-odd parliamentary questions and have had these debates, in the last of which, in July 2003, the then Under-Secretary of State for Health, Melanie Johnson, said of NICE:
"Central to our modernisation programme is the National Institute for Clinical Excellence, which we established to give clear national guidance on the use of drugs and other treatments. Its work reaches into all aspects of the NHS, from wider judgments on whether a new treatment is both clinically and cost effective, to assessments of what care is best for individual patients."
"We set up NICE to tackle postcode prescribing and inequality, and it is central to our plans to modernise the NHS and drive up standards."—[Official Report, Westminster Hall, 8 July 2003; Vol. 408, c. 240–41WH.]
I could not demur from that, as that is a laudable set of aims, so why am I back here two years later? It is because of some reports that I heard in the Whitsun period after the general election. In the July 2003 debate, I was told that NICE was to receive extra money and resources to enable it to go from doing two appraisals a year to three, but I now hear that it is to move backwards and go from three appraisals to two.
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Of the various reasons for that, the main one seems to be that because the Health Development Agency was assimilated by NICE in April, NICE has had to make a budget cut of £3.5 billion to subsume the new work and combine the two organisations. I am told that that is the reason for the change in the number of yearly appraisals. I do not know whether that is true. I understand that Ministers deny that there is any cut in the budget to NICE, but whatever is happening with the finance, the number of appraisals is to be reduced. A long queue of things, which are of great need to individuals in all our constituencies, were being assessed, but that has now stopped.
When I considered other treatments, such as drug alternatives to blood transfusions, an argument immediately started about how to assess the true and total cost. How do we assess true value in the NHS? I do not say that in an accusatory fashion, but I have observed that it is difficult for the NHS to value things in the way that I see them. For example, I get into discussions that are like a cross between metaphysics and linguistic philosophy. I might say, "Well, surely if you introduce this treatment, this will mean that someone can go home earlier. Therefore you will make an efficiency gain and a bed will be flung free for someone else to use." I am told, "Ah, now hang on a minute: what's a bed day? What's a bed? What's a day?" So no change is made because there is apparently no way of deciding what the real value is or whether efficiency is achieved.
There are organisations and engines that are supposed to help—apparently—the greatest of which, I have been told, is the National Institute for Health and Clinical Excellence. It was supposed to be a mechanism of change that could reconcile some of the problems, square a number of the circles and build a community of understanding of the real value of something. Now, however, I am told that the situation is as I have described it.
The number of appraisals has declined, and although NICE is supposed to help with such things, I was told in an answer to one of my questions that NHS circular 1999/176 says that, in the mean time,
"national health service bodies should continue with local arrangements for the managed introduction of new technologies where guidance from the National Institute for Clinical Excellence"
has not yet been issued. It went on:
"These arrangements should involve an assessment of the available evidence on clinical effectiveness."—[Official Report, House of Commons, 7 Mar 2005; Vol. 431, c. 1568W.]
That all sounds fine, but I am being told, on the one hand, that we need that engine of change and that it exists, but, on the other, that it is being reduced, although that does not matter because there is another process. The truth is that without NICE making a declaration there is no real agreement about money, which takes me back to the original response that I received.
The question is not only whether something is efficient in the sense of being effective as a medical treatment, but whether it is efficient in the sense that we should spend money on it. Without that, whatever the local arrangements, the budgets will not allow certain treatments. That is the power that NICE has because it
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gives local people the ability to square the circles, and that is the problem. A lack of NICE guidance means that local arrangements cannot really apply, unless there is a magical way of finding money to make things work.
That is the background, and I shall give a few examples to demonstrate why a lack of NICE guidance is so important. Some new medical technologies and treatments are licensed and some are not. Hon. Members will know the argument that runs, "Well, there's this fancy thing that I've found on the internet, but I've been to the doctor and it's not got a licence." We all encounter such problems as constituency MPs, but in the NHS the problem is bigger. There are also licensed technologies and treatments that do not have NICE approval.
In the UK, to reduce both bed blocking, which is a huge inefficiency problem in the NHS, and waiting lists, thereby allowing patients to leave hospital more quickly, there is a set of treatments for wounds. There is a huge problem with MRSA. People have wounds in hospitals for different reasons—they might go in as a trauma case, for instance. However, there is now a technology that, I understand, works on a vacuum system—it is a machine as opposed to a drug—and is put on to the patient in some way. The wound is sealed up and kept treated. Multiple wounds are treated and the person is allowed to go home, rather than staying in an environment where they can get an infection.
If nothing else, the precautionary principle suggests that it would be sensible to fund that technology to improve efficiency in the health service and the quality of care for the patient. I am told that the MRSA rapid review panel—a different body again—looked at the technology and said, "But this is not a new technology. The only new thing about it is that it is portable. We will not, therefore, include it in our assessment of what might be useful in combating MRSA." If NICE cannot appraise it or has not got the time to do so, perhaps another body could. Perhaps that body could license its use—but apparently not.
Wounds can result in all sorts of things, and diabetics are probably most affected in that respect, as a result of ulcers, sores and so on. People in my community are in that situation. There is ill health in a number of forms in the Welsh valleys and similar communities, as a result of diet and the rest of it. People have to go into hospital, sometimes just for simple things such as foot ulcers. Those things can be treated in such a way that people do not have to remain in hospital and are not exposed to infections. Yet, it has not been agreed that this technology is the best process and the best practice. That is not because of the arguments about what is efficient and what is good quality care for patients, but because it does not fit with the budgetary processes.
A diabetic can end up with wounds and the rest of it, and the only treatment may be to amputate. Some of the treatments that are given in such circumstances go back almost to Trafalgar—Nelson would recognise some of this stuff. However, there is no need for these things to come about when there is a new technology that can avoid these problems in hospital and when people can be given better quality care that allows them to stay at home. There are examples of this technology being used. I know of a nurse in Scotland, for example, who has a
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problem and who is using the machine. She is out of hospital and back at home, so she is not exposed to extra infection. She is also back at work.
Another thing that interests me is that there is a budget for lopping off limbs, but no budget for introducing this machine, which seems barking mad in the 21st century. I do not understand how we can move from one position to the other without engines of change to allow us to do so. NICE is one of those engines of change, and every time I look at it, as a lay person trying to understand the edifices, the interest groups, the old boys' clubs, the reasons why things cannot happen and the budgetary processes, I see ever more clearly why we have arrived at this situation. It is obvious to me as a lay person that we should make the change, but we cannot seem to find a way to agree on that.
As I understand the figures, such a change could save huge amounts of money—billions of pounds. A study estimated recently that pressure ulcers alone account for £2 billion annually. That is 4 per cent. of the NHS budget. I have no difference with the Minister about the declaration of aims. If we look back at my previous debates, it is clear that we have always ended up agreeing about the need to move to European standards. We need to do all these things because we need to improve. I am told that mechanisms will be in place to help us to do that, but I find out daily that they are not. The mechanisms are dysfunctional and deficient, and resources need to be made available, but NICE is now getting fewer resources.
Perhaps all this can be explained away and I can be told that I am a naive shaver who does not understand these things, but I have seen examples and I have mentioned them. I want to know when that technology will be properly assessed. If NICE cannot do the appraisals, when will it be considered? It seems relatively simple to do that, but there is no mechanism. That is completely ridiculous.
The other thing I have discovered is that there are different drug therapies and technical assessments of technologies. I am a lay person, so I simply look at things from a straightforward point of view. The wound technology is not a treatment—it is a machine, not a drug—and such technologies have to follow certain criteria. So there is a problem in getting technologies assessed, but once they are, there is a problem with the criteria—another barrier. Apparently, the assessment has to be done with a blind randomised testing procedure, because the patient is not supposed to know about it, but it is a little difficult not to know about it if a machine is strapped to your body. It might be possible to do that with a drug, but not with a vacuum pump. So once one hurdle is cleared, there is another. All those things are barriers in a process rather than equipment in the tool bag of someone working on the engine of change to ensure the progress that we all apparently want.
I should like the Minister to consider that problem, if nothing else. We need to think about the criteria used for technological and medical processes—in other words, drug or pharmaceutical processes—so that we do not end up with anomalies. Frankly, the criteria seem to be excuses for not making changes and not being able properly to see the value of such technology to society.
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I intend to deal with where the Treasury sits on the subject because the nurse who I mentioned earlier is still in work. She is contributing to society. She is not on benefit, does not need a carer and is not drawing the support that she would otherwise need. Her mental health and her quality of care are better. As a consequence, her family is better off. There are costs beyond the simple budgetary processes of the NHS, so it is not entirely an NHS matter. A wider understanding is needed of the value of such technologies, so that they can drive efficiency within the NHS and beyond, to the broader macro-economic benefit of the country. That is my experience of the examples that I recently found out about.
The differences between the various parts of the United Kingdom can be problematic. You, Mr. Cook, will understand that, as we have discussed it before. As a Member for a Welsh constituency, I know that a number of health matters are devolved, and I remember discussing whether we might have devolved arrangements in the north-east. Nevertheless, there is a relationship between different practices. I know that my hon. Friend the Member for Bristol, North-West has a particular view of the matter because he sits on the border between England and Wales, where there are several examples of different practices.
My experience is that NICE informs all decisions across the whole of the United Kingdom. It could be said that they apply in both England and Wales. However, that relationship became a little more disturbed recently because the NHS in Wales decided to put more emphasis on the All Wales Medicines Strategy Group, an equivalent organisation trying to do similar things. In Scotland, the situation might be slightly problematic for the Scottish Medicines Consortium; in the absence of guidance being adopted by the Scottish Parliament, the NICE guidance would apply.
The situation is simple. In England, if NICE makes a decision the funding has to come within three months. However, Wales and Scotland may not adopt NICE decisions in quite the same way, which is why those relationships and what they should achieve have been considered. However, the All Wales Medicines Strategy Group now makes decisions about licensed products in Wales; things happen within three months.
Other considerations are the number of appraisals that NICE can do and the various things that it can look at; indeed, the speed with which things happen is part of the argument. It seems that we have a group in Wales that is able to move more speedily than NICE, which covered the area before and made appraisals within three months. As I understand it, the Scottish medicines consortium takes a similar time, taking three months to evaluate something.
Patients in Wales can now get different types of treatment. NICE was set up for the purpose, among other things, of getting rid of postcode prescribing. That was the political declaration that was made. However, postcode prescribing happens not only in England, or even in parts of Wales or Scotland, but also, it would seem, between different parts of the United Kingdom.
Let us take as an example someone from Wales with rheumatoid arthritis. There is a problem with rheumatoid arthritis in Wales; in January this year
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agreement was given for a new anti-tumour necrosis factor drug, called Humira, to be used in Wales. The patient might go to a hospital on the border, in Herefordshire. Although a patient from Wales being treated in an English hospital would get the treatment, a patient from England being treated there might not get it because NICE has not come to the same agreement as the Welsh body.
The Welsh organisation can apparently act and assess matters more quickly than the English one. That is positive for me in Wales, I suppose. I could be challenged to say why I am complaining; the Welsh patient is getting the treatment, so what is the problem? However, what I have outlined illustrates the problem that exists across the piece: how do we evaluate and change processes? How do we decide on the best treatment and standard, the way to apply it and the way to follow the money?
I am told that the only thing that we can rely on is NHS circular 1999/176, which tells us, "OK, that doesn't matter, because if NICE has not appraised a treatment, things can still be done locally." I recently encountered an example from Birmingham relevant to that approach. A patient went to Birmingham for cancer treatment. That was fine; the treatment was great and the patient came back. I have a list of 10 drugs from the cancer network in Birmingham, which I can provide to the Minister later. What interested me is that without NICE having agreed standards for the drugs, the default position is that all drugs, including the 10 on the list, will not be prescribed unless and until it is possible to find—what is the phrase?—"a clinical champion".
When I saw that, I thought, "What does that mean?" Presumably it means finding someone with some dosh to pay for the drugs—someone who is able to juggle a budgetary process somewhere to provide the treatment. There is an understanding that the treatment is the best one, but it cannot be given. There is now almost a conspiracy. That is perhaps a bad word to use. There is a coincidence of understanding within the cancer network in Birmingham and among the commissioners, the primary care trusts. That is not my patch. I apologise to Birmingham Members; I just have that example and use it for what it is.
The situation may not be entirely as I understand it. However, it seems to me that the real message is that unless a series of agreements is struck elsewhere through NICE there is a problem, and the only way to cater for the need in question is to take a default position in which no one gets the treatment unless someone somewhere comes up with the money to pay for it and shows us how to juggle the budget.
That brings me to the point that I made earlier. It seems that there is a silo mentality. I do not know why the health economists in the Department of Health cannot find a way through. It seems that there is a budget for that and a budget for this, and there is no quick way to change the arrangements and move money with the patient. Yet that is what the declaration was about. There can be a budget for chopping off arms and legs but not one for the vacuum pumps, so we have amputations instead of pumps. There is a budget for transfusing blood but not one for pushing a drug alternative into someone. No way can be found to make the best decision. The only decision that can be made is
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the one allowed by the process. That is why I want to make the point about the necessity for process change and my view of the system as dysfunctional.
I am quite happy to share examples of cross-border care with the Minister, but what I have outlined needs to be examined if those default positions are being adopted, and if that is what circular 1999/176 really means. It looks positive, and I am sure that it is positive in intention. It tells people that they can make the best arrangement locally. The truth is that they cannot, because the other processes will not allow them to. The circular can also be used negatively rather than positively, and people can go off and do their own thing. I suspect that it is being used as an excuse not to apply some of the NICE guidance, or to slow things down and find ways of avoiding it.
Perhaps I am being accusatory about things that I should not be, and perhaps I only half understand the problem, but these things warrant investigation and go some way towards illustrating the problems of the laws of motions that apply here. Does the Minister agree?
I return to the point about finance. In all this, there is a desire to improve standards of care. Indeed, the Government have made political declarations about improving standards of care and about spending money. In practice, we are spending huge extra sums, but there is tension as to whether the efficiency changes will come in concert with investment. That is what I am trying to get at. All those political declarations are fine and the actions are good; I simply feel frustrated that the practice on the ground is not delivering results.
The Secretary of State said at the NHS conference this week that it was paramount that best value was delivered and that every pound going into the NHS must deliver it. I agree entirely, but the politics are also important. The politics of the personal are important. Every day, I see individuals who could have a better quality of life but are not getting it. I see people who live in valleys who have difficulties with transport. Even the NHS has difficulties in transporting them from their properties to their places of treatment. If those people were treated differently, they might not need to make half the journeys that they make. They could be liberated by the quality of their care, and what they can do as individuals could change as a result of changes to the system.
Politics more broadly is important. The Government have declared that they will increase national insurance contributions by 1 per cent. to provide all this extra money for the NHS. I applaud that. That is exactly what we should have done, but we were going to get the efficiency gains that went with it. That is what I am questioning, because if we do not increase national insurance contributions and get those gains, the harpies will be on the wire saying, "You won't do it, and you'll have to raise taxation, Gordon." We see them there every day—the City scribblers who write in the press. We must address the problem whether we like it or not. We must have real change and real efficiency, not spurious processes.
I differ from the Government on how to effect that change. I do not believe that the market does it. We must drive the process if we want a real improvement in
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efficiency. That is how we save the money and improve the quality of care. We do not do that through managerial arrangements elsewhere. To me, that is a false notion. This is the guts of the argument if we are to improve health, deliver better treatments and increase efficiency.
Some of the problems are avoidable. I do not believe that, having put men on the moon in 1969, we cannot do this. Perhaps I am naive, but I take that point of view. A woman who comes to my surgery with foot ulcers because she is diabetic is going through the whole process that I described when she does not need to. It is simply more efficient for the hospital not to see her. We have to find ways around this. How do we do that? I asked that question when I met the Minister, along with a delegation, to discuss another example of the problem. This warrants further examination by Departments working together.
This is the point at which I return to the subject of the Treasury. As you know, Mr. Cook, I served on the Defence Committee during the previous Parliament. In many ways, we had a similar debate. There was a huge overspend on defence budgets, and the Treasury said, "Oh well, we will have resource-cum-budgeting. We will have this, that and the other, and we will sort out all these problems by keeping stocks." Neither the Ministry of Defence nor the Department of Health is Tesco, however. It would be fine if we had a load of tins of beans on a shelf and we wanted to move them quickly and would not be punished for keeping stocks. That is one bit of the argument.
There is, however, something much more fundamental, which relates to process. I want standards such as resource accounting and budgeting—or whatever the other mechanism is—applied across the piece to find the engines of change, one of which I believe is NICE. One could advance a political argument against that, querying whether making a decision about medical efficiency and spending for a bunch of technocrats is a good idea. However, if such a procedure will deliver a change, I do not care about that, because political responsibility will still rest at the top.
Processes must be found to take such action. I hope that the Treasury will take account of the arguments that have been advanced today. Perhaps the Minister can promote a way in which all the Departments responsible for such matters are not subject to blame, but understand the reality of saying, "How do we make two things happen?". That takes me back to the first time that I spoke about such matters in 2002, probably under your chairmanship, Mr. Cook. At the time, I said that two outcomes could be achieved: step change and good, consolidated implemental change in the processes that deliver not only efficiency of spend, but quality of care, with standards being driven up for patients.
Frank Cook (in the Chair): Order. For the convenience of hon. Members, I wish to call to mind the fact that we start the first of the three wind-up speeches 30 minutes before conclusion of the debate. We are due to finish the debate at 4 pm, which means that wind-up debates must start in 29 minutes. I ask hon. Members to bear that in mind when making their contributions and also when accepting, and responding to, interventions.
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3.2 pm
Dr. Richard Taylor (Wyre Forest) (Ind): I am delighted to take part in the debate and will be as brief as possible. I congratulate the hon. Member for Merthyr Tydfil and Rhymney (Mr. Havard) on being granted the debate because it is important.
I refer the Chamber to two reports undertaken by the Health Committee in the previous Session, the first of which is the report on the National Institute for Clinical Excellence in 2001–02. The second report concerns the pharmaceutical industry inquiry that the Health Committee has just completed. The first inquiry led NICE to be much more open in its work, to put itself before the World Health Organisation for a review and to be much more open with the bible that all doctors carry, the "British National Formulary", in which NICE recommendations are now summarised, a huge help.
The second relevant report is the fourth report of the Health Committee, undertaken in 2004–05. The Committee inquired into the pharmaceutical industry and the report gives a useful summary of NICE and its work. It defines technology appraisals, clinical guidelines, cancer service guidelines and interventional procedures. It states that NICE publishes about 25 technology appraisals, 12 clinical guidelines and 60 pieces of interventional procedures each year. That is all it can do. I completely support the hon. Member for Merthyr Tydfil and Rhymney (Mr. Havard) and agree that NICE is limited in the amount that it can do. The fact that it is taking on extra work is a bit of a disaster for its future work load.
I wish to concentrate briefly on some current concerns. I am sure that we have all been bombarded with letters about the drugs for dementia. Although NICE reviews cold, scientific evidence, there must be a place for the human element by which to take account of the value to the patient and carer, which, sadly, cannot be measured. Another worry is the inequality of availability of recommended drugs.
The hon. Member for Merthyr Tydfil and Rhymney touched on that; he referred to anti-TNF drugs, which are vital for patients with rheumatoid arthritis. I am delighted to be able to inform the House that NICE has approved them in England. The problem is that some primary care trusts do not have enough money to follow the NICE recommendation. Those drugs are very important. One of my rheumatologists has about 80 patients on them, 75 per cent. of whom have been absolutely transformed; they no longer rely on piles of drugs, and they are mobile again. That sort of drug is crucial.
That point brings me on to the prioritisation of assessments by NICE. Somehow, potential major advances must be fast-tracked so that they become available sooner. Let me give an example from the past to illustrate that. Herceptin is a crucial drug for a relatively small group of patients with breast cancer; in my opinion, it is far more important than drugs for influenza, but I do not think that it was fast-tracked in any way. The anti-TNF drugs are also very important; much more important than the COX-2 inhibitors, which were the drugs that were supposed not to have any side effects for people with rheumatoid arthritis.
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This is where there is tremendous conflict with the pharmaceutical industry and the Health Committee report tries to crystallise that. To remain viable, pharmaceutical companies have to make profits and recoup their costs, and there have been press reports recently of the United Kingdom drug industry calling GPs luddites for being slow and a little conservative in introducing new drugs to medical practice. Therefore, there is a conflict, and the Health Committee report makes several recommendations. One of them is
"that consideration be given to limiting those who can prescribe a new drug in the two years following launch. Drug and Therapeutics Committees would be well-placed to implement this."
So, the Health Committee feels that the rapid, explosive liberation of a new drug is, perhaps, not the best thing. I was brought up by a very conservative and very senior physician who was around when rheumatoid arthritis was first treated with cortisone. Patients who took cortisone appeared immediately to be cured by it, and it was only after a few months that it was realised that that was all an illusion and that they were in fact made very much worse.
A later recommendation is also crucial:
That is because those committees are much more widely spaced than NICE, and they can review and give wise advice, provided that they are all of the same high standard as some of the committees that we saw during our inquiry.
On the way that NICE is used, let me read out another quote from the report:
"The Department of Health asks the Institute to look at particular drugs and devices only where the availability of the drug or device varies across England and Wales or where there is confusion or uncertainty over its value."
Therefore, it does not have to look at all drugs and, hopefully, drug and therapeutics committees in trusts and hospitals can provide a great deal of the input that is needed.
I would like NICE or the Department of Health to address some ridiculous situations. One has arisen, particularly with the non-steroidal anti-inflammatory drugs since the revelation that the new, selective ones, including Vioxx, can lead to cardiac problems. Unbelievably, other NSAIDs have been examined and have also been shown to cause a risk of cardiac problems. Ibuprofen, which has been around for 40 years and has been the mainstay of anti-inflammatory treatment is now found to be not free of cardiac risk. Walking along a road is not free of risk, neither is driving a car, nor is going on the tube, but we do so. We must guard against some purist scientist or safety expert taking away a lifeline of chronic rheumatoid patients like this, rather as Coproxamol has been removed because of the risks of abuse.
I have a final plea. NICE carries out valuable work, but it acts too slowly and covers only a proportion of the drugs available. The Health Committee recommends increased funding for NICE to allow it to evaluate more medicines more quickly. The consequent improvement in prescribing standards should make such investment cost-effective.
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3.11 pm
Dr. Ian Gibson (Norwich, North) (Lab): Thank you, Mr. Cook. Just watch me go.
I congratulate my hon. Friend the Member for Merthyr Tydfil and Rhymney (Mr. Havard) on securing this debate. I am sure that you are delighted too, Mr. Cook, given your sterling work on laser eye surgery in the previous Parliament, which will continue into this one.
From my point of view, and that of many others, thank goodness we have NICE; it would have been a lot worse without it. Although we are feeling the frustrations all the time, we are getting some decisions out of it and we aim to improve those decisions, both their number and the areas that are investigated. NICE has a huge agenda, comprising medicines, medical devices, diagnostic testing, surgical procedures and health promotion, but most of its time is spent with medicines and medical devices get a little share of its time and energy. However, in the past 18 months NICE's interventional procedures advisory committee has come up with lots of sets of guidance so that it is on the move. Our job is to ensure it gets weaving and gets a faster move on.
The frustrations are not just being mentioned here today, but are out there in the community, with the people who practise medicine and use the devices, and particularly with patient groups, which are well informed about these issues. Hon. Members will know that last week at the NHS Confederation conference the Secretary of State for Health said that there are three big challenges in our time:
—it is important that we are making politics do things—
I think that all hon. Members are glad that these will be the priorities.
CancerBACUP, which could be described as the scourge of NICE, has been going for a long time—Relenza was the first campaign that we all got involved in—and is continually pushing on, through Taxotere and other cancer drugs, and supporting many patients. Its latest dossier—"A Dossier of Delay"—says that additional delays are unacceptable and it is calling for NICE to introduce a system of fast-tracking for cancer treatments that have shown significant results.
The dossier illustrates 10 new cancer treatments that CancerBACUP thinks should be made widely available to patients and is trying to encourage those to be looked at. It has been told that it will have to wait for one to two years before some of the drugs are used.
The same is true for medical devices. We know now that there are stents and catheters made of certain alloys that prevent hospital infections. MRSA is not the biggest hospital infection of patients, and catheters are one way in which hospital infections have been reduced. There has been a long delay after the approval of a certain catheter before getting it into service. Lots of things are going on in that area.
Last week I saw a woman—she works for "Newsnight"—who has back pain, which is a formidable problem for many people. There is now a bionic arm that can manipulate the spine much better than the human
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hand, and it can give great relief. I notice that, in the United States, the Food and Drug Administration approved that hand in no time at all; it got on and did it, and it is bringing great relief to people.
Many other devices are coming through, and one of the biggest is positron emission tomography scanning, which is used to scan the heart. That gives us knowledge about what further treatment should be given, and can be used for brain scans, cancers and so on. That is more readily available in the private than the public sector. I live for the day when everyone gets a PET scan for free in this country. It is expensive, but it gives people the chance to get further treatment, and it prevents many things from happening.
While that is all going on, we are worried about lifestyle illnesses, such as obesity and smoking. Those issues are taking up a lot of time, and prevention is getting much more of a hearing than ever before. I welcome that; because of it, down the line less money perhaps will be needed by the health service for such problems, and so we will have more to make these devices available.
I feel that we have a future ahead of us, but there will be more and more devices, and more pressure for them to be looked at. As I say, NICE has got to get weaving. When nanotechnology sets in across the world and in this country there will be an explosion of new devices in this area. I say to NICE, "Please, carry on the good work, but you will have to increase your resources, your number of people, the number of appraisals you make and so on, so keep the pressure on. Stop sitting back and saying that you are doing a good job but are under pressure; we want more." We need that evidence-based medicine; it is out there and available, and we politicians have to open the door so that it can be introduced.
Frank Cook (in the Chair): Thirteen minutes available, and two Members bidding. I call Dr. Naysmith.
3.17 pm
Dr. Doug Naysmith (Bristol, North-West) (Lab/Co-op): I congratulate my hon. Friend the Member for Merthyr Tydfil and Rhymney (Mr. Havard) on calling for this debate, which could hardly be more timely. [Interruption.] I am dropping a big chunk of my speech, you will be glad to see, Mr. Cook.
Like my hon. Friend the Member for Norwich, North (Dr. Gibson), I have been a supporter of NICE since it was set up. If used properly, it offers the opportunity to combine evidence-based medicine with evidence-based politics, something that is not always achieved, even in this House. There is no doubt that NICE has contributed enormously to rational decision making in this country since its inception. There is good reason to believe that many other countries have looked at the NICE methodology and have set about adopting something similar. The occasional controversy has only strengthened the case for continuing with NICE; if its findings were never controversial, it would suggest that all it was doing was bureaucratic rubber-stamping, and I do not believe that that has been the case.
I want to talk a little about myeloma, partly because I am a supporter of the International Myeloma Foundation UK, which this very week celebrates its
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seventh awareness week. The organisation has campaigned for some time for faster access to the latest treatments for people with myeloma. It is right to speak about the subject in this debate, partly because there is currently controversy about a drug believed to be of importance in fighting this disease.
Myeloma has been under-recognised for years, and only in the past few years have there been dramatic advances, with treatments that promise significantly to improve patients' quality of life, halt progress of the disease and improve chances of survival. A recent example is Velcade, or Bortezomib, which is the first treatment to be licensed for myeloma in over 10 years. The All Wales Medicines Strategy Group recommended the use of this drug in NHS Wales earlier this month, pending ministerial ratification. The treatment has also been made available in Scotland, following approval by the Scottish Medicines Consortium last year. Unfortunately, this treatment is not due to be reviewed by NICE until its 12th wave work programme, and therefore is unlikely to be appraised until 2007 at the earliest. That will be too late for many people who currently have myeloma and could result in a disparity of access between England and its neighbours. Such delays with NICE appraisals send confused messages to cancer networks and primary care trusts, which refuse to fund treatments in the absence of NICE guidelines, as we have heard.
It has recently been reported that all the PCTs in Birmingham are also refusing to fund Velcade, and a number of other important cancer treatments yet to be approved by NICE, on those grounds. In other areas of England, such as the Thames valley, there is a wide disparity of access between those who can get it and those who cannot. Surely that is an unacceptable and unfair situation for patients suffering from rarer cancers in England and demonstrates that change must take place, perhaps in the way in which NICE appraises treatments. Possibly more importantly, there needs to be an increase in the new organisation's capacity, which seems unlikely if its funds are reduced for whatever reason.
We need to put more resources into the new organisation, not less. As was pointed by the hon. Member for Wyre Forest (Dr. Taylor), who is a fellow member of the Health Committee, NICE has been studied twice by that Committee. On both occasions, it recommended increased capacity and increased funding. In 2002, it said:
"This may necessitate an increase in NICE's capacity and/or a change in its organisational structure".
In a more recent report, it said:
"We recommend increased funding of NICE to allow it to evaluate more medicines more quickly. Consequent improvement in prescribing standards should make such investment cost-effective."
I am not too sure about that last statement, but I am sure about the first.
Frank Cook (in the Chair): There are nine minutes remaining.
3.21 pm
Dr. Desmond Turner (Brighton, Kemptown) (Lab): I, too, congratulate my hon. Friend the Member for Merthyr Tydfil and Rhymney (Mr. Havard) on securing
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this debate. This is an important topic, because it is vital in terms of achieving the aim that we set out when we came into Government in 1997 of ending postcode prescribing, and getting best practice and best treatments made universally available in the health service.
I want to declare a personal interest: I am the beneficiary of an example of medical technology, without which I would not have been able to carry on as an MP. I can think of two other Members who are in the same position. Just over 10 years ago, I was finally diagnosed with osteoarthritis in the hip.
I was refused any treatment by an orthopaedic surgeon, who, when I was eventually seen, said, "Well, you got in my office without a stick. You are not bedridden. You are not dosing yourself up to the eyeballs with painkillers. Go away. Come back and see me in 10 years when you are completely crippled." That was effectively what happened to anyone who was not aged 60-odd and severely crippled.
The situation was making life impossible, and I read about a new treatment that had been developed; metal on metal arthroplasty. It is more popularly known as Birmingham hip resurfacing or the McMinn prosthesis. It is quite different from a total hip replacement. It works marvellously, has a 30-year expected lifetime and is virtually impossible to dislocate, which means that I have taken up fencing again. That was how I damaged my hip in the first place. Anyone who knows about fencing will be aware that the movements involved would immediately dislocate any normal total hip replacement.
I could not get that treatment on the NHS—I am talking about a time before NICE, obviously—and I was very miffed. It went well against my principles to go to private medicine, so I had the operation done by McMinn, who led the team that developed the treatment. When I got into this place and when NICE was formed, I wanted that treatment available on the NHS. I agitated for it to be studied by NICE. Its response was to do a study of total hip replacements and it swept the McMinn prosthesis into that study. That, of course, was a disastrous thing to do. It was like comparing apples and doughnuts; they were so different that there was absolutely no point. It would have been disastrous to have had it in that study so it was finally made the subject of a separate study.
There was then the problem of NICE's methodology for considering technologies, as opposed to drugs. My hon. Friend the Member for Merthyr Tydfil and Rhymney has already referred to it; NICE operates with the mindset appropriate for a double-blind clinical trial. That is fine for drugs, although double-blind clinical trials are done as part of the licensing process. All NICE has to do is agree that a drug is effective and that the trial results are okay, and consider cost-effectiveness; those are the only decisions that it has to make.
However, there are clearly no double-blind clinical trials for technology. NICE set out to study the Birmingham hip by saying, "We shall do it as if it were a clinical trial and compare it with watching and waiting." Setting up a clinical trial on that basis would be totally unethical because patients—even in a double-blind trial, they would know whether they had had an operation—
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would be offered the choice of having a treatment that would give them their bodies back or having a painful time. Clearly, that would go against all ethics.
However, NICE used that mindset as the basis for its cost-effectiveness calculation. The only things that went into that were the relative costs of the operations—it got that wrong, because the cost was exactly the same as with the total hip replacement—and the benefits. It would be difficult to compare the benefits enjoyed by people getting the Birmingham hip with those enjoyed by people who had had total hip replacements, because the people getting the Birmingham hip would not be having THRs and would be a younger and more active cohort. There is just no comparison.
A sensible, holistic approach to cost-effectiveness would take into account the impact of immobilisation on health. Immobilisation certainly had an impact on me; I put on two or three stones, and have never been able to get them off since, because this place does not leave me with time for the violent exercise I need to keep my weight down. That obviously impacts on blood pressure, cholesterol and the chances of developing coronary artery disease.
Obviously, there is a cost—it may run to many thousands—to the health service as a result of that. In the long run, it is clearly much cheaper not to have to treat a patient for coronary heart disease, and that disease can be avoided by restoring a patient's activity at an earlier stage in life. The cost-effectiveness calculation did not take such things into account. When the provisional assessment came out, it was going to deny the use of the treatment. There was a bit of to-ing and fro-ing. We finally got it, and I am happy to say that now the treatment is approved.
However, NICE anticipated that about 5,000 of the operations would be carried out, and was worried when the number turned out to be 14,000. Any rational person might think, "If that is not an indication of success, I don't know what is." There is a problem with NICE's approach to technology assessment, and it needs to be looked at carefully. Part of the problem is that NICE is underfunded and cannot afford the correct people to do assessments. It tends to farm work out for very low fees to university departments, which will use the most junior postgraduate student around. One gets the results that one pays for, if one is not careful, and that is only one of NICE's problems. Do not get me wrong; I support the principle behind NICE wholeheartedly, but I think that we need to get it absolutely right.
There is also the question of NICE blight; I had it, and many people still do. It relates to drugs. In the case of drugs, the pharmaceutical industry calls NICE the fourth hurdle, and I do not like to hear it described in that way. We need to speed up and systematise all of these assessments, and after that we have to eliminate the seasonal prescribing that occurs when NICE has made a recommendation that should be available but PCTs are running over budget. Those problems have to be ironed out before we can finally get to where we want to be.
3.30 pm
Steve Webb (Northavon) (LD): We all agree that it has been a worthwhile debate this afternoon, and I congratulate the hon. Member for Merthyr Tydfil and
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Rhymney (Mr. Havard) on bringing this important subject before us. There is a good deal of support throughout the House for the principle of NICE. It has to be right that such assessments are conducted systematically and free of political interference as far as possible, and that guidance should be made available throughout the health service.
This afternoon we have heard examples of where that process is not working as well as it should, and I want to refer to that aspect this afternoon. We heard the hon. Member for Merthyr Tydfil and Rhymney mention the discrepancies between England and Wales and we heard from the hon. Member for Bristol, North-West (Dr. Naysmith), my constituency neighbour, about treatments available in Scotland.
I want to cite one such example. The chemotherapy Taxotere was licensed in January 2005, a couple of years after the data were first presented. Guidance from NICE in England is not expected until February 2007, but guidance from the Scottish Medicines Consortium is expected this autumn. The important question here is why we are getting a different answer in Scotland and Wales. Some things should be devolved, but some things should not be. It seems crazy to me if there is unnecessary duplication, different bodies doing the same work on different schedules. In a sense, Scotland has every right to decide what its drug priorities are, but that is a different question to that of whether something is a cost-effective treatment or not.
The Government should ensure, perhaps in co-operation with the devolved Assemblies, that we minimise duplication and, for example, where the Scottish Medicines Consortium has looked at something, NICE should be able to piggyback on that, and vice versa, to try to ensure that a treatment agreed to be cost-effective and clinically effective is available as broadly and as quickly as possible.
We heard some of the problems of assessing new technologies, but I want to focus on the assessment of new drug treatments. We heard from the hon. Member for Norwich, North (Dr. Gibson) about the campaign by CancerBACUP and some of the treatments it has mentioned. Herceptin has been very much in the news and CancerBACUP is concerned that it could be 2009 before that treatment is widely available—four years hence—despite the growing body of evidence of its potential effectiveness now.
The merger of NICE and the Health Development Agency raises a fundamental issue of resources. I have tabled questions, as has the hon. Member for Merthyr Tydfil and Rhymney, about the resourcing of NICE. The Government's answer is a bit paradoxical; they do not quite say, "NICE is nothing to do with us", but they do say that it is up to NICE how it spends its money. If NICE has decided that it does not have the money to run three appraisal committees, but only two, and if NICE is saying that it will take an extra four months to assess some cancer drugs, it is not good enough for the Government to wash their hands of the issue and say, "That is not a matter for us, it's up to NICE." The Government need to take responsibility for such matters and if the system is not properly resourced, they need to ensure that it is.
There are a range of drugs where there are delays in the system, and one suggested possible alternative is whether, for example, a treatment that is pretty
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uncontentious should necessarily take its place at the back of the queue, or whether there should be a fast-track option for treatments that most people can see make a lot of sense. We would also need to work out whether that would reduce, as it were, the greatest good of the greatest number. Trying to weigh up the competing claims of a cancer sufferer of one sort and a cancer sufferer of another is a very difficult business, but if there are treatments that everyone understands would go through pretty quickly, making them wait may not be a good idea.
I would be interested to hear the Minister's comments on running the licensing of new drugs and the NICE appraisal of new drugs much more in tandem, rather than having a sequential process whereby, first of all, the licensing procedure happens and then the appraisal starts. Perhaps a lot of the appraisal could be done at the same time, avoiding duplication of effort, probably much more cost-effectively. I imagine that things of this sort are starting to happen, but I do not sense that it is the norm. I hope that the Minister looks into that.
There are some aspects of what NICE does that are transparent, and that is welcome. One of the things that is not terribly transparent, however, is how the Government determine the work programme for NICE. I hope the Minister will respond positively to the suggestion that there might be better parliamentary scrutiny of what goes on the list in the first place. Once NICE is looking at these different drugs, we will see what is going on. Yet how does something get into their in-tray in the first place? How far does this place scrutinise that process? We do not want politicians deciding which drugs work and which do not but, clearly, as representatives of our local communities, we might well want to have a say in which drugs might be examined first, at least. That is a legitimate area of democratic accountability.
I was interested in the comments of the hon. Member for Wyre Forest (Dr. Taylor) about the issue of the speed of take-up of new treatments once they have gone through the NICE process. Certainly, coming to this cold, my assumption was that once NICE has said that something works and is cost-effective, we want people to get on with it. His suggestion was that perhaps we do not want people to get on with it, and should be a bit cautious. His example of cortisone was from the days well before NICE; had it been through a NICE process, some of the worries about effectiveness would have been dealt with in advance. Perhaps, however, I can discuss that with him outside this Chamber.
The hon. Member for Wyre Forest also mentioned dementia treatments. I hope the Minister can give us an update on that. It is an interesting case study, because it is one where, as politicians, we think NICE gave the wrong answer. We have all heard from local Alzheimer's groups and individuals who are very worried that treatments might not be available. We feel, particularly because of the concerns of carers and people with dementia, as the hon. Gentleman mentioned, that we want them to have the treatment. The Government seem to have responded to that political pressure by, if I can put it charitably, deciding that perhaps NICE was not asked quite as complete a question as it might otherwise
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have been. My feeling is that if NICE is not being asked complete questions, which it probably is not, we should not just ask them when there is a big fuss, but should do so systematically. I wonder whether the Minister has any views.
NICE is asked to assess drugs. An economist thinking in terms of cost-benefit analysis would say that we need to ensure that it is looking at the really big picture. The hon. Member for Merthyr Tydfil and Rhymney hinted at this; there is a danger that if we are looking at silos—individual budgets here and there, local and national budgets, budgets of different Government Departments—we will not see the big picture. Surely something like NICE can do precisely that. I hope that that will not be just in the case of dementia drugs but, more broadly, that NICE will say that a treatment is cost-effective in the broadest sense, taking into account the whole range of what the public sector spends and, indeed, intangibles. Obviously, there are techniques for trying to put a value on the benefits to carers of the people they are caring for getting proper treatment, and for trying to factor that in.
I do not think anybody is here to criticise the principle of NICE. I think most of us would want to see a better funded NICE, and Ministers not washing their hands of responsibility for it. We would want to see systematic answering of big questions, not just very narrowly-defined ones. We would like to see a lot more transparency in how the work programme of NICE is determined, involving all of us in that process, while accepting their right to be independent, scientific analysers, free of political interference.
3.38 pm
Dr. Andrew Murrison (Westbury) (Con): I congratulate the hon. Member for Merthyr Tydfil and Rhymney (Mr. Havard) on securing the debate. It is an important debate, and an important organisation. There is cross-party support for NICE. Since 1999, it has served a very good purpose. My party certainly hopes that it will continue to do that, perhaps in an even more positive way. It certainly marries very well with our plans for health care in this country. So we wish it a fair passage, and very much hope that the Minister will take any criticism that we may have in good heart, perhaps as constructive criticism.
There are problems, however. We have touched on excessive delays, which are of greatest concern to our constituents in respect of this particular body. CancerBACUP has done a fantastic job of tabulating in a dossier—certainly not a dodgy dossier—the delays experienced in appraising a large number of cancer drugs. Time does not allow me to go through the whole list, but I am sure that during the past few days hon. Members have received that list in their mailbags. I suggest that they, and the Minister in particular, study it carefully and compare the dates for which treatments were licensed for various cancer types with the expected dates for NICE to publish its guidance. They should then consider what that means in terms of lost opportunities for treatment of many people with cancer.
It falls to us to examine why NICE is not operating as efficiently as it could. Is it due to lack of resources? The Minister said on 8 June that it was not and that NICE
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was adequately resourced. We must explore other reasons why NICE guidance is not coming on line as rapidly as it ought to, and it behoves us to consider other, similar systems of analysing medication and health care technologies. All we have to do is look north of the border to the Scottish system and the Scottish Medicines Consortium, which was set up at about the same time. It will consider an intervention in three months; NICE is taking 12 months. We must consider why the Scottish system can issue its guidance so much more rapidly. The answer seems to be that the Scottish system produces quick and dirty assessments—if it is not too pejorative to say so—of the technologies and treatments for which there is no huge amount of controversy, and for which there is a general acceptance that they are good and beneficial. The Scottish system has not gone to the huge lengths that NICE has to approve some treatments.
It would be reasonable for the Minister to consider whether, given that there is no vast difference between the appraisals produced by the two systems, we might adopt more closely the Scottish model. At the very least, closer co-operation between the Scottish Medicines Consortium and NICE would be useful. The hon. Member for Northavon (Steve Webb) touched on the point that we appear to have two parallel systems in what is, despite the devolved settlement, essentially the same system. That seems to me, and I think it would seem to most of our constituents, somewhat inefficient. I hope that the Minister will comment on that.
Although NICE is not that old, we see some early signs of ossification. There appears to be no mechanism for re-scheduling or re-prioritising. We must appreciate that medical research moves far more rapidly than NICE is able to consider its guidelines. One particularly good example of that has been anti-Alzheimer's drugs. Research during the past few months has shown that the drugs affect the condition at a bio-chemical level, and that the number of brain cells killed in the process of Alzheimer's disease are reduced as a result of the use of anti-Alzheimer's drugs. However, we see no reflection of that in the determination made by NICE. I wonder if NICE's structure is insufficiently flexible to incorporate research as it comes on stream. The structure seems to be far too retrospective, and it would be interesting to know how it could it so that it is more reactive to research.
I am sure that hon. Members will have received in addition to CancerBACUP's useful contribution to the debate, the Alzheimer's Association's response to NICE guidelines on anti-Alzheimer's drugs. I share the concern expressed today by several hon. Members that the question of cost-benefit analysis—how much it costs and who it benefits—has not been precisely explored by NICE in connection with that range of treatments. In particular, we see precious little reference to the benefits to carers, for example. Most health economists would say that that is a relevant consideration. Over the past few years, Ministers have made great play of their concerns for carers. It is extraordinary that the benefits that undoubtedly accrue to carers from this range of drugs have not been incorporated in the guidance. Given the concerns expressed by carers' organisations, I very much hope that the Minister will comment on the issue.
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Concern has been expressed about the lack of transparency in the pre-appraisal and scheduling of NICE assessments, and I am talking here about the work that is given to NICE. Clearly, NICE's considerations are not political, and rightly so. Indeed, that is one of its charms. However, the work that is fed to it clearly is politically influenced, and there is a lack of clarity and transparency at that stage. The Minister might like to comment on how she sees us improving clarity and transparency. Perhaps she can illustrate her point by commenting on the 12th wave of appraisals. When will they be presented to NICE? Perhaps she would like to share with us what that 12th wave might contain. What will be the justification for inclusion in or exclusion from it? Presumably, it is on her desk at the moment.
We have seen a little in the press recently about the part that the so-called citizen's council plays in the NICE process. I think that we all agree—I hope that hon. Members see from my comments about carers that I certainly do—that patients and carers need to be involved fully in NICE appraisals. They have a legitimate voice, which must be heard.
The more excitable elements of the media may have deliberately misunderstood that organisation and they seem to be suggesting that it is engaging in ageism. I am sure that the Minister would join me in condemning any ageism in NICE appraisals, while accepting that certain interventions are beneficial for certain age groups and that that is a legitimate concern for NICE. I hope that she will also condemn the notion that people who are elderly and who have fewer years left to run are therefore less deserving of certain treatments, as the media have suggested in the past few days. I am sure that we would all condemn that Robespierre version of citizen's councils.
Finally, it would be useful to hear the Minister's comments about improving the uptake of NICE guidelines. We have heard mention of the drug Herceptin, and NICE has produced guidelines on its use in metastatic breast cancer. NICE's investigation into whether it might be beneficial for earlier-stage breast cancer is some way down the track. None the less, it issued guidelines on the use of Herceptin for metastatic breast cancer very early on; indeed, it was about three years ago. Yet, cancer networks in some parts of the country are making the drug, shall we say, less than fully available. Surely, that is not acceptable, given that they have now had three years in which to implement the NICE guidelines. It would be interesting to hear how the Minister feels we can improve practice so that NICE guidelines—when they eventually emerge—are fully implemented.
Finally—this really is my final remark—we need some comments on the 1999 health service circular referred to by the hon. Member for Merthyr Tydfil and Rhymney. It appears to have been used to indulge, to a certain extent, in a postcode lottery, particularly in relation to Taxotere. It would be interesting to hear whether the Minister has audited the effectiveness of the guidance that she issued at that time, because it seems not to have been fully implemented.
3.49 pm
The Minister of State, Department of Health (Jane Kennedy) : Mr. Cook, I was right in what I said prior to our debate; my hon. Friend the Member for
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Merthyr Tydfil and Rhymney (Mr. Havard) is indeed a serial offender in securing these debates. I welcome the opportunity to listen once again to what is clearly a professionally well informed debate. I appreciate that my hon. Friend has a keen interest in health issues, especially those where he feels that guidance from the National Institute for Health and Clinical Excellence would be of benefit. However, as a new Minister, if I had just picked up on the tone of this debate—the gloom, the disaster, the chaos that has been described—I might have been forgiven for running screaming from the Room. A new Minister might be dismayed if what has been described were the case, but, on the contrary, I regard this as a really exciting time to be invited to take on this brief.
I accept that there are concerns about the operation of NICE and the wider picture and I will focus on that, rather than being drawn into some of the individual examples that have been offered. Before I go any further, I welcome the hon. Member for Northavon (Steve Webb)—it is good to see him in his new role; he is following me across Departments—and I also welcome the hon. Member for Westbury (Dr. Murrison) to his position speaking for the Opposition on this subject. I welcome his constructive approach and look forward to debating these issues with him. Both hon. Gentlemen raised an important point, which I want to study further, about devolution and the way in which these processes and procedures are working across the devolved authorities. I am interested in that and wanted to acknowledge it.
A quick question was asked by the hon. Member for Westbury about the 12th wave. That is under consideration and he is quite right; it is on my desk as we speak. I cannot give him an exact timetable, but it will be submitted to NICE very shortly.
I will come on to the concerns that were raised about the transparency of the process and the procedures. There are concerns about how topics are selected for referral to NICE and there is not always universal agreement about the priority of the topics that are referred. However, this area is given careful consideration. The topic selection process involves a wide range of individuals, including representatives of professional and patient groups, the pharmaceutical industry, the NHS, NICE itself and Department of Health officials.
The views of all those groups are taken into account in deciding which topics should be referred to NICE through the wave process. All the parties involved consider the suitability of the potential topics for referral against the published selection criteria, taking into account first the available evidence base, secondly, the likely impact on NHS resources and, thirdly, the relative priority of the topic against strategic issues. Nothing is referred to NICE capriciously, and I know that nobody is suggesting that.
I accept, too, that the topic selection process could be faster and that matter is subject to ongoing review by officials in the Department of Health and by me. We are already looking into ways in which the process could be shortened, whether it could include greater NHS and public health representation and whether it could be more flexible. I am pleased to say that some changes
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have already been introduced; for example, referring clinical guidelines to NICE earlier in the process. We should see benefits flowing from that.
My hon. Friend the Member for Merthyr Tydfil and Rhymney asked three important questions. He pressed me about the move from three committees to two. I understand that NICE expanded from two to three appraisal committees about two years ago. The expansion was made on the basis of an anticipated significant increase in the number of new technologies that would need appraisal and would be referred by Ministers. However, the expected expansion in referrals of new technologies has not been as significant as NICE thought and the three appraisal committees have not been working at full capacity. I can tell by my hon. Friend's face that he has a degree of scepticism about my reply.
I will turn to the other issue that my hon. Friend raised; his suspicion that there are budgetary reasons for the change. The reason why I gave the answer that I did—about how NICE organises its resources—was not because I wanted to duck responsibility. Let me quickly explain the budgets. Rightly, my right hon. Friend the Secretary of State talked to the NHS Confederation about finances last week. It is important to remember that all this work is going on in the context of a threefold increase in the resources available to the NHS globally by 2008. It is always in that context that I address representations about organisations needing more resources.
The 2005–06 budget for the new National Institute for Health and Clinical Excellence—following the Health Development Agency joining it on 1 April—is £29.9 million. Members might like to know that the previous year's funding for NICE—without the HDA—was approximately £19 million, and that the HDA's budget was about £12.5 million. It does not take much to work out that if those two sums are added together we get a total of £31.5 million. One of the reasons for bringing these two organisations together was to achieve administrative savings that could then be ploughed back into front-line work. That is what has happened.
Sometimes, the reason given for not funding treatments, medicines or devices is lack of resources. That is not exactly an excuse, but it is a way of ducking decisions at strategic health authority level. We will carefully look into that, because I take very seriously the concerns that we might be reintroducing a different kind of postcode variability in treatment. We must examine the effects of what we are doing.
As always in important debates, I have not got enough time to say all that I wish to say. I have spoken about the topic selection process. The hon. Member for Wyre Forest (Dr. Taylor) referred to the World Health Organisation report. I want to quote from another section of that report. The WHO recognised:
"NICE has developed a well-deserved reputation for innovation and methodological developments that represent an important model for technology appraisals internationally".
Its report went on to say that NICE is
and it particularly praised "the transparency" and "inclusiveness" of the appraisal process, as well as "the commitment" of NICE and its partner organisations.
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The fact that NICE's processes are so thorough raises the question of the effect on the uptake of new medical technologies in the interim period while the publication of NICE's recommendations are awaited. The Department of Health has issued guidance to the NHS advising that health bodies continue with local arrangements for the managed introduction of new technologies. My hon. Friend the Member for Merthyr Tydfil and Rhymney raised this matter.
NICE's procedures may well not always be the most appropriate route to take for the appraisal of some new technologies and treatments. My hon. Friend the Member for Brighton, Kemptown (Dr. Turner) described an experience he had; that might be—I am not suggesting that it definitely is—an example of a treatment that, as he said, could have been dealt with in a better way than it was. He described his experience in detail, and it is precisely that sort of experience that a Minister gets benefit from in these sorts of debates.
A number of Members talked of the improvements that have taken place. That is one of the good effects of NICE. There has not just been one long catalogue of problems and inefficiencies. For instance, there was a 1,000 per cent. increase in the space of 12 months in the use of two drugs for ovarian cancer—I am not even going to attempt to pronounce them, given my last experience—following the publication of NICE technology appraisals. It is not unusual for there to be that sort of increase following the publication of NICE recommendations.
We should go back to the issue of what should happen in the meantime. The Department of Health has made things clear to health authorities—
Frank Cook (in the Chair): Order. We must move on to the next debate.
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