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27 Nov 2007 : Column 38WH—continued
Of course, it right that we must regularly review treatments used in the NHS to ensure that they are both clinically effective and cost-effective. As my hon. Friend is aware, NICE has yet to conclude its review of earlier guidance on using drug-eluting stents in the treatment of narrowed heart arteries. It issued a consultation document last summer, and its appraisal committee met earlier this month to consider the responses submitted.
Clearly, it would not be appropriate for me to go into the detailed discussions about the possible content of NICE’s recommendations while guidance is still being developed. All the Members who spoke touched on the importance of the independence and thoroughness of NICE’s procedures. I hope that I can reassure my hon. Friend the Member for Stockton, North that robust mechanisms are in place for the consideration of the concerns that he raised.
I say to my hon. Friend that the advice given to me was that we were expecting NICE to publish its final guidance next March. I have not been provided with the date when the next series of documents will be available following the appraisal committee’s discussions. If he will bear with me, I will look further into the date of 31 December that he mentioned. Perhaps I can write to him on that, as I do not have the details before me.
Dr. Pugh: On the robust measures being adopted to remedy any complaints that people may have, a point that has been made persistently in the debate is the rather narrow research base on which NICE is working. What will be the robust mechanism to address that? Will a peer review be presented to convince sceptics that the Liverpool research should be relied upon?
Dawn Primarolo: If the hon. Gentleman will bear with me, I wish to touch in the same sequence as my hon. Friend the Member for Stockton, North did on what treatments should be available, their price and the collection of evidence. I shall come in a moment to the point that a number of Members have made about the Liverpool data.
It is precisely because of the complexities of modern treatment and the opportunities offered that we need to ensure equity, clinical effectiveness, as my hon. Friend repeatedly said, and value for money for patients. Those were the reasons for the establishment of NICE as an independent body. It should take into account all the factors that he suggested in coming to conclusions and making recommendations.
Before we had NICE, guidance was issued by numerous bodies at national, regional and local levels, which had different ways of appraising evidence and developing recommendations. The status and implications of that guidance procedure were not clear, which led to confusion for clinicians who, as my hon. Friend said, rightly want to know what care they should be expected to give, and for patients, who want to know what care they should expect to receive. They want the evidence, advice and guidance on that to be coherent, so that we do not have variations in practice emerging across the country, as my hon. Friend said. NICE therefore has to have robust, evidence-based guidance, which we expect clinicians to take fully into account. NICE has modernised the way in which decisions are made in the NHS, bringing greater certainty, clarity and confidence. It spreads good practice, helps to protect patients from outdated or unproven treatments and is internationally recognised for its excellence.
In October 2003, NICE published a technology appraisal of the use of stents in operations for heart diseases. As my hon. Friend so eloquently explained, stents are tiny mesh scaffolding devices that are used to hold open damaged arteries. There are two main types: the older, bare metal stents; and the more recently developed drug-eluting stents, which—I shall not attempt to improve on my hon. Friend’s excellent description—are coated with drugs to reduce the likelihood of the artery later becoming inflamed or obstructed.
In its 2003 guidance, NICE stated that the decision on which type of stent should be used should depend on the person’s syndrome and the size and shape of the narrowed part of the artery. It recommended the use of drug-eluting stents for arteries of small diameter or with longer narrowed areas. As with that 2003 appraisal, NICE returns to and routinely reviews its earlier guidance, as it is now doing. It has to publish an appraisal consultation document, which it did last July. I absolutely agree with my hon. Friend that the focus should be on therapeutic outcomes and what needs to be developed.
Between 2003 and now, stent technology has developed rapidly and many new products have come on to the market. There has been some comment on price, and I must point out that in that period, unusually, the list price for drug-eluting stents has increased. It is now in a price range of about £650 to £1,500, whereas the cost of bare metal stents has fallen. My hon. Friend rightly touched on the question of those costs and more complex relationships, to which I shall return. First, I want to make it clear that the draft recommendations do not constitute NICE’s guidance to the NHS. All recommendations are preliminary and may change after it has considered the full range of consultation responses that it has received.
Frank Cook: I am encouraged by the Minister’s assurances, but I think that she should check the basis for the statements that she has made in the past two minutes. I have done up-to-the-minute research on this issue and I know for a fact that the unit cost of drug- eluting stents has been falling progressively in the past 18 months. It is somewhat incorrect to say that they cost the amounts that the Minister has just presented to the House. I entreat her to get her team to check the basis on which she has made those remarks.
Dawn Primarolo: I have done precisely that. If my hon. Friend looks at the NICE “Ischaemic heart disease—coronary artery stents (review): appraisal consultation document”, under paragraph 3, “The Technologies”, he will see the collection of data on price.
The key consideration for NICE when making its determination on this issue is the cost-effectiveness of drug-eluting stents compared with bare metal stents, and it is undertaking work on that. When making a recommendation, it has to be confident that it is using a price that is stable, transparent and available to any NHS purchaser of that drug or device. That is why it relies on the manufacturer’s list price as the most effective and reliable guide to the cost of devices, and that is precisely the way in which we would expect it to determine reliable prices.
Dr. Desmond Turner: Surely the most realistic estimate of cost is not the price of individual stents but the cost of the whole procedure. If NICE’s cost-effectiveness calculations were based on the cost of the whole procedure, taking into account the high occurrence of restenosis and repeat procedures with bare metal stents, the outcomes would be very different, because the percentage differential between the two forms of angioplasty with two different forms of stents is only in single figures—about 5 per pent.
Dawn Primarolo: That is precisely the work that NICE undertakes. We all want transparency and reliability in the NHS on the cost of drugs and devices. The calculations that my hon. Friend has just described—comparing the clinical effectiveness and price of bare metal and drug-eluting stents, as well as the benefits—is precisely the work that NICE is undertaking. I know that many representations have been made on this during the consultation period, and I do not want to stray into speculation because of independence considerations. The issue is this: if we cannot rely on the list price that manufacturers say they are charging, how do we get a reliable, transparent price that enables NICE to make complex assessments on clinical need and effectiveness?
Frank Cook: I make these remarks with the utmost respect to you, Sir John, but I am afraid that we are in danger of succumbing to the accountant’s mentality of looking at the cost of everything, rather than the value. The case that I am making is not about whether drug- eluting or bare metal stents, bypass or drugs should be used. They are all part of the panoply of techniques that a cardiologist and cardiac surgeon can use. Which one is used on which patient is entirely a medical decision to be made by professional people who are fully trained and experienced. My case is that there is a danger, as my hon. Friend the Member for Brighton, Kemptown (Dr. Turner) said, of NICE removing from the toolbox the drug-eluting stent tool when, in fact, it is eminently sensible to use it in certain cases. If it is not there, a patient who is badly in need of the technique may be penalised. That is the whole purpose of the debate—it is not to say which technique is best here or best there. That is for the consultant to decide.
Dawn Primarolo: I do not think that my hon. Friend and I disagree on the point about what constitutes appropriate treatment, but the debate is about the assessment that NICE is undertaking of the clinical effectiveness of the bare metal stent as compared with the drug-eluting stent. The work that NICE does involves a complex collection of information and research, using what is referred to as a QALY—a quality adjusted life year—to consider precisely the point that my hon. Friend rightly raises: whether, for the extra cost, there are extra benefits that make one treatment more clinically effective. The question is not whether treatments are available.
I have listened carefully to my hon. Friend’s points, and I know that NICE will consider this debate alongside its other considerations. At present, the recommendations are preliminary and they may
change after NICE has considered the full range of consultation responses. The advice currently in place is from 2003.
I assure my hon. Friend that the Department of Health—alongside professional organisations such as the British Cardiovascular Intervention Society, representatives from industry and patient organisations—has contributed its views to the consultation exercise. NICE’s appraisal committee is reflecting on the responses. As I said, it would not be appropriate for me to try to pre-empt what it may conclude, as it is independent, but I want to reassure Members about the Liverpool assessment group’s view on costings. The Department has asked for the economic model to be reviewed because of concerns about the use of the Liverpool data. NICE is taking that information into account in its consideration of all the responses to the consultation, which I am informed it will publish on its website. Therefore, I reassure my hon. Friend that the specific points about the Liverpool assessment group have been taken up. Let me be clear: until NICE concludes its review, its early guidance remains in place. It is entirely appropriate for clinicians to follow the 2003 guidance.
Ensuring the most up-to-date, evidence-based, high-quality clinical care for people with heart disease is of course pivotal to the work of implementing the national service framework for coronary and heart disease. Since the publication of that framework in March 2000, the hard work and commitment of NHS staff in tackling heart disease has meant that some 178,000 lives have been saved. We have already met our 2010 target to reduce mortality from cardiovascular disease by 40 per cent. in people aged under 75; in fact, it was met five years early. Since 2005, no one has had to wait more than three months for heart surgery, and 68 per cent. of people who suffer a heart attack are treated with clot-busting drugs within 60 minutes of calling for help.
Of course, there is more to do. As my noble Friend Lord Darzi of Denham outlined in his interim report, “Our NHS, our future”, we have been running a feasibility study to look at expanding the use of stenting, or primary angioplasty, as the main treatment for heart attack right across England. That vision is set out in more detail in “Mending hearts and brains”, the December 2006 report by the national clinical director for heart disease and stroke, Professor Roger Boyle, who was referred to earlier.
I absolutely assure my hon. Friend and others who have taken part in this debate that the treatment of heart disease continues to be a high priority for this Government. The great strides that have been made since the publication of the national service framework should be built on. I hope that I have been able to stress—without straying outside my specific responsibilities and inadvertently into the independence of NICE—the value of having a completely independent body to review a complex and ever-changing evidence base and to take proper and due consideration of all of the evidence and views expressed on the subject.
I again thank my hon. Friend and the other contributors to this thoughtful and reflective debate on these incredibly important issues. NICE should and will consider their comments carefully.
Post Office Closures
12.28 pm
Mr. Paul Burstow (Sutton and Cheam) (LD): It is a great pleasure to have this opportunity to initiate a debate about post office closures in the London borough of Sutton. The issue is of great concern to many of my constituents and those of my hon. Friend the Member for Carshalton and Wallington (Tom Brake), who hopes to catch your eye, Sir John, and who has the agreement of the Minister to contribute to the debate.
This debate is a continuation of one that started in the chamber of Sutton council just last week when the local authority debated its concerns about the network change programme that is about to be unleashed on the residents of Sutton. On behalf of the local authority, I pass on to the Minister its serious concerns about the methodology and adequacy of the envisaged consultation, and its desire to sustain and support a proper network of sub-post offices in the London borough of Sutton and to engage seriously with the team that is conducting the consultation.
I come here with three pleas. The Minister will not be surprised to hear that the first is a plea to abandon the plans that are unfolding around the country, and to seize the opportunity to launch a rethink about future ways of securing the network. However, if that plea falls on stony ground, I have two others to which I hope the Minister will give further consideration. The first is that there needs to be more time for the consultation regarding the network change programme if it is to be meaningful and if the public are to have any confidence in it.
My final plea concerns the need for greater flexibility in the decision-making process. I come to this debate with experience of the network reinvention programme of two or three years ago, which saw six post offices close in my area. Many of my constituents believe—I share their belief—that the consultation exercise was little more than a sham. It started with the suggestion that substantial sums of money would be offered to sub-postmasters who opted to close, and they signed contracts, which effectively tied their hands to a decision by Post Office Ltd. Those financial incentives made the consultation exercise unfair, and the consequence was unplanned gaps in the network.
My constituency witnessed the closure of Belmont village post office, which left a lot of my constituents many miles away—bus journeys away—from the nearest post office. Lack of common sense behind the proposals led to, for example, the closure of the Cheam village post office. Again, that post office was well used not just by local residents but by local businesses, which must also now go further afield to bank their cash.
The intention was that the network reinvention programme would be a strategic process to stabilise the network, but how long was it supposed to stabilise it for? Here we are again, with more proposals on the way. The network change programme threatens every local sub-post office in the land. We understand that in Sutton the proposals are being rushed out on 19 February next year for six weeks’ consultation, which brings me to my first substantive point. The six-week
consultation period is just not enough to do justice to the proposals that we are likely to face. It is a breach of the Cabinet Office’s rules, which say that the written consultation period should be a minimum of 12 weeks. I know that it is not a Government consultation, but it flows directly from Government policy and should therefore follow Cabinet Office guidelines.
Six weeks is not enough for customers, and it is not enough for my constituents. It is certainly not enough for local authorities and other local organisations to engage meaningfully, to criticise, to scrutinise and to examine the justification for the proposals. Indeed, I agree with the report of the Select Committee on Trade and Industry, which will be debated later this week, that it was hard to understand why an extra six weeks could not be justified, given that, despite the argument that that would create further uncertainty for sub-postmasters, they have been living with uncertainty since 1999 at the very least. Slightly more time for consultation would help to ensure that if the closures go ahead, the outcome will be more durable and will not result in our returning to the matter in two or three years to seek another set of closures to stabilise the network again.
My second point concerns flexibility. Predetermining the number of closures—2,500 on this occasion, of which 1,250 are in urban and suburban areas—turns the consultation exercise into little more than a data validation or checking exercise. There must be more flexibility on the number of post office closures, so that the consultation is seen to be meaningful and genuine in affecting the outcomes and totality of closures. My constituents want to be reassured that the methodology for selecting post offices for closure is fair and well grounded in evidence. There should be transparency, even if that only helps to validate the data on which the decisions are made. We also need to be sure that when the Post Office says that 90 per cent. of the population will live within a mile of a post office and 99 per cent. within three miles, that is not just an exercise of drawing circles on maps, and that real weight is given to local knowledge, transport infrastructure, the way in which major roads and railway lines disrupt access, and commercial and regeneration factors. If those matters are not included in the decision making, I fear that we may have a network that looks perfect on paper but is not fit for purpose on the ground.
The Government must make a clear decision about what they are doing to support the post office network. Departments have made a number of decisions that continue to destabilise the network. For example, the decision of the Department for Work and Pensions not to renew the Post Office card account contract beyond 2010 means that £1 billion of post office network revenue will be lost. Local post offices are a vital lifeline. They contribute to the vitality of the local economy, and their closure causes difficulties and hardship. Research by Help the Aged found that between 2001 and 2005, the proportion of elderly people who use post offices once a week went up, which is an example of more people wanting to use post offices. If their local branch closed, 88 per cent. of older people would have to make special travel arrangements. The fear is that this further round of closures will not stabilise the network, but will simply leave it in an even more vulnerable condition.
It remains unclear what happens when an unplanned closure takes place. If the programme goes through and we have a new, lean, mean network, and if branches start to close, how will the gaps be plugged, and what guarantees are there that those gaps will be plugged? Instead of managing the decline of the network, why do the Government not take steps to improve the competitiveness and diversification of services? Why not unlock some of the value of the Royal Mail to reinvest in the network, and to bring new capital into the business?
My constituents have seen the number of post offices fall from 16 in 1999 to seven today. The local postal network is already full of holes, and more closures will result in even more holes. We were told that the network reinvention programme was the answer, but we are debating the matter again today. Clearly, it was not the solution for stabilising the network. We are now told that the network change programme is the answer, but will it be? If there must be more closures, I hope that the Minister will say today that there will be more time for consultation so that there can be meaningful dialogue with local people and their representatives, and that there will be more flexibility regarding the outcomes. If that is not possible, my constituents will rightly draw the conclusion that in February next year they will be faced with yet another sham consultation and yet another piece of evidence that the Government are content to preside over the decline of our postal network.
12.37 pm
Tom Brake (Carshalton and Wallington) (LD): I thank my hon. Friend the Member for Sutton and Cheam (Mr. Burstow) for allowing me to speak in this important debate about the future of post offices in Sutton. No one can be in any doubt about the importance of post offices. People understand that, and often refer to the fact that, they are the lifeblood of rural communities. Indeed, they are often the lifeblood of urban and suburban communities. Just last week, I was in the queue at my local post office—I try to give it as much custom as possible—and the person behind me tapped me on the shoulder and said, “You won’t let them close it, will you?”. That view is no doubt supported by the 600 or so people who have signed a petition in the past few weeks about the future of local post offices.
Post offices provide a lifeline for people, and the postmasters who run them often bend over backwards to provide additional services not only to help their customers, but to ensure the longer-term survival of their businesses. For example, they may provide free cash machines in places where they were not previously available.
As my hon. Friend said, it is extremely disappointing that the proposals for yet another round of closures are coming so soon after the closures that came with the network reinvention programme, which has an Orwellian ring to it. That saw the closure of post offices in Westmead road, Stanley Park road, Stafford road, Plough lane, and Banstead road in my constituency, to name but a few. When such closures take place, consideration should be given to the impact on remaining post offices, because the queues at post offices that are still open are dramatic. That must be factored in when these matters are looked at.
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