---

Health Care Prioritisation

May I first place on record my sincere thanks to hon. Members from both sides of the House and the Officers in the Lobby who virtually led me by the hand to ensure that I was here on time and did not miss a huge opportunity? I believe that I can speak for approximately an hour and 45 minutes, but I reassure you, Mr. Deputy Speaker, that I, too, would like to get away. I will speak for a little more than quarter of an hour, but not interminably. The debate provides a great opportunity for me to climb on to one of my hobby horses—the minefield of health care prioritisation. I want to speak under four headings. The first is, ““Why is prioritisation necessary?”” Secondly, I want to demonstrate the difficulties with prioritising health care. Thirdly, I wish to welcome the Government's attempts at it so far. Fourthly, and most importantly, I want to suggest the way in which I believe that the Government should tackle the problem and how, coincidentally, that could go a long way towards helping them rebuild the electorate's confidence after the many blows of the past few weeks. Why is prioritisation necessary? First, we are all living a great deal longer, so we all have a longer time to be ill—we also have a longer time, I hope, to be healthy. The second reason is the complexities of the treatments now possible. People are now surviving with long-term illness, while children with severe disabilities are surviving long beyond their late teens and early 20s, which was their lot a few years ago. I qualified, I hate to say, 48 years ago. When I qualified, we had only about three antibiotics; now there are myriad antibiotics. Beta-blockers had not been invented, nor had modern diuretics, ACE inhibitors—inhibitors of angiotensin-converting enzyme—or antidepressants. There were no ulcer-healing drugs. A heart attack was treated with bed rest and masterly inactivity. In almost 50 years there has been an immense change in the treatments available—treatments that patients will demand, now knowing more about them. There have been tremendous changes in the treatment of heart disease, strokes and cancer. However, we cannot afford everything in a tax-funded system with inevitable cash limits. In my request for this debate, I asked that it be entitled ““Health care rationing””. When I discovered that the title had been altered, I talked to the Table Office and was told to my amazement that the word ““rationing”” was not really acceptable on the front of Government business papers. I found that absolutely staggering. ““Prioritisation”” and ““rationing”” mean pretty much the same, but ““rationing”” goes that little bit further and suggests that some things may fall off the bottom of the list as being unaffordable. I am therefore talking not only about prioritisation, but about rationing and the things that might fall off the bottom. That is the whole point of my debate. I do not often quote Lenin, but in 1936 he said, ““Liberty is precious—so precious it must be rationed.”” I obviously do not agree with him, but I shall pinch his statement and make it: ““Health care is precious—so precious it must be rationed.”” Talking about the national health service's current surplus of £1.8 billion, the Secretary of State told the Select Committee on Health last week that it was enough to meet ““our”” priorities. That is my first difficulty—whose priorities are we talking about when we talk about prioritisation? Are we talking about the elderly, the disabled, those with mental health difficulties or ethnic minorities? All those groups have been and continue to be neglected, according to recent reports by Mencap, the Joint Committee on Human Rights and the Disability Rights Commission. Are we talking about the priorities of the blind, the deaf, pregnant women, those with rare diseases, those with common diseases, those with fatal illnesses, those with emergency conditions or those with long-term conditions? Somehow we have to address everyone's priorities. That is one of the huge difficulties. The second difficulty to which I should like to draw attention is the power of various lobby groups. Obviously there are well-organised pressure groups for many of the major illnesses. I fully understand that and have no objection to it, but in any debate about prioritisation one must remember the other people. The illnesses that have a national service framework or national clinical directors, or that have achieved national priority status obviously have a huge advantage. I am not saying that that is wrong, but we must remember the others. I remind the House of what the hon. Member for Newport, West (Paul Flynn) said in his superb 10 commandments for MPs, in his little book ““Commons Knowledge””. Two of those commandments were that we must"““Seek the silent voices””" and"““Serve constituents, the weak and neglected””." Those are the very people we have to seek out; we must ensure that we take their concerns into account. I would much rather call a spade a spade and talk about rationing. What have the Government done so far? I shall mention NICE, but I shall not go into much detail. As you will know, Mr. Deputy Speaker, the Health Committee has completed its second inquiry into NICE and is working on its report now, so I would be in huge trouble if I leaked any of it. However, we produced a report on NICE in 2002 and I shall read one of our recommendations set out in paragraph 134. It states:"““Prioritisation of healthcare spending is an issue of overwhelming importance, and during the course of this inquiry it has become clear to us that a more open debate on healthcare prioritisation needs to take place. Our inquiry has persuaded us that, with so many competing interests vying for attention and funding in an area where resources are finite, it is not sufficient to have implicit healthcare prioritisation. We feel that NICE has been laid open to unfair criticism in respect of the 'rationing' debate and as a consequence of the lack of clarity… here.””" What else have the Government done? Before having a debate on priorities, one has to ensure economy and efficiency. Here, the Government have made a very serious attempt—or the beginnings of one—with their paper, ““Better Care, Better Value Indicators””. I thoroughly welcome the examination in it of matters such as length of stay, days of admission before an operation, certain surgical procedures and whether they should be done at all, and the prescribing of generic drugs, particularly the statins. These better care, better value indicators have shown a tremendously wide range of performance between primary care trusts and acute trusts, for example. If the quality of service in respect of the indicators were improved to the top 25 per cent. of PCTs and acute trusts, there could be potential savings of £2 billion. I understand that there are further indicators in the pipeline, which I hope will be examined carefully and, if comparable to the first ones, wholeheartedly welcomed. At the Health Committee last week, the Secretary of State listed four ways of saving money: best practice, which must, of course, be evidence based; better procurement, cashing in on economies of scale; community-based services, which are obviously cheaper than hospital-based ones; and, of course, the whole issue of drug pricing. The Government are absolutely right about that and all sensible economies and increases in efficiencies must be made, yet it is still a bottomless pit, so I think that rationing is necessary. Let me continue briefly with some of the unacceptable results of the current situation. I shall talk about postcode rationing, which, I am afraid, does exist and leads to obvious inequalities and inequities across the NHS. A new anti-cancer drug called Sunitinib prolongs the lives of people with renal carcinoma. In some parts of the country, even though the drug has not gone through NICE, it is available; in other parts, including mine, it is not available. It is very hard for people in my area to understand that when they read about the huge surpluses in the NHS and they know people in different parts of the country close at hand who can get these extra few months of life, while they cannot. Another example is the use of cochlear implants for the very deaf. I am afraid that I made a rather tactless mistake in this connection. One of my constituents badly needs cochlear implants, and I was stupid enough to write to her and compare her need with people's need for Sunitinib. As might be imagined, I got a very large flea in my ear. I shall read some of my constituent's excellent letter to the House. She wrote:"““I think it is unfair to compare my case with cancer patients. I am a person with a severe hearing disability and looking for prosthetic Cochlear Implant in order to improve my quality of life. Does the PCT put a limit each financial year for the provision of artificial limbs or eyes? Do they limit the number of hip and knee replacement procedures even cataract operations to improve failing eyesight? I would like to suggest that everybody should put earplugs in for a day and see how they get on trying to live their normal day either at home or work!””" She went on to say that my PCT in Worcestershire had"““the worst record for funding Cochlear Implantations in the whole country.””" In another paragraph, she wrote:"““Regardless of Worcester PCT's financial position, at a time when the NHS has never been better funded with taxpayers money, you must agree with me that it is completely unacceptable for the PCT to reduce funding for Cochlear Implantation to the detriment of people with a major disability. I am sure the Government and the Minister of Health in particular, in addition to the RNID, would find this completely unacceptable.””" Further examples are treatment for wet age-related macular degeneration, which was covered very thoroughly by a debate in Westminster Hall last week, and fertility treatment. We hear from gynaecologists and obstetricians that fertility treatment varies strikingly across the country. Whether that variability of provision is due to better resourcing of some trusts or to better management I do not know, but I believe that there must be an open debate to decide whether those treatments should be available to everyone, and, if so, what must go in order to pay for them. It is sad that Members of Parliament are thought to be able to influence prioritisation. I for one was disappointed by what happened with Herceptin, when the Institute for Health and Clinical Excellence appeared to be rather hijacked by a previous Secretary of State. Although it is clearly right for people to be given Herceptin in certain circumstances, it seemed that the whole method had been circumvented, which led constituents to think that Members of Parliament can circumvent the process. That cannot be right, and there should be no need for it. How can we make progress? First, we must face up to the problem. Everyone agrees that the NHS must be free at the point of delivery, and it is marvellous that everyone agrees with that, but can provision actually be comprehensive? Sadly, I fear not. However, the appropriate party is in government, and perhaps its members will follow Bevan's words of 1949:"““The language of priorities is the religion of Socialism.””" Hopefully they are on the same wavelength, believing that priorities and prioritisation may improve the equality of health care. As I have said, we must first focus on all the economies. That is why it is good to see in the Government's proposed Bills a focus on prevention and a focus on public health. We must try to persuade the Government that more money spent on prevention in the short term, even if that has to be taken away from acute care, will save money in the long term. We must also focus on staff levels and quality of care, because at present immense sums of money are wasted on litigation, and even if we have to do more rationing of acute care now to improve prevention and to cut down litigation, that could be helpful in the long term. An example of the tremendous power that some lobby groups have is demonstrated by the cancer reform strategy published today. Obviously, I have not had time to read every word of it, but I was glad to see when glancing through it that there is an emphasis in it on prevention, which will, of course, not cost that much. It is also keen that one should understand when rationing is necessary and when decisions are not those of rationing.