Mental Health and NHS Performance

Philippa Whitford Excerpts

Monday 9th January 2017 Commons Chamber

[Mr Hunt]

Yes, I can do that. It is a very important point. We have had a patchy record in the NHS of ensuring that money promised for mental health actually reaches the frontline. The way that we intend to address this is by creating independently compiled Ofsted-style ratings for every CCG in the country that highlight where mental health provision is inadequate. Those ratings are decided by an independent committee chaired by Paul Farmer, who is responsible for the independent taskforce report, so he is able to check up on progress towards his recommendations. I am confident that, by doing that, we will be able to shine a light on those areas that are not delivering on the promises that this Government have made to the country.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

After the Health Committee’s recent inquiry into suicide, I absolutely welcome the extra funding for mental health. I am sure that the Secretary of State remembers some of the discussions that we had in that room.

I also pay tribute to the staff. Obviously, with my background, I know exactly what it is like when A&E is swamped and there is nowhere to put people. The staff across NHS England are not afraid of us discussing this topic and weaponising it. They are in tears; they are exhausted; and they are demoralised. They have never experienced a winter like this. Perhaps the Secretary of State will explain why his figures suggest 19 diverts and only two trusts in serious problems, whereas we are hearing from the Nuffield Trust that that 42 or 50 trusts are diverting, which is a third. That means that the problem is widespread.

I totally agree with the point about people going to A&E when they do not need to be there, but they are not the people who are three-deep on trolleys waiting for a bed for 36 hours—those are people who need a bed and who are there because they are ill. We have discussed sustainability and transformation plans and NHS sustainability on several occasions. The concern that people have is that, because there is not the money for a redesign, there will be A&E closures and bed cuts. I hope that this incident will show that that is simply not possible. It is not possible for the UK, particularly NHS England, to lose any more beds. In Scotland, we face the same problem of increased demand and shortage of doctors, yet 93.5% of our patients were seen within four hours in Christmas week. The president of the Royal College of Emergency Medicine estimates that in areas of England the figure is between 50% and 60%. That difference is down to how it is organised. It is the fragmentation and the lack of integration. There are things that can be done. We can use community pharmacies and GPs, and try to bring the NHS back together.

[Mr Speaker]

I hope that the hon. Lady will not take offence—she has vast experience in this field—if I say that her questions must be judged to be rhetorical, because I did not observe any question marks, although I am sure we will in future.

Accelerated Access Review

Philippa Whitford Excerpts

Tuesday 13th December 2016 Westminster Hall

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Access to new drugs seems to be almost the commonest theme of debates in Westminster Hall. Having spent years as a breast cancer specialist involved in trials, I can say that it is really frustrating to have access to drugs within a trial and then lose that access when the drug is passed. The United Kingdom can be up to five years behind Europe or America in accessing such drugs. We talk all the time about having more research on brain tumours and other diseases, but that does not help us if, at the end of the research, our patients cannot get the drugs.

Cystic fibrosis is one of the commonest of what we call the rare diseases. It involves a problem with transmission of salts through membranes, which results in incredibly thick mucus that clogs various organs, most commonly the lungs. As the right hon. Member for Leigh (Andy Burnham) mentioned, if it is diagnosed late, damage will already have been done. The earlier patients with cystic fibrosis are treated, the less damage is done and the healthier they are. The life expectancy has changed from childhood to middle age, due to a combination of approaches.

I am shocked to hear that people in England with cystic fibrosis have to pay for their prescriptions, because that would amount to quite a lot of money; they are on a lot of medication. We do not have prescription charges at all in Scotland, because you get an increased rate of people not collecting their prescription, or going to the chemist and saying, “Excuse me, dear, which are the two most important drugs for me to take?” and that ends up not being cost-effective. I would have thought that people with a chronic condition should at least have their names on a list as being exempt. I would have thought that that was the least the Government could do.

The right hon. Member for Leigh said that we have been through this with Kalydeco and many other drugs. Orkambi is a synergistic combination of Kalydeco, or ivacaftor, with lumacaftor, which makes it work much better. They are the first drugs that are not just antibiotics or mucolytics; they are trying to attack the disease itself. In that sense, they are transformative. The problem in the access review is that the definition of “transformative” going forward will not necessarily help those drugs. We do not suddenly find a drug that is a cure for any of these conditions; we move step by step, often adding drugs together or making new discoveries.

There is a real concern among those who develop drugs that in the consultation between NICE and NHS England, the levels considered acceptable for such highly specialised treatments are being changed. The problem is that if we send out the message to people with rare conditions, “I’m sorry; you’re just outside the pale,” we will be letting them down. We need a different approach. I think we need a different conversation for all drugs. The NHS in the United Kingdom brings a cohesive system that allows for follow-up data and allows a lot more information to be sent back to companies over time, which is not easily available in other countries. That should be on the table as part of the negotiations.

I have a real concern, going forward after Brexit, that in this country we will be further down the list for people to even apply for licences here. It may well be that the application to the Medicines and Healthcare Products Regulatory Agency for 60-odd million people in the United Kingdom may well cost an amount very similar to an application to the European Medicines Agency for a market of 450 million. That means we could end up in the same position as Canada, where it often takes about a year before a company decides to apply for a licence. The problem is that if, going forward, companies see that they must pay to apply to NICE, which will turn them down so they will have to pay to apply again, they may just decide that it is not worth the candle. That must be taken into consideration.

Obviously, England has the Cancer Drugs Fund, the idea of which is to allow a little bit of flexibility on access to new drugs, which are often expensive, but it does not help you if you do not have cancer. In Scotland, ours is a new medicines and rare diseases fund, which as a proportion of the population is three times the size of CDF, so it is more flexible. It cannot be a long-term solution for such drugs, or the funds would get sucked up, but it is important that when we are going through a phase of considering the real-life use of expensive drugs we have some flexibility for patients, and not just cancer patients.

We had a debate in the main Chamber last week about the Health Service Medical Supplies (Costs) Bill, and one discussion involved funding. In Scotland, the pharmaceutical rebate goes to fund the new medicines and rare diseases fund. In England, it goes back into core funding, which means that along the line, the beneficiary is the Treasury. If the NHS is managing attribution and access to new drugs in such a way that it gets a rebate, it should be able to use that to access more innovative medicines. That is why the pharmaceutical industry agreed to it. It also creates a better relationship with the pharmaceutical industry. We cannot have a situation where the industry just pulls a price out of the air and we must rise to it—of course we must get value for money—but it is really important that we do not leave people with certain conditions knowing that there is utterly no chance that they or their children will access treatment.

--- Later in debate ---

[Mrs Hodgson]

My hon. Friend is right to raise those concerns. We do not want to move into a new system that will create new unintended consequences. Perhaps the Minister will touch on that in his speech.

Although some are calling for interim solutions to help people who are stuck waiting for the accelerated access review’s recommendations to be implemented, it is also important that the Government get on with implementing those changes. The review was announced more than a year ago and was published two months ago now. It is important to remember that the transformation that we all want to see will not happen straight away, but it is still right that we keep up the pressure for the recommendations to be implemented. There are many such recommendations, and I hope that the Minister will be able to update us today on the progress on each of them. There are two in particular that illustrate what can be done to resolve the deadlock around Orkambi—the immediate establishment of an accelerated access partnership and the setting up of a new flexible strategic commercial unit.

The accelerated access partnership is one way in which, through co-ordination and collaboration across the system, we could see drugs brought on to the market more quickly to benefit patients who need access to them. I would be interested to hear from the Minister what progress has been made on its creation, especially in conjunction with the issues surrounding the deadlock on Orkambi.

It is clear that the strategic commercial unit could help to benefit those who wish to see Orkambi offered on the NHS. The unit could work with those involved in this dispute to end the current deadlock through facilitation of the flexibility and transformational change promised by the accelerated access review. That would go some way towards helping to access data on drugs such as Orkambi and getting them out to patients. There is a willingness out there for that flexibility to be brought into the system; for example, the Cystic Fibrosis Trust has offered to use the UK cystic fibrosis registry to help to provide essential data that can help to prove how effective drugs can be and what more needs to be done. We have already heard how substantial that registry is; it includes 99% of sufferers. I understand that the trust’s offer has been welcomed by all sides in the negotiations but is blocked due to the lack of progress in implementing the changes set out in the review. I hope that the Minister will give us some clarity on when the unit will be created and when we can see a culture shift within the system that will allow for flexibility to accept data and information that show how much effect these drugs have on people’s lives.

[Dr Philippa Whitford]

Does the hon. Lady share my concern about drugs for other conditions, such as sofosbuvir for hepatitis C? Even after they get NICE approval, those more expensive drugs are now being rationed at the NHS England stage. At the moment we are fighting to get through NICE, but it needs to be a smooth path all the way through.

[Mrs Hodgson]

The cost of drugs sometimes leads the NHS into the terrible and unfortunate situation in which rationing seems to become the norm. There can also be a postcode lottery, which is another element that we need to look at. The price of drugs really is the crux of the issue.

In conclusion, I hope that the Minister will offer some insight into the progress being made on the recommendations of the accelerated access review. The case of Orkambi can help to drive through these changes and to end this deadlock, which, as we have heard, is causing unnecessary suffering for those living with cystic fibrosis. The review has established a space for change and for patients to access new and innovative drugs and treatments. It is important that there is no stalling or delay in transforming the system, because people’s lives depend on the changes called for by the review. I am sure that the Minister will keep that in mind when he goes back to his officials.

CQC: NHS Deaths Review

Philippa Whitford Excerpts

Tuesday 13th December 2016 Commons Chamber

[Mr Hunt]

I thank my hon. Friend, who does a huge amount of work on patient safety, not least because of sadness in her own family’s experiences that gives her particular passion in this respect. This is absolutely about creating a just culture. Inspiring people like James Titcombe, who lost his own son at Morecambe Bay, talk far more eloquently than I can about the need to get this right. Part of that just culture is about justice for people who use the NHS in future, to whom we have a responsibility to learn the lessons and make sure that mistakes are not repeated. One of the really important things we need to get right is to make sure that when something goes wrong in one place, there is a national way in which the lessons can be conveyed right across the NHS as quickly as possible.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I welcome this statement and remember the discussion of this tragic case. Obviously the majority of people who go into hospital and die in hospital will be people who are simply too ill for us to save, but we must not be nihilistic in imagining that that applies to everybody. The particular failure here was that people with learning difficulties or mental health needs were somehow just set aside and not looked at.

I welcome the idea of a safety board; there will be lots of things that can be learned and shared in that. I slightly pick up the Secretary of State on what he said about the Scottish patient safety programme, which is a national programme that has been running since the beginning of 2008. Part of that was about breaking down all the barriers, very much like in the airline business—being on first-name terms and making it everybody’s business so that even the cleaner in the theatre feels they can point out that they think a mistake is going to be made, but then when something happens having these adverse case reviews. In my hospital, we also reviewed near misses, and I commend that. It means that there is a review when what might have happened would have been serious. Certainly in the cases that I have been involved in, the family have been involved repeatedly. That is really important.

I also welcome the idea of a safe place for whistleblowers. People who have raised issues in the past and have been appallingly treated by the NHS still stand there as a terrible example to those who currently work in the NHS, so there needs to be some ability to go back to these old cases and provide justice for people who have ended up losing their careers by trying to raise patient safety issues.

[Mr Hunt]

I thank the hon. Lady for her contribution. I recognise the progress made in the Scottish patient programme, and particularly the inspirational leadership of Jason Leitch, who has done a fantastic job in Scotland and some very pioneering work.

The hon. Lady made some good points that I will take in reverse order. On whistleblowers, I asked Sir Robert Francis to look at this in his second report. He concluded that it would be very difficult, if not impossible, to go back over historical cases, because the courts have pronounced and it is very difficult to create a fair process where legal judgments have already been made. However, I take on board what she says, and I do not think that that means that we cannot learn from what has happened in previous cases; they are very powerful voices.

The hon. Lady is absolutely right about near misses, and we will include that issue in the “learning from mistakes” ambition.

The hon. Lady is most right of all about people with learning disabilities. The heart of the problem is deciding when a death was expected and when it was unexpected. About half of us die in hospitals. As she rightly says, the vast majority of those deaths are expected, but when a person has a learning difficulty it is very easy for a wrong assumption to be made that they would have died anyway. That is a prejudice that we have to tackle, and one that Connor Sparrowhawk’s mother talks about extremely powerfully. We have to make sure that this is not just about lessons for the whole NHS, but particularly about ensuring that we do better for people who have learning disabilities.

Social Care Funding

Philippa Whitford Excerpts

Monday 12th December 2016 Commons Chamber

[David Mowat]

My hon. Friend is right. There is a raft of measures that need to be taken on informal carers and on the holy grail of better integration of health and social care funding, and we are pursuing that vigorously.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

This was the substance of the letter from the Health Committee to the Chancellor, calling for extra money not for the NHS, but particularly for the capital budget and social care, because the back pressure from social care is what is causing the NHS to struggle. I totally agree with the Minister as regards integration. In Scotland, where we have the integrated joint boards, it has brought a change more quickly than we would have hoped. Our delayed discharges are down 9% in a year; in England they are up more than 30%. But this is not easy and it needs to be funded. We have debated the sustainability and transformation plans, which could be the basis for the future integration of the NHS, but all we hear within those plans is community hospitals being shut, losing the opportunity to have step-up and step-down beds, A & E departments being shut, and beds within hospitals being shut. This is the wrong way round. STPs could work, but they cannot start with the number they must reach—they have to design themselves around a service that keeps patients at home and keeps them well.

[David Mowat]

The hon. Lady made two points, both of which I agree with. The first was that in Scotland there has been a 9% reduction in delayed transfers of care. It is also true that in England many parts of our system, particularly those that have integrated most quickly, have achieved reductions of that size and more. She is right that the STPs are part of the process of re-engineering the system. Adult social care and the integration of adult social care are a big part of that and we need to ensure that we deliver.

Health Service Medical Supplies (Costs) Bill

Philippa Whitford Excerpts

3rd reading: House of Commons & Report stage: House of Commons
Tuesday 6th December 2016 Commons Chamber

[Keith Vaz]

In a little test tube! I carried my own blood to the laboratory, because it was the quickest way I could get a reading. Incidentally, from the look of him, my hon. Friend carries his blood very well. We want this innovation and research and development. The drugs companies should be able to plough back profits within the industry, and in the long run this innovation will make a great deal of difference.

When I went to New York for a meeting on Yemen, I stopped in at the diabetes centre of the Mount Sinai Hospital, and was told about the incredible innovation in diabetes in the US. I also went to see Mayor Bill de Blasio’s diabetes team. As Members will know, New York cut the level of sugar in soft drinks, as we are doing now, but the centre of its diabetes initiative is the lifestyle coach, not the GP.

As we look at these provisions, we see every opportunity for a cogent and coherent review that will particularly help—this is my main argument today—those with diabetes, but also others with similar problems connected with their illnesses. I urge the Minister, who I know has been extremely reasonable on this Bill, to look seriously at the new clause. If he cannot accept new clause 1 itself, will he at the very least give an undertaking from the Dispatch Box that the points embodied in it will be reported back to Parliament in a few months’ time?

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Like the shadow Health Minister, we will not obstruct the Bill, because we support the basic aim to control prices in order to achieve a good return to the NHS from the drugs that it uses.

We also support in principle new clause 1. Six months might be a little early technically to bring things together, and there should not be just a single report because we will only see change over time. To look at the success of these actions, we need to see a price being controlled, and to spot when prices are sliding out of control. I would therefore suggest looking at the data and information on an annual basis and perhaps laying it before Parliament to show that the Bill’s aim is being achieved and that the concerns of the official Opposition are being allayed.

We support amendment 8 because it advocates the same approach that we have in Scotland. While the Cancer Drugs Fund in England is welcome and has clearly helped many patients, it is limited in the sense that if people do not have cancer they cannot access the medicines fund. That means that people with rare diseases are left somewhat abandoned. Frankly, if it were left solely to NHS England, those people would be left in the desert. It is important that significant money will be released, and the provision could gain support from the pharmaceutical industry if it sees that the money it is returning is enabling innovative medicines to come to the NHS earlier. Sometimes when we compare certain illnesses such as cancer, we find that the gap is in relation to people with more advanced diseases struggling to access the newest medicines. If the amendment helps to address that, we would support it.

The Scottish Medicines Consortium was reformed in 2014, and Scotland has now moved up from passing 53% of all applications to 77%, with a further review going ahead at the moment to see how to improve this further. The aim is not to avoid using drugs; the aim is to access them at a decent price. If the pharmaceutical industry is returning money to the NHS, it should enable earlier access.

Amendment 9 was tabled by SNP Members and we put it before the Public Bill Committee. It deals with clause 5, which extends a power that in fact already existed but was never used—to control the price of medical services and medical supplies as well as drugs. I am slightly disappointed that we did not manage to get this amendment adopted, so I raise again the issue of quality control and ask the Government to consult on it.

I know I spoke extensively in Committee about surgical gloves, but they provide a good example in that the range of quality is vast, and if poor quality gloves are used, there is likely to be extra cost to the NHS either when gloves have to be changed two or three times within one operation or more subtly if a surgeon is exposed to blood at the end of an operation from a tiny pinhole that was not visible. The same point applies to gowns and drapes. Taking off a gown that is meant to be protective and discovering that you are soaked to the skin in blood is a pretty unpleasant experience, and it obviously increases the risk to staff. The idea that surgeons are not exposed to diseases such as HIV or hepatitis B and C is naive. I knew colleagues over my career who suffered from those conditions, which they caught from patients. There is clearly a responsibility to staff and to patients to avoid any possibility of cross-contamination. I mentioned in Committee, too, some fairly cheap items such as gauze swabs, because if they are shedding threads, it can lead to intra-abdominal infection—something that we do not want. This amendment is about consultation and looking further at the mechanism.

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[Rob Marris]

As hon. Members know, overall I welcome the Bill, which is broadly a socialist Bill. It reinforces price controls and profit controls on big pharma, when appropriate. I always like to encourage the Conservative party, sadly now in government, to come a little further down the socialist road. They claim to be the workers’ party, and that is good.

New clause 1, tabled and moved by my hon. Friend the Member for Ellesmere Port and Neston (Justin Madders), is central to what we should be talking about in many spheres of public life—namely, evidence-based policy. All too often in this House—this applies to Governments of both colours—policy appears to be made on a political whim.

I remember in, I think, 2008 the then Leader of the House, the right hon. Member for Blackburn, Jack Straw, writing certainly to Labour MPs asking what we wanted in the Queen’s Speech that year—[Interruption.] We were in government, but perhaps he should have written to the right hon. Member for Chelmsford (Sir Simon Burns). I replied, because I believe in evidence-based policy, that in that year’s Queen Speech I wanted not a single piece of legislation. I said that after 10 years of a Labour Government, I wanted Parliament to spend a year on scrutiny, looking at the legislation that we had introduced over that period to see what had worked and what had not worked.

To my astonishment, the Leader of the House did not accept that proposal, as those who were Members then will recall, and we had another full legislative programme. Let me add, as an aside—if you will grant me a small bit of latitude, Madam Deputy Speaker—that by the end of the Labour Government I had stopped voting on crime Bills because we had had so many. Some of them—this may have happened under the previous Conservative Government—repealed parts of earlier crime Bills introduced by a Labour Government which had never been brought into force. That was extraordinary.

I urge the Minister to recognise that evidence-based policy making is encouraged by new clause 1. I hope that, in the context of innovation, which was so eloquently addressed by my right hon. Friend the Member for Leicester East (Keith Vaz), he will say a little about the way in which the National Institute for Health and Care Excellence operates.

As the Minister may know, there is an issue involving cystic fibrosis and the drug Orkambi, which NICE turned down owing to a lack of sufficient data. I understand that, because it is NICE’s job to weigh the evidence, such as it may be. The drug is registered for use in this country, but it is not available on the NHS. Since NICE decided that the cost-benefit analysis did not stack up, some long-term data from the United States, which I understand to be robust, has been made available. I gather, although I may be wrong, that NICE has not yet reviewed its decision on Orkamb, although the evidence from the United States suggests that in certain cases it can be extremely effective in treating cystic fibrosis. I hope that when we are discussing processes, innovation, efficiency and policy-based decision making, the Minister will say a little, not necessarily about Orkambi itself, but about the process whereby NICE might, in the light of new evidence, promptly—I stress the word “promptly”—review its decisions.

[Dr Philippa Whitford]

There is an additional issue. Drugs or treatments are being passed by NICE but not actually introduced. Either they are rationed and limited to a certain number of patients a month, as is the case with hepatitis C drugs, or the decisions are being left to clinical commissioning groups, which means that we are enshrining postcode prescribing instead of getting rid of it.

[Rob Marris]

I entirely agree with the hon. Lady, who, as ever, speaks with authority on these issues. I am a bit of a centraliser, because I do not like postcode lotteries. We will already have that in a cross-border sense—between England and Wales, Scotland and Northern Ireland—but it is a great deal worse when just some CCGs in England are making a drug available when it has been signed off by NICE as safe for use but it is not mandatorily available, and not every patient for whom it is medically appropriate can obtain it from every CCG. That sort of postcode lottery undermines the “national” part of the national health service, which is regrettable.

Amendment 8, tabled by my hon. Friend the Member for Burnley (Julie Cooper), would ring-fence savings made through the provisions of this Bill and earlier legislation so that the money thereby saved, or paid into the pot by a pharmaceutical company, can be retained for expenditure on medicines and medical supplies. I hope the Government will support that. All too often we hear that Governments do not like ring-fencing, and I understand why: it fetters their discretion. Earlier this afternoon, however, I asked the Secretary of State for Justice whether the education budgets devolved to prison governors would be ring-fenced, because I feared that a prison governor who was under other budgetary pressures might not spend the money on education and prison education would not improve as it needs to. I was greeted with a very welcome one-word answer, which was “Yes.” I hope that, in a slightly different context, the Minister can give the same assurance this afternoon, because this is an excellent amendment which clarifies a slight gap in the Bill.

As for amendment 9, about which the hon. Member for Central Ayrshire (Dr Whitford) spoke so eloquently, efficiency is of course important, but so is quality. I do not know whether the old saying “Penny wise and pound foolish” is used in Scotland—she is nodding—but it certainly is in my part of the west midlands. We have seen that time and time again with privatisations. When services are privatised they go to the lowest bidder, and what do we find? Either the service is not up to scratch, or, all too often—I think this happened when Circle ran Hinchinbrooke hospital—the companies go bust because they find that it is not as easy as they thought it would be to make a profit out of, in this case, the health service. That may happen to other suppliers as well. Quality matters, and the national health service is not a commercial organisation.

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The hon. Member for Central Ayrshire (Dr Whitford) has supported this amendment, and while it is not for me to comment on the policies of the Scottish Government, we know that the NHS in Scotland has raised concerns that the new medicines fund, to which she referred, only funds medicines at the end of life or for rare diseases, meaning that funding for other areas is not getting the same priority.

[Dr Philippa Whitford]

indicated dissent.

[Mr Dunne]

The hon. Lady is shaking her head. That is my information, but if that is not the case, perhaps she would like to enlighten me further.

[Dr Whitford]

It is a new medicines and rare diseases fund, and it includes orphan, ultra-orphan and end of life, but it is not only about end of life.

[Mr Dunne]

No, it is not only for end of life, but also for rare diseases. That was my understanding, but I stand corrected. However, my main point is that it should be for clinicians to decide what is spent across the range of activity. If money is ring-fenced into a specific fund for new medicines, that might not always be the right clinical decision.

[Dr Whitford]

Does the Minister accept that it is a slightly bizarre public relations thing to have a medicines fund that is only for cancer, ruling out people with other life-threatening illnesses? That is the case here in England.

[Mr Dunne]

The new cancer drugs fund was set up specifically to provide funds to deal with one of the most common causes of mortality in the country, and was a priority of the previous Government; I will not go into the reasons for that.

Returning to amendment 8, it was suggested that what happens to the receipts is not clear, but all income generated by the voluntary and statutory schemes is reinvested in the NHS. Estimates of income from the pharmaceutical payment regulation scheme are part of the baseline used in the Department’s spending review model. The model was used to calculate the funding increase that the NHS sought at the time of the 2015 spending review, and it helped to secure the £10 billion of real-terms funding over the course of this Parliament. The income from the voluntary and statutory schemes can and does fluctuate; that is the biggest problem with ring-fencing, which could bring risks in this area. For example, the annual income from the PPRS has varied between £310 million and £839 million in a full financial year in England, so there is the potential for the income that it generates to vary widely, which could disadvantage patients by making treatment dependent on income from a pricing scheme with unsteady income generation.

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[Mr Dunne]

I am grateful to the hon. Gentleman for his advice, but I am afraid that I do not think it is relevant to my point about the fluctuation in income coming from the scheme. It is relevant in relation to whether NICE or politicians make such decisions. They need to be made by clinicians.

[Dr Philippa Whitford]

rose—

[Mr Dunne]

I will give way, but then I will make some progress.

[Dr Whitford]

I thank the Minister for kindly giving way. The cancer drugs fund has a budget of some £350 million, so if he is saying that the money that can be retrieved varies from £300 million to over £800 million, that would allow for the expansion of a new medicines fund.

[Mr Dunne]

It might if the move was always in the same direction. My concern is that the amount could decline between one year and the next; it may not always go up—certainly not up in a straight line.

Separately from the Bill, the Government are taking action to secure the UK’s future as an attractive place for the life sciences sector and to support faster patient access to medical innovations. I have already touched on the recently published accelerated access review, which sets out ways to increase the speed at which 21st-century innovations in medicines, medical technologies and digital products get to NHS patients and their families. The review’s recommendations included bringing together organisations from across the system in an accelerated access partnership, and creating a strategic commercial unit within NHS England that can work with industry to develop commercial access arrangements. We are considering those recommendations with partners and will respond in due course.

NHS England and NICE are jointly consulting on several proposed changes to NICE standard technology appraisals and highly specialised technology appraisals, including around speeding up the appraisal process. The Department of Health continues to work closely with NHS England and other stakeholders to improve uptake of new medicines. A key element of that is the innovation scorecard that I have already referenced. With those comments about our concerns about what is proposed in amendment 8, I ask the hon. Member for Burnley (Julie Cooper) not to press her amendment.

Turning to amendment 9, tabled by the hon. Member for Central Ayrshire, the Government recognise that section 260 of the National Health Service Act 2006 does not explicitly state that the Government are obliged to consult industry. However, I am aware that the Act does explicitly state that there is an obligation on the Government to consult when it comes to controlling the cost of medicines. A similar amendment was tabled by the hon. Lady in Committee. I want to reiterate that I am happy to consider with her how we could best introduce a general requirement to consult industry in section 260. Indeed, my officials have been in discussions with her, and I am grateful for her time and constructive comments.

I note the hon. Lady’s reference to the effect of any pricing controls for medical supplies on maintaining the quality of those supplies. I assure her that the Government would take into account all relevant factors, including any concerns raised by industry about the quality of medical supplies, when making and consulting on any price controls for medical supplies. The Government would not however be in favour of putting one of those many factors in the Bill.

The Medicines and Healthcare Products Regulatory Agency is responsible for the safety, efficacy and quality of medical supplies, and the Bill will not change that. The MHRA has assured me that any use of the price control powers in the Bill would not affect any of the quality or safety requirements that must be met before medical supplies can be placed on the market.

The hon. Lady referred to the procurement system in Scotland; I assure her that the Government are committed to improving procurement across the NHS. She will be well aware of the Carter report, which concluded that there is considerable variation in the value that trusts extract from their expenditure on goods and medical supplies. NHS Supply Chain is working hard to deliver procurement efficiencies, to meet recommendations to increase price transparency, to lower costs, and to reduce the number of products and suppliers used across the NHS to deliver economies of scale. The hon. Lady referred to 600,000 products, but it has had success in reducing the range in the catalogue down to 315,000 to help NHS organisations purchase products more efficiently. It continues to work to reduce that number. I am aware of similar work in Scotland. In England, we are using the Carter review to deliver that.

While I understand the intent behind the hon. Lady’s amendment, I am not fully convinced that, as drafted, it would have the desired effect. If she will continue to work with me and my officials, the Government would be happy to consider, while the Bill is in the other place, how we could best introduce the requirement to consult into section 260. On that basis, I invite her not to press her amendment for now.

--- Later in debate ---

I have a couple of remarks about amendment 10, which was tabled by the hon. Member for Central Ayrshire. New section 264B in clause 6 enables the Secretary of State to disclose the information that is collected to a range of bodies, including NHS England, special health authorities, NHS Digital, other Government Departments and the devolved Administrations. The Government have concerns about this amendment, as we are dealing with confidential and commercially sensitive information that can be used only for specific purposes. We are therefore reluctant to introduce a requirement to disclose information to, for example, any Government Department or NHS England. It is important that the Government can be trusted with the information that they collect, and that there are sufficient safeguards to ensure that it is treated as confidential or commercially sensitive.

[Dr Philippa Whitford]

rose—

[Mr Dunne]

I would like to conclude this point for the hon. Lady, as I hope it will satisfy her. Her concern is about how the Government will behave in response to requests from devolved Administrations; we recognise that we need to give reassurance to the devolved Administrations that, in the light of the constructive conversations we have already had with them, they will have full access to all relevant data that the Government collect. We are quite happy to do that. We have indicated that we will enter into a memorandum of understanding, which will be discussed and agreed with the devolved Administrations. Those discussions will cover whether they have automatic access to this information—in real time, or in some other format—and whether that is done through giving them direct access to the systems, or by forwarding the data that we collect, immediately on request. We need to get into the detail of that in discussion on the memorandum of understanding, rather than committing that to the Bill at this stage. On that basis, I hope that the hon. Lady will not press her amendment to a vote.

[Dr Whitford]

I welcome the Minister’s comments, and I am happy not to press the amendment if we can reach the point of a clear memorandum of understanding. I just point out that all my amendment does is to say that the groups listed by the Bill should be able to ask for data on request; it does not add anyone else. I understand that my attempt at the amendment in Committee included groups that it should not have, but that has been corrected. This amendment does not spread confidential information any more widely.

[Mr Dunne]

I am grateful to the hon. Lady for that clarification. I think this is best addressed through a memorandum of understanding, rather than in primary legislation, in case we need to adjust the memorandum in subsequent years.

Finally, I wish to address Government amendment 7, which provides a definition of “equipment”. The hon. Member for Wolverhampton South West took us through the drafting on the definition of “medical supplies”. The amendment gives a definition of “equipment” in the National Health Service (Wales) Act 2006 to ensure consistency with the National Health Service Act 2006. “Equipment” is defined as including

“any machinery, apparatus or appliance, whether fixed or not, and any vehicle”.

When taken in tandem with the common definition of “medical supplies”, the definition is broad enough to capture any medical supplies on the market, from bandages to MRI scanners. The point of distinction was not so much the definition of “medical supplies” as the definition of “equipment”, which is a subset of the medical supplies definition. I hope, therefore, that hon. Members will accept the amendment.

I have spoken at length on these amendments. I hope I have made my position clear, that Opposition Members will not press their amendments to a vote, and that the House will accept the Government amendments.

--- Later in debate ---

[Dr Philippa Whitford]

I will open my remarks with thanks, because this is the first Bill that I have helped to take through the House, and I am therefore very grateful to you, Madam Deputy Speaker, the Chairs of the Public Bill Committee and all the staff who have worked on this, particularly those in the procedural hub; as a newbie, being able to go and ask them what happens next has been immensely helpful.

Obviously, we welcome the basic premise of the Bill, particularly clauses 1 to 4, which give the Secretary of State the power to control the price of drugs and avoid the excesses we have seen recently, as was highlighted in the article in The Times, particularly by those companies that are in the voluntary scheme but also produce generics, and therefore the price of those generics is not controlled. There are also those companies that have picked up drugs that have orphan status—they are no longer produced by anyone else—and basically robbed the NHS by increasing the price by many thousand per cent. That is just unacceptable.

When we accept relatively high prices for new drugs, we often excuse that on the basis of research and development. We need to realise that not all research and development is done by big pharmaceutical companies; they often collect drugs by buying small, spin-out companies from universities. With regard to generic or repurposed off-patent drugs, the R and D is usually done by clinicians within the NHS, or by academics in university departments. Companies have admitted in the past that they do not always price drugs in relation to their R and D costs; they sometimes do so simply by what they think the market will bear. We must not always allow them the excuse that they are spending huge amounts on R and D, because that is simply not always the case.

I tabled two new clauses in Committee. Now that the Secretary of State will have this power, I hope that the two issues raised by my new clauses will be dealt with. One is the issue of specials, which are simply hand-made preparations, usually an ointment for dermatological use. I arranged for the briefing from the British Association of Dermatologists, which highlighted companies that had a Scottish price list and an English price list, to be sent to the Minister. I therefore hope that those powers will be used. In Scotland it is done by using an NHS producer who makes the drug and therefore keeps the price down, rather than simply paying a pharmaceutical company or a pharmacy company, because the pharmacy with which the patient is dealing might have a mother or sister company and they are simply taking a very high price from them.

The other issue, which was raised last November, is that of repurposed off-patent drugs. As the shadow Minister explained at the time, an off-patent drug may be picked up by a new company and used for its new purpose, such as simvastatin for multiple sclerosis, but with the merest tweak it could be put out as if it is a new drug, and suddenly at a price that people cannot access. That also touches on the hierarchy whereby doctors must prescribe a licensed version before an unlicensed one. If a licensed drug came on the market that was actually just a version of an off-patent drug, doctors would be under pressure to prescribe it.

I understand that work has gone ahead since last year’s Bill, but I exhort the Minister, and through him the Secretary of State, to ensure that the powers given by this Bill are used in all these circumstances to ensure that prices are controlled. Otherwise, what happens is not a matter of expenditure to the NHS on its own, but usually that CCGs will not allow these drugs to be accessed, which is what is happening in the case of specials. We now have the powers. We welcome that, but hope that they will be used.

National Health Service Funding

Philippa Whitford Excerpts

Tuesday 22nd November 2016 Commons Chamber

[Madam Deputy Speaker (Natascha Engel)]

Order. Before I call the SNP spokesperson, I must inform hon. Members that, including her speech, we have calculated, generously, that every speaker will have five minutes, but we will probably have to go down to four minutes at some point.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Does that include five minutes for me also?

[Madam Deputy Speaker]

Obviously the hon. Lady has no speech limit, but the speech limit has been calculated with her mind. I am just saying that the longer someone speaks for, the less time everyone else will have.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Okay, well that is fairly disappointing, given what I have prepared.

UK-wide, the NHS faces sustainability issues. One of the key issues is the increase in demand from an ageing population and the increasing complexity of those demands. The way to tackle that demand is through public health and social care that ensures that those people do not end up in the most expensive place. Secondly, we have a lack of staff, both nurses and doctors. The lack of training nurses has been referred to. We also face the threat of losing some of our staff from the EU. The third threat to sustainability is money, but the money is the one we can fix, because money is a decision; the others will take a decade each to fix—by training more nurses and doctors, preventing illness and finding better ways to look after an ageing population.

As I have said in the Chamber before, I welcome the idea of STPs, because they should mean a return to place-based planning and integration and a move away from fragmentation and competition. The problem is, however, that they have to be based on patient-centred care, whereas, according to what is leaking out, they are being discussed on the basis of budget-centred care. We heard in the Health Committee that the STP groups were being given a figure that they had to meet by 2021 and then were working back from that. That will never work.

If we want to decrease inefficiency and increase efficiency we need to target the inefficiencies in the system, not just take an axe to the whole thing. When hospitals or GPs run out of money and take urgent action, it will be poorly thought out and immediate-survival action. We need to look at where the fat is and at the natural inefficiencies in the system, and some of that comes down to the lack of integration. STPs are a great opportunity but an opportunity we will look back on as missed if we do not do it properly.

The Secretary of State says that there is no privatisation in the NHS, but there certainly is marketisation and outsourcing. I graduated in 1982, so I have lived through every single iteration from both sides and three Governments. In 1982, we were just skimped. Basically, the NHS got 5% of GDP and it dropped to 4.5% over the ’80s. Instead of increasing that to where it is now, what we had was constant redesign.

The first was the internal market and GP purchasing. A GP would refer to our clinic, but if I decided the patient was not surgical and I referred them to gynaecology, the GP would refuse to pay. What started to happen? Surgeons and clinicians began sending the patient back to the GPs, so that they would refer them. Of course patients fell through the cracks; some never got that second referral and things were missed.

After the purchaser-provider split, we started to change the whole shape. We went from 100 health authorities to 300 primary care trusts, even though the leaders of the PCTs earned the same money as the leaders of the health authorities. People were made redundant and transitional change was hugely expensive. In the mid-2000s, we went from 300 PCTs to 150—again with redundancy and transition. As we move on, we start to see the private finance initiatives. As has been said, the NHS has paid over £60 billion for £11 billion-worth of buildings. That was not an effective thing to do.

Eventually, of course, we come to the Health and Social Care Act 2012, which got rid of the 150 PCTs and replaced them with 211 clinical commissioning groups. This is described as “putting power in the hands of the GPs”, but following a freedom of information request I know that less than 18% of CCGs have a GP majority on them. Some 47% of CCGs do not even have a clinical majority, so the idea that CCGs give power back to primary care is, I am afraid, a complete fallacy.

What we have seen, I am afraid, has come from all Governments. It was the Labour Government who took the purchaser-provider split and introduced independent treatment centres, giving them block grants. All the talk about patient choice was not really patient choice at all: the GP had to send the patient to the ITCs for their hips, because it had already been paid for. To try to counteract that, we have seen payment by results, which was the forerunner of the tariff. What that did was increase activity, so it helped with waiting lists and waiting times, but what we now have is activity that is just growing and growing. Hospitals get paid for activity, not for whether that activity is right.

In Scotland, we abandoned trusts in 2004, and we abandoned primary care trusts in 2009. Let us look at our costs book, which publishes the costs of administration. This is not just the costs of the market; it deals with all the administration of the NHS. Ours has fallen from 7.6% in 2006-07 to 6.7% in 2015-16. When it comes to the Department of Health or NHS England, no one has any idea. A piece of work was done for the Department of Health in 2005, which estimated admin costs at that time as 14%. I suggest that the current market is an awful lot more complex than it was then.

I think some things can be done around procurement. In Scotland, our national procurement gives hospitals a choice of 9,000 items. The supply chain in England has 600,000 items. It is not limiting; it is not national procurement. Our logistics division, which delivers that, will pick items per ward and deliver them all the way from a central depot to that ward. That allows us to cut some of the costs, as suggested in the Carter review.

We absolutely need to keep agency prices down. It is important to try to keep staff on a staff bank rather than get them through agencies. Why are we not asking the bigger question? Why are nurses choosing to work for an agency rather than the NHS? Is it that they earn more money? Is it flexibility? Is it family-friendliness? Would it not be better to look at how we let them work, so that they work for us rather than feeling that they have to go and work in an agency? From the point of view of job quality and job satisfaction, they would all rather be in one place than be in a different place every week.

There are things that could be done. There could be a better use of community pharmacies, and a better use of community hospitals for “step up” and “step down” services. It is crucial that we fund social care so that elderly people are looked after in their own homes. I think that STPs have potential. However, I ask the Secretary of State not to go on and on with marketisation, given that no cost-benefit analysis has ever been carried out and there is no evidence of benefit from it. The NHS could save an amount that is estimated conservatively at £5 billion a year, and that would have a significant impact on the debt.

The right hon. Member for Surrey Heath (Michael Gove) suggested that we needed to bring solutions. I am offering the ones that I can think of from Scotland, and I recommend them to the Secretary of State.

Oral Answers to Questions

Philippa Whitford Excerpts

Tuesday 15th November 2016 Commons Chamber

[Mr Dunne]

My hon. Friend will be aware that the sustainability and transformation plans discussed earlier today are designed to bring closer integration of health providers and commissioners within a health system area, such as the east midlands. The ambition is to integrate better health and social care provision to avoid some of the challenges he identifies.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

The A&E target the Minister mentions is actually a measure of the entire acute system. Important in that is the flow of patients from admission through treatment to discharge. In Scotland, delayed discharges have fallen 9% since health and social care were integrated. In England, they have gone up 30%. Does the Minister accept the need to fund social care properly to relieve the back pressure on A&E?

[Mr Dunne]

I listen with great interest to what the hon. Lady says, but I gently remind her of two things. First, as the result of the generosity of the Barnett formula, Scotland receives £1,500 per capita more to spend on health than England. Secondly, the Auditor General for Scotland recently reported that NHS Scotland was failing to meet seven out of eight key targets, including waiting times for A&E.

[Dr Whitford]

I wonder how many targets are being missed in England. The Royal College of Emergency Medicine report demonstrates that in the 176 emergency departments in England there are only enough consultants to provide the cover of one for 16 hours a day. On top of that, rota gaps among junior doctors are causing safety concerns. What exactly is the Minister going to do this winter and will he agree to lift his ban on locum agency staff to help to keep A&Es functioning?

[Mr Dunne]

We recognise that there have been pressures on emergency departments for some years, which is why we have put particular effort into recruiting more consultants. There are, I believe, 50% more consultants working in emergency departments in England than there were in 2010, and 25% more doctors.

Health Service Medical Supplies (Costs) Bill (Third sitting)

Philippa Whitford Excerpts

Committee Debate: 3rd sitting: House of Commons
Tuesday 15th November 2016 Public Bill Committees

[The Chair]

I think later would be helpful, thank you, Minister.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I want to raise a small, perhaps technical, issue on amendment 11, which it seems would insert the rules and definitions with respect to excepted persons for Scotland, Northern Ireland and Wales under a new subsection defining health service products for England. It seems out of place, and there is no definition of English excepted persons.

The amendment would insert new subsection (8A) into new section 264A, which clause 6 inserts into the National Health Service Act 2006. It seems out of place because the provision would deal with English health service products, then the definition of the excepted persons in the devolved nations, and then Scottish, Irish and Welsh health service products. It may just be a technical issue, but I wanted to raise it.

--- Later in debate ---

[The Chair]

I am sure that the hon. Lady knows, but if she wants to speak to amendment 48 now, she can do so.

[Dr Whitford]

My colleague will speak to that amendment.

[Martyn Day (Linlithgow and East Falkirk) (SNP)]

It is a pleasure to serve under your chairmanship today, Mr Pritchard. I am somewhat reassured by many of the Minister’s comments, and I thank him for his explanations. Much of this stuff is technical, and I hope he sees amendment 48 in a similar light. I think it would improve and strengthen the measure.

The clause does not currently set out a mechanism for the disclosure of information to devolved Administrations or bodies. For example, how will the information be disclosed, and by what means? Will it be only the Secretary of State who can disclose? In short, will the devolved Administrations be able to get the information when they want and need it, so that it ties in with the figures and statistics they are seeing and they can see patterns? It is about flexibility.

The amendment is fairly straightforward and we think it would help to strengthen and improve the Bill. I hope that the Minister agrees. We would like him to clarify whether the Government intend to leave disclosure to the discretion of the Secretary of State, on an ad hoc basis. Otherwise, what would the terms of disclosure be?

--- Later in debate ---

[Mr Dunne]

First, in relation to amendment 11 and what the hon. Member for Central Ayrshire said, I think she made a perfectly reasonable point. As a lay reader of parliamentary drafting, if I may say so, it would be easy to be perplexed by the sequencing that she highlighted and brought to the attention of the Committee. I am advised, however, that the purpose of the amendment is to ensure that the UK Government collect information from English pharmacies and GP practices, but not from pharmacies in the areas of the devolved Administrations. Therefore, the reference to “Excepted person” includes pharmacies and GP practices in the devolved Administrations, but specifically does not include those in England, because their information is already collected by the UK Government. The terminology relates to where the GPs and pharmacies are and who is doing the collecting. I hope that helps.

[Dr Whitford]

I understand that, but I could not find reference to that in the National Health Service Act 2006, and I thought that the aim was to bring everything together in this Bill, so it seemed odd that there was no mention of English excepted persons. That is fine—that information is already being collected—but the Bill still separates the definition of English health service products from the definition of the health service products of the devolved nations. It seems an odd place to insert the amendment; it seems it is being attached to the definition of English health service products.

I totally accept that I am a complete novice, so there may be something I am not understanding, but to me, reading it logically, it does not seem to make total sense, and I thought that the aim of the Bill was to bring all the powers into one place. It seemed odd for there to be no definition of English excepted persons, even from an old Act, because what is happening here is that different things are being brought from the 2006 Act and from the Scotland Act 1978 into one place.

[Mr Dunne]

I thank the hon. Lady for that clarification. I hope that inspiration will arrive before I sit down.

To address the specific point made by the hon. Member for Ellesmere Port and Neston on devolution to Manchester, it is an interesting idea, which reflects some of the challenges arising from the increasing use of devolution of powers across our country. I can see why he might seek to secure a carve-out of income for Manchester. I would say, “Nice try”, but at present the funding arrangements for Manchester and other devolved areas in England are agreed via NHS England. That applies to the totality of funding available for health provision within the Manchester area, so the allocation already includes income derived from the voluntary scheme, and it will not be ring-fenced as a subset of the funds, because there chaos would lie.

--- Later in debate ---

[Mr Dunne]

Each year, when NHS England agrees its commissioning budgets and tariffs with providers, an allocation is made. That is based on the overall sum received by NHS England. Increases in revenues that derive from the Bill will help to swell that pot relatively modestly, although every penny counts, and that will therefore be taken into account when determining allocations to all CCGs, including those in Manchester.

I will give the Government’s response in relation to amendment 48; I do not have many comments to make. I sincerely hope that, before I reach the end of these remarks, I will be able to address the further point, on English exclusion, made by the hon. Member for Central Ayrshire.

Proposed new section 264B in clause 6 enables the Secretary of State to disclose the information collected to a range of bodies, which includes Government bodies such as NHS England, special health authorities, NHS Digital, other Departments and the devolved Administrations. It also enables the Secretary of State to prescribe representative bodies, or other persons in prescribed regulations, to whom he can disclose information in the future. For example, that might include certain information going to trade associations or other bodies that it might be appropriate to provide information to in future, with respect to the operations of the Bill.

The effect of the amendment tabled by the hon. Members for Central Ayrshire and for Linlithgow and East Falkirk would be that any of those bodies could in future access any information that the Government have collected. We do not believe that it would be right for representative bodies to be able to access information that the Secretary of State collects, primarily for purposes of commercial confidentiality. There are examples in other legislation in which we have taken specific steps to protect commercially sensitive information. I am not suggesting that one company would directly get access to information on another company’s profitability, but third-party advisers, for example, might get access to that information.

We do not want to provide opportunities for risking breaches of commercial confidentiality, because that would undermine confidence in the information gathering for all the companies, which includes major multinational companies. We think that the amendment might open us up to criticism from the major suppliers that there was greater risk of that intervention, which we would not want to see.

[Dr Whitford]

If the Minister looks at our amendment, which is incredibly short, he will see that all it says is “at that person’s request.” We do not want to widen the list in any way at all; we are not looking to add to the list. All we are saying is that, if it is accepted that a devolved Government should be able to access this information, it should be at the request of that devolved Government. It should not be, “We will tell you every April how you’re doing.” If a devolved country sees a pattern emerging, it should be able to say, “Can we request our data?” The issue is that data are to be collected centrally but not belong to the devolved nations to which they pertain. We are not trying to add anyone; we are just trying to give the devolved countries the power to request.

[Mr Dunne]

I completely understand that that is the intent of the hon. Lady’s amendment, and I think I have another way of addressing it, which I am now going to come on to. We think it entirely appropriate that at some point the devolved Administration might wish to change their information requirements. They might wish to add requests for information that they are not initially getting, which is a reasonable request.

We think that the right way to address that, rather than putting something in the Bill that might inadvertently allow other representative bodies access to information—I am sure the hon. Lady agrees that that might not be appropriate—is for a memorandum of understanding to be agreed between the Department of Health and each of the devolved Administrations that would allow requests for information to be submitted and dealt with in a manner agreeable to both parties. In the consultation process that will follow, we intend to enter into a memorandum of understanding that will include the procedures for requesting and sharing information.

I assure the Committee that the Government intend to continue to work constructively with the devolved Administrations to ensure that they have access to the relevant information collected in a format convenient to both sides, so that we do not end up with special data sets that are hard for an Administration to create because the data are not readily available from the information provided. Aside from that, we would honour the reasonable requests of any devolved Administration to be able to get access to the data, which I acknowledge the Administration may not own if the information has been gathered by the Department of Health.

On that basis, I hope that the hon. Lady and the hon. Member for Linlithgow and East Falkirk will not press their amendment.

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[Mr Dunne]

Before I go into the clause as a whole, I would like to respond in further detail to the hon. Member for Central Ayrshire about excepted persons. Clause 6 will add a new section to the National Health Service Act 2006. It brings together information collection practices, both statutory and voluntary. The Secretary of State collects information from a sample group in England from time to time, but not from GPs and pharmacies in the devolved Administrations. Therefore, the definition of “excepted persons” covers those persons whom the Secretary of State does not intend to collect information from directly, because he would be relying on the devolved Administrations to do so. The terminology used in proposed new section 264B is new; it is not based on the 2006 Act, which the hon. Lady has read so diligently. I thank her for bringing the matter to the Committee’s attention and I hope that that explanation meets her concern.

[Dr Whitford]

To clarify, is there a rational reason for the positioning of the section as between English health service products and the other health service products? I am sorry if, as a novice, I am creating extra work.

[Mr Dunne]

I think that is to do with parliamentary drafting on which I stand to become an expert; I look forward to seeing whether there is a clear explanation for that, which I can give to the hon. Lady as we debate the clause.

The clause enables the Secretary of State to make regulations that require any person who manufactures, distributes or supplies health service products, which includes health service medicines, medical supplies and other related products, to keep, record and provide on request information on prices and costs.

The clause brings together and consolidates existing information requirements related to controlling the costs of health service medicines, as well as medical supplies, in one place in the Act, as we discussed this morning. It also allows the information to be used for the purposes set out in the clause.

The clause also expands and strengthens our information collection. It enables the Government to make regulations to put current voluntary information provision arrangements on a statutory footing. For example, we collect information from manufacturers and wholesalers of unbranded generic medicines and specials to inform reimbursement arrangements for community pharmacies. The Bill will enable us to make regulations to get information on more products and from more companies. That is necessary to ensure that reimbursement prices for pharmacies reflect market prices of the whole market, rather than just of those companies that currently supply data to us. As in any industry, there are new market entrants and participants leave the market; this is a dynamic market and we need the flexibility to bring in new products from new companies.

The clause will also enable the Government to collect information to assure us that adequate supplies of health service products are available, and that the terms on which they are available represent value for money. If we were to have concerns about the supply chain or parts of it, or about specific products, we could obtain information from companies in the supply chain to assure us that the products, or the supply chain, provided value for money to the NHS and the taxpayer. Although the Government are generally not the purchaser of health service products, they do pay for them and therefore transparency and value for money of the supply chain are important. For example, if we were to consider limiting the price of a high-priced generic, the power to obtain information would be crucial to determine whether excess profits were being made. We could obtain information from a manufacturer, which would help us to determine whether the price it was charging the NHS was unreasonably high. That information would also inform our decision on what the right price should be.

The purposes for which the Government can collect information are limited and involve three areas: cost and pricing schemes, reimbursement of pharmacies and GPs, and assessing value for money. The clause provides the Secretary of State with the power to request any information for the purposes set out in the Bill. It also provides an indicative list of the type of information that the Secretary of State may request. Most of the types of information listed are already collected by the Government under statutory or voluntary arrangements.

The clause will also enable the Government to share information with a range of bodies, including Ministers in the devolved Administrations, the NHS, other Departments and persons providing services to those prescribed bodies.

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[Justin Madders]

I beg to move, That the clause be read a Second time.

As is explained in the explanatory note, the new clause would put a duty on the Secretary of State to place before Parliament an annual report on the impact of the Act and, in particular, on the pricing and availability of medicines and other medical supplies, research and development, and the NHS’s legal duty to promote innovation. I think we all agree that there are examples of unreasonable behaviour, but there may be occasions when there is a difference of opinion as to what amounts to unreasonable pricing practices, not least between the producers and the NHS.

We would be more assured if the consultation on the regulations had been completed by this stage. We are obviously not going to be in a position to know what that consultation has to say for some considerable time, so we believe the implementation of such a requirement would allow Parliament to scrutinise the impact of the legislation.

There has been some unease in the sector about the impact of the legislation and there is a certain amount of uncertainty, particularly around the future of the European Medicines Agency and the medium-term implications of Brexit not only for that agency, but for the research and development sector and the pharmaceutical industry as a whole.

We are one of the foremost countries in the world for drugs development, and our share of sales of the top 100 prescription medicines is 14%. The UK pharma industry employs 73,000 people, with very high-quality jobs in academia and science, but we cannot be complacent about the state of UK pharma, particularly as investment decisions are often made by parent companies in other parts of the world. That concern is compounded by the small volume of sales in the UK compared with other countries. We face increasing competition from emerging economies for R and D investment, with rapid growth in areas such as Brazil and China. That is not a new problem.

A report for the Secretary of State for Health by Professor Sir Mike Richards in 2010 on the extent and causes of international variations in drug usage explored levels of medicines uptake for 14 categories of drug in 14 high-income countries during 2008-09. The study showed that the UK ranked eighth out of the 14 countries. A follow-up study by the Office of Health Economics updated the quantitative analyses and ranked the UK ninth across all the medicines studied.

Apart from disadvantaging patients, the relatively low take-up of new medicines may put at threat R and D investment in the UK. We need some assurance on that and an ability to monitor and engage with the Government on it. We know many other countries are queuing up to take the European Medicines Agency off our hands, and there are real concerns about the knock-on impact of that.

The impact assessment for the Bill says there will be a reduction in revenue for the pharma sector, unsurprisingly. It also says:

“Reduced pharmaceutical company revenues are also expected to lead to a reduction in investment in research and development… and consequent losses of spill-over benefits for the UK economy, valued at £1.0m pa.”

While we agree that it is vital that those who abuse the system to drive obscene profits for themselves are dealt with, we do not wish to find the UK becoming a less attractive place for research and investment because other countries have made themselves more attractive.

We ask that the report become an annual feature of the Secretary of State’s duties to ensure that we can judge the effectiveness of the Bill. The converse point is that if we continue to see price increases, we want to be assured that the regulations are effective in driving best value for the NHS.

[Dr Whitford]

I rise to echo some of the points raised. We have discussed a lot of issues around the decision to leave the EU, including the loss of the EMA. As well as possibly losing international and multinational pharmaceutical companies—particularly those from the London area, which have based themselves here because of the EMA—it is clear that drugs may end up going through a licensing process for the UK later than is currently the case. They are likely to go through the American market and then the EU market, which will still have 450 million people, and we are likely to slide down to be more like Canada and some other countries. This is a very unstable time for research, because of the loss of Horizon 2020 and the EMA, and for our pharmaceutical industry, which is a major player in the UK. It is incumbent upon Government to ensure that the Bill has no unintended consequences that exacerbate that.

--- Later in debate ---

[Dr Whitford]

I beg to move, That the clause be read a Second time.

The point of the new clause is to explore a particular problem with what the Minister referred to earlier as “specials”. They are unlicensed preparations, often topical medicines, often used for severe skin conditions such as hard-to-control psoriasis. The British Association of Dermatologists reports that patients in England, Wales and Northern Ireland are struggling to get them prescribed, because the costs have spiralled out of control.

In Scotland, until last September, three quotes had to be obtained and one of them had to be from an NHS manufacturer. That has been streamlined, and a single quote, provided it is from an NHS manufacturer, is now acceptable. The British Association of Dermatologists looked at the 12 top specials that its members prescribe and estimated that if an NHS manufacturer had been used, instead of £845,000, the cost would have been £162,000. The association also reported that several private manufacturers are keeping two price lists—one for Scotland and one for England—and some of the dermatology items in England are eight times the price in Scotland.

That is literally holding people to ransom, and the result, because CCGs are hard pressed for cash, is that they are not comfortable funding specials and GPs are not allowed to prescribe them. Anyone who has ever had a dermatological condition of any kind, or knows someone who has, knows how unpleasant and utterly dominating of one’s life it can be. It is awful that patients, in particular in England, are not able to access such medicines. The new clause is looking at whether specials will be covered and whether enough attention is to be paid to them. The number of patients is small—hence the top 12 still come to less than £1 million—but for those patients this is a major issue.

[Mr Dunne]

Again, I am grateful to the hon. Lady for drawing the Committee’s attention to the issue. I confirm, for the benefit of the Committee, what the specials are—she has characterised them well.

From our perspective, unlicensed medicines or specials can be manufactured or imported to meet a patient’s individual needs when no licensed product is available. By their nature, specials are bespoke, and costs need to be balanced against the availability of treatment for an individual. I am aware of concerns that some specials, especially those not listed in the drug tariff, are not being prescribed because of their cost—the hon. Lady highlighted those for dermatological treatment. It must be recognised, however, that with specials, because of their bespoke nature, there are few if any economies of scale and they can be expensive to manufacture.

Under section 262 of the 2006 Act, the Government have the power to limit the price of any health service medicine, as long as the manufacturer is not in the voluntary scheme. Manufacturers or importers of specials are generally not in the voluntary scheme. Specials are health service medicines and we can therefore limit their prices. At the moment, the Government do not use their power to control the prices of specials. The hon. Lady gave an example, without naming the product, of a significant price differential between Scotland and England; if she is willing to write me a note after the Committee, I am interested in exploring why we have chosen not to take advantage of the power that we already have in that case, because on the face of it, it would appear to be an example of where the power perhaps ought to be used.

[Dr Whitford]

While there are not major economies of scale, if national health manufacturers are used, it is possible at least on a regional basis to pool some together. As things are at the moment, a pharmacy can simply approach its sister or mother company and ask for a price, which creates a vested interest in making the price high. I think that things can be done, which seem to be working in Scotland, so they are worth trying.

[Mr Dunne]

Again, I am grateful to the hon. Lady—

--- Later in debate ---

[Mr Dunne]

As we broke—literally, I was saved by the bell—I was describing how setting prices as suggested by the new clause could have unintended consequences. We are concerned that it may lead to manufacturers stopping the production of some specials if they are no longer profitable and patients facing adverse consequences.

By setting reimbursement prices in the drug tariff in primary care, the Government encourage pharmacy contractors to source specials as cheaply as possibly, which in turn creates competition in the market and, as a result, reimbursement prices decrease. For those specials not listed in the drug tariff, pharmacy contractors have no incentive to lower the list price. Currently, less than 1% of the total expenditure on medicines in primary care is on specials. Nevertheless, I believe those products, like all other products destined for the health service, should provide value for money to the NHS and the taxpayer. The information power in the Bill will help the Government to determine whether the products provide value for money and the illustrative regulations include an obligation to review those provisions.

The new clause would require the Secretary of State to commission a review of the adequacy of existing powers to control prices of specials, including the enactment and enforcement of those powers. The Government keep their power to control prices under review all the time; it was a review of those powers that led to the Bill in the first place. The Government believe that we have sufficient powers to limit the prices of specials if need be. The hon. Member for Central Ayrshire appears to have evidence of specials being priced to Scotland materially more advantageously than to England. If she would be willing to make that information available to us, we would be delighted to consider it.

[Dr Whitford]

I wonder whether the Government have given any consideration to having NHS manufacturers provide these products or to including some of the topical specials in the drug tariff, so that the price is kept down. Otherwise, despite the Bill, these drugs will be left outside its provisions. They are going to be too expensive and patients will suffer from that.

[Mr Dunne]

For the reasons that I have said, we have the power to look at the pricing of the specials already and we have not had evidence that the pricing has been abusive. We already have that power. We will keep prices and specific drugs under review. The best way to take that forward is to leave the powers as they are and not to proceed with the new clause, but to invite hon. Members to highlight specific examples that they are aware of.

--- Later in debate ---

[Rob Marris]

I thank the Minister; that is helpful. He is on top of his brief, as ever, and needed no inspiration to tell me that. It is helpful. The power does exist. I would like to ask the hon. Member for Central Ayrshire, because she has considerable expertise in the field. My expertise, such as it is, is as a lawyer. I see in her new clause the words

“ unlicensed medicinal products for human use”.

She may be able to tell me, because it is her new clause and she may have been looking at this issue. Where in the 2006 Act, or indeed in the Bill, although I think not, can we find what that phrase means? It may well be understood by medics—the topicals, the specials and so on—but it may not be understood by judges, for example. Can she help me on that when she winds up this debate? Otherwise, it seems to me as a layperson that the phrase

“ unlicensed medicinal products for human use”

could cover homeopathic so-called remedies. I do not think that the Secretary of State should be reviewing the pricing of homeopathic remedies.

To make my position clear, I think that homeopathy is bad science and a load of nonsense except for the placebo effect, but I use it as an example of unlicensed products that claim to be medicinal. I suspect that the hon. Member for Central Ayrshire would agree with my broad characterisation of homeopathic so-called medicines, apart from the placebo effect. What does that phrase in her new clause mean, and is it defined anywhere in law, or is it so obvious to medics that they and everybody in the pharmaceuticals business know what it means?

[Dr Whitford]

The phrase is the standard definition of specials. I cannot remember off the top of my head where exactly it comes from, but it is the recognised definition. It would not usually mean things such as homeopathic medicines. It is often things that are quite old and that have been around a long time that are not worth licensing, because they are not new and nobody will make any money out of them. We have a lot of products like that, but they are recognised within the practice of medicine. They are particularly common within dermatology, because of different topicals and the need to make different strengths of topical depending on the condition being treated.

I wanted to try to draw attention to this matter. The Minister has said that the Government have had the power all of this time and not used it. In part it is about bringing powers into line and creating consistency. I call on him to use those powers. Even though only a relatively small percentage of drugs are affected, the impact on patients from not being able to access them is significant. I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

New Clause 4

Review of extending provisions to repurposed off-patent drugs

‘(1) Within six months of the passing of this Act, the Secretary of State shall commission a review on whether the provisions of this Act shall extend to the regulation of the prices of repurposed off-patent drugs and shall lay the report of the review before the House of Commons.’—(Dr Whitford.)

Brought up, and read the First time.

[Dr Whitford]

I beg to move, That the clause be read a Second time.

The new clause seeks to explore one of the other anomalies that was challenged through a private Member’s Bill last November but unfortunately was talked out by the Minister at that time: repurposed off-patent drugs. Those are drugs designed for a particular use that, often during their use for that condition, contribute in relation to another condition.

Today, we have had considerable talk about the need to support pharmaceutical industries and encourage research and development, but the finding of a new purpose for a drug rarely comes from the pharmaceutical industry; it is usually done at a clinical or academic level through noticing patterns in clinical practice and following those up with trials. It is therefore not really something for which the pharmaceutical industry should receive a major award financially, although naturally if more of a company’s drugs sell and it is still producing them, it will see a benefit, which is totally fair enough.

One of the concerns is that, for a medic under the General Medical Council, there is a hierarchy of what we can prescribe, and at the top of that is licensed drugs for the purpose of the licence. Below that come repurposed drugs, which are therefore not licensed for that purpose. It is specifically stated that “they do the same” is not a sufficient excuse for using an off-patent generic drug.

With some of the drugs we have, new purposes are being discovered. Some statins can reduce brain atrophy in progressive multiple sclerosis. We have, as was referred to earlier, the use of bisphosphonates to prevent metastatic breast cancer and the use of tamoxifen to try to prevent breast cancer. That Bill was partly about trying to promote the use of those drugs, because they are off-patent and cheap, but one of the concerns among the medical profession is about a drug company buying a drug, tweaking it ever so slightly and then suddenly re-releasing it as a drug for multiple sclerosis at 10 grand a day instead of sixpence. What I do not see in this Bill is a recognition of the ability of people to come back and license a drug and totally change the price or to manufacture that drug simply as a generic with a massive price.

There was a case with the drug Lyrica, which is also known as pregabalin. The commonest use of that is for neuropathic pain: people who have had nerve damage from surgery or trauma and have difficult-to-control pain. The drug was originally designed for epilepsy, and Pfizer, which makes it, managed to get a court order saying that the patent on its use for neuropathic pain would continue to 2017 and that it would sue general practitioners who prescribed it as generic. That case has run for quite a long time, and I am proud to say that GPs basically ignored that order and have used the generic, but the advice of NHS England, which still sits on the website, says that GPs must prescribe Lyrica as Lyrica, which is obviously much more expensive. Therefore, over the last year GPs have had to be sitting out there exposed, open to the threat of litigation.

That is a real concern with repurposed drugs. That profit has been earned not by pharma’s research but by the research of other people usually in the public sphere: academics and in the NHS. Again, the new clause is to raise an issue that is not covered in the Bill and to see whether it has been considered at all by the Government.

[Mr Dunne]

I am grateful to the hon. Lady for raising this issue by tabling her new clause, because it gives us an opportunity to discuss an issue of considerable interest across the House. I am delighted to be able to inform the Committee that we do not believe we need to review whether the Bill’s provisions should be extended to repurposed off-patent drugs, because they will apply to those drugs whether they are licensed branded medicines or generic medicines. The new clause is therefore not necessary, because those drugs are already included.

Any licensed branded medicines that are developed may be included in either the voluntary or statutory scheme and be subject to all the provisions of those schemes. Unbranded generic medicines are subject to competition in the market, which keeps prices competitive and secures value for money. As we know, and have already debated today, there are examples of unscrupulous companies making unjustified price hikes for unbranded generic medicines when there is no competition in the market. As we have said, both today and on Second Reading, the Bill provides the Secretary of State with powers to intervene in such cases, in addition to the powers that the Competition and Markets Authority can exercise.

Having once again explained the specifics of how repurposed medicines will be affected by the Bill’s provisions, it might be helpful if I outline for the Committee some of the progress that has recently been made in supporting repurposing. For the reasons the hon. Lady identified, repurposing has benefits for patients in allowing drugs to be introduced as quickly as possible to provide alternative treatments to those originally intended by their manufacturers, where there is robust clinical evidence for new uses of existing medicines. Since November last year, a range of organisations have come together to work collaboratively to examine the issues at play in drug repurposing and to develop positive ways of handling those issues to ensure that patients benefit from robust research outcomes.

Officials in the Department have been working on the issue with the Association of Medical Research Charities and many of its members, as well as with NHS England, NICE, the publishers of the “British National Formulary” and the Medicines and Healthcare Products Regulatory Agency. All are committed to taking non-legislative measures to make sure that there is a clear and accessible pathway to ensuring that robust evidence showing new uses for existing drugs can be brought more systematically into clinical practice to benefit patients. That working group has made significant progress, and I would like to thank the organisations that have come together in a true spirit of co-operation to achieve rapid progress.

The General Medical Council has provided better advice for doctors about prescribing drugs outside their licensed indications, when that is clinically indicated. The “British National Formulary” has introduced new processes to ensure that information about repurposed drugs is captured more systematically and is therefore much more readily available for the clinical prescribers whom the hon. Lady referred to as the people at the forefront of this innovation. The Committee has heard from Dr Keith Ridge about the role that regional medicines optimisation committees will be asked to take in supporting prescribers to take up and use new evidence, particularly about unlicensed medicine use. Significant work has also been done on the development of a pathway that maps the routes from research result into clinical practice, which will help researchers and clinicians ensure safe and timely implementation.

NICE has published more than 50 evidence summaries for unlicensed and off-label uses of medicines. Although I said I did not want to go into detail, there are a couple of examples that the hon. Lady will be familiar with but other members of the Committee might be less so. NICE has made recommendations and guidelines on the use of tamoxifen to prevent familial breast cancer, and on the use of antidepressants—selective serotonin reuptake inhibitors—to treat irritable bowel syndrome.

I hope that with that explanation, hon. Members will agree not only that repurposed medicines are included within the Bill’s provisions, but that robust action is being taken by the Department and across the medical establishment to support repurposing for the benefit of patients. I ask the hon. Lady to withdraw her new clause.

[Dr Whitford]

I welcome the Minister’s explanation of what has been happening behind the scenes since the Off-patent Drugs Bill last year. The Bill Committee, of which I was a member, had a lot of discussion about the need to have a system for recognising the drugs, giving doctors and other prescribers the reassurance they needed to use them, and using the “British National Formulary” as a tool. We have heard nothing for a long time, so I really welcome the update that the issue is being taken forward. Prescribers are not all doctors now, and it is important that everyone who prescribes has the reassurance of knowing that they can safely prescribe and not be open either to making an error or to litigation. I beg to ask leave to withdraw the motion.

Clause, by leave, withdrawn.

New Clause 5

Extending price control to other medical supplies

‘In section 260(5) of the National Health Service Act 2006, after first “includes” insert “, but is not limited to, investigative,”’—(Rob Marris.)

This new clause is to ensure that the Bill’s provisions on price control apply to other capital equipment such as MRI scanners by including such items within the definition of “medical supplies”.

Brought up, and read the First time.

[Rob Marris]

I beg to move, That the clause be read a Second time.

I am glad that the Committee has generously left me sufficient time to deal with the new clause, which involves a tweak in the wording of the Bill. Clause 6 inserts section 264A into the 2006 Act, and section 264A(9) states:

“‘Medical supplies’ is to be read in accordance with section 260(5)”

of that Act. There is a synopsis of the subsection in paragraph 66 on page 14 of the explanatory notes, which hon. Members may have in front of them.

Page 162 of the 2006 Act states, in section 260(5):

“In this section and Schedule 22—

‘medical supplies’ includes surgical, dental and optical materials and equipment…and ‘equipment’ includes any machinery, apparatus or appliance whether fixed or not, and any vehicle.”

That definition is fairly clear but not sufficiently wide, hence my new clause, which would clarify it. Regarding medical supplies, there are, to my mind, three adjectives there qualifying two nouns, the three adjectives being “surgical”, “dental” and “optical”, and the two nouns being “materials” and “equipment”. There is considerable NHS expenditure on equipment—and materials, but particularly on equipment—that is not, as I understand it, surgical, dental or optical. A particularly expensive form of such equipment, as I outline in the explanatory note, which is helpfully on the amendment paper, is MRI scanners. They vary, obviously, but in round terms they cost about £2 million a throw and the NHS, understandably, has an awful lot of them—they are a magnificent diagnostic tool. There may well be other pieces of equipment that are perhaps not quite as expensive but which would not come under the rubric of surgical, dental or optical.

It seems, therefore, that there is a gap in the 2006 Act, and the new clause, which I am sure the Government will accept, is intended to plug that gap by indicating that those three adjectives are descriptive of the two nouns, but other adjectives could also be applied. For example, “investigative” is included in the new clause. The new clause would therefore simply ensure that there is no misunderstanding of the intent of section 260(5) of the 2006 Act. It is a helpful clarification to the Government.

Health Service Medical Supplies (Costs) Bill (Second sitting)

Philippa Whitford Excerpts

Committee Debate: 2nd sitting: House of Commons
Tuesday 15th November 2016 Public Bill Committees

[Mr Dunne]

The Department of Health receives income from a number of different sources. It mostly deals with expenditure but also receives income from activities conducted through the NHS. One source of income is the rebate through these schemes, which forms part of the funding available to the Department. We have committed that funds available out of the scheme will go into the NHS. The hon. Gentleman raised the issue of the £10 billion. I gently remind him that, in 2014-15, the funds available to the NHS from the Department of Health were £98.1 billion, and by 2021 that figure will be £119.9 billion, which in cash terms is a £20 billion increase and in real terms is a £10 billion increase.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

As the hon. Member for Burnley said, the system functions quite differently in Scotland. We have a new medicines and rare diseases fund, rather than a cancer drugs fund, which means that the use of funding to access new medicines is not limited to one cohort of patients. Our fund is £90 million, which, given that we are less than 10% of the UK population, means it is proportionately almost three times the size of the cancer drugs fund. As was mentioned, this is very much funded by the PPRS. It is committed to that. The pharmaceutical industry expects the rebates to be used to enable access to new medicines. One problem here is that the rebate goes into base funding, which means it disappears like water in the sand.

We have so many debates in this House about patients who are struggling to access new treatments. Amendment 46 talks about innovation and research, which we support in Scotland. We are quite a research-oriented country. Our research funding to our universities is 30% higher, in proportion to our population. The NHS in Scotland commissions research, particularly on things like informatics and data management around health and social care, which are the big challenges we face in the future.

The Scottish Medicines Consortium, which makes our decisions in the same way as NICE, was reformed in 2013. Since then, we have had a 40% increase in drugs being passed. What we see in England is that even if a drug is passed at the level of NICE, it sometimes does not come into use in the NHS, because the funding is simply not earmarked to make it available.

--- Later in debate ---

[Mr Dunne]

I do not have complete recollection of what the Secretary of State said, but he may have been referring to things such as the over-prescription of antibiotics, which we know is a problem globally. A great deal of work is being undertaken right across the NHS and with other health bodies around the world to reduce the scale of antibiotic prescription.

[Dr Whitford]

Is it not the case, however, that we seem to be developing this additional rationing system between NICE and patients of the NHS? I am talking about NICE’s recommendations being accepted but not funded. The hepatitis C drugs are basically being rationed to a certain number of patients per month, even though they have been passed by NICE and trying to eliminate the viral load in the community can be more effective in the long term.

[Mr Dunne]

Inevitably, some decisions have to be taken when introducing new drugs as to the extent to which they are applicable. Those are clinically-led decisions. There is not a completely bottomless funding pot for the prescription of medicine, so those decisions have to be taken by ordinary clinicians within their practices and within the infrastructure of approvals, which is entirely independent and led by NICE in England.

[Dr Whitford]

With respect to the Minister, that is not what I am hearing from clinicians who work in the field of HIV and hepatitis C. They are being told, “You can have”—for example—“50 patients a month,” and they are having to pick who gets the drugs and who does not.

[Mr Dunne]

I will not be drawn into the detail on a specific drug, because the hon. Lady may have access to information that I do not, but in relation to hepatitis C, as she has raised it, there has been a discussion between the trust and NICE. As I understand it, the trust is continuing to work with NHS England collaboratively to discuss the issue of access to the new hepatitis C drugs. We will always have some discussions about applicability when a new treatment is introduced, to see whether it is appropriate for all conditions; it may be that only some benefit from the drug. I think that that is as far as I can go on this issue.

To return to the Government’s view of the amendment, we are concerned that it would in effect circumvent the critical system of checks and balances around clinicians’ prescribing freedoms. That would present a danger to patients and the sustainability of the NHS. It is also not the purpose of the Bill to address matters other than the cost of medicines and medical supplies.

Treatments that do not demonstrate efficacy, safety and value for money should not be routinely available on the NHS. The National Institute for Health and Care Excellence, an internationally respected organisation that provides evidence-based guidance to the NHS, ensures that the treatments recommended for patients deliver value for money and improved patient outcomes. NICE’s recommendations are developed free from political interference and help NHS organisations to design services that are in line with the best available evidence and that meet the needs of their local populations.

--- Later in debate ---

[Mr Dunne]

Then I will continue.

Certain companies appear to have made it their business model to buy the marketing authorisations for medicines without any patents outstanding. They then de-brand the medicines and abuse the existing freedom of pricing for unbranded generic medicines. Although the practice is not widespread, it must be addressed, which is the reason for the clause.

Currently, our only recourse is to refer such cases to the Competition and Markets Authority, as I mentioned. When the CMA investigates, we must wait for the outcome, and in the meantime the NHS continues to have to pay high prices. The Department consulted on the issue as part of the consultation on the statutory scheme that was launched in December 2015. The Department has been working closely with the Competition and Markets Authority and has referred cases to it. The CMA is about to issue a decision in a case on a high-priced unbranded generic medicine. As I have just said, it has also recently opened another investigation.

The powers under section 262 of the 2006 Act to limit prices of health service medicines can be exercised through directions or regulations. The Government’s intent is to work with directions, which will enable us to limit the price of a specific medicine from a specific manufacturer. The Government are obliged to consult the industry representative body when we want to direct the price of a medicine. In the case of high-priced generics it would be the representative body of the unbranded industry—currently the British Generic Manufacturers Association, which appeared before the Committee last week.

The Government would of course also engage with the company involved before issuing a direction that limited the price of a medicine. As I have indicated, there may be good reasons for a price increase, and it is important that the Government understand the reason behind a price increase before issuing a direction. As I said, the new information powers will help us with that.

My officials have initiated talks with the unbranded generic medicines industry representative body and the CMA to explore how in practice we would determine what should be considered a reasonable price. Any decision by the CMA in the cases that I highlighted earlier could help set a useful precedent. I can reassure the Committee that companies charging unreasonably high prices for unbranded generic medicines is not a common practice. The Government do not intend to use the power where competition in the market for unbranded generic medicines is working. However, the Government need the right legislative tool to be able to address unreasonably high prices of unbranded generic medicines. The clause will give us that tool, and I ask the Committee to agree to it.

[Dr Whitford]

Basically, we welcome the measures in clause 2 to try to close the specific loophole whereby companies that are part of the PPRS voluntary scheme and that also produce generic medicines are able to increase the prices of generic medicines. However, the Minister talked about the British Generic Manufacturers Association—largely companies that focus on generic medicines—which would be more to do with clause 3. My understanding is that the change will close the specific loophole relating to large pharmaceutical companies that also produce generic medicines, rather than companies that focus only on generic medicines, which we will come on to in clause 3. We welcome the closing of that loophole, but those two things are quite different and we should therefore not conflate them. It is not the competition authority that would tackle them. That is much more related to purely generic companies.

[Mr Dunne]

We will obviously come on to clause 3 shortly. The primary intent behind clause 3 is to modernise the statutory scheme, rather than to address the difference between one type of company that produces only generics and another that produces generics and branded medicines. I am not sure that I agree with the hon. Lady’s distinction.

[Dr Whitford]

My point is just that what the Minister has described applies more to clause 3, on companies that produce purely generic medicines, so the attempt would be to strengthen the statutory scheme that they might be part of. It is the production of generics by the group of companies under the PPRS scheme, the big pharmaceutical companies, that is getting under the wire. That is covered by clause 2(2). The Minister was talking about the Competition and Markets Authority and the British Generic Manufacturers Association, and I think clause 3 is more relevant to that. Clause 2 is more of a surgical change, which we absolutely support.

[The Chair]

The Minister can respond either now or later.

--- Later in debate ---

[Julie Cooper]

I beg to move amendment 43, in clause 3, page 2, line 27, at end insert—

‘(2A) An amount calculated under subsection (2) may only be calculated using the same methodology as an amount payable by any member of a scheme made under Section 261 of the National Health Service Act 2006 (voluntary schemes for controlling the cost of health service medicines) is calculated.”

We support clause 3 in principle and the amendment aims to clarify that. Under the current system, following the National Health Service Act 2006, two schemes operate to control prices of medicines: the statutory scheme and the PPRS voluntary scheme. It is important to align those two schemes, because since 2014 there has been a significant movement of companies deciding to shift from the PPRS scheme to the statutory scheme to reduce the level of rebate payable. That has reduced savings to the NHS, so it requires urgent revision.

We agree with the principles of the Bill on ensuring that both schemes achieve the same level of savings and that the system is not open to abuse. We are concerned, however, that the Bill is not specific about how payments would be calculated under the statutory scheme. We agree with the Secretary of State that the purpose of the Bill is to clarify and modernise provisions to control the cost of health service medicines.

The amendment seeks to clarify beyond doubt that the Bill is in line with the stated aim of achieving equivalence between the two price-control schemes, by ensuring that under the statutory scheme members' rebates are calculated using the same methodology as for PPRS members. We commend the amendment, but will not push it to a Division. I am interested to hear the Minister’s comments.

[Dr Whitford]

One issue arises because the statutory scheme was based on prices in December 2013. The further on in time we are, the less proportional the return. Whether it is the same or a similar mechanism, we should avoid having a price rebate to the NHS stuck in time, which might be five years ago, and does not reflect the actual costs of the drugs.

[Mr Dunne]

The voluntary schemes are introduced and refreshed every five years. The current scheme was negotiated in 2014, so we are two years into that. One reason for having a time limit on the scheme, from the Government and NHS perspective, is that companies like to find ways during the course of time to adjust their commercial behaviour for their benefit. Having the opportunity to renegotiate the voluntary scheme every few years enables us to try to avoid the circumstances referred to by the hon. Lady.

[Dr Whitford]

If I could clarify, the voluntary scheme runs for five years but what I was talking about, with regard to clause 3, is the statutory scheme and the price rebate related to a requirement for a percentage reduction from the price in December 2013. That is how the rebate in the statutory scheme is defined. The further one gets away from that date point, the less one gains. It is the statutory scheme I am talking about rather than the voluntary one.

[Mr Dunne]

My understanding is that under the statutory scheme, the percentage applies based on sales achieved in the previous year. Therefore, the percentage reduction that we seek for the statutory scheme can be adjusted year by year. That is the intent of what we seek to do. I will seek further inspiration to ensure that I have exactly addressed the point that the hon. Lady makes.

Amendment 43 would have the effect of linking the payment mechanisms of the statutory and voluntary schemes. I understand why that might appear a desirable objective, so I understand the intention behind the amendment. We think there is merit in aligning the two schemes in some respects. However, to require them to be the same is inappropriate, because it removes some flexibility that the Government have, and from which the NHS benefits, in being able to negotiate the voluntary scheme on a periodic basis. The voluntary scheme has other aspects beyond pure price. Aligning the two in what will become a statutory scheme would restrict the scope for the two schemes to operate in a complementary manner.

The voluntary scheme is a matter for negotiation with industry on a periodic basis. As such, there is scope to include a range of measures. Those measures may change with each iteration of the scheme, to reflect the priorities of each side at the time of renegotiation. To illustrate that, the current voluntary scheme includes a range of provisions developed through negotiation with industry that sit alongside the payment mechanism. That includes price modulation, which enables companies to put prices up and down as long as the overall effect across their portfolio is neutral. That may have benefits for them, not only for their sales to the NHS but in the pricing references used by selling to the NHS in jurisdictions in other countries. That is of potential commercial value to companies, which may be willing to accept a higher payment percentage as a result—in other words, a higher discount to the NHS.

There are also provisions on the uptake of new medicines by the NHS, such as making NICE-approved medicines available within 90 days of a NICE decision. We are keen to encourage that. By contrast, the statutory scheme is intended to be a more straightforward approach. As such, the payment percentage applied may be slightly different from that applied to any voluntary scheme, in order to achieve a broadly similar level of savings once all elements of the schemes are taken into account.

As we heard in oral evidence last week, the freedom to negotiate the voluntary scheme is greatly valued by both industry and Government. We intend that any future voluntary scheme should be established through such negotiation, but linking the payment mechanisms would inevitably restrict that flexibility and freedom for both sides. In addition, while the Government welcome the collaborative approach of a voluntary scheme, we cannot guarantee that Government will always want two schemes in future. The amendment would constrain the Government’s discretion to run a single scheme if they and the House thought it best to do so. For those reasons, I urge the hon. Member for Burnley to withdraw her amendment.

--- Later in debate ---

[Mr Dunne]

The clause amends the provisions relating to statutory schemes in section 263 of the National Health Service Act 2006, which describes the purposes for which the Secretary of State can make statutory schemes. The amendments make it clear that a statutory scheme may require companies to make payments to the Government, based on their health service sales. For those companies not in the voluntary scheme, the Government operate a statutory scheme. That is currently based on a cut to the list price of products, rather than a payment mechanism on company sales, as in the voluntary scheme. The cut to the list price has delivered fewer savings to date than the payment mechanism under the voluntary scheme.

[Dr Whitford]

That was the point I was trying to make earlier. One is a percentage return on sales and profits, and the other is a cut in price. The further we are from the time set, which was December 2013, the less value we have from that in proportion to current prices.

[Mr Dunne]

I am grateful to the hon. Lady for making that clear to the Committee. The different approaches to price control between the voluntary and statutory schemes have led to some companies making commercial decisions to divest products from the voluntary scheme and sell them through the statutory scheme, thereby reducing the effectiveness of the voluntary scheme and savings to the NHS. The introduction of a payment mechanism in the statutory scheme would save the health services across the UK an estimated £90 million a year, as set out in the impact assessment.

In response to the Government’s consultation on introducing a payment mechanism in the statutory scheme, the pharmaceutical industry queried whether the Government had the powers to introduce a statutory payment system. The clause clarifies the existing powers to make it clear that the Government have the power to introduce a payment mechanism in the statutory scheme. The ability to make the statutory scheme by way of regulations rather than setting out the detail in primary legislation provides us with the flexibility to respond to changes in the wider economy, the medicines market and patient needs. We have provided illustrative regulations to support scrutiny of this delegated power.

The clause makes a further amendment to section 263 of the National Health Service Act 2006. Currently, the power to make a statutory scheme cannot be applied to members of a voluntary scheme, which means that if the Government introduced a statutory scheme for unbranded generic medicines—although we have no current plans to do so—we would be unable to apply the scheme to manufacturers of unbranded generic medicines that have a mixed portfolio of branded and unbranded generic medicines, and are members of the voluntary scheme. The clause therefore amends the Act in such a way that the power to make a statutory scheme cannot be applied to products covered by the voluntary scheme rather than member companies of the voluntary schemes.

The Government’s view is that, for the most part, competition works well to keep down the price of unbranded generic medicines. Should that situation change, this amendment would enable the Government to use their clause 2 powers to take action beyond individual products or companies. I hope that is clear to the Committee. If so, I ask the Committee to agree that clause 3 should stand part of the Bill.

--- Later in debate ---

[Mr Dunne]

No, I mean the Home Secretary.

We believe that competition is the best way to drive prices of medicines down for the NHS, and generally speaking that works well. In the case of the specific unbranded generics where there is a single supplier, we have seen that there is an opportunity for market abuse, and I agree with my hon. Friend the Member for South West Bedfordshire that the clauses are designed to use the device of price controls to avoid excess profit abuse by individuals in British companies, which we have seen.

I gently remind the hon. Member for Wolverhampton South West that successive Governments since 1957, including the Government whom he proudly supported for many years, had price controls in place for the cost of medicines.

[Dr Whitford]

The Minister was obviously not happy with the amendment on aligning the two schemes, but he talks about a mechanism of price control under clause 4. Will he give us even the broad principle of what he thinks the price control mechanism in the statutory scheme will be?

[Mr Dunne]

The mechanism in the statutory scheme will be to allow the discount to be changed periodically. That will be determined through consultation with industry in the same way as applies in the voluntary scheme.

[Dr Whitford]

To clarify, therefore will the situation continue to be that the statutory scheme is based on a price reduction as opposed to a percentage above a mark being returned to the NHS, as in the voluntary scheme? Will it be a similar mechanism to what we have today?

[Mr Dunne]

I believe that that is the case, but if I have misunderstood the hon. Lady’s question I shall clarify that later in the sitting, if I may. Our intention is to consult on the matter, so the precise mechanism has not yet been finalised; hence there is some uncertainty.

--- Later in debate ---

[Mr Dunne]

I can help the hon. Gentleman directly with a specific example. The Secretary of State already has those powers under the 2006 Act, which the hon. Gentleman’s Government enacted.

Question put and agreed to.

Clause 4 accordingly ordered to stand part of the Bill.

Clause 5

Control of maximum price of other medical supplies

[Dr Whitford]

I beg to move amendment 47, in clause 5, page 3, line 39, at end insert—

‘(7) Before making regulations under Clause 5 the Secretary of State must conduct a consultation on the potential effect of this clause on the maintenance of quality of those medical supplies, and seek representations from manufactures, suppliers and distributors of medical supplies as part of the consultation.”.

This is a probing amendment on an issue of concern. The Secretary of State has obviously had powers since 2006, and perhaps earlier, to seek to control the price of medical supplies. That power has not really been utilised, and neither have the informatics of that. When controlling the price of drugs, the quality of those drugs is controlled by the Medicines and Healthcare Products Regulatory Agency so that pushing down the price does not result in loss of quality.

My concern is that, beyond a kitemark or a CE mark, we do not have anything in the United Kingdom that controls quality, particularly of consumables such as swabs and gloves. As a surgeon for 30-odd years, I can tell the Committee that the range in quality of things such as surgical gloves can be immense. A surgeon might use two or three pairs of gloves during an operation. If there is a leak in those gloves that is not visible, it might be only when the surgeon washes their hands afterwards that they see they have blood on their finger, which means that staff are exposed to blood contamination. Poor-quality swabs might result in thread or fluff coming off inside a patient, which can contribute to sepsis. There is no quality controller specific to medical supplies, so if we just drive down the price, we may drive down the quality.

We use a lot of central procurement in Scotland, and NHS National Procurement has helped us to control our prices for everything from consumables through to major machine purchases, which is already saving money for the NHS in Scotland. If there were a reduction in quality, our concern is that it would be UK-wide. It would be something that producers were doing, which would in turn undermine what the devolved Government were trying to do. Procurement remains devolved, but if the quality started to drop overall, that would affect all the devolved health services, as well as NHS England.

The amendment calls for consultation and for consideration of some form of quality regulation or control that would mean those items having to be way above the very basic CE level, at a point considered high enough quality for NHS use.

--- Later in debate ---

[Mr Dunne]

Rather unusually, I start by thanking the hon. Lady for proposing the amendment. She has raised an issue for which we have considerable sympathy. She touched on the way in which medical products are procured in Scotland. I can confirm that we are looking to introduce more centralised purchasing across the NHS under the efficiency proposals made by Lord Carter in the other place. One of the areas of focus was the variability, in purchasing terms, of standard commodity items. She mentioned surgical gloves—I will not go into detail on those with her, because she has obviously used them considerably more than I can conceive of and is therefore very experienced when it comes to the variability not just in price but in quality of such commodity products. We are looking to introduce closer central purchasing—I think 12 items are currently being trialled or introduced in parts of NHS England.

We recognise that, as currently drafted, the Bill does not explicitly state in relation to section 260 that the Government are obliged to consult industry. I am aware that the 2006 Act, in relation to controlling the cost of medicines, does explicitly state that there is an obligation on the Government to consult. The hon. Lady’s amendment is appropriate in its intent. I invite her to withdraw it at this stage, but I undertake to work with her. My officials will consider how to amend the amendment to give it the effect that she seeks, but in a way that works in the context of the Bill. There are technical drafting issues with the amendment that mean that it would give us some unintended difficulties. That is the Government’s position on the amendment; I hope she is happy with that.

The hon. Lady referred to the effect of any pricing controls for medical supplies on the maintenance of those products’ quality. I can assure the Committee that the Government will take into account all relevant factors, including any concerns raised by industry about the quality of medical supplies, when making and consulting on price controls if they were to apply to medical supplies. The Government would not be in favour of putting any of those many factors in the Bill, because it may unnecessarily constrain the conduct of future Governments or the NHS.

[Dr Whitford]

If there is a move to more central procurement, will the Minister consider some form of quality control regulation or power at that point, so that central procurement is not just driven to accept the lowest price and there is some safety mechanism, in the same way we have the MHRA for drugs?

[Mr Dunne]

We will consult with industry on the impact of the Bill on medical supplies. Although I am not going to give the hon. Lady an absolute assurance that we can introduce a threshold for quality, which is quite hard to prescribe given the immense variety of supplies we are talking about, there is a clear intent that, if we are centralising procurement of equipment, that equipment has to meet a quality threshold in order to be acceptable to the clinician. I understand the point she makes. The intent is not to buy substandard equipment to treat patients, but to remove variability in pricing for the same equipment depending on different purchasers, which is inappropriate and means effectively the taxpayer is the funder of all these different entities.

--- Later in debate ---

[Mr Dunne]

Yes, I think that is the correct answer. We do have those powers under the 2006 Act, but they have not been used, partly because generally speaking medical supplies is a competitive market. We have not seen the kind of abusive price behaviour that we are trying to address elsewhere in the Bill.

[Dr Whitford]

Will the Minister give way?

[Mr Dunne]

I am about to conclude but I will happily give way.

[Dr Whitford]

I would like to clarify the reason for introducing this, if there has not been a problem in the market, as we have seen with the price hikes in generics, and it is much harder to do. Why are the Government extending a power they have had for 10 years but never used?

[Mr Dunne]

In essence, we are trying to bring the regimes for medical supplies and drugs into the same environment, so that we are able in future to use the powers, which we are introducing for the first time for drugs, for medical supplies on the same basis, so that we do not have to treat one thing under one Act and the other under another. I hope that is clear.

[Mr Dunne]

I am not aware of any particular examples of medical supplies that we are concerned about at this point. However, I am sure that, if there are people outside watching who have good examples, they will let the Committee know before we conclude our deliberations.

Reverting to the hon. Lady’s amendment 47, we understand the intent behind it. We are not fully convinced that the current drafting would have precisely the effect that she is hoping. I invite her to work with me and my officials between now and Report. The Government will be happy to consider how we could best introduce the requirement to consult in relation to section 260. On that basis, I invite her to withdraw the amendment.

[Dr Whitford]

I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Question proposed, That the clause stand part of the Bill.

[Mr Dunne]

Clause 5 amends section 260 of the 2006 Act, which enables the Secretary of State to control the maximum prices of medical supplies other than health service medicines. As we have just discussed, the Government have powers to control prices of medical supplies and we are not currently using those powers. It is important that we continue to have those powers, should we decide it is necessary to control prices of medical supplies in the event of market abuse.

With an increasing spend on healthcare products, the Government need the tools to be able to control prices, if there is any indication that medical suppliers do not provide value for money to the NHS and the taxpayer. The measures would ensure that the same enforcement and territorial extent provisions apply to controlling the cost of medical supplies and health service medicines.

Existing enforcement provisions in relation to medical supplies are draconian compared with those for medicines. Currently, a contravention or a failure to comply is in fact a criminal offence in relation to medical supplies, whereas it is not in relation to medicines. We are aligning the enforcement provisions to those for medicines and making them much more proportionate. That is done through clause 7, through consequential amendments. On that basis, I ask the Committee to agree that clause 5 stand part of the Bill.

Community Pharmacies

Philippa Whitford Excerpts

Wednesday 2nd November 2016 Commons Chamber

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

The Minister kindly referred to the system in Scotland, which has been running for 10 years since we passed the Smoking, Health and Social Care (Scotland) Act 2005. It took time to introduce the new system, but now all pharmacies in Scotland are community pharmacies, meaning that they all provide services. They do not get a big payment merely for existing—they receive a quite tiny £1,730—but they do get payments based on needs that reflect a population’s age, vulnerability and deprivation, so those things are taken into account in their global funding. That funding is due to go up 1.2% in Scotland while there is talk of a reduction of 4% here.

The services provided have been referred to as the minor ailment scheme. Many pharmacies in England make provision under that scheme, but it is not a national system. In Scotland, the scheme is national and such services must be provided. One issue is that the pharmacies have to invest. They have to build a consulting room and change their building so that people can be seen privately when their minor ailment is diagnosed. They work to protocol for a whole list of ailments that they can diagnose and have the ability to treat. The ailments are minor things that many people would experience, and the approach avoids their having to go to a GP.

[Stephen Pound (Ealing North) (Lab)]

The hon. Lady makes an incredibly important point. People who go into a community pharmacy today will see a special treatment room where they can get phlebotomy, advice on blood pressure and all sorts of other things. Is it not perverse, cruel and utterly irrational to say to a group of professionals, who have done all this work to change the way they deliver their services, “Now we are finished with you. Out you go. You’ve done your bit. We are going to put you out and close down your pharmacy”?

[Dr Whitford]

I agree with the Government about looking for more services, but this is not the way to work with the profession, given that they want those in it to do more work and to work differently. Sadly, during my time in the House, we have repeatedly seen the Government not sitting down with a profession and saying, “Why not look for where savings can be made?”, but simply making a cut.

[Karin Smyth (Bristol South) (Lab)]

I was going to intervene on the Minister to follow up the point made by the Chair of the Health Committee. We are looking at bottom-up planning in England for the first time for a number of years with the sustainability and transformation plan process, so this is completely the wrong time to be making these irrational and random cuts.

[Dr Whitford]

We recently debated STPs and the potential they provide. The danger is that at the moment we are seeing finance-centred care, instead of patient-centred care. Going back to place-based planning, which is what we have kept in Scotland, where we still have health boards, means that we can look at integrating services, and pharmacies definitely need to be part of that. They have the potential to be a significant front-line player.

[Maria Caulfield (Lewes) (Con)]

I am interested in the experience in Scotland, although we do not have the same system in England. What does the hon. Lady think about moving pharmacists into GP surgeries? I think that it is a mistake. I would much prefer the approach that is being taken in Scotland, where pharmacies are expanding by having consulting rooms of their own.

[Dr Whitford]

Scotland actually has both. We do have pharmacists who are in a consulting room within a practice, and our Government have put £85 million into taking on an additional 140 pharmacists who work in primary care with GPs. We are not, as has been done in the past, saying, “Everyone on drug A must change to drug B because it is cheaper,” without giving any thought to how that affects the patient. We are consulting patients, who are often on 10 or 15 medications, all of which interact and have different side effects, and then rationalising that and giving the patient advice. We are therefore providing a clinical service rather than just a changeover service.

Our community pharmacy system has been running for 10 years, so it is quite mature. Patients register with a pharmacist in the same way as they register with a GP. The aim is for all people to be registered with whomever they consider their local pharmacist to be, as that means that they can access minor ailment treatment. It also means that people who are on chronic medication have a chronic medication service, with their prescription sent electronically to the pharmacy, which then keeps track of when it is due and therefore ensures that patients do not run out of medication. The pharmacies also provide an acute medication service for people who have not signed up to the other service but suddenly find they have no tablets, as they had not thought to re-order them with their GP. If they are regulars at the pharmacy, a single round of drugs can be prescribed for them there so that they do not have a gap in their treatment. The important thing is that our vision is to have all our pharmacists as prescribers by 2023, and to have our public registered with pharmacists by 2020.

[Mr Jim Cunningham (Coventry South) (Lab)]

The hon. Lady makes two important points: this move is cuts-led, rather than well planned; and just as communities rely on their doctor, they rely on the facilities at their pharmacy. That is particularly true of elderly people and those with disabilities, who may have to travel miles, depending on where the pharmacy is.

[Dr Whitford]

It is crucial that the service covers all areas, including those that are deprived and those that do not have good public transport. Distance is not everything; this is also about how people travel that distance. In many places, the distance involved might not be that great, but there simply may not be a bus going in the required direction.

[Catherine McKinnell]

I wanted to make this point to the Minister: the closure of community pharmacies will clearly lead to a poorer service, a loss of patient choice and poorer health outcomes for those in more deprived parts of the country. Is this not just another example of Government short-term cuts that will cost us more in the long term?

[Dr Whitford]

If this is introduced badly, the cost will be greater in the long term. When the Minister talks about a more service-based approach, I think that he aspires to something more like the Scottish model, which I would commend. I just feel that this is being done “backside forward”.

[Anna Turley (Redcar) (Lab/Co-op)]

rose—

[Dr Whitford]

I need to make a bit of progress.

We need to design the services with the people who work in them. Some 18% of Scotland’s population—nearly 1 million people—are registered with and do access the minor ailment service, which takes pressure off accident and emergency, because there is availability out of hours, and GPs. The fourth service that we have is the public health service, with 70% of all smoking cessation work in primary care being carried out in our community pharmacies. These four services together—minor ailments, chronic medication, acute medication and public health—represent a huge breadth of service for a community. It is important that pharmacies in England that are currently just retail and dispensing pharmacies are encouraged to go in that direction, because it brings benefit for the NHS.

My biggest concern is the random nature of how this process might develop. If the Government simply cut and let the dice fall where they will, the problem is that they will not end up with an integrated service. Scotland still has health boards, so if a community pharmacy is to open there, an application needs to be made to the health board. When the project started, the boards decided which places got to become community pharmacies, and they decide whether there is a need to open a new community pharmacy. The biggest mistake in this scheme is its randomness.

One issue raised by the hon. Member for South West Wiltshire (Dr Murrison) was the profits made when drugs are sold on. The Government could look at the vertically integrated wholesalers—the big chains. In the mid-2000s, they were not considered. The Government do not know how much profit they make or where that profit is made, and the system is totally unregulated. These chains control about 40% of the pharmacy market. One of the biggest chains, Walgreens Boots Alliance, has declared profits of almost £1 billion, yet it has somehow been able to reduce its tax bill by more than £1 billion in this country. We are talking about people who are make almost half their profit from taxpayers yet do not pay their full share of tax. I absolutely agree that under this proposal the big chains will survive and the small, independent, very community-based pharmacies will be lost.

[Neil Coyle]

The Minister accused those who highlight concerns of “scaremongering”. Atul, who runs St George’s pharmacy at the Elephant and Castle in my constituency, says:

“We may survive the first set of”—

in-year—

“cuts by compromising on our services. But the second set of cuts next April will most definitely place us at a real risk of closure.”

Does the hon. Lady agree with Atul that it is right for us to highlight our concerns, especially in constituencies such as mine, where we face losing 18 community pharmacies?

[Dr Whitford]

Losing that many pharmacies in any area would be a disaster. This is a bit like groundhog day, because this is our third discussion on this topic in as many weeks. The Minister said that there absolutely would be protection, but the pharmacy access scheme still largely comes down to the amount of dispensing that is done and the distances. It does not take account of which pharmacies are providing a good service, which ones are set up to provide a good service and how to encourage others to develop. This is what is completely wrong in the Government’s approach. They are just slicing money off and leaving individual businesses to decide whether they think they will be profitable. The danger would be that we get a whole lot of pharmacies deciding to sell out and walk, instead of someone saying for a particular area, “Eighteen is too many”—especially if they are all around one town square—“so which ones are best able to develop a service? Let them bid for it and let them be inspected, and let’s see how they take it forward.”

The Government could make a lot of savings by addressing the wholesalers. In Scotland, we have margin sharing, which means that a price control group looks at the profit that is made at various stages, and some of it has to be shared back. We do have people who are trading on the open market and moving drugs around, especially in the big chains. As we heard earlier, we would get a better result by sitting down with the profession and designing a service. STPs could provide the model within which to look at how many community pharmacies there should be and where they should be, and then it would be a case of working backwards.

The danger of the Government’s approach is that it is the wrong way round. Just calling something an “efficiency cut” does not make it efficient, and the danger is that we just slash something and it falls over. The pharmacy access scheme is not enough of a protection or of an intervention. There needs to be planning. I commend the idea of a proper services-based pharmacy system, but the aspiration should be not just that a few pharmacies choose to do it and others do not. It should be that a patient who walks into a community pharmacy will know what services they can get, and we should aim to have that right across the country.

[Several hon. Members rose—]

--- Later in debate ---

[Oliver Dowden]

I thank my hon. Friend for that intervention. Equally, many such pharmacies do not provide any of the wider community health benefits. In essence, they are just dispensing services.

[Dr Philippa Whitford]

Is it not estimated, however, that those will be the ones that survive, purely because they are big, while the small, high-service pharmacies in communities are more vulnerable?

[Oliver Dowden]

That is precisely the point that I am coming to. As we proceed with these reforms, hon. Members need to recognise that we will need further savings in this area. I am not attacking large retailers because of their size; it is because of the lack of such wider provisions. We need to look at ways of securing further savings from them which we can plough back into the community pharmacies that are providing the services on which all our constituents rely. I completely accept that pharmacies that are purely dispensing services are very inefficient as such. They are highly labour-intensive; it is just a very expensive way of delivering drugs. We need to identify ways in which we can bifurcate the two different types of providers.

I pay tribute to what the Minister has announced so far. He clearly demonstrates an understanding of the situation, as we have seen in relation to the protection of key local pharmacies through the community access scheme. For example, in my constituency, the services in places such as Elstree and Shenley, where we have small, rural communities, often with an elderly population, will be protected. Equally, the quality payment scheme recognises some of these wider community benefits.

However, I urge the Minister to do more in that area. Let me make two brief suggestions. First, we need more detailed recording of the sorts of services that are provided by pharmacies which take pressure off the NHS. As I understand it, there is no systematic way in which these additional benefits are recorded, and we are all working on the basis of estimates. We could have a system whereby the community pharmacies systematically recorded the benefit that they provided, and then they could be better rewarded for those benefits. At the same time, there would be a means by which we could penalise, or find further cuts from, the pharmacies that did not provide those additional services.

Secondly, the hon. Member for Central Ayrshire (Dr Whitford) rightly commented on the common ailments scheme that operates in Scotland. The Minister indicated that the Government are moving down that route. I urge the Government to go further on this. There is absolutely no reason why patients suffering from things such as common cold and flu symptoms or head lice could not be referred directly from their GPs to pharmacies, thereby saving money for GPs and providing additional income for those pharmacies.

I support the overall direction of reform, but as the Government proceed with these reforms, they could do with engaging more in looking at ways of supporting what is best in community pharmacies while providing further savings from the services that do not provide them.

--- Later in debate ---

[Maggie Throup (Erewash) (Con)]

As many hon. Members have already described, our community pharmacies play a vital role in all our communities. When my mum was seriously ill and housebound, her local pharmacist and all his staff were amazing. Nothing was too much trouble, whether it was changing her medicines at the last minute and delivering them to her home, or offering to deliver things like toothpaste and loo rolls at the same time. That is what community pharmacists are all about—being at the centre of the community, wherever they are.

Being part of the local community is even more important in rural areas, especially for the elderly who are often housebound, or have limited access to cars and so rely on public transport. That is why I welcome the pharmacy access scheme that the Minister has put in place. It should safeguard those pharmacies that are more than a mile apart and, more importantly, protect their patients. The Minister has gone further by adding in areas with high health needs. That must be welcomed, but I would like more specific information to help to reassure pharmacies in my constituency.

We all know that pharmacists can and want to do more. It is imperative that every community pharmacy across the country plays its part in providing first-class healthcare outside the hospital setting. Pharmacists are highly trained professionals with a wealth of knowledge that must be used to its fullest. As we hear time and again, our GPs are under a great deal of pressure. Our pharmacists are a group of professionals who can and do shoulder some of that workload. To name just a few of the services they can provide, they can give flu jabs, test cholesterol, monitor warfarin and check blood pressure. There is no reason why they cannot carry out other simple tests, such as point of care C-reactive protein tests to distinguish between viral and bacterial infections, and so play their role in combating antimicrobial resistance.

I have a request for the Minister. He should be more ambitious with the timescale for roll-out of the minor ailments service. We have already heard from the hon. Member for Central Ayrshire (Dr Whitford) about just how successful that service is in Scotland. We must combat any barriers that the CCGs put forward, as my hon. Friend the Member for Amber Valley (Nigel Mills) suggested.

The 18% increase in the number of pharmacies over the past 10 years has in many instances led to clusters of three or more pharmacies within just one location. Each gets a guaranteed payment of £25,000 every year regardless of the quality of service they offer, the number of prescriptions they process or whether increased capacity in the area was needed when they actually opened. I am sure many of my constituents will think that is wrong and wonder whether it is the right way to spend taxpayers’ money.

[Dr Philippa Whitford]

Does the hon. Lady recognise that pharmacies were allowed to open simply because they were willing to be open for 100 hours? The growth was random, and my concern is that this cut is random. Planning is the issue.

[Maggie Throup]

I completely agree that growth has not been controlled. We need to go back a number of years to learn from what happened and ensure it does not happen again. We also need to ensure that we put the right reforms in place now.

It is important that the £25,000, just for opening the doors, is not offered to other retail stores on the high street. It is vital we get the best possible deal for the taxpayer and the patient. The patient must be at the heart of everything. We must also remember that every pound saved by these changes will be invested back into the NHS. We need to get the important message out that, whether it is for cancer treatment or other life-saving treatment, every penny counts.

If the proposed reforms reward quality, pay pharmacists for their value added services and fully embed community pharmacists into the urgent care pathway, they will be welcome. However, we need to ensure they do what they are intended to do, and that we do not, as the hon. Member for Central Ayrshire said, end up with what we have now.