22nd June 2005
Mr. Dai Havard (Merthyr Tydfil and Rhymney) (Lab): First, I know that other hon. Members are interested in the debate, which I am pleased to have secured. I know also that my hon. Friends the Members for Norwich, North (Dr. Gibson), for Bristol, North-West (Dr. Naysmith) and for Brighton, Kemptown (Dr. Turner) want to talk about their experiences with the National Institute for Health and Clinical Excellence.
I want to do four things: review the current situation; talk about and give examples of technology and different types of treatments and how they are dealt with; talk about related relationships within the United Kingdom, because NICE has an interesting relationship with the rest of the UK beyond England—there are organisations in Wales and Scotland that do similar work—and say something about how all that affects commissioners and delivery agencies; and to assess how such issues affect financial efficiency, the making of changes and the improvement of standards.
Running through the subject is a second aim because two things are involved. One aim is to consider efficiency, process and practice when making changes, but that has to be done for a particular reason, because relative to all that are the human tragedies and journeys. Patients and families are people, so the second aim is to drive up the quality of their care by the efficiency changes, as well as efficiency being gained simply for its own sake.
I have had three Westminster Hall debates on the subject, and you will know from those, Mr. Cook, because you chaired one of them, of my interest in it. I became involved because there was, at that time, a huge incidence of cancer in my constituency and I had been looking at how to improve standards of cancer care. One thing that came to my attention was people's treatment in relation to anaemia and blood. As a consequence of that, I looked at how standards were applied for alternative technologies to blood transfusion, for example. That led me to NICE and the process of rationing in the NHS. Since then, I have asked 50-odd parliamentary questions and have had these debates, in the last of which, in July 2003, the then Under-Secretary of State for Health, Melanie Johnson, said of NICE:
"Central to our modernisation programme is the National Institute for Clinical Excellence, which we established to give clear national guidance on the use of drugs and other treatments. Its work reaches into all aspects of the NHS, from wider judgments on whether a new treatment is both clinically and cost effective, to assessments of what care is best for individual patients."
She went on to say:
"We set up NICE to tackle postcode prescribing and inequality, and it is central to our plans to modernise the NHS and drive up standards."—[Official Report, Westminster Hall, 8 July 2003; Vol. 408, c. 240–41WH.]
I could not demur from that, as that is a laudable set of aims, so why am I back here two years later? It is because of some reports that I heard in the Whitsun period after the general election. In the July 2003 debate, I was told that NICE was to receive extra money and resources to enable it to go from doing two appraisals a year to three, but I now hear that it is to move backwards and go from three appraisals to two.
Of the various reasons for that, the main one seems to be that because the Health Development Agency was assimilated by NICE in April, NICE has had to make a budget cut of £3.5 billion to subsume the new work and combine the two organisations. I am told that that is the reason for the change in the number of yearly appraisals. I do not know whether that is true. I understand that Ministers deny that there is any cut in the budget to NICE, but whatever is happening with the finance, the number of appraisals is to be reduced. A long queue of things, which are of great need to individuals in all our constituencies, were being assessed, but that has now stopped.
When I considered other treatments, such as drug alternatives to blood transfusions, an argument immediately started about how to assess the true and total cost. How do we assess true value in the NHS? I do not say that in an accusatory fashion, but I have observed that it is difficult for the NHS to value things in the way that I see them. For example, I get into discussions that are like a cross between metaphysics and linguistic philosophy. I might say, "Well, surely if you introduce this treatment, this will mean that someone can go home earlier. Therefore you will make an efficiency gain and a bed will be flung free for someone else to use." I am told, "Ah, now hang on a minute: what's a bed day? What's a bed? What's a day?" So no change is made because there is apparently no way of deciding what the real value is or whether efficiency is achieved.
There are organisations and engines that are supposed to help—apparently—the greatest of which, I have been told, is the National Institute for Health and Clinical Excellence. It was supposed to be a mechanism of change that could reconcile some of the problems, square a number of the circles and build a community of understanding of the real value of something. Now, however, I am told that the situation is as I have described it.
The number of appraisals has declined, and although NICE is supposed to help with such things, I was told in an answer to one of my questions that NHS circular 1999/176 says that, in the mean time,
"national health service bodies should continue with local arrangements for the managed introduction of new technologies where guidance from the National Institute for Clinical Excellence"
has not yet been issued. It went on:
"These arrangements should involve an assessment of the available evidence on clinical effectiveness."—[Official Report, House of Commons, 7 Mar 2005; Vol. 431, c. 1568W.]
That all sounds fine, but I am being told, on the one hand, that we need that engine of change and that it exists, but, on the other, that it is being reduced, although that does not matter because there is another process. The truth is that without NICE making a declaration there is no real agreement about money, which takes me back to the original response that I received.
The question is not only whether something is efficient in the sense of being effective as a medical treatment, but whether it is efficient in the sense that we should spend money on it. Without that, whatever the local arrangements, the budgets will not allow certain treatments. That is the power that NICE has because it gives local people the ability to square the circles, and that is the problem. A lack of NICE guidance means that local arrangements cannot really apply, unless there is a magical way of finding money to make things work.
That is the background, and I shall give a few examples to demonstrate why a lack of NICE guidance is so important. Some new medical technologies and treatments are licensed and some are not. Hon. Members will know the argument that runs, "Well, there's this fancy thing that I've found on the internet, but I've been to the doctor and it's not got a licence." We all encounter such problems as constituency MPs, but in the NHS the problem is bigger. There are also licensed technologies and treatments that do not have NICE approval.
In the UK, to reduce both bed blocking, which is a huge inefficiency problem in the NHS, and waiting lists, thereby allowing patients to leave hospital more quickly, there is a set of treatments for wounds. There is a huge problem with MRSA. People have wounds in hospitals for different reasons—they might go in as a trauma case, for instance. However, there is now a technology that, I understand, works on a vacuum system—it is a machine as opposed to a drug—and is put on to the patient in some way. The wound is sealed up and kept treated. Multiple wounds are treated and the person is allowed to go home, rather than staying in an environment where they can get an infection.
If nothing else, the precautionary principle suggests that it would be sensible to fund that technology to improve efficiency in the health service and the quality of care for the patient. I am told that the MRSA rapid review panel—a different body again—looked at the technology and said, "But this is not a new technology. The only new thing about it is that it is portable. We will not, therefore, include it in our assessment of what might be useful in combating MRSA." If NICE cannot appraise it or has not got the time to do so, perhaps another body could. Perhaps that body could license its use—but apparently not.
Wounds can result in all sorts of things, and diabetics are probably most affected in that respect, as a result of ulcers, sores and so no. People in my community are in that situation. There is ill health in a number of forms in the Welsh valleys and similar communities, as a result of diet and the rest of it. People have to go into hospital, sometimes just for simple things such as foot ulcers. Those things can be treated in a such a way that people do not have to remain in hospital and are not exposed to infections. Yet, it has not been agreed that this technology is the best process and the best practice. That is not because of the arguments about what is efficient and what is good quality care for patients, but because it does not fit with the budgetary processes.
A diabetic can end up with wounds and the rest of it, and the only treatment may be to amputate. Some of the treatments that are given in such circumstances go back almost to Trafalgar—Nelson would recognise some of this stuff. However, there is no need for these things to come about when there is a new technology that can avoid these problems in hospital and when people can be given better quality care that allows them to say at home. There are examples of this technology being used. I know of a nurse in Scotland, for example, who has a problem and who is using the machine. She is out of hospital and back at home, so she is not exposed to extra infection. She is also back at work.
Another thing that interests me is that there is a budget for lopping off limbs, but no budget for introducing this machine, which seems barking mad in the 21st century. I do not understand how we can move from one position to the other without engines of change to allow us to do so. NICE is one of those engines of change, and every time I look at it, as a lay person trying to understand the edifices, the interest groups, the old boys' clubs, the reasons why things cannot happen and the budgetary processes, I see ever more clearly why we have arrived at this situation. It is obvious to me as a lay person that we should make the change, but we cannot seem to find a way to agree on that.
As I understand the figures, such a change could save huge amounts of money—billions of pounds. A study estimated recently that pressure ulcers alone account for £2 billion annually. That is 4 per cent. of the NHS budget. I have no difference with the Minister about the declaration of aims. If we look back at my previous debates, it is clear that we have always ended up agreeing about the need to move to European standards. We need to do all these things because we need to improve. I am told that mechanisms will be in place to help us to do that, but I find out daily that they are not. The mechanisms are dysfunctional and deficient, and resources need to be made available, but NICE is now getting fewer resources.
Perhaps all this can be explained away and I can be told that I am a naive shaver who does not understand these things, but I have seen examples and I have mentioned them. I want to know when that technology will be properly assessed. If NICE cannot do the appraisals, when will it be considered? It seems relatively simple to do that, but there is no mechanism. That is completely ridiculous.
The other thing I have discovered is that there are different drug therapies and technical assessments of technologies. I am a lay person, so I simply look at things from a straightforward point of view. The wound technology is not a treatments—it is a machine, not a drug—and such technologies have to follow certain criteria. So there is a problem in getting technologies assessed, but once they are, there is a problem with the criteria—another barrier. Apparently, the assessment has to be done with a blind randomised testing procedure, because the patient is not supposed to know about it, but it is a little difficult not to know about it if a machine is strapped to your body. It might be possible to do that with a drug, but not with a vacuum pump. So once one hurdle is cleared, there is another. All those things are barriers in a process rather than equipment in the tool bag of someone working on the engine of change to ensure the progress that we all apparently want.
I should like the Minister to consider that problem, if nothing else. We need to think about the criteria used for technological and medical processes—in other words, drug or pharmaceutical processes—so that we do not end up with anomalies. Frankly, the criteria seem to be excuses for not making changes and not being able properly to see the value of such technology to society.
I intend to deal with where the Treasury sits on the subject because the nurse that I mentioned earlier is still in work. She is contributing to society. She is not on benefit, does not need a carer and is not drawing the support that she would otherwise need. Her mental health and her quality of care are better. As a consequence, her family is better off. There are costs beyond the simple budgetary processes of the NHS, so it is not entirely an NHS matter. A wider understanding is needed of the value of such technologies, so that they can drive efficiency within the NHS and beyond, to the broader macro-economic benefit of the country. That is my experience of the examples that I recently found out about.
The differences between the various parts of the United Kingdom can be problematic. You, Mr. Cook, will understand that, as we have discussed it before. As a Member for a Welsh constituency, I know that a number of health matters are devolved, and I remember discussing whether we might have devolved arrangements in the north-east. Nevertheless, there is a relationship between different practices. I know that my hon. Friend the Member for Bristol, North-West has a particular view of the matter because he sits on the border between England and Wales, where there are several examples of different practices.
My experience is that NICE informs all decisions across the whole of the United Kingdom. It could be said that they apply in both England and Wales. However, that relationship became a little more disturbed recently because the NHS in Wales decided to put more emphasis on the all-Wales medicine strategy group, an equivalent organisation trying to do similar things. In Scotland, the situation might be slightly problematic for the Scottish medicines consortium; in the absence of guidance being adopted by the Scottish Parliament, the NICE guidance would apply.
The situation is simple. In England, if NICE makes a decision the funding has to come within three months. However, Wales and Scotland may not adopt NICE decisions in quite the same way, which is why those relationships and what they should achieve have been considered. However, the all-Wales medicine strategy group now makes decisions about licensed products in Wales; things happen within three months.
Other considerations are the number of appraisals that NICE can do and the various things that it can look at; indeed, the speed with which things happen is part of the argument. It seems that we have a group in Wales that is able to move more speedily than NICE, which covered the area before and made appraisals within three months. As I understand it, the Scottish medicines consortium takes a similar time, taking three months to evaluate something.
Patients in Wales can now get different types of treatment. NICE was set up for the purpose, among other things, of getting rid of postcode prescribing. That was the political declaration that was made. However, postcode prescribing happens not only in England, or even in parts of Wales or Scotland, but also, it would seem, between different parts of the United Kingdom.
Let us take as an example someone from Wales with rheumatoid arthritis. There is a problem with rheumatoid arthritis in Wales; in January this year
agreement was given for a new anti-tumour necrosis factor drug, called Humira, to be used in Wales. The patient might go to a hospital on the border, in Herefordshire. Although a patient from Wales being treated in an English hospital would get the treatment, a patient from England being treated there might not get it because NICE has not come to the same agreement as the Welsh body.
The Welsh organisation can apparently act and assess matters more quickly than the English one. That is positive for me in Wales, I suppose. I could be challenged to say why I am complaining; the Welsh patient is getting the treatment, so what is the problem? However, what I have outlined illustrates the problem that exists across the piece: how do we evaluate and change processes? How do we decide on the best treatment and standard, the way to apply it and the way to follow the money?
I am told that the only thing that we can rely on is NHS circular 1999/176, which tells us, "OK, that doesn't matter, because if NICE has not appraised a treatment, things can still be done locally." I recently encountered an example from Birmingham relevant to that approach. A patient went to Birmingham for cancer treatment. That was fine; the treatment was great and the patient came back. I have a list of 10 drugs from the cancer network in Birmingham, which I can provide to the Minister later. What interested me is that without NICE having agreed standards for the drugs, the default position is that all drugs, including the 10 on the list, will not be prescribed unless and until it is possible to find—what is the phrase?—"a clinical champion".
When I saw that, I thought, "What does that mean?" Presumably it means finding someone with some dosh to pay for the drugs—someone who is able to juggle a budgetary process somewhere to provide the treatment. There is an understanding that the treatment is the best one, but it cannot be given. There is now almost a conspiracy. That is perhaps a bad word to use. There is a coincidence of understanding within the cancer network in Birmingham and among the commissioners, the primary care trusts. That is not my patch. I apologise to Birmingham Members; I just have that example and use it for what it is.
The situation may not be entirely as I understand it. However, it seems to me that the real message is that unless a series of agreements is struck elsewhere through NICE there is a problem, and the only way to cater for the need in question is to take a default position in which no one gets the treatment unless someone somewhere comes up with the money to pay for it and shows us how to juggle the budget.
That brings me to the point that I made earlier. It seems that there is a silo mentality. I do not know why the health economists in the Department of Health cannot find a way through. It seems that there is a budget for that and a budget for this, and there is no quick way to change the arrangements and move money with the patient. Yet that is what the declaration was about. There can be a budget for chopping off arms and legs but not one for the vacuum pumps, so we have amputations instead of pumps. There is a budget for transfusing blood but not one for pushing a drug alternative into someone. No way can be found to make the best decision. The only decision that can be made is the one allowed by the process. That is why I want to make the point about the necessity for process change and my view of the system as dysfunctional.
I am quite happy to share examples of cross-border care with the Minister, but what I have outlined needs to be examined if those default positions are being adopted, and if that is what circular 1999/176 really means. It looks positive, and I am sure that it is positive in intention. It tells people that they can make the best arrangement locally. The truth is that they cannot, because the other processes will not allow them to. The circular can also be used negatively rather than positively, and people can go off and do their own thing. I suspect that it is being used as an excuse not to apply some of the NICE guidance, or to slow things down and find ways of avoiding it.
Perhaps I am being accusatory about things that I should not be, and perhaps I only half understand the problem, but these things warrant investigation and go some way towards illustrating the problems of the laws of motions that apply here. Does the Minister agree?
I return to the point about finance. In all this, there is a desire to improve standards of care. Indeed, the Government have made political declarations about improving standards of care and about spending money. In practice, we are spending huge extra sums, but there is tension as to whether the efficiency changes will come in concert with investment. That is what I am trying to get at. All those political declarations are fine and the actions are good; I simply feel frustrated that the practice on the ground is not delivering results.
The Secretary of State said at the NHS conference this week that it was paramount that best value was delivered and that every pound going into the NHS must deliver it. I agree entirely, but the politics are also important. The politics of the personal are important. Every day, I see individuals who could have a better quality of life but are not getting it. I see people who live in valleys who have difficulties with transport. Even the NHS has difficulties in transporting them from their properties to their places of treatment. If those people were treated differently, they might not need to make half the journeys that they make. They could be liberated by the quality of their care, and what they can do as individuals could change as a result of changes to the system.
Politics more broadly is important. The Government have declared that they will increase national insurance contributions by 1 per cent. to provide all this extra money for the NHS. I applaud that. That is exactly what we should have done, but we were going to get the efficiency gains that went with it. That is what I am questioning, because if we do not increase national insurance contributions and get those gains, the harpies will be on the wire saying, "You won't do it, and you'll have to raise taxation, Gordon." We see them there every day—the City scribblers who write in the press. We must address the problem whether we like it or not. We must have real change and real efficiency, not spurious processes.
I differ from the Government on how to effect that change. I do not believe that the market does it. We must drive the process if we want a real improvement in
efficiency. That is how we save the money and improve the quality of care. We do not do that through managerial arrangements elsewhere. To me, that is a false notion. This is the guts of the argument if we are to improve health, deliver better treatments and increase efficiency.
Some of the problems are avoidable. I do not believe that, having put men on the moon in 1969, we cannot do this. Perhaps I am naive, but I take that point of view. A woman who comes to my surgery with foot ulcers because she is diabetic is going through the whole process that I described when she does not need to. It is simply more efficient for the hospital not to see her. We have to find ways around this. How do we do that? I asked that question when I met the Minister, along with a delegation, to discuss another example of the problem. This warrants further examination by Departments working together.
This is the point at which I return to the subject of the Treasury. As you know, Mr. Cook, I served on the Defence Committee during the previous Parliament. In many ways, we had a similar debate. There was a huge overspend on defence budgets, and the Treasury said, "Oh well, we will have resource-cum-budgeting. We will have this, that and the other, and we will sort out all these problems by keeping stocks." Neither the Ministry of Defence nor the Department of Health is Tesco, however. It would be fine if we had a load of tins of beans on a shelf and we wanted to move them quickly and would not be punished for keeping stocks. That is one bit of the argument.
There is, however, something much more fundamental, which relates to process. I want standards such as resource accounting and budgeting—or whatever the other mechanism is—applied across the piece to find the engines of change, one of which I believe is NICE. One could advance a political argument against that, querying whether making a decision about medical efficiency and spending for a bunch of technocrats is a good idea. However, if such a procedure will deliver a change, I do not care about that, because political responsibility will still rest at the top.
Processes must be found to take such action. I hope that the Treasury will take account of the arguments that have been advanced today. Perhaps the Minister can promote a way in which all the Departments responsible for such matters are not subject to blame, but understand the reality of saying, "How do we make two things happen?". That takes me back to the first time that I spoke about such matters in 2002, probably under your chairmanship, Mr. Cook. At the time, I said that two outcomes could be achieved: step change and good, consolidated implemental change in the processes that deliver not only efficiency of spend, but quality of care, with standards being driven up for patients.
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