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8.31 pm
Mr. Weir: I want to make a brief contribution on Third Reading. I reiterate the Under-Secretary’s comments about CSA staff. They are the one group who are not to blame for its problems. As a constituency Member of Parliament, I have often had to phone the CSA and I have always found the staff as helpful as they can be, given the computer system with which they have to work. Many have struggled manfully, if that is the right word, with an inadequate system over the years, trying to provide a service.
I have often felt that my office has acted as a firewall between the CSA and irate constituents who are at the end of their tether. Unfortunately, many CSA staff have experienced that frustration from constituents on the end of a telephone before they reach their Member of Parliament. We have been able to sort out many cases; some are easier, but others seem to disappear into a black hole—and such is their complexity that it is almost impossible to get them out. I hope that efforts will be made to deal with those legacy cases, because it is important to get them sorted out. The Child Maintenance and Enforcement Commission genuinely represents a new beginning.
I am pleased that CMEC will have Crown status. That is welcome—the staff in particular will welcome that. The CPS union, which is concerned about the matter, has canvassed me on it. I am glad that the Government have listened, and I congratulate the Under-Secretary on that.
We had a good Committee stage, with interesting debates, which is not always the case. The Under-Secretary and his colleagues listened patiently and answered questions. They did not change their minds on many matters, but I live in hope that perhaps they will some day. On Report, and in Committee to some extent, we focused on issues that were in dispute, but much of the Bill’s content is not controversial: we are all travelling in the same direction and we all want a system that works for children and families. We may disagree on the best way in which to achieve that, but we are generally going in the same direction.
However, two points need to be considered in more detail. The first is minutes of agreement. I shall not go through the arguments again. I have tried on many occasions, but the Under-Secretary is not yet convinced. Again, I live in hope that, some day, he will see the light and realise that I am right and he is wrong. However, I am not holding my breath.
Secondly, the systems constitute a missed opportunity. One of the most worrying aspects of the CSA was the existence of two systems, which ran side by side with totally different outcomes, depending on when someone first got into the system. Two people who worked side by side, in exactly the same circumstances, could pay vastly different amounts. The Bill introduces a third system with CMEC, which may lead to further frustration. The Government have clearly set the percentages at a level not vastly different from the CSA system 2. However, nothing has been done to deal with those who remain in the original system. When the Under-Secretary was tackled about that in Committee, he said, pretty honestly, that time would deal with the matter. I believe that the hon. Member for Daventry (Mr. Boswell) dubbed that the “biological solution” to the problem. That is a shame because the problem will continue to resonate and undermine CMEC’s fresh start.
I was amazed that we got through Report without the hon. Member for South-West Bedfordshire (Andrew Selous) taking us to Australia, but then the reference popped up on Third Reading. He gave us the reason for his fondness of Australia. My knowledge of that country comes mostly from watching “Neighbours”, but one of the current story lines deals with child custody. I wait with bated breath to see whether we will see one of the child centres about which the hon. Gentleman has spoken so much throughout the Bill’s progress.
I join the general welcome for part 4. Many people in Scotland, Wales and all the former industrial areas suffer from the dreadful disease of mesothelioma. Part 4 constitutes a good way forward to ensure that they are compensated before it is too late. The Government are genuinely to be congratulated on introducing those provisions, which have all-party support.
The Scottish National party and Plaid Cymru support Third Reading. We have one or two reservations, and we shall wait and see whether we can try again. However, the general thrust of the Bill is welcome.
I hope that the mistake that was made with the CSA will not be made with CMEC. The CSA was underfunded from the beginning, and that led to many of its problems. When it was created I was a practising solicitor dealing with the old system—and frankly, I was glad to get out of it when I was elected to Parliament. I wish all those who have to deal with CMEC well, and I wish the body well for the future.
Bill accordingly read the Third time, and passed.
Health Care Prioritisation
Motion made, and Question proposed, That this House do now adjourn.— [Alison Seabeck.]
8.37 pm
Dr. Richard Taylor (Wyre Forest) (Ind): May I first place on record my sincere thanks to hon. Members from both sides of the House and the Officers in the Lobby who virtually led me by the hand to ensure that I was here on time and did not miss a huge opportunity? I believe that I can speak for approximately an hour and 45 minutes, but I reassure you, Mr. Deputy Speaker, that I, too, would like to get away. I will speak for a little more than quarter of an hour, but not interminably.
The debate provides a great opportunity for me to climb on to one of my hobby horses—the minefield of health care prioritisation. I want to speak under four headings. The first is, “Why is prioritisation necessary?” Secondly, I want to demonstrate the difficulties with prioritising health care. Thirdly, I wish to welcome the Government’s attempts at it so far. Fourthly, and most importantly, I want to suggest the way in which I believe that the Government should tackle the problem and how, coincidentally, that could go a long way towards helping them rebuild the electorate’s confidence after the many blows of the past few weeks.
Why is prioritisation necessary? First, we are all living a great deal longer, so we all have a longer time to be ill—we also have a longer time, I hope, to be healthy. The second reason is the complexities of the treatments now possible. People are now surviving with long-term illness, while children with severe disabilities are surviving long beyond their late teens and early 20s, which was their lot a few years ago.
I qualified, I hate to say, 48 years ago. When I qualified, we had only about three antibiotics; now there are myriad antibiotics. Beta-blockers had not been invented, nor had modern diuretics, ACE inhibitors—inhibitors of angiotensin-converting enzyme—or antidepressants. There were no ulcer-healing drugs. A heart attack was treated with bed rest and masterly inactivity. In almost 50 years there has been an immense change in the treatments available—treatments that patients will demand, now knowing more about them. There have been tremendous changes in the treatment of heart disease, strokes and cancer. However, we cannot afford everything in a tax-funded system with inevitable cash limits.
In my request for this debate, I asked that it be entitled “Health care rationing”. When I discovered that the title had been altered, I talked to the Table Office and was told to my amazement that the word “rationing” was not really acceptable on the front of Government business papers. I found that absolutely staggering. “Prioritisation” and “rationing” mean pretty much the same, but “rationing” goes that little bit further and suggests that some things may fall off the bottom of the list as being unaffordable. I am therefore talking not only about prioritisation, but about rationing and the things that might fall off the bottom. That is the whole point of my debate.
I do not often quote Lenin, but in 1936 he said, “Liberty is precious—so precious it must be rationed.” I obviously do not agree with him, but I shall pinch his statement and make it: “Health care is precious—so
precious it must be rationed.” Talking about the national health service’s current surplus of £1.8 billion, the Secretary of State told the Select Committee on Health last week that it was enough to meet “our” priorities. That is my first difficulty—whose priorities are we talking about when we talk about prioritisation? Are we talking about the elderly, the disabled, those with mental health difficulties or ethnic minorities? All those groups have been and continue to be neglected, according to recent reports by Mencap, the Joint Committee on Human Rights and the Disability Rights Commission. Are we talking about the priorities of the blind, the deaf, pregnant women, those with rare diseases, those with common diseases, those with fatal illnesses, those with emergency conditions or those with long-term conditions? Somehow we have to address everyone’s priorities. That is one of the huge difficulties.
The second difficulty to which I should like to draw attention is the power of various lobby groups. Obviously there are well-organised pressure groups for many of the major illnesses. I fully understand that and have no objection to it, but in any debate about prioritisation one must remember the other people. The illnesses that have a national service framework or national clinical directors, or that have achieved national priority status obviously have a huge advantage. I am not saying that that is wrong, but we must remember the others. I remind the House of what the hon. Member for Newport, West (Paul Flynn) said in his superb 10 commandments for MPs, in his little book “Commons Knowledge”. Two of those commandments were that we must
“Seek the silent voices”
“Serve constituents, the weak and neglected”.
Those are the very people we have to seek out; we must ensure that we take their concerns into account. I would much rather call a spade a spade and talk about rationing.
What have the Government done so far? I shall mention NICE, but I shall not go into much detail. As you will know, Mr. Deputy Speaker, the Health Committee has completed its second inquiry into NICE and is working on its report now, so I would be in huge trouble if I leaked any of it. However, we produced a report on NICE in 2002 and I shall read one of our recommendations set out in paragraph 134. It states:
“Prioritisation of healthcare spending is an issue of overwhelming importance, and during the course of this inquiry it has become clear to us that a more open debate on healthcare prioritisation needs to take place. Our inquiry has persuaded us that, with so many competing interests vying for attention and funding in an area where resources are finite, it is not sufficient to have implicit healthcare prioritisation. We feel that NICE has been laid open to unfair criticism in respect of the ‘rationing’ debate and as a consequence of the lack of clarity... here.”
What else have the Government done? Before having a debate on priorities, one has to ensure economy and efficiency. Here, the Government have made a very serious attempt—or the beginnings of one—with their paper, “Better Care, Better Value Indicators”. I thoroughly welcome the examination in it of matters such as length of stay, days of admission before an operation, certain surgical procedures and whether they should be done at all, and the prescribing of generic drugs, particularly the statins. These better
care, better value indicators have shown a tremendously wide range of performance between primary care trusts and acute trusts, for example. If the quality of service in respect of the indicators were improved to the top 25 per cent. of PCTs and acute trusts, there could be potential savings of £2 billion. I understand that there are further indicators in the pipeline, which I hope will be examined carefully and, if comparable to the first ones, wholeheartedly welcomed.
At the Health Committee last week, the Secretary of State listed four ways of saving money: best practice, which must, of course, be evidence based; better procurement, cashing in on economies of scale; community-based services, which are obviously cheaper than hospital-based ones; and, of course, the whole issue of drug pricing. The Government are absolutely right about that and all sensible economies and increases in efficiencies must be made, yet it is still a bottomless pit, so I think that rationing is necessary.
Let me continue briefly with some of the unacceptable results of the current situation. I shall talk about postcode rationing, which, I am afraid, does exist and leads to obvious inequalities and inequities across the NHS. A new anti-cancer drug called Sunitinib prolongs the lives of people with renal carcinoma. In some parts of the country, even though the drug has not gone through NICE, it is available; in other parts, including mine, it is not available. It is very hard for people in my area to understand that when they read about the huge surpluses in the NHS and they know people in different parts of the country close at hand who can get these extra few months of life, while they cannot.
Another example is the use of cochlear implants for the very deaf. I am afraid that I made a rather tactless mistake in this connection. One of my constituents badly needs cochlear implants, and I was stupid enough to write to her and compare her need with people’s need for Sunitinib. As might be imagined, I got a very large flea in my ear. I shall read some of my constituent’s excellent letter to the House. She wrote:
“I think it is unfair to compare my case with cancer patients. I am a person with a severe hearing disability and looking for prosthetic Cochlear Implant in order to improve my quality of life. Does the PCT put a limit each financial year for the provision of artificial limbs or eyes? Do they limit the number of hip and knee replacement procedures even cataract operations to improve failing eyesight? I would like to suggest that everybody should put earplugs in for a day and see how they get on trying to live their normal day either at home or work!”
She went on to say that my PCT in Worcestershire had
“the worst record for funding Cochlear Implantations in the whole country.”
In another paragraph, she wrote:
“Regardless of Worcester PCT's financial position, at a time when the NHS has never been better funded with taxpayers money, you must agree with me that it is completely unacceptable for the PCT to reduce funding for Cochlear Implantation to the detriment of people with a major disability. I am sure the Government and the Minister of Health in particular, in addition to the RNID, would find this completely unacceptable.”
Further examples are treatment for wet age-related macular degeneration, which was covered very thoroughly by a debate in Westminster Hall last week, and fertility treatment. We hear from gynaecologists and obstetricians that fertility treatment varies strikingly across the country.
Whether that variability of provision is due to better resourcing of some trusts or to better management I do not know, but I believe that there must be an open debate to decide whether those treatments should be available to everyone, and, if so, what must go in order to pay for them.
It is sad that Members of Parliament are thought to be able to influence prioritisation. I for one was disappointed by what happened with Herceptin, when the Institute for Health and Clinical Excellence appeared to be rather hijacked by a previous Secretary of State. Although it is clearly right for people to be given Herceptin in certain circumstances, it seemed that the whole method of prioritisation had been circumvented, which led constituents to think that Members of Parliament can circumvent the process. That cannot be right, and there should be no need for it.
How can we make progress? First, we must face up to the problem. Everyone agrees that the NHS must be free at the point of delivery, and it is marvellous that everyone agrees with that, but can provision actually be comprehensive? Sadly, I fear not. However, the appropriate party is in government, and perhaps its members will follow Bevan’s words of 1949:
“The language of priorities is the religion of Socialism.”
Hopefully they are on the same wavelength, believing that priorities and prioritisation may improve the equality of health care.
As I have said, we must first focus on all the economies. That is why it is good to see in the Government’s proposed Bills a focus on prevention and a focus on public health. We must try to persuade the Government that more money spent on prevention in the short term, even if that has to be taken away from acute care, will save money in the long term. We must also focus on staff levels and quality of care, because at present immense sums of money are wasted on litigation, and even if we have to do more rationing of acute care now to improve prevention and to cut down litigation, that could be helpful in the long term.
An example of the tremendous power that some lobby groups have is demonstrated by the cancer reform strategy published today. Obviously, I have not had time to read every word of it, but I was glad to see when glancing through it that there is an emphasis in it on prevention, which will, of course, not cost that much. It is also keen that one should understand when rationing is necessary and when decisions are not those of rationing.
Dr. Doug Naysmith (Bristol, North-West) (Lab/Co-op):
I thank the hon. Gentleman for giving way; I cannot refer to him as my hon. Friend, but he is a friend and a colleague on the Health Committee. I agree with much of what he has been saying and congratulate him on securing the debate. He has given two or three examples of treatments that have not yet been assessed by NICE—which are, so to speak, waiting to go through the process—and it is therefore perhaps not surprising that there is some variability in implementation from PCT to PCT. NICE has, however, recommended on a number of treatments that are not being fully funded by some PCTs—good examples are fertility treatments and rehabilitation for cardiac surgery patients. Do we not need to find some mechanism to
ensure that PCTs implement decisions that have been made by NICE and recommendations that have gone through it?
Dr. Taylor: I thank the hon. Gentleman for that intervention, and I agree with what he says. I have, however, been circumspect in talking about NICE, and I am hoping that our inquiry and the report will address some of those questions, so I will not be drawn into addressing this matter further at present.
I was about to explain a little in respect of the cancer reform strategy. In the section on community-based prostate health clinics, there is the following significant sentence:
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