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Health and Social Care Bill

I was concurring with the noble Lord, Lord Warner, and the noble Baroness, Lady Cumberlege, about the quality of the NHS and, indeed, the quality of the regulators who serve the NHS. That world-class quality is something that we should be proud of and hope to develop. Of course, it is true that, as the noble Earl, Lord Howe, mentioned in his powerful introductory remarks, equality of access and lack of consistency are the key questions here. NICE is not the only appraisal system that we have in the United Kingdom. I have already said that the value of the NHS to this country is immeasurable, but it is an NHS that has core central principles that are consistent throughout the nation states of the United Kingdom. It is an NHS that is changing and diverging, quite properly, through the devolved legislatures in Scotland and Wales. New systems are now being looked at and developed and there is a degree of constructive divergence, which I think impinges on the work of NICE. At the outset, I echo noble Lords’ words in saying that I have a high regard for the quality of the work at NICE and for the people who carry out the multiple technology appraisals. They have established a world-class standard for doing that. I do no want to go into too much detail, but noble Lords may know that in Scotland we have the Scottish Medicines Consortium, which does things differently, and in Wales there is the All Wales Medicines Strategy Group. These three different systems are rotating and operating together, but I think that it is now time that we had another look at how they are all gelling—if, indeed, they are all gelling—where the gaps lie and how those gaps can be addressed. Noble Lords probably all know that NICE deals only with the medicines, techniques and procedures that are referred to it—that is, something like 20 per cent of the new medicines that come on stream. Therefore, 80 per cent of medicines are left outside the NICE appraisal net. NICE has done roughly 130 appraisals since it was set up in 1999, but multiple technology appraisals take nearly two years on average to complete and cost a quarter of a million pounds each. By definition, the scrupulous way in which NICE carries out those appraisals means that there are pressures in the system. I can illustrate that very easily. There is a drug called Alimta that deals with mesothelioma. It is a single medicine in its class; it is the only one available. I had better be careful that I do not sound as though I am being Scottish and triumphalist about this because that is not the case. I am talking about different systems and I understand perfectly well that NICE is a different system from the Scottish Medicines Consortium. They have evolved from different backgrounds, so I am not saying that one is right and one is wrong. However, Alimta was available to the ship workers at Rosyth who were clearing out some of the ships that the Royal Navy was decommissioning and who had been exposed to asbestos for many years. They had access to that drug in July 2005. On the other hand, the ship workers in the shipyards in Southampton got access to Alimta only earlier this month after NICE had taken nearly 1,000 days to appraise it. That cannot be right and it must be a matter of concern to the Government. If the Government are prepared to listen to evidence from the Committee this afternoon, perhaps I may adduce, in support of my case, the Office of Fair Trading report produced in February 2007. The Office of Fair Trading is obviously more concerned about price structuring, which is understandable, but under the heading, ““The medium term””, the report states: "““The cost effectiveness analysis required to form a view on value-reflective prices would be undertaken by NICE, SMC and AWMSG””." So it would be carried out in England, Scotland and Wales. The next sentence states: "““The work between the bodies would be coordinated by agreement between the UK health departments””." That is the part that is missing. It is not that NICE is not doing the right thing or that the SMC is doing something better; it is that there is an absence of co-operation at a local level. The noble Earl, Lord Howe, has referred to this and I can think of many examples that are well known and well founded. I do not think that that has changed. Certainly in my former incarnation as a Member of the House of Commons up to the last election, I discovered to my horror that hospital prescriptions are all recorded on paper. There is no IT in the primary care system. If you go to your GP and you are prescribed a drug, it is all carefully taken down, analysed and evaluated. Summaries are made to which GPs can refer to ascertain whether prophylactic treatments for certain conditions have proved effective in other patients before deciding whether or not to prescribe them. If you go into hospital and get the same drug, the paper prescription goes into a cardboard file. Therefore, the possibility of evaluating cost-effectiveness, as advocated by the OFT, is somewhat diminished. The OFT introduced the excellent idea of value-based pricing for the first time in 2007 and the Care Quality Commission should embrace it as an important part of its primary work. For all these reasons, there is an urgent need to engage deeply the Care Quality Commission in some of the work of medicines appraisals currently carried out by NICE, the Scottish Medicines Consortium and the All Wales Medicines Strategy Group. The noble Lord, Lord Warner, is right to say that cost is a significant factor. It is true that the Scottish Medicines Consortium works on a much smaller scale, but it is working within an NHS context because its members are derived from within the NHS and not from clinicians and academics outside it. Indeed, the SMC holds the pharmaceutical industry deliberately at arm’s length and treats it with some suspicion. The SMC is scrupulous about not being influenced in any way, shape or form and about retaining its objectivity. A great deal of work can and should be done. On costs—and I am not trying to say that because the SMC is Scottish it is therefore the best—the SMC has an annual budget of less than £1 million compared with the NICE budget of £30 million, but there are many issues on which we can learn and share best practice and co-ordinate in a way that is not possible at the moment. These systems were set up in 1999-2000 and it is understandable that it is only now that we can start to get a grip on how they have developed, how they are working and how they can be improved. We have the chance to do that with this amendment. If the Government are not willing to accept the amendment—I would be amazed to hear a constructive, common-sense reason for not accepting it—perhaps between now and Report they will consider a proposition that has been put to me which makes perfect sense. It derives from the fact that the Scottish Medicines Consortium, which was formed in 2001, took the view very early on that a NICE MTA would always supersede anything done by the SMC. The time has come for the Government, following what the OFT said about value-based pricing, to recommend that NICE should confer the status of NICE guidance on all Scottish Medicines Consortium advice on medicines that are not in the NICE work programme—the other 80 per cent of new treatments. If the Scottish Medicines Consortium thinks that medicines are good enough using single technology appraisals, not multiple technology appraisals—doing it faster, cheaper and in the context of an NHS where primary care trusts are already taking advice from the Scottish Medicines Consortium website—surely that could be formalised. Perhaps the Care Quality Commission needs to do this, but someone needs to investigate the positive prospect of getting some of those medicines and techniques into patients’ and users’ hands faster but safely. There are ways of doing that, of which that is one. The Government were solicitous yesterday about suggestions from all sides of the Committee. I do not know what the noble Lord, Lord Darzi, was told when he was taken back to the office by his hard-faced officials, who are allegedly sometimes sitting behind him, but I hope that the Government will think seriously about this. Amendment No. 21, in particular, is very hard to argue against. It is of great importance to me and I hope that the Government will treat it seriously, think about it carefully and give us a clear answer. The noble Earl, Lord Howe, was absolutely right: the response to the Select Committee report, which says that this is something for the Care Quality Commission to do in future, is completely inadequate for the purpose and for the importance of the task that he is trying to address with this important amendment.