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We have decided, since we will not know the composition of the House unless and until we reach a decision about that, to leave the name until we know the nature of the House.
We propose that there should be a greater facility for wider representation of religious and faith groups. If there is a movement for the disestablishment of the Church of England, that is fine. I do not regard that as a priority. Meanwhile, we should accept that it is a second-order issue. If those of us who believe in reform reach the stage that I have outlined, we will have gone a long way.
Fiona Mactaggart (Slough) (Lab): The Leader of the House pointed out that, on the last occasion when we considered the matter, an unholy alliance formed between those who felt that their perfect options had not been accepted and therefore voted against all others, and those who wanted no change, which delivered no result. I perceive the development of another unholy alliance. The right hon. Member for Maidenhead (Mrs. May) claims that the proposal does not fulfil her demand for greater democracy, and my hon. Friends who do not want an elected House of Lords claim that it does not meet their demands. Will he try to demonstrate that the proposal is the only mechanism whereby we can achieve the result that most Members of this House want? It will enable us to achieve the reform, which successive Governments of all parties since 1908, have failed to deliver.
Mr. Straw: I will do my best, and I would be grateful for my hon. Friends support. It is entirely legitimate for those who want no change at all to vote for that. It is unacceptable, however, for those in that position to seek to use a wholly defective voting system to ensure that those who want some change are denied the opportunity to come to a decision.
Mr. Soames: As the Leader of the House knows, I am generally regarded as a standard bearer for reform and in the white heat of modernisation. It is a mark of good government, however, to know when to leave things alone. There is absolutely no demand for this change or reform anywhere in the country. The House of Lords fulfils its tasks extremely well. What is the point of proceeding with this arrant nonsense?
Mr. Straw: The point of proceeding with it is that the British public are not in quite the same position as the hon. Gentleman. More to the point, his party does not share his view either; he stood at the last election on a manifesto proposal that happens to be even more radical than ours.
Mr. Andrew Love (Edmonton) (Lab/Co-op): I welcome the White Paper, and congratulate my right hon. Friend on its terms, which need to be debated in the House. After the appalling introduction to that report by Her Majestys official Opposition, may I plead for the House to have a reasonable time to debate the issues? My right hon. Friend talked about finding the centre of gravity, which everyone recognises is incredibly important. We will only be able to do that, however, if we have proper and effective debate before coming to a decision.
Mr. Straw: Yes; I am grateful for my hon. Friends comments. There will be a day to determine and come to a vote on the procedure, and about a week later a two-day debate will take place on the reform and composition of the House of Lords.
Mr. Richard Shepherd (Aldridge-Brownhills) (Con): The preamble to the Parliament Act 1911 held out a better prospect than anything offered by the Leader of the House today [Interruption.] I am just anticipating a situation that will come about. My point is that the demand for primacy of the Commons does not wash if the House of Lords is elected. The central proposition of a democratic system is that those who make the laws should be accountable to those who bear the laws. His proposals, and his extraordinary voting system, defeat that. Some Members of this House will welcome another House that can bring to check the dreams and ambitions of the Crown in Downing street and the Executive here.
Mr. Straw: I was not sure whether the hon. Gentleman was in favour of or against a fully elected Chamber. That is his opinion, however, and he is fully entitled to exercise it and, under the voting system suggested by the Government, gain the maximum support. The House would then come to a decision.
Martin Linton (Battersea) (Lab): I congratulate my right hon. Friend not only on his clear set of proposals but on having the courage to recommend a way of taking the decision that will lead to a clear outcome. Does he agree that opposition to a preferential vote is a disguised way of blocking reform and lacks candour, given that all parties in the House select their candidates and leaders through various forms of preferential voting?
Mr. Straw: I agree entirely. Were the Conservative party really committed to reform, it would have no alternative but to back the system of voting that I propose.
John Thurso (Caithness, Sutherland and Easter Ross) (LD): May I welcome in general the progress made by the Leader of the House? My preference has always been for a wholly or predominantly elected House, but I would accept a lesser number of elected to make progress. Does he agree that the critical issue is to get the mechanics of the election right, and particularly to have regionally-biased constituencies to complement the population bias of this House?
Mr. Straw: I look forward to getting to those sunlit uplands where we can have a serious debate about the electoral system. As I said to the Opposition Chief Whip, however, I have sought to show flexibility, and let us hope that that can continue.
Jane Kennedy (Liverpool, Wavertree) (Lab): I hesitate to contradict my right hon. and dear Friend, but the House is entitled to reject all the options, which was what happened last time. It was not a train wreck or an unholy alliance. The fact is that there was not a majority for any one of the proposals made. Trying to change the voting procedure to bring about a decision smacks of not liking the original set of decisions taken by the House. He knows that I have the highest regard for him, but could he please divert his prodigious talents and enormous energies to some other subject?
Mr. Straw: My right hon. and dear Friendthe admiration is mutualis right in some respects, particularly towards the end of her remarks. If she wants to vote against all the options, however, there will be an opportunity, on a traditional yes/no vote, to vote for no change. The voting system is entirely different from last time. If the House wants change, however, it must indicate which preference commands a majority. There are only two ways of doing that: through an exhaustive ballot, which I do not mind but which would take far too long; or through its equivalent, which is the alternative vote.
Mr. William Cash (Stone) (Con): As someone who has been in favour of a directly elected Chamber for about a decade, may I ask the Leader of the House whether he accepts that basing that on a change of functions and different constituencies is legitimate, but that going for a system that is intrinsically undemocraticnot only in the procedure adopted for voting in this House but in the party list system to which he has referred with respect to voting outsideis not legitimate and fatally undermines his case?
Mr. Straw: I think that the hon. Gentleman is agreeing in part with the proposals, but exercising some disagreement about the electoral system. Incidentally, I congratulate him on not mentioning Europe in his question for the first time in a very long while. I look forward to his support for the process that we propose, as he can then exercise his vote and, say, support 80 per cent. or 100 per cent. elected.
Martin Salter (Reading, West) (Lab): Out of affection for the hon. Member for Stone (Mr. Cash), I will mention Europe. Does my right hon. Friend acknowledge that although 48 of the 67 second chambers in the world are largely or wholly elected, including in advanced democracies such as Australia, Switzerland, Austria, Ireland and the Netherlands, their powers are almost wholly subordinate to those of the primary chambers concerned? Does not history and experience expose the flaws in the argument that a more democratic House of Lords, as promised in our and other parties manifestos, would automatically challenge the primacy of the Commons?
Mr. Straw: The answer to my hon. Friend is yes; he is absolutely right.
Mr. Edward Leigh (Gainsborough) (Con): Does the Leader of the House agree that there is no point in having clones of MPs in the other place: people who climb the greasy pole in order to become Under-Secretary for paperclips, and never vote against their own party? I know that he does not agree with me on elected Members, but does he at least agree that there is some merit in making those people like congressmennot MPswho serve in a kind of senate, cannot become Ministers and therefore maintain their independence of spirit?
I agree with almost all that the hon. Gentleman said. The cross-party group has agreed to reflect the recommendations of the Wakeham commission precisely to ensure that new Members, whether elected or appointed, do not become clones of MPs, that
they are elected for a single term that runs for a long timewe suggest 15 yearsand that there is a quarantine period after the expiry of their normal 15-year term of, say, five years, before such individuals could stand for election to this place. By that time, I think, their ambition will have been exhausted.
Clive Efford (Eltham) (Lab): May I caution my right hon. Friend against turning the voting procedure into the issue? He seems to be suggesting that a vote against what he is proposing is a vote against any form of reform. He should put an option for a voting procedure to the House.
There is one issue on which there is unanimity among Labour Members, and that is that the remaining hereditary peers should be removed. Any procedure that my right hon. Friend puts to the House must allow a separate vote on that issue.
Mr. Straw: I will certainly take that into account. I will talk to my hon. Friend about whether we should have a specific vote on the removal of hereditaries, and then another vote on further reform.
Sir George Young (North-West Hampshire) (Con): I welcome what I perceive to be a genuine attempt by the Leader of the House to unblock the logjam and give the House an opportunity to resolve the issue one way or another quite soon. Will he confirm that when we last discussed it, the proposal that commanded the least support was for a wholly appointed Chamber, which is where we are now? If the views of this House are to have primacy, it must be right for us to consider that again.
Mr. Straw: The right hon. Gentleman is absolutely correct, and I am grateful to him. Just 245 Members voted for a 100 per cent. appointed House of Lords, compared with the 281 who voted for an 80 per cent. elected House.
Mr. Speaker: Order. We must move to the next business.
Mr. Wayne David presented a Bill to amend section 33 of the Health and Safety at Work, etc. Act 1974: And the same was read the First time; and ordered to be read a Second time on Friday 27 April, and to be printed. [Bill 58.]
Mr. Speaker: Before I call the hon. Member for Tunbridge Wells (Greg Clark), I have a statement to make. The hon. Gentleman has asked me to exercise my discretion to allow him to present his motion, in view of the forthcoming judicial review of the process by which the National Institute for Health and Clinical Excellence developed guidance on the use of drugs for treating Alzheimers disease. I have agreed to exercise my discretion to allow him to present his motion, but he should be sparing in any direct reference to the specific matter that is subject to judicial review.
Greg Clark (Tunbridge Wells) (Con): I beg to move,
That leave be given to bring in a Bill to require the National Institute for Health and Clinical Excellence to consider the impact of proposed drugs and treatments on carers and patients when assessing their cost effectiveness; and for connected purposes.
I am pleased to see that the Minister of State, Department of Health, the right hon. Member for Doncaster, Central (Ms Winterton) is present. It was very kind of her to come.
This is a simple Bill to correct what I regard as a serious flaw in the way in which NICE evaluates proposed new drugs. At present it is required to balance the benefits to the patient against the costs to the national health service and the personal social services budget. On the face of it that would seem an extremely reasonable way of operating, until we consider that the benefits of many new treatments fall as much on carers as on the patients themselves. The requirement under which NICE operates is too restrictive in that regard.
Let me make clear at the outset that I am not saying NICE should be allowed to breach the public-expenditure constraints under which it operates. Rightly, NICE is there to take a view, given the current level of resources for the NHS. I think, however, that if it were able to take account of the costs and the benefits to the quality of life of carers, a more sensible and rational balance could be achieved.
I have no objection at all to the existence of NICE. I think it essential for the national health service to benefit from an independent body that is able properly to consider and weigh up the costs and benefits of different treatments. But NICE operates under directions from the Secretary of State, and those directions are very clear: it is required to take into account the clinical costs and benefits of proposed treatments. I think we could change that definition, and I think the Secretary of State for Health could change the directions that she gives to NICE.
Let me give an example of an application of the guidance. Consideration was given to licensing a new class of drugs that can treat Alzheimer's disease. The drugs were assessed by NICE, and the most recent judgment was given in November this year in response to various appeals. The clinical effectiveness of the drugs is not in doubt, but they were withheld, and the recommendation is that they should continue to be withheld from people displaying the symptoms of mild Alzheimer's disease. That is not because they were not effective in slowing the progression of the disease,
alleviating some of the symptoms and allowing people to have more self-confidence and to engage in everyday tasks. They were held not to be cost-effective, although the cost is about £2.50 a day.
The key part of the appraisal that is missing relates to the impact on the cost of carers. The final appraisal document leading to the most recent NICE judgment states:
The Committee noted that the relevant NICE guidance on performing economic evaluations states that the evaluation should be conducted from the perspective of the NHS and PSS decision maker... The Committee therefore concluded that it would not be appropriate to include carer costs.
One of the principal effects of Alzheimer's disease is on carers for sufferers from that dreadful disease. The evidence is overwhelming. According to a recent survey, 72 per cent. of carers and sufferers felt that their symptoms were improved by the application of these drugs. It is also the case, crucially, that on average an hour a day of hands-on caring time was saved if the drugs were administered.
I believe that the minimum wage is currently £5.35 an hour. If the value of an hours caring time were valued at the same rate as the national minimum wage, the benefit to carers would be twice the daily cost of the drugsand that is leaving aside the effect on patients themselves. It is at least arguable that an evaluation that was allowed to consider the effects on carers might come up with a different conclusion.
I said that the evaluation did not take into account the effect on the quality of life of carers. Of course, that is significant too. In his recent review of social care for the Kings Fund, Sir Derek Wanless described the extra caring burden as producing
anxiety, depression and psychiatric illness, increased susceptibility to physical illness, lowered social functioning, increased rates of chronic diseases during episodes of caring and general negative impacts on physical well-being.
The effects on carers deserve to be taken into account, and could well make a difference to the evaluation.
I am not alone in concluding that we need to broaden the scope within which NICE is constrained to operate. As part of its consideration of the appeal, NICE asked five independent experts to comment on the evaluation process. Professor John OBrien, of the Institute of Ageing and Health at Newcastle university, told NICE:
The economic model fails to take into account many significant benefits of the drugs, for example reduced carer time
in supervising patients with dementia... to use this as the sole basis for decision making in this case remains a fundamental flaw.
All five experts were of the same view: that the current NICE methodology was flawed.
In his review, Sir Derek Wanless said:
the burden on informal carers is particularly acute with dementia care.
That cost, he said, required greater attention. During the last Parliament, the Houses own Health Committee concluded in one of its reports:
we recommend that NICE should consider the wider societal costs and advantages of particular treatments.
There are 290,000 people with Alzheimer's disease in England and Wales, more than 500 in each of our constituencies. Everyone knows a family with a member who suffers from that cruel disease, and everyone knows that, devastating though the consequences are for the sufferer, the effects on carers are even more distressing. It is painful enough for people to go through the process of seeing a loved one such as a father, a mother, a husband or a close friend suffering and, before their eyes, becoming a different person from the person they had known all their lives. That is a harrowing experience, the like of which most of us will never go through. However, for the carers of those people there is also a practical effect: their lives are transformed, as they become, effectively, full-time carers.
We owe it to such people, who do heroic work on behalf of all of us by looking after their loved ones, to make sure that their role is recognised and respected in the evaluation of new treatments that come before NICE which can make a difference to Alzheimers and many other diseases.
Bill ordered to be brought in by Greg Clark, Mike Penning, Mr. Jeremy Hunt. Mrs. Jacqui Lait, Mr. Mark Field and Mr. Adam Holloway.
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