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House of Lords

Tuesday, 3rd April 2001.

The House met at half-past two of the clock: The LORD CHANCELLOR on the Woolsack.

Prayers--Read by the Lord Bishop of Oxford.

Rheumatoid Arthritis: Anti-TNF Drugs

Lord Roberts of Conwy asked Her Majesty's Government:

    When the National Institute for Clinical Excellence (NICE) is expected to complete its appraisal of anti-TNF therapy drugs for rheumatoid arthritis.

The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt of Kings Heath): My Lords, the National Institute for Clinical Excellence expects to give guidance to the National Health Service on the clinical and cost effectiveness of etanercept and infliximab for rheumatoid arthritis in October this year, provided that no appeals are made.

Lord Roberts of Conwy: My Lords, I am grateful to the Minister for that Answer. Will he ensure that NICE sets the cost of these drugs against the high cost of rheumatoid arthritis to this country, estimated at 1.3 billion per annum, as well as the benefits which accrue to sufferers who do not respond to standard treatments?

Will he also remind those health authorities across the land which are using reference to NICE as an excuse for denying funds for the purchase of those drugs that that is discouraged, if not prohibited, under the terms of his relevant circular?

Lord Hunt of Kings Heath: My Lords, NICE is required to assess evidence on all the clinical and other health-related benefits of treatment and to judge whether on balance they would represent a cost-effective use of NHS and personal social services resources. That provides the right framework for dealing with the important issue which the noble Lord raised.

Policy guidance issued to health authorities was set out in National Health Service Circular HSC/1999/176. In the light of that overriding guidance, we made clear that health authorities and primary care groups and trusts should not wait for guidance from NICE but should develop policies for the managed introduction of those drugs, as for any other clinical development, based on the availability of evidence as to their clinical and cost effectiveness. The guidance should not be used as a mechanism for failing to take a decision. If the noble Lord has particular cases in mind, I should be happy to investigate them.

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Lord Ashley of Stoke: My Lords, the Government offer advice to health authorities, as my noble friend explained. However, what action can they take when those health authorities choose to ignore their advice and refuse to fund the kind of drugs mentioned?

Lord Hunt of Kings Heath: My Lords, if the advice from NICE is that a certain drug should be used for certain conditions, we expect the health authority to implement that guidance. The whole basis of the establishment of NICE is that it enables us to ensure much greater consistency in the introduction and use of cost-effective drugs and other treatments.

As part of our appraisal of the success of NICE, we are monitoring to ensure that health authorities implement such guidance.

Lord Walton of Detchant: My Lords, is the Minister aware that research has shown that the sensitised white blood cells which attack the joints in rheumatoid arthritis produce a substance called "tumour necrosis factor" and that the drugs to which he referred are the first which have been shown directly to counteract that particular factor and thus strike at the heart of the pathological process which is responsible for the disease? Is it not remarkable that these remedies, which were developed in the United Kingdom, are freely available in the USA, Holland and Germany but very scantily available in the UK?

Lord Hunt of Kings Heath: My Lords, I am most grateful to the noble Lord for clearly explaining the potential effectiveness of those drugs. I must agree with him that the clinical evidence for the two drugs is convincing. The history of the NHS over many years involves the inconsistent and patchy introduction of new treatments and drugs which have been found to be more effective than previous ones. The purpose of establishing the national institute was to ensure that we achieve a more consistent introduction and use of such drugs.

Lord Clement-Jones: My Lords, Ministers claimed that the introduction of NICE would end postcode prescribing. That was said to be its key function. The Minister mentioned that the acceptance of the NICE guidelines were being monitored but can he give more details of that? Can he also describe the nature of the enforcement that is taking place? Surely, if we are to end postcode prescribing it is vital that the appraisals and recommendations of NICE are put into practice.

Lord Hunt of Kings Heath: My Lords, indeed it is, which is why we are monitoring the introduction of the guidance. We expect health authorities fully to implement that guidance and we should be most concerned if instances were brought to our attention showing that was not happening. The whole purpose of NICE is to ensure consistent approaches throughout the NHS.

Lord Morris of Manchester: My Lords, I am very often informed by correspondents that these drugs, so

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important in the treatment of rheumatoid arthritis, are, as my friend the noble Lord, Lord Walton, explained, available in many other countries. How do I answer their question: why cannot they be made available here without that most painful form of rationing known as "postcode prescribing"?

Lord Hunt of Kings Heath: My Lords, I agree with my noble friend that postcode prescribing, which has been an endemic problem in the National Health Service, is unjustified given the national nature of the service. But I believe that the introduction of NICE is the best way to enable a consistent approach to be taken and to allow for the speeding up of the introduction of effective medicines and treatment. The whole benefit and purpose of NICE is to provide advice, based on the most careful judgment, as to whether a particular treatment or drug is effective, including cost-effective. Once that advice has been given it will lead to its speedy implementation throughout the National Health Service. I believe that that is the best way to deal with postcode prescribing.

Earl Howe: My Lords, is there evidence to show that what the Minister has just said is correct? Does the noble Lord agree that, surely, it is one thing for NICE to make a judgment about a particular treatment, but it remains for health authorities to fund that treatment once the judgment has been forthcoming, and that has not always been seen to happen in practice?

Lord Hunt of Kings Heath: My Lords, the noble Earl raises two points. It is surely right to expect health authorities to fund the implementation of NICE guidelines from their allocations which, as the noble Earl will be aware, are at a record level. We expect health authorities to implement those guidelines, and we are monitoring that at the moment. If we find an instance in which it has not been implemented we take it up vigorously with the health authority concerned.

Constitutional Change

2.44 p.m.

Lord Renton of Mount Harry asked Her Majesty's Government:

    What lessons they have learnt from the constitutional changes they have so far introduced.

The Lord Chancellor (Lord Irvine of Lairg): My Lords, our major programme of constitutional reform of course drew out profound debate in Parliament and the country about the nature and effectiveness of our institutions, their mutual relationships and our sense of national identity. The Government have both contributed to and learnt from that debate. But we have concluded that we were right to have removed the hereditary peerage from this House, subject to a temporary right for one-tenth to remain; right to have created the Scottish Parliament and the National Assembly for Wales; right to press ahead with

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democratic self-government for Northern Ireland as part of the peace process; right to create the regional development agencies and to restore an all-London tier of government; right to have put the Freedom of Information Act on the statute book; and right to have introduced the Human Rights Act. The Human Rights Act will stand as a major legislative and constitutional monument to this Government's first term of office.

Lord Renton of Mount Harry: My Lords, I thank the noble and learned Lord the Lord Chancellor for that Answer. I heard a great many "rights" in his response. With his well known reputation for listening and taking advice, in the quiet weeks ahead will the noble and learned Lord reflect on two points? First, has devolution in Scotland, Wales and Northern Ireland made the trend towards an English national parliament at Westminster irreversible? Do any of us really want that? How could it be reversed? Secondly, on a more domestic front, is it not time that serious all-party consideration was given to the appropriate powers of this revised upper Chamber? If we are to have a credible ability to revise and delay, is it not time that we went back to the situation in which we had the ability to delay public legislation for two years rather than 13 months?

The Lord Chancellor: My Lords, I do not believe that there is any appetite in England for a national parliament for England. As to the second point, the Wakeham commission was of the clear view that the basic scheme of the Parliament Acts should remain unchanged, and we agree. The noble Lord's proposition would turn back the clock from 1949 to 1911 and allow the Lords to delay for two Sessions, not one, the will of the elected Chamber. That does not find any support from the Government.


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