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“Improved support for men in making decisions about further investigation or treatment would not be a form of rationing, but rather a way of ensuring that men have the best possible information and support when making difficult decisions.”
There is rather a move to imply that a PSA—prostate-specific antigen—screening programme is not being rolled out nationwide because of financial difficulties, but that makes it clear that that is not the reason why, and that the reason is that the case for screening is not entirely proven as yet.
All of this calls for great courage from the Government. To open an honest public debate about priorities, admitting that some treatments might fall off the bottom and get rationed out, will be difficult for the Government to consider. Vitally, however, this subject is also important the other way around, in respect of the £1.8 billion surplus. I know we keep on being told that it is only 2 per cent. of the whole NHS budget, but £1.8 billion is still a lot of money to anybody, and after the restoration of education budgets and the ending of the vacancy freeze on staff one would think there should be some left. I think that people should have a say in what the surplus is used on. For me, one of the high priorities would be to reduce the postcode rationing.
I shall briefly consider what could be removed from health care provision and what could be given a low priority. I had hoped that we were still using lots of medicines that did nothing, but NICE told us in an open session of the inquiry that it had looked at this matter and found that few drugs that do nothing were still being used. That is sad, because I remember as a houseman writing up in dog Latin super things such as mist. ipecac. co. That was a delightful medicine whose very taste made one feel better. It was supposed to stop one coughing, but it rightly fell out of use ages ago.
Should we provide cosmetic surgery in respect of tattoo removal or varicose veins? Should we provide travel immunisation or, more controversially, gender change operations, vasectomy reversal or surgery for obesity? What about surgery for some conditions if the patient continues to smoke or drink? That is just the start of a list. How should we take it on?
Hospital Doctor, one of these widely circulated free newspapers for hospital doctors, recently reported on a survey of medical opinion, and it called for an urgent review of NHS rationing. Admittedly its evidence was mostly anecdotal evidence of deaths, suffering and complaints resulting from our higgledy-piggledy rationing by local availability of resources. Hospital Doctor called
on the Government to commission an independent review of how treatment is rationed in the NHS. It specifically wanted:
“More transparency in how rationing decisions are reached and communicated; Stronger and wider-ranging guidance either from NICE or another independent source; Less political interference, from MPs campaigning for certain treatments to individual primary trust management decisions.”
Those are all reasonable aims.
The Royal College of Surgeons has joined the debate. Recommendation 2 of its response to the British Medical Association’s discussion paper, “A rational way forward for the NHS in England” referred to core services. It stated:
“There are difficult choices to be made regarding the deployment of NHS resources. This College believes that decisions on priority setting, like those on reconfiguring services, should be made primarily on the basis of clinical need and not in the interests of financial or managerial expediency. There must be an open and honest debate about the services which are freely available on a national basis, those which require some form of co-payment and those which cannot be provided by the state.”
The college goes on to draw attention to some of the obvious difficulties that we would encounter were we to embark on such a debate.
My challenge to the Government is to accept that the NHS is potentially a bottomless pit, and that most people want a tax-funded service free at the point of delivery but that a fully comprehensive service is probably impossible. We thus need to have a debate on the top priorities—the core services—and the lesser priorities, some of which might fall off the bottom of the affordable scale.
An open and honest debate on the issue might restore some confidence in the Government and show that they are prepared to listen. A debate would also give the Government the chance to demonstrate that they can take advice—something that was thrown into doubt by the treatment of the Home Office Minister in the House of Lords recently.
If such a debate took place, headlines such as those in The Guardian today might no longer be possible. Two examples were, “Prospect of moving to a care home frightens two thirds of Britons” and “NHS ignoring human rights of people with learning difficulties”. Perhaps the Minister could persuade his ministerial colleague in the House of Lords to add this dimension to his review of the NHS. His vision is of
“a world class NHS focused relentlessly on improving the quality of care”.
I cannot argue with that, but I wish that we could add to the vision how that is to be achieved and how we can tackle the inequity that exists. We must recognise that we cannot afford everything, and the consultation must address the issue of prioritisation or rationing. I have demonstrated tonight how much support there is for doing so.
9.6 pm
The Parliamentary Under-Secretary of State for Health (Mr. Ivan Lewis):
I congratulate the hon. Member for Wyre Forest (Dr. Taylor) on securing the debate. The House benefits from his clinical expertise and long history of fine service to the NHS. He has
also become gradually aware of how to be a streetwise politician, as is clear from some of his recent contributions to debates.
The hon. Gentleman entered the House in the first place through an attempt to have an honest and open debate about health care in his local community. He campaigned very emotively on behalf of the local hospital and succeeded in removing the sitting MP. The hon. Gentleman will therefore understand why there might be parameters to people’s willingness to be open about the need for change and transparency in the NHS. However, I will not hold that too much against him this evening.
The hon. Gentleman raises several fundamental issues that we need to address now and in the future, given the changing nature of our society and of health care. It is important to contextualise the debate. This Government have put in an unprecedented level of resources over a sustained period, in terms of the history of the NHS. As a consequence, we have had a massive improvement in patient care, beyond all recognition compared with the state of the health service only 10 years ago.
Between September 1997 and September 2006, nearly 36,000 more doctors and nearly 80,000 more nurses were employed in the NHS. Waiting times are now at the lowest levels since records began. Only five years ago, thousands of patients waited for anything up to 18 months for in-patient treatment; now, the vast majority are seen and treated within six months. By 2008, all patients will be treated within 18 weeks of referral from a GP in the vast majority of circumstances.
More than 99 per cent. of patients with a suspected cancer are seen by a specialist within two weeks of being referred by their GP, which is a huge improvement over only 63 per cent. in 1997. More people than ever before who are diagnosed with cancer begin their treatment within a month of diagnosis. We have increased the number of cancer specialists by 45.6 per cent. since 1997, while cancer mortality in people under 75 fell by nearly 16 per cent. between 1996 and 2003. Leaving aside the statistics however, that means that 50,000 lives have been saved.
We are proud of the cancer reform strategy that we announced today. It puts great emphasis on prevention, but we want to go even further in terms of the advances that have been made.
In the hon. Gentleman’s community, Worcestershire primary care trust will receive allocations of £617.7 million in 2006-07 and £679.3 million in 2007-08. Those allocations represent an extraordinary cash increase of £130.4 million, or 20 per cent. over two years, although it is about the national average.
The hon. Gentleman quoted Lenin and Nye Bevan. I shall not be able to emulate him in that respect, but I shall mention that John Lennon wrote “Imagine”, a song that gave an idealistic view of the world and which said that we should be optimistic and positive about the future rather than grudging, cynical and negative. At different stages in the development of the NHS there have been people who have preached doom and gloom; they said it was not doable, not possible or no longer viable. Much of the reform in the Conservative
Government’s agenda for health between 1979 and 1997 was underpinned by the notion that if they eroded public confidence in the national health service that Labour created, and which we believe in, over time the public would stop believing in the NHS, too, and wholesale privatisation would be the inevitable consequence. I am delighted that they were never allowed to finish their mission. In any case, the British people would have rejected it overwhelmingly.
There is no doubt that we live in a changing society and the health service cannot function in isolation. People are living longer, and they suffer from more challenging conditions. There are medical and technological advances. Patients have different expectations nowadays from 10, 15 or even 20 years ago, so the hon. Gentleman is right to say that the health service has to adjust, not just to present-day realities, but to our changing society.
The hon. Gentleman says that people with learning disabilities are not treated properly in the NHS and that there is a failure to respect the dignity of older people. He should talk to some of his professional colleagues and the managers in the service about why some of those things happen. It is not because there are not enough resources to fund the system properly. That cannot be used as justification for not treating older people with dignity and respect and not treating people with learning disabilities properly. We should not entirely let NHS management and professionals off the hook in terms of their responsibilities to some of the most vulnerable patients. It is important that we talk about quality, accountability and responsibility.
A number of factors will influence an equitable and fair NHS in the future. The building blocks are in place. NICE is world-class by any comparable standards, and I thank the hon. Gentleman for being positive about its role, as well as for being realistic about some of the difficulties and tensions the organisation faces. NICE is consulting on its technological appraisal methodology, and I urge hon. Members and members of the public to comment on whether that methodology should be changed in any way.
Whatever the system, if it comes up with popular results, an organisation will be applauded to the heavens, but when its decisions are more controversial or unpopular the organisation will inevitably attract significant flak and criticism. That is why we must be consistent in our support for the integrity and independence of NICE. The organisation is relatively young and new, but it does a very good job indeed.
The other factors that will influence the long-term sustainability of the NHS, its universality and the comprehensive nature of what it offers people, include resource allocation. We are consulting on the resource allocation system in the NHS. What are the characteristics and ingredients that make up the formula that determines how resources are distributed across the system? Factors such as the nature of a local population, need within the community, poverty, the number of elderly people, sparsity and rurality are all important when looking at whether the distribution of resources across the system is as fair as possible.
The hon. Gentleman rightly raised the question of where we spend the existing money. As the Minister with responsibility for social care, mental health and children’s health, I think that there is an issue about significantly shifting resources in the national health
service from acute NHS care to early intervention and prevention, and community-based services. That requires courage from people such as the hon. Gentleman, who is respected for his clinical judgment; such people should argue fiercely that no change is not an option in terms of best patient care and that the position of Her Majesty’s official Opposition, which appears to be a moratorium on any change to services, is highly irresponsible and not in the best interests of patient care.
Dr. Naysmith: I agreed with much of what the hon. Member for Wyre Forest (Dr. Taylor) said, but I did not agree with him wholeheartedly when he talked about a widespread discussion of the options and slightly disparaged politicians, various experts and perhaps even one or two clinical colleagues. There have been a number of attempts in this country and America to find out what the public think about the distribution of resources. There are a couple of famous studies, particularly from America, in which people are asked to rank the spending priorities. They tend to go for cancer and flash subjects at the top, and disabled individuals and mental health services come at the bottom. It is really important that politicians, who understand the need for the distribution of resources, have a say in what happens. It should not just be the experts. Does the Minister agree?
Mr. Lewis: I agree with my hon. Friend about most things to do with the health service. He is absolutely right. It is important to understand that we spend large amounts of taxpayers’ money on health. Health is a massive concern to every voter and citizen. The notion that comes from some clinicians—I do not think it comes from the hon. Member for Wyre Forest—that politicians should butt out entirely of decisions about the national health service is disingenuous.
We have to define appropriately the respective responsibilities of the different players in our national health service and its relationship with other bodies. I will come to that in a moment. What is the responsibility of the Department of Health nationally, of Ministers and senior officials in terms of policy, and of strategic health authorities and primary care trusts? What are the responsibilities of front-line clinicians and other NHS staff? What power—and accountability—should we give to individual patients, users and carers, as well as local communities, when it comes to influencing decisions that affect the NHS and social care in their areas?
We know that there has been an increasing role for overview and scrutiny committees and local authorities, and we want to see that role expand. What is the proper place for local elected members to have some sort of influence? I am not sure that we want to have a stale debate about whether local government should run the NHS or whether the NHS should take over social care, because inevitably we will then get into debates about organisational restructuring, which could lead us down a road that we do not need to go down. However, as the hon. Member for Wyre Forest said, we have to address honestly accountability, respective responsibilities and relationships among the different players.
I was talking about shifting resources from acute care to early intervention and prevention. It is important that people do not see this as ideology, because it is also about patients’ choice and expectations. The vast majority
of people want to remain in their own homes for as long as possible. Medical and technological advances—the hon. Gentleman referred to this—mean that there is no rhyme or reason as to why many treatments that have historically and traditionally been undertaken in hospitals need to take place in a hospital building. Equally, we need to reassure the public that our investment in primary and social care, and community-based health provision, will be put in place so that the shift in resources does not lead to a diminution in services, but results in things being done differently, with a stronger approach on patient care.
In the context of finite resources, we have a responsibility to consider health inequality. It cannot be doubted that the family into which citizens are born and the postcode area in which they happen to live can have a dramatic impact on their quality of life, life expectancy, and health and well-being. Part of being honest and transparent in the debate—Nye Bevan would be proud of a Labour Minister saying this in 2007—is not apologising for recognising that in any funding allocation system, it is entirely appropriate to focus a significantly greater proportion of resources on those in the greatest need. We need to make it clear that people in the greatest need can be living in relatively affluent areas, so the way in which we target additional resources to address health inequality is also a challenge.
There is a question about the relationships among the national health service, local government, social care, public health and the wider range of services that contribute towards citizens’ well-being in local communities. If we are going to move towards prevention and early intervention, and recognise that the ability to have a job has a direct impact on many people’s health and that their ability to access education and training contributes to their well-being, we will need a step change in the integration of local government, the NHS, the voluntary sector and the private sector in every local community. Over time, we need a more integrated approach on not only the commissioning of services, but their planning and, in many cases, collocation. I say gently to the hon. Gentleman that it is important that the NHS understands that many of its objectives will be achieved only through its connectivity with local government, the third sector and the private sector.
Practice-based commissioning will be incredibly important. On the basis of a population needs assessment, we will be giving practices a lot more power to commission services. That is another vehicle to ensure equity of access as well as quality of care. The priorities in the NHS operating framework obviously determine the view of the chief executives of PCTs and provider trusts on what is important when allocating resources and focusing on delivery. The operating framework is crucial, as are the outcome framework for the NHS and the new performance and outcome framework for local government. It is important that we try to secure synergy in a world in which we are trying to achieve more of our policy objectives through local area agreements. Such agreements bring local agencies on the ground together around shared objectives, shared accountability and shared responsibility.
I urge the hon. Gentleman and my hon. Friend the Member for Bristol, North-West (Dr. Naysmith), as members of the Select Committee on Health, to start conducting serious analysis on the new performance
framework locally and its implications for securing the health and well-being of a local population. All of us—Ministers, officials, Health Committee members and parliamentarians—need to start looking holistically at the health and well-being of citizens and local populations. We will be able to do that only if we examine not only connectivity among the NHS, local government, the voluntary sector and the private sector, but the power, control and choice that we put in the hands of patients, users and carers.
Lord Darzi is undertaking tremendous work in the other place on the next stage in the national health service’s transformation. The question is how we move from having fixed the NHS and rebuilt its foundations—the Government are proud of that—to creating a world-class, cutting edge national health service. A couple of weeks ago, my noble Friend Lord Darzi became probably the first Minister in history to have saved two lives in 48 hours. I cannot think of many politicians who have been praised for saving one person’s life, but to save two in 48 hours must be a historic achievement. Lord Darzi is a massive asset to our ministerial team and to our development of national health policy. His views and aspirations are based on his everyday experience; the same is true of the hon. Member for Wyre Forest. Lord Darzi is a world-class clinician in his field, so it is important that he is at the heart of what we are doing, and is working closely with an excellent Secretary of State to make sure that we go from having fixed the NHS to creating a world-class system.
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