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Health and Social Care Bill

moved Amendment No. 21: 21: Clause 2, page 2, line 20, at end insert— ““( ) the need to provide equity of access to medicines and other therapeutic treatments through the consistent application of guidance and technology appraisals produced by the National Institute for Health and Clinical Excellence.”” The noble Earl said: I wish to move Amendment No. 21 and speak to Amendments Nos. 56, 71 and 88. We come to an issue that to the veterans of health legislation over the past eight or nine years will not be new: equity of access to medicines and other approved treatments. In January this year, the Health Select Committee in another place published its report on the National Institute for Health and Clinical Excellence. The report made a number of recommendations about the implementation of NICE guidance and the uptake of medicines that NICE has approved. The problem here is a serious one. At present there is no consistency round the country as to the uptake of NICE-approved therapies. Some PCTs go to considerable trouble to build NICE guidance into their plans, whereas others do little more than pay token regard to it, if that. The result is what is often referred to as the postcode lottery for medicines, although the analogy with the lottery is not a particularly good one. I could give many examples to illustrate the lack of consistency to which I referred. I shall mention just a few, starting with osteoporosis treatments. NICE issued guidance in January 2005 strongly recommending that women aged 75 and over who have suffered a prior fragility fracture should be treated with osteoporosis therapy. However, a recent survey undertaken by the NHS Information Centre found that the worst performing quartile of GP practices could demonstrate that only 18 per cent of eligible patients received care in line with this part of NICE guidance. The best performing quartile could demonstrate that only 32 per cent of eligible patients received the care that NICE guidance recommended. The same NICE guidance also recommends that women aged between 65 and 74 who have suffered a prior fragility fracture be referred for a DEXA bone density scan to assess future fracture risk. Here the picture was even worse. Even the best performing quartile of GP practices could demonstrate that only 12.5 per cent of eligible patients received care in line with the NICE guidance. On prostate cancer, NICE issued the guidance Improving Outcomes in Urological Cancers in September 2002 and set a December 2007 deadline for its full implementation. However, the latest available data show that seven of England’s 30 cancer networks were not on course to have implemented the guidance by the deadline—a full five years after the guidance was issued. Herceptin was recommended by NICE for use in women with HER2-positive advanced-stage breast cancer in March 2002 and for use in women with HER2-positive early-stage breast cancer in August 2006. Previous audits show that the implementation of NICE guidance has improved over time, but significant variations in usage around the country remain. The latest data, adjusted for incidence, show that the seven best performing cancer networks in England provide around 65 per cent of eligible patients with Herceptin but that the seven worst performing cancer networks provide it to less than 35 per cent of eligible patients. The failure of some cancer networks to implement this NICE guidance is why England, on average, lags a long way behind the European comparator countries in the use of this medicine. My final example is rheumatoid arthritis. A class of drugs called anti-TNFs was recommended by NICE for the treatment of this condition in March 2002. Even now, many years later, problems still remain in implementation. In 2005, the Audit Commission said that anti-TNF therapies were among the three treatments approved by NICE that PCTs most frequently failed to make available to patients. In late 2006, the British Society for Rheumatology said that half of rheumatologists were reporting funding restrictions relating to anti-TNF therapies. An investigation by the All-Party Group on Inflammatory Arthritis found that less than 60 per cent of PCTs were offering anti-TNFs to patients in accordance with NICE guidance. What did the Select Committee say about this? Two of its recommendations are especially pertinent in this context. In recommendation 26, it said: "““There need to be additional measures to improve the implementation of clinical guidelines. There should be more help for PCTs to implement guidelines””." In recommendation 27, it said: "““Better measurement of guidance implementation is also needed. Self-assessment is not enough. We recommend that the Healthcare Commission should conduct more in-depth inspections of this element of practice””." It was interesting that NICE itself was enthusiastic in its response to both these recommendations, particularly the first. The Government’s response was more cryptic. They referred to the Healthcare Commission’s annual health check, which relies in part on self-declarations by PCTs and trust boards and in part on inspections, the implication being that this process is working entirely without problem. They then go on to say: "““Once established, the Care Quality Commission will develop the criteria and methodology it will use to assess and review ""regulated health and adult social care. We will ask the commission to reflect on the committee’s recommendations in the course of that work””." I hope that the Minister will not think it unfair of me if I say that the Government’s policy and intentions do not emerge very clearly from that answer. What role do the Government intend the CQC to play in relation to NICE guidance? Do Ministers agree with the committee that PCTs should play a larger part in making sure that NICE guidance is implemented and that they should receive help in doing so, if necessary from the department itself? The question that is begged in all this is: what action counts as implementing NICE guidance? In other words, how little do you have to do as a PCT to claim correctly that you have implemented it? For me, and I suspect for many of us, NICE guidance ought to be defined as the minimum standards for healthcare providers to meet. We surely cannot say that a PCT has correctly ticked the box of implementing NICE guidance when only a small proportion of eligible patients actually receive the recommended treatment. In response, the Minister may repeat what previous Ministers have said, which is that all this is down to local decision-making. I understand the point, but we have a rule, in the form of a direction of the Government’s own making, that NICE guidance should be regarded as mandatory and subject only to the clinical judgment of doctors in individual cases. If you ask patients what they think they can expect from the NHS in some of these treatment areas, the answer will usually be that they are completely confused. The NICE guidance on atypical medicines for schizophrenia is currently binding because it is guidance, but it is being revised and looks set to be turned into non-binding guidelines. The NICE guidance on medicines to treat ADHD will shortly mutate into guidelines but, unlike the guidelines on atypicals, they will retain a binding requirement on PCTs to provide funding. The NICE guidance on osteoporosis treatment is being reviewed with the intention of incorporating the appraisal in an osteoporosis guideline; here again, unusually, the guideline will remain subject to the ministerial direction on funding. No wonder there is confusion. Among other things, the amendment would provide an opportunity for patients to get a clearer picture on the implementation of NICE guidance because, with a more transparent evidence base, there is a much better basis for patients and carers to exercise more informed choice on the treatment options available to them. We also have here an opportunity for Parliament to strengthen good governance in healthcare, to raise standards and to enhance equity of access to treatment for patients. It will be possible for the Government and NICE through the Bill to get NICE decisions on medicines universally implemented, leaving the Care Quality Commission to ensure that the guidance is consistently applied locally. I beg to move.