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That is one example, but it is small; we need to accumulate such evidence bases much more widely. I am interested in the idea of Nottingham as an early intervention city and in how my hon. Friend seeks to improve the evidence base at a local level to make the
case for spend to save. We would like to learn more of Nottinghams progress on such issues, and I will be happy for the Treasury to come to Nottingham to see that emerging evidence and help in the work that my hon. Friend is leading.
My hon. Friend also suggested that with a better evidence base we could do more to shift the focus of policy and spending on to prevention and early intervention. The local government White Paper has committed to giving local areas more freedom to set local priorities, reducing the amount of central direction and allowing more freedom to shape spending to meet prioritiesincluding, when the case can be demonstrated, more emphasis on prevention.
I am also interested in my hon. Friends suggestion to allow local areas to borrow funds in anticipation of future savings. Although as a Treasury Minister I can see potential pitfalls in that approach, it is right that we should consider the idea further and give it due attention to ascertain whether it is a way to strengthen the ability of local leadership to promote early intervention. As my hon. Friend acknowledged, we have produced funds to facilitate pump-primingfor example, the £780 million invested in the childrens fund in the past four to five years; one of that funds key aims is to deliver better preventive services. In addition, over the past seven years the invest to save budget has invested £420 million in projects, a number of which have been in the field of preventive support for children and families. By the end of next year, nearly a third of local authorities will have received support from the DFES to identify how to create service efficiencies that allow a move to prevention.
Case studies have been done by the DFES: in north Lincolnshire, a more preventive approach reduced re-registrations on the child protection register from 18 to 11.5 per cent.; and in Blackpool, the identification of cashable efficiency savings in childrens residential care released resources for prevention. I am keen to see what more can also be done in Nottingham to benefit from that kind of flexibility.
As my hon. Friend knows, in the Budgets spending review we announced a significant investment in the capacity of childrens services for supporting prevention and early intervention as part of an overall increase in the education budget. It will rise by 2.5 per cent a year in real terms on average between 2007-08 and 2010-11. The review will build on the progress made against the Every Child Matters agenda by building resilience, providing greater responsiveness and personalisation of services, and offering proactive and preventive support for families who are facing severe difficulties caused by complex needs.
We recognise the need for early intervention and there will be implementation in respect of taking forward the ideas in our discussion paperI am thinking in particular of the strands on high-risk, high-harm families, disabled children and their families, and youth services. We must ensure that
spending on the early years is sustained through the primary school years and into the teenage years. Educational attainment is not enough, because this is about developing wider social and emotional skills to improve life chances and build resilience. That can be done only by ensuring that services are even more responsive and that we can engage children, young people and families in decisions about what is made available to support their own efforts and ambitions. That involves all the local services, the professionals in those areas, from head teachers to general practitioners, and others more widely.
My hon. Friend mentioned support for early intervention in Nottingham, and in particular support for health visiting and the nurse-family partnership scheme. The evaluations of nurse-family partnerships in the US suggest significant short-term and long-term benefits to mothers, children and wider society from intensive support to first-time parents with the highest levels of need. He cited that research in detail. It encouraged us to introduce Sure Start in the early years of this Government. It deliberately brings together education and health services for first-time parents in more deprived communities.
That research also shows why the Government announced last September that they would establish 10 projects to demonstrate models of health-led parenting support for parents of children from pre-birth to their teenage years. The work will build on the experience of the US and will involve a structured programme of home visits by trained health visitors and community midwives to test how the model is best applied in the UK. In particular, it will try to evaluate and quantify the long-term cost savings, including the wider, downstream costs to society, such as those associated with antisocial behaviour and criminality. My hon. Friend cited those in his speech.
Mr. Allen: Will the Minister consider the possibility of the Treasury commissioning more work in this area? I am pleased that Treasury officials will come to Nottingham, but will he consider doing so in order to see the work that we are doing?
Ed Balls: I would be happy to return to the city in which I grew up to meet my hon. Friend and his local strategic partnership. One thing that we could do would be to examine how this model of nurse-family partnerships in Nottingham could be part of the wider early intervention strategy that he is taking forward and leading. As I have said, local leadership makes change happen. It is only through local leadership that we can have effective early intervention. The kind of local leadership that is benefiting Nottingham is something that we want to learn from in the Treasury and the Government, so that we can spread best practice around the rest of the country, and I could learn from it by taking up the invitation to visit my home city as soon as possible.
Sir George Young (North-West Hampshire) (Con): This debate follows neatly on from the earlier one. I heard the Economic Secretary speak about prevention and early intervention and I hope that those sentiments will inspire the Minister of State, whom I welcome.
I welcome the opportunity for a brief debate on age-related macular degeneration, which causes a progressive and irreversible loss of central vision in older people, and accounts for more than half of all registrations for blindness or partial sight. The Macular Disease Society is based in my constituency and I am grateful to its chief executive, Tom Bremridge, the Royal National Institute of the Blind and Simon Kelly, a consultant ophthalmic surgeon in Bolton, for a briefing for this debate. A number of colleagues share my interest, and I am pleased to see my hon. Friends the Members for Reading, East (Mr. Wilson) and for Weston-super-Mare (John Penrose) in their place. The Macular Disease Society brought to my attention a case from the constituency of the hon. Member for North Norfolk (Norman Lamb), who may catch your eye, Mr. Amess, after I conclude.
There are two types of AMDdry AMD, which is caused by the slow deterioration of cells on the retina at the back of the eye, which is incurable and untreatable, and wet AMD, which is the most aggressive type. It is caused by the leakage of blood and fluid on to the retina. The macula, which processes detailed central vision, becomes obscured, and a healthy eye can then become blind and useless in three months, unless it is treated. People with AMD, who are usually otherwise healthy people and fully functioning citizens, suffer a diminished quality of life. They become unable to read, drive, recognise friends, tell the time or carry out many other everyday tasks. They run a higher risk of falls, hip fractures and depression, and are, of course, higher users of health care and community-supported services.
In 2004, the RNIB published an estimate of the costs of blindness. It showed that the annual total cost of sight loss was in the region of £4.9 billion. That figure makes it clear that treatments that can halt, or even reverse, sight loss will not only help people who suffer from AMD to avoid the distressing consequences, but will significantly reduce the consequential cost. Thus, rationing treatment to save PCT costs is short-sighted. Allowing any individual to go blind when there is a cure is indefensible. It is also extremely expensive for the taxpayer.
Happily, there are now two new licensed treatments for wet AMD. They stabilise sight loss, prevent blindness and in many cases restore lost vision, as long as diagnosis and treatment are relatively swift. They are Macugen, which was licensed for use last May, and Lucentis, which was licensed in January this year. The treatments have dramatically improved the prospects for sufferers, and the medical and public health professions are understandably lobbying for them to be made more widely available. Less happily, most patientsabout 26,000 present themselves with the disease each yearcannot benefit from the new treatments because of the NICE review process, which started in September last year and is not due to
complete until October; that is a period of 13 months. Yet in the meantime the drugs are in widespread use in the USA, Australia, France and Germany, and Macugen has been licensed for use by a similar process in Scotland, where it has approval. In the case of many other new therapies that NICE examines, an alternative treatment may be available in the meantime, but the new drugs for wet AMD are unique and there is no alternative.
The Department of HealthI welcome the Minister, although I may say some unkind things about his Departmenthas said that the NICE review process should not be a barrier to the use of new treatments, but it has in effect opted out and delegated the decision on whether funding should be authorised to the 152 primary care trusts in England. Many are overspent, and do not have the resources to conduct the effective reviews of the treatment that they are obliged to carry out. The RNIB and the Macular Disease Society have told me that many primary care trusts hide behind the absence of NICE guidance and simply refuse treatment point blank. In Oxford, a consultants application for permission to treat was referred to the PCTs exceptional circumstances committee, which takes a month. It turned down the application because going blind was not regarded as an exceptional circumstance. Consultants in Bristol have been told not even to apply for funding. Therefore, in effect, there is a blanket ban on using those treatments for patients. Many of my hon. Friends will know that their own PCTs are under enormous financial pressure and unless they have to provide a treatment, many decide not to.
John Penrose (Weston-super-Mare) (Con): I congratulate my right hon. Friend on the way in which he is making his case. I shall strengthen his argument by citing the example of North Somerset primary care trust in my constituency, which effectively runs the system that he is describing. Basically, if something is not mandatory under NICE guidelines, because there is a double deficit situationboth the PCT and the hospital are in deficitthe treatment is simply not available.
No patient should be refused Lucentis or Macugen simply because NICE guidance does not yet exist. [Official Report, 6 February 2007; Vol. 456, c. 692.]
It is not all bad. Some enlightened PCTs and commissioners of services have authorised the new treatments. If someone lives in Salford they are all right, but if someone lives in Wigan, they are not. Other PCTs have mitigated the cost by authorising the use of the unlicensed treatment Avastin, which is having good results. The Secretary of State has suggested a head-to-head trial between Avastin and Lucentis and I want to press the Minister on the progress of those trials. I understand that Professor Usha Chakravarthy in Belfast and Professor Simon
Harding in Liverpool are leading such a trial with funding from the Health Development Agency. If it goes ahead, the trial will provide good evidence that would allow regulators such as NICE to recommend the use of Avastin over Lucentis and save the NHS a considerable amount of money. I am interested to find out today whether it would be possible to refer people who live in PCT areas, such as those of my hon. Friends, to whatever centres the trials take place in, so that they can have the treatment offered under the trials. That would effectively create a way through the current bottleneck and postcode lottery.
If all patients with wet AMD in the UK were treated with standard dose Lucentis, costs to the NHS by year two would be approximately £1,008m a year; if Avastin were used the cost would be about £4m a year.
Putting to one side for a moment those PCTs that are prescribing Macugen or Lucentis and those that are using Avastin off-licence, for the most part, PCTs are simply saying no to the use of the treatments because they are not under any compulsion from the Department of Health to provide them. For example, Mrs. Beeby has been refused treatment in Southampton. She is already blind in one eye and her consultant said that apart from going to him privatelyprivate treatment varies from £1,000 to £1,750 per injection and up to eight injections may be needed in the first yearthe only option was for him to ask her GP to apply for treatment in another area. That does not strike me as a good advertisement for a national health service.
What should the Minister do? Only a tiny minority of people know that smoking causes blindness as well as lung cancer and heart disease. More teenagers said that they would quit smoking if they had early signs of blindness compared with lung or heart disease. Does the Minister think that it is time to warn the public of that risk and perhaps to have the message smoking causes blindness on tobacco products as well as the more conventional warnings?
I have already said that there is a role for the Government in the head-to-head trials between Avastin and Lucentis and I want to find out whether there is enough funding available for those trials to take on board the constituents of my hon. Friend the Member for Weston-super-Mare and, indeed, the constituents of other hon. Members who find that they are blocked by the current funding policy of their PCT. I hope that the Minister can assure me that the centres at which the trials are taking place will have enough capacity to deal with those people who I am particularly concerned about.
More should be done now. As I said, 26,000 people a year present themselves with this disease and treatment is available now, so it should be provided now. The Government should tell those PCTs that hide behind the absence of NICE guidance that it is unacceptable not to provide the treatment, and that all applications for treatment by consultants should be processed
promptly with a presumption that treatment will be given unless there are clinical reasons for that being inappropriate. Ministers should reaffirm that we have a national health service, not a collection of independent trusts, and that the current postcode lottery for treatment must come to an end.
Wet AMD eyes do not wait for the NICE review, for PCTs, for exceptional circumstances, for committees to convene and come to a decision, for patients to appeal against local decisions, or for lobbying to MPs. Such eyes do their own thing and to leave people to go blind within three months is unacceptable, so I ask the Minister to prescribe some humanity now and to provide the service that I am sure he would want for his mother or father.
Norman Lamb (North Norfolk) (LD): May I first congratulate the right hon. Member for North-West Hampshire (Sir George Young) on securing this important debate? I am grateful to him for enabling me to speak in it.
I want to highlight the cases of two constituents. First, Jack Strange hit the headlines last week. He is elderly and has had to spend most of his life savings to pay for Avastin. His family tell me that it had an immediate and dramatic effect on his quality of life, and has halted his developing condition. That very rapid improvement has come only because he could pay for it, but he has used all his life savings in doing so.
The second case is a 56-year-old who is in work as a self-employed gardener. He has not yet had a decision, so he is waiting as he loses his sight in one eye. He has been told that he could lose his sight in both eyes within five years. That will ruin his quality of life, but he will also become completely dependent on the state. For reasons of quality of life and the overall cost equation for the country, it is ludicrous for people who could benefit from the treatment not to have access to it.
I want to reinforce the fact that time is of the essence because the disease is time-sensitive. I understand that it involves the formation of unstable new blood vessels in the macula, right at the heart of the eye, under the retina, and that scarring occurs with irreversible loss of sight. The drugs work only when that process is occurring. When it has occurred, it is too late and nothing can be achieved. For those who need help now, time is slipping away, and it is so important for them that a speedy decision be made.
It is interesting that the Norfolk and Norwich hospital has proposed to Norfolk primary care trust that it should use Avastin. As the right hon. Gentleman pointed out, it seems that it works effectively in many patients. However, Norfolk primary care trust has a deficit of around £47 million, so it is caught between a rock and a hard place. It is unfair and unacceptable that people are paying the price. They need their sight to be saved, and it is crazy for the rest of us to have to pay for the care of someone who becomes blind when their sight could have been saved.
The Minister of State, Department of Health (Andy Burnham): I begin by paying tribute to the right hon. Member for North-West Hampshire (Sir George Young) for bringing us here today to discuss what he rightly said is a crucial matter. We have all had constituents who have been in this position. It is of huge significance to them and their families. The hon. Gentleman is right to say that there are approximately 26,000 new cases of wet age-related macular degeneration every year and that it is the most common cause of sight loss in people over 60.
Mr. Rob Wilson (Reading, East) (Con): I, too, congratulate my right hon. Friend the Member for North-West Hampshire (Sir George Young) on bringing this important matter before the House today. May I tell him briefly about the case of Les Dean, which was covered recently in the Reading Evening Post?He woke up one morning with bloodshot eyes and was quickly diagnosed with wet AMD. He was refused the drug Lucentis soon after. He is a 79-year-old man and he has had to spend his entire life savings on buying the drugs himself. He was forced to choose between going blind and spending his life savings. Does the Minister agree that it is not morally right that any Government or local organisation should force someone into that position?
Andy Burnham: I am afraid that I do not have the details of that case. I hope that the hon. Gentleman will allow me to say that the issues are complex. We will get into some of the complexities that face decision makers in the public sector later in the debate. We have to recognise the important and difficult job that they do on behalf of all patients in their local communities.
I should like at the outset to pay tribute to the Macular Disease Society, which is based in the constituency of the right hon. Member for North-West Hampshire, for the important work that it is doing to raise public awareness of these issues and to the RNIB. I worked very closely with the RNIB as a Back Bencher on issues related to age-related macular degeneration, particularly around the time when photodynamic therapy was being introduced. It ran an excellent campaign across the country to look at areas where, with greater focus, the services could be introduced more quickly. I co-operated with it on a scheme in Wrightington, Wigan and Leigh hospital.
I wanted to assure the right hon. Gentleman that I understand the importance of the issues he raises. If he will permit me, I will just give some background on the Governments commitment to eye care services. In 1999, the Government reinstated free sight tests for everyone aged 60 or over, recognising the increased risk of eye disease as people age. The eye test remains one of the main, if not the primary means by which age-related macular degeneration can be detected.
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