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The price of the drugs that NICE assesses is a matter for the manufacturers, but I can confirm that I am working closely with the pharmaceutical industry on new and more flexible pricing arrangements that will
increase patients’ access to new drugs. Those arrangements will include enabling drug companies to supply drugs to the NHS at lower initial prices, with the option of higher prices if value is proven at a later date. The new arrangements will also build on patient access schemes already developed for particular drugs. That will help to ensure that patients can access medicines that would not otherwise have been deemed cost-effective by NICE. I expect to be able to say more about that soon.
In addition, NICE has for some time been concerned about its ability to take into account the premium that society places on helping those with terminal illnesses. Professor Sir Michael Rawlins has written to me to outline a new, more flexible approach to the appraisal process in order to address those concerns. NICE proposes to introduce more flexibility in the evaluation of higher-cost drugs, which have been shown to extend the lives of terminally ill patients, and where the less common nature of a particular condition may mean that the more flexible pricing arrangements we are discussing with the industry are not in themselves sufficient. The proposal will be implemented immediately while NICE holds a full consultation
Those two measures will ensure that more treatments, which in the past patients may only have been able to access privately, will be available free on the NHS. The work of NICE is necessarily complex, but as we highlighted in the cancer reform strategy, it sometimes takes too long. Its appraisal guidance has often not been available for two years or more after a drug has been licensed. Steps have already been taken to address that, with, for example, fast-track procedures to appraise automatically significant new cancer drugs, but the time it takes NICE to publish guidance can lead to significant local variation.
In response to Professor Richards’s report, I am today setting out a new timetable to speed up the appraisal process for all drugs evaluated by NICE. In 2009, draft or final guidance will be available within six months of licensing for about half of the drugs that are being appraised through the fast-track single technology appraisal programme. In 2010, draft or final guidance for all new cancer drugs will be available within six months, on average, of a drug being licensed. We will work with NICE to explore further ways of speeding up the appraisal process with the intention of announcing the outcome of our work early in the new year.
All of those measures will dramatically reduce the instances where a drug is available on the market but primary care trusts have no guidance from NICE on which to base their decisions about funding. However, we cannot totally eliminate instances of primary care trusts having to make decisions in the absence of NICE guidance.
Professor Richards has found that patients and professionals are often unclear about who takes such decisions or how they make them. Patients and their families are often left bewildered about why a particular treatment has been denied, despite what they see as a clear clinical need. As we highlighted in the NHS constitution, we need to do more to improve the quality and consistency of the decisions, especially in any interim period before NICE’s guidance is released.
We will therefore publish a set of core principles to inform the way in which primary care trusts make decisions about funding new drugs. It is essential that the process, as well as the decisions, is clear and accessible to patients and the public so that, if a patient is denied
access to a particular treatment, the reasoning behind the decision is transparent and consistent. We will publish detailed good practice guidance for primary care trusts about the processes that they should have in place to make decisions about funding new drugs and handling exceptional cases.
Better local decision making, a faster appraisal process, fairer pricing and greater flexibility in evaluating certain treatments will address the main issues that have fuelled the demand from some patients for additional private treatment. However, it would be unreasonable to expect the NHS to fund every single new treatment, and we cannot guarantee that we will completely eradicate the circumstances in which a small minority of patients wish to pay for a drug that the NHS does not provide.
The vast majority of people to whom Professor Richards spoke during his review thought that, in such circumstances, it would be wrong to take away a patient’s entitlement to NHS care because they had purchased additional treatment privately. Professor Richards recommends that that practice should end and I agree. It will end with immediate effect.
However, Professor Richards is also clear that there must be tight controls to prevent the NHS from becoming a two-tier system. Today, we will publish draft revised guidance, to take immediate effect, to ensure that the NHS is clear about how to deal with the rare occasions—which, with the implementation of the proposals already mentioned will be even rarer—when patients opt to fund additional drugs privately. The guidance will make it clear that NHS care should never be withdrawn and that administering private care should take place separately from NHS care to ensure that NHS funds are never used to subsidise private care. In short, there is no question of patients who can pay more being able to access a different and higher level of NHS treatment, but neither should any patient who has at some point paid for private treatment lose their entitlement to NHS care.
Today’s draft guidance sets out that, in such circumstances, private treatment should be provided in a private facility so that it is always clear whether a particular treatment is NHS or private. That removes any confusion about what constitutes a single visit or single episode of care. It will also remove any question of a two-tier system, whereby those who pay for additional care have their private care subsidised by the NHS.
The NHS must, by definition, continually evolve and improve to fulfil rising expectations and offer the latest advances in medical care to all our citizens, irrespective of wealth, class, ethnicity or disability. The debate has been critically important to the NHS and the values that underpin it. I believe that the measures that I outlined today will, in enabling the NHS to exercise its natural compassion, help secure those values for the future.
We are fortunate in Britain to have a health system that provides a comprehensive service for all patients, based on clinical need, with public funds for health care devoted solely to the benefit of the people it serves. The report by Professor Richards enhances those principles and I commend the statement to the House.
Mr. Andrew Lansley (South Cambridgeshire) (Con): I am grateful to the Secretary of State for advance sight of his statement. I am sure, too, that the House will wish to thank Professor Mike Richards for his report.
I regret, however, that the Secretary of State’s statement, far from clarifying the issues, leaves them as unsatisfactory as ever. Professor Richards’s report says on page 6:
“I believe that the option of NHS top-ups should be rejected”.
However, the Secretary of State says that if patients are denied access to new cancer drugs by the NHS, they can pay for them without losing their entitlement to NHS care. So, contrary to past guidance and in a U-turn on policy, patients will be able to be both private patients and NHS patients in relation to the same course of treatment, even if the Government dress it up as separate care, with patients being wheeled to another ward in the hospital to have their cancer drug administered and then a bill sent to them by the NHS.
I refer Government Members to page 6 of the report, where the Secretary of State requires strategic health authorities to say where private drugs are going to be administered, which includes designating an area of an NHS hospital for the delivery of privately funded treatments, and to page 51, where the proposed option for separate care says that patients will receive different care from the NHS and the private provider, although this will often be the NHS, so the NHS will be the private provider.
The Secretary of State has not really answered the question: is he in favour of top-ups or is he against them? In reality, the Government have jumped out of the frying pan and into the fire, from, on the one hand, denying cancer patients their entitlement to NHS care, which has rightly been abandoned, to, on the other, requiring patients to pay for their cancer drugs and thereby creating two-tier access to NHS care.
That has happened because the Secretary of State, after we have asked him time and again, has not answered the key question: why are NHS patients in England not receiving clinically effective life-extending cancer treatments that are routinely available in other European countries? An OECD report published last week on pharmaceutical pricing said that UK spending on medicines per capita is below the OECD average.
The Government admitted last year in the ministerial industry strategy group that the uptake of new cancer drugs in this country was slower than across Europe. We know from the Minister’s reply that we spend 5.6 per cent. of our NHS budget on cancer services, whereas France spends 7.7 per cent. Why does the Secretary of State not understand that the heart of the issue is about enabling clinicians in this country to provide the cancer treatments that they believe are necessary for their patients?
There are many steps that we could take on that. Why has the Secretary of State not followed the advice that we have published on NICE and taken ministerial referral out of the system? That would take six months out straight away and speed up NICE appraisals.
Despite the talk from the Secretary of State about more flexible pricing—frankly, for two years I have been urging this on Ministers—why did he not implement a fully value-based pricing system for new medicines in the review of the pharmaceutical price regulation scheme this year, so that patients can access the treatments through the NHS and the price paid will reflect the therapeutic and innovative value? Instead, the Secretary of State still seems to be prepared to contemplate cancer patients paying thousands of pounds for their
medicines, just as long as they are administered by the NHS in another ward, as separate care. If so, is he planning new primary legislation to introduce a new power for NHS trusts to charge for treatment?
Is the Secretary of State preparing legislation to remove the private income cap on foundation trusts, which specialist cancer hospitals such as the Royal Marsden or the Christie would otherwise breach? How will he stop the new rules from becoming a bureaucratic nightmare? How can his rules be applied if patients exercise choice and go to an independent hospital or even go abroad in future, using the cross-border health care directive?
How will the Secretary of State prevent the NHS from becoming a core service, with increasing numbers of top-up treatments or patients being pressurised to buy more treatments and services privately? Will he confirm to the House that separate care will often mean private health care provided by NHS trusts?
Based on the Secretary of State’s proposals today, how can he still argue that treatment through the NHS would be available based on need rather than on the ability to pay? Let us take the case of a patient with bowel cancer, whose hospital consultant recommends Erbitux, a life-extending treatment. At the moment, some primary care trusts provide that treatment, while others do not. Some hospitals pay for it themselves, while others require it to be administered at home with the patient paying. Still others require it to be administered wholly privately, with all the associated treatment costs being paid for.
In today’s statement, only that last case has been ruled out, and rightly so. It has always been morally repugnant to make cancer patients pay for their continuing NHS care. We made that clear months ago, and the Secretary of State could have made this decision months ago. It is equally unacceptable for cancer patients still to be put through months of delay—whether as a result of NICE appraisals or exceptional case panels—while not knowing whether their treatment will be provided by the NHS, even if their consultant says that it is the best, and sometimes the only, option for them.
Those patients might also be aware that Erbitux will be provided for bowel cancer treatment in every other country across Europe, but not here. Indeed, it was Erbitux to treat bowel cancer that Linda O’Boyle needed to pay for. Hers was one of the central cases that gave rise to the review. I pay tribute to my hon. Friend the Member for Billericay (Mr. Baron), who represented Linda O’Boyle, her family and her interests assiduously in the House.
The Government are planning to stop cancer patients having to pay £7.10 for a prescription, yet they are still prepared for those patients to pay £11,500 to acquire Erbitux for their bowel cancer treatment. The Rarer Cancers Forum estimates the cost of extending access to new cancer drugs at £175 million a year. The NHS surplus last year was 10 times that amount. This summer, the Secretary of State imposed a price cut on the pharmaceutical price regulation scheme, saying that that would save £300 million a year. Where is this money going? Why is the money voted by Parliament to
provide care for patients not providing the cancer services that our constituents need, and which they know other countries provide?
Let us be clear about this. There are two principles involved: if a patient has cancer, they expect the NHS to provide the treatments that they need and that are recommended for them, including those that will extend their life; if they want something different, and pay for it privately, the NHS should not penalise them for doing so. Those are two simple principles. Why could not the Secretary of State have made it that simple today? Why could he not have got up and said that those would be the principles that we would work to, while respecting the values of the NHS?
Alan Johnson: I am very surprised by the hon. Gentleman’s response, not least because, if he has read the report, he will know that Mike Richards looked at a spectrum of alternatives. The first point—the important point—is that we will no longer withdraw NHS treatment from people who have to pay for a drug that has been recommended by their clinician but which is not available on the NHS. The hon. Gentleman says that he raised this issue months ago, but I never heard a single word about it from Conservative Front Benchers until the Conservative party conference, three months after we had announced the review. Yes, there was a question a year ago from the Opposition Back Benches, but it was not followed up at all by those on the Front Bench. Yet, suddenly, the Mr. Know-alls have always been aware of this problem and always been determined to resolve it.
Why has Professor Richards, after talking to all his colleagues, come up with this proposal? At one end of the spectrum, there is the current, rather cruel, practice. Incidentally, I too pay tribute to the hon. Member for Billericay (Mr. Baron) for the work that he has done on behalf of Linda O’Boyle’s family. At the other end of the spectrum, there is something that Mike Richards calls top-ups. I do not want to get bogged down in the terminology, but the understanding of people in the profession was that some people were concerned about the change in practice, and a thorough debate took place on the issue. The understanding was that a top-up system would involve an NHS patient being offered a range of choices, one of which would involve the patient in bed No. 1 being offered a drug that was not available on the NHS and paying the NHS for it, while the patient in bed No. 2 could not afford to pay for the same drug. However, Mike Richards points out that the only people who were vehemently proposing that option were the people who felt that a tax-funded system could not survive and that, at some stage, we would need to move to an insurance-based system. They are the only people, Mike Richards says, who put forward that view. That is top-up.
What Mike Richards has said, of course, is that we should not withdraw this treatment; we should ensure that NHS treatment continues; we should allow the patient to pay for that treatment; but we should not under any circumstances—to reiterate a point put to me in a consultation by the hon. Member for Billericay—endanger the principles of the NHS. The system of top-ups would, however, endanger that principle. [Interruption.] This is a serious issue, so let us not have barracking from the gallery; let us rather try to understand what Professor Richards has done in a very important report over a short period. We will deal with Europe
and all the other peripheral issues, but what Professor Richards has said is that we cannot carry on with this cruel system, but neither can we allow the NHS to be used to subsidise private care.
I do not know the current position of Conservative Front Benchers on this issue. It has been all kinds of things over the last 10 years and I am not sure what it is today on this particular Wednesday; it might well have changed again— [Interruption.] Sorry, it is Tuesday today, so it will no doubt change again tomorrow. The real issue is this: what Mike Richards says is that we should have separate care, perhaps provided in a private facility in an NHS hospital; that is fine, because we allow private care in NHS hospitals. If such care is not available in an NHS hospital, the patient can get the drug from a private practitioner and have it administered at home, which is what happens in Birmingham. However, NHS care will not be withdrawn from such patients and they will be allowed to buy those drugs.
The final point made by the hon. Member for South Cambridgeshire (Mr. Lansley) was about flexible and value-based pricing, which was in the Office of Fair Trading review of the pharmaceutical industry a while ago. The hon. Gentleman and the Conservative party need to understand this: either we keep the current system, which Labour Members value, of reaching a voluntary agreement with the pharmaceutical industry through the PPRS or we move to reference pricing—the European model. I believe that we would lose out from that system. [Interruption.] The hon. Member for South Cambridgeshire asks why we did not introduce value-based pricing earlier. The answer is that we need to negotiate it with the pharmaceutical industry. If we do not negotiate it, we will have to introduce it through legislation, which is not the route we want to take. The negotiating route has led us to a patient-access scheme, which is being used for some drugs, and we will soon, I hope, conclude our negotiations and have a flexible pricing scheme.
The worst scheme would be the Conservative policy launched a couple of days ago, which amounts to a huge bureaucracy with every drug having to be evaluated through the system. We would lose the voluntary agreement with the pharmaceutical industry and probably lose some major research and development in pharmaceuticals. I think that Conservative Members need to get their act together; as far as I can see, the policy seems to be put forward by “Confused of Conservative central office”.
Mr. Deputy Speaker (Sir Alan Haselhurst): Order. By any test, this is slow moving and we have other business to complete. I want to allow all Members seeking to catch my eye to make their contributions, but I need brevity from now on—brevity in both questions and answers.
Mr. Kevin Barron (Rother Valley) (Lab): I welcome the announcement that the timetable for the NICE evaluation process is going to be speeded up, which the Health Select Committee recommended in our last report. Professor Richards says that tight controls will be needed to avoid a two-tier NHS. Does that mean that NICE will need to be more flexible so that drugs presently not available on the NHS become available?
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