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Alan Johnson: Yes, indeed it does. NICE has seen that people are concerned about this aspect of end-of-life care and believe that as people approach the last years of their lives, society should put a premium on that, which is not reflected in the current system. The supplementary system announced today will indeed mean more of these drugs being made available.
Norman Lamb (North Norfolk) (LD): I thank the Secretary of State for early sight of the statement and join hon. Members in thanking Professor Mike Richards for his work in producing the report.
The statement—albeit it a remarkable U-turn, albeit that it comes after pressure of a threatened judicial review and albeit that the Government seem to be fudging or drawing a distinction between what is proposed and the principle of top-ups—is none the less a welcome step. It is a complex area. There are understandable anxieties about the implications of moving in the direction outlined, but the bottom line is that we cannot justify a cruel and pernicious system that threatens to withdraw NHS care if a patient chooses to follow a clinician’s advice in paying for a drug that is not available under the NHS. However, allowing top-ups must go hand in hand with reforms to ensure that access under the NHS is available to drugs that are routinely accessible in Europe but are not currently available in this country.
On proposals to extend access, the Secretary of State’s ambition is to achieve draft or final guidance within six months, but he will only achieve that for all drugs by 2010. Surely if it is only draft guidance within six months, there could be a further long delay in producing the final guidance. Why will it take so long to get to the six-month point, given that there is already a much faster system in Scotland? I know that the process there is different, but it usually ends up achieving the same verdict as we do in England only it does so much quicker. That the system is taking so long results in a great sense of unfairness in England.
The Secretary of State said nothing about the need to reform the requirement of ministerial referral. Surely we should scrap that and allow NICE to make its own decisions. Surely, also, we should ensure that there is complete transparency of the modelling that NICE undertakes in reaching its decisions.
The Secretary of State referred to the need for more flexibility in the evaluation of high-cost drugs. Will he consider widening the factors that NICE takes into account—the impact on carers and the potential to get an individual back to work—in assessing whether a drug is cost-effective? There is a key question for him: under the reforms, which drugs that have been rejected does he expect will become available? What analysis has he undertaken of that? He must have done some. Will appraisals be reopened on drugs that have recently been rejected by NICE? He said that the current rules would come to an end with immediate effect, but at the same time he announced a consultation on how those new rules will apply. What will happen in the meantime?
The right hon. Gentleman said that treatment must be in a separate facility, but is that not inconsistent with good quality patient care and patient safety? Will he address that specific concern?
With regard to the importance of local transparency in the decision-making process by primary care trusts, when will the Secretary of State announce those core
principles, and will they take into account social factors—family circumstances—in determining whether a drug should be available?
The statement contained nothing about the absolute importance of independent advice to patients on whether it is right to pay for an additional drug. It also said nothing about the potential need to regulate any market that might develop in dealing with very vulnerable people at a critical stage in their life. Finally, the right hon. Gentleman said nothing about addressing the potential conflict of interest for clinicians and the NHS in making these difficult judgments. Will he address those concerns as well in his response?
Alan Johnson: I thank the hon. Gentleman for his welcome for the statement. He says that it is a remarkable U-turn, but this guidance has been around for many years. We can track it back to the early ’80s, under the Thatcher Government, and it was there before that. [Interruption.] He says from a sedentary position that it is a U-turn from what I said, but I said that if we allowed NHS care and private care to be given together—I talked about an episode of treatment, to introduce a new variation into all the descriptions, back in December last year—that could be the end of the founding principles of the NHS. It could be, and Mike Richards has accepted that it could be, which is why separate care is an important part of his proposals. [Interruption.] Everyone in the House apart from those on the Conservative Front Bench understands that Mike Richards’ terms of reference were to defend the principles of the NHS, and that combining private and NHS care would be the route to an insurance-based system and the end of a taxpayer-funded system.
The hon. Gentleman said that the proposal would have to go hand in hand with greater availability. That is what Mike Richards recognised, and that is why a large part of my statement was concerned with that. The hon. Gentleman asked the reason for the delay in NICE’s appraisal of the drugs. I understand that it is due to the tail in the system. We committed ourselves to a more rapid appraisal a year ago in our cancer strategy, and as new drugs come in we can move quickly, but the old drugs are still being appraised under the old system. It will take us some time to work our way through the backlog, but NICE has already announced that it is increasing the number of appraisal teams and standing committees and starting more appraisals earlier, so I think that the time scale is realistic.
The hon. Gentleman mentioned ministerial referral, which was also mentioned by the hon. Member for South Cambridgeshire. We are not handing the whole process over to NICE and taking politicians out of it completely, but once a drug has been referred to NICE, the process becomes a NICE process, independently run. NICE also has an enormous role in the earlier process of selecting drugs to be referred. It is responsible for the consideration panels of experts before the matter is sent to the referral oversight group, which consists of clinicians. The ministerial sign-off for which my right hon. Friend the Minister of State is responsible is a very short part of that process.
Mark Simmonds (Boston and Skegness) (Con): It takes 12 months.
Alan Johnson: It does not take 12 months. Here is £13 billion of taxpayers’ money, and once again the Conservatives want to remove Government completely from the process and allow a giant unelected quango to deal with it.
The hon. Member for North Norfolk (Norman Lamb) referred to the consultation that NICE has undertaken. NICE has said that the new procedures will apply while its consultation takes place. Those new procedures start today. I believe that members of NICE are the best people to say which drugs are likely to come through the process, and I believe that NICE will reappraise drugs through the process as well if they are referred.
The core principles put forward by the PCTs should be ready early in January.
Dr. Howard Stoate (Dartford) (Lab): I welcome the measures proposed in the statement, which will go a long way towards speeding up the process and making more drugs available. However, I have some concerns about what my right hon. Friend has said. One of the founding principles of the NHS is that it is based on medical need rather than ability to pay. If a drug is medically necessary, how can it be right to make it accessible only to those who can afford it? If a drug is needed it should be available, and it should be available to all.
Alan Johnson: The drugs that come through the NICE process will be available, thanks to the NHS constitution which will make it absolutely clear that patients have a right to access the drugs. There will be more of those drugs coming through. The PCT exceptional circumstances committees will have a far more transparent way of considering drugs that have not come to NICE for appraisal, have been refused by NICE or are off-label, so there will be a better system.
I would previously have shared my hon. Friend’s fear that there is no way of ending the previous co-payment advice without jeopardising the basic principles of the NHS, but I think that Mike Richards has found a way of doing that. Even when drugs come through the new system which are not available on the NHS—and there will be fewer of them—we will no longer withdraw treatment, but will ensure that it is administered privately.
Mr. John Baron (Billericay) (Con): Today’s announcement is very welcome. I thank the Secretary of State and Professor Richards for our constructive meetings. Let me also briefly pay tribute to my constituent Mr. Brian O’Boyle. He had the courage to speak openly about the death of his wife, which helped to spark off the process and the review.
The announcement is positive for two reasons. First, it ends the obscene threat that NHS care could be withdrawn from patients simply because they wished to access care that was not available on the NHS. Secondly, it will, I hope, act as a catalyst to widen access to beneficial treatment for cancer patients. May I, however, press the Secretary of State on the issue of continuity of care? Can he put my mind at rest by assuring me that the separate care to which he referred will not involve sending patients halfway across town to have their private care administered? I am sure he will agree that continuity of care is important, given that some drugs need to be administered concurrently, and given the condition of many patients.
Alan Johnson: I welcome the hon. Gentleman’s remarks, and I, too, pay tribute to Brian O’Boyle. The hon. Gentleman eloquently described that case of a woman who had spent her whole life in the NHS being charged for the cost of her treatment or having that treatment withdrawn, and any politician who came across the case would have felt that if there had not previously been the time to review the guidance, the time had certainly come now.
The hon. Gentleman raised an important question—which the Liberal Democrat spokesman, the hon. Member for North Norfolk, also raised, but which I did not get around to addressing in my reply to him. Professor Richards says in his report that there may be circumstances in which one would need to give such care to a patient in an NHS environment for clinical safety reasons; he expects such situations to arise very rarely, but they may do so because patient safety comes first.
In terms of where patients would have to go, there is currently no difference: they would have to access the medicine from the private sector. What we are saying in the report, as one of Mike Richards’ recommendations, is that strategic health authorities should look at this, to make sure that patients know exactly where they need to go to access the drugs in a private setting—it may be in an NHS hospital, a private clinic or at home. Professor Richards and his colleagues think this is entirely appropriate, and that it will work well and will not cause any concerns, and it is certainly far better than the current system in which, as the hon. Member for Billericay pointed out, the cruelty of withdrawing such treatment is beyond anything we in this House would want to cause.
Ms Gisela Stuart (Birmingham, Edgbaston) (Lab): I welcome the Secretary of State’s statement and his recognition that some health economies, such as Birmingham’s, have already successfully worked out a way of dealing with the private sector and the NHS. However, I did not quite get a sense of whether there is any distinction in the primary care trust drugs guidance for situations where the pharmaceutical company has, for its own reasons, never applied to NICE for recognition. Does this apply to all of them, irrespective of whether they applied?
Alan Johnson: If the drug company has not applied for this, the same circumstances will apply: the drug has not been NICE-approved, because the company has not applied to have it NICE-approved. However, that does not stop a PCT allowing that drug to be prescribed, which is why the transparent and clear process around PCT exceptional circumstances committees—which is where such matters would rest—is an important part of the Richards review.
Sir George Young (North-West Hampshire) (Con): I welcome the Secretary of State’s statement, but I would be grateful for clarification on one point. The Richards review was about those who are required to pay for their NHS care because they have opted to pay for drugs privately. Can the Secretary of State confirm that, from today, none of those patients will receive an invoice from the NHS for their NHS care?
Alan Johnson:
In terms of what has gone on before today, I can assure the right hon. Gentleman and the House that the old guidance has gone and the new
guidance replaces it with immediate effect. What has happened before will be for PCTs to deal with. In the Linda O’Boyle case, the PCT refunded the money. I would not like to make those decisions for them because all kinds of circumstances could be involved, but I think the PCT in Southend set a good example.
Charlotte Atkins (Staffordshire, Moorlands) (Lab): I very much welcome the Secretary of State’s statement, particularly his comments on the speeding up of NICE decisions, the more realistic pricing of drugs in the future, and the ending of the cruel withdrawal of treatment from the terminally ill who want to buy drugs privately. However, many people will be worried that this is the thin end of the wedge, undermining NHS principles of treatment free at the point of need. Also, I have concerns—
Mr. Deputy Speaker: Order. I do not think we need an “also”, as the hon. Lady has made her point.
Alan Johnson: I understand my hon. Friend’s concerns. This has been a difficult process because of the very strongly held views, as anyone will know who heard the debates on the radio or in this House, or the debates organised by the British Medical Association or the King’s Fund. There are strong opinions on both sides of the argument. The evidence submitted by the Royal College of Nursing sticks in my mind. It made the point that the NHS is about providing services, not withdrawing them, and it made the cruelty case—it said there was a lack of clarity and a lack of charity in how the current arrangements applied. My hon. Friend the Member for Sunderland, South (Mr. Mullin) was the first person to raise this issue with me. He said to me a while ago, “Look, we need to rethink this.”
I do not believe this is the thin end of the wedge for the NHS. I think carrying on with the previous system is what would endanger the principles of the NHS, because people saw it as dogmatic and ideological, and not in any way related to the person’s individual needs. So I think this strengthens the NHS, rather than weakens it.
Mr. David Curry (Skipton and Ripon) (Con): But does the Secretary of State accept that two patients can have an identical operation carried out in the same hospital by the same consultant, but because they live in different PCT areas one will have that operation paid for whereas the other will have to pay for it himself or herself? Does he understand the resentment that that provokes? What can be done to remedy the problem?
Alan Johnson: I understand that. The NHS constitution, when we finally get it launched, will help in some ways. Mike Richards makes a recommendation pointing out that in the north-east of England an overview of this issue is taken, so that PCTs do not make different decisions. Not only is there work to be done with the PCTs, but, as he recommends, we should examine how they deal with this on a regional basis. The right hon. Gentleman correctly says that this causes huge resentment and great upset.
Mr. Doug Henderson (Newcastle upon Tyne, North) (Lab):
I usually find eulogistic questioning awkward and it is always counter-productive, but may I compliment the Secretary of State on his statement? In comparison with the arguments put forward by Conservative Members, it was clear, concise, coherent, fair and based on sound common sense, and it will be very much welcomed in
my constituency. Does he believe that NICE will need additional resources to be able to carry out its reviews more speedily?
Alan Johnson: I preferred my hon. Friend’s description of my statement to the Conservative party’s one. I can confirm that this is all eminently doable within NICE’s current budget. Medical science moves on; end-of-life treatments and the drugs available to treat rare diseases, such as melanoma and so on, were not an issue five or 10 years ago. NICE has been keen to keep pace with those changes, and there is nothing to prevent it from introducing this immediately and taking note of the consultation in five weeks’ time. We will then make a further announcement in January.
Dr. Evan Harris (Oxford, West and Abingdon) (LD): Does the Secretary of State accept that there are lots of unanswered questions? For example, how does he deal with the situation of an NHS consultant referring and recommending a private treatment given by himself in an NHS pay bed with the income going to that trust? How does he deal with the problem faced by someone who responds to a private treatment that keeps them alive but then runs out of money and finds that the drug is not allowed on the NHS because it worked for only a few people? Surely that treatment should then become payable by the NHS. Does he accept that more work needs to be done on those questions?
Alan Johnson: I accept that, as does Mike Richards. He has done a thorough piece of work in a short space of time; he needed to do so, given the urgency that the public attach to this. He says in his recommendations that measures need to be in place to prevent what the hon. Gentleman described. I think that the ethos and the integrity of doctors, their contract, the fact that they are not allowed to raise the issue of private drugs—it must be raised by the patient, rather than by the practitioner—and perhaps some other measures that we could introduce would resolve those problems. If we stick to the current system, what the hon. Gentleman describes could happen just as well, except that tied on to it would be this withdrawal of NHS treatment.
Rob Marris (Wolverhampton, South-West) (Lab): I welcome the statement. Some PCTs need money to pay for these drugs, and some PCTS, such as Wolverhampton’s, still do not receive full funding as per the Government’s own formula. By what date will all PCTs receive full formula funding?
Alan Johnson: I cannot give a date for that. All I can say to my hon. Friend is that, as he will know, we started off with many PCTs being about 15, 16 or 20 per cent. away from having their proper funding formula; no PCT, not even the one in Northamptonshire, is now more than 3 per cent. away from that target. This is the way we must go if we accept that we do not want to take money away from more affluent areas. We do not want to reduce the health spend; we want to increase it for everyone, but we want to increase it most for those areas with the most deprivation. We need a gradualist approach. As a good Fabian, he will recognise that that is the way to go.
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