GP Indemnity Costs: England

Steve Baker Excerpts

Wednesday 15th March 2017 Westminster Hall

[Mr Steve Baker (Wycombe) (Con)]

It is a pleasure to serve under your chairmanship, Mr Turner. I congratulate my hon. Friend the Member for Cheltenham (Alex Chalk) on his excellent speech and on securing this debate, and very much concur with what he said.

Before I go any further I should say that my wife is a general practitioner, a former Royal Air Force senior medical officer who now works as a locum for the Ministry of Defence. I should also say that any errors or omissions in my remarks are entirely my own; I only spotted this debate this morning so I have not had a chance to discuss the issues with my wife. The scale of indemnity fees and the rate of price inflation in them has been an occasional—possibly frequent—topic of dinner table conversation. It is quite clear that something is going on when we see such steep rises to such high levels.

I want to pick up on a few of my hon. Friend’s points. He made the point about GPs being the foundation; we cannot overstate that, particularly in the context of ever-increasing specialisation in secondary care. The point I wish to make to my hon. Friend the Minister is that it seems that, as secondary care becomes more specialist, the burden of diagnosis will increasingly fall on general practitioners. I have heard accounts, which I may relay imperfectly, of a thoracic problem, for example, being referred to secondary care; the consultant might exclude a heart problem, but then it has to be referred again to exclude a lung problem, and again for whatever it may be. My sense from listening to my wife and other GPs is that increasing specialisation in secondary care sometimes shifts the burden of diagnosis on to primary care.

It seems to me, if I may say so from the perspective of an aerospace engineer, that diagnosing people is a slightly less exact science than diagnosing machinery. That is partly because it relies on what people say about their own condition, and partly because it relies on their coming forward at the right moment in the development of their illness or condition. I wonder whether specialisation has led to a transfer of risk, which is material to premiums. I put that point to the Government; I appreciate that they might not be able to answer it today.

My other point is about the status of partnerships, which is both relevant to the future of general practice and tied into this subject. I have recently had occasion to discuss with a senior partner how it has become financially less attractive over recent years to be a senior partner. I have mixed feelings about that. One of the little discussed realities of the NHS is that general practice was never nationalised, so partnerships have always had this special status where they are private businesses tightly coupled to a state-funded and run NHS.

It seems that the problem of steeply rising indemnities is material to problems that partners face in continuing in business, often in ageing premises that they are locked into through mortgage conditions. If the Government intend for the partnership model to continue indefinitely, and if there is cross-party agreement on that, the cost of indemnity needs to be considered, along with a range of other factors in relation to that model.

My hon. Friend the Member for Cheltenham mentioned that he sees GPs as having a special status, and I think he is absolutely right on a number of levels. They are special in the sense of the GP’s place in the hearts of the public; special in the sense that, as specialism increases, so does the burden of diagnosis on them; and special in terms of the status they have as businesses operating within the NHS. More than that, as clinical commissioners, general practitioners now have the great burden of determining what care will be deployed where in the NHS.

It is proper that I restate that I have an interest in this, but I observe that the support being given in relation to GP indemnities is not being extended to the MOD’s locums at this stage. Armed forces personnel need healthcare too, and because of how armed forces medicine operates, the armed forces often need locums. I ask the Minister to consider the general point that the MOD might need the same support in relation to indemnity fees that general practice would enjoy everywhere else.

Finally, I do not think that this is a confrontational debate. We live in times when medicine has changed, people’s attitudes to risk have changed and the role of the GP is changing. We are all united—at least on this side of the Chamber, but I hope across it—in recognising that the Government are seeking to rise to all those challenges, and I look forward to hearing what my hon. Friend the Minister has to say.

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[The Parliamentary Under-Secretary of State for Health (David Mowat)]

It is a pleasure to serve under your chairmanship, Mr Turner, and I congratulate my hon. Friend the Member for Cheltenham (Alex Chalk) on bringing this really important subject to Westminster Hall this afternoon. The NHS spends between £1.5 billion and £2 billion a year on legal and indemnity costs. If we could find a way to spend that massive slug of money better, that would be better for patients and our constituents, and all that goes with that.

I will start where my hon. Friend started in his really lucid speech. We need to emphasise how much we value GPs, as all Members did who have spoken today. In a speech that I gave recently to GPs, I used a sentence from the foreword by Simon Stevens to the “General Practice Forward View”, and I will use it again now:

“There is no more important job”

in the country

“than that of the family doctor.”

I think that is very good—everybody is nodding, so I think we all agree. There is no harm in our reminding any family doctor who may be listening to this debate of the esteem in which they are held.

My hon. Friend the Member for Cheltenham made some interesting points about the potential for legal reform. We are consulting on that and I will say a bit more about what we are doing. I will give the House one statistic that stuck in my mind as I was preparing for this debate: for legal cases with awards of £10,000 or less, the average costs are three to four times higher than the actual amount paid to the patient. That is indicative of a broken system that we need to fix. He made a point about using the central scheme, which applies to hospital doctors, for GPs. That is an option, but as he also said, the three insurance organisations are non-profit-making, so it is not absolutely clear how it would help.

Another thing I was surprised about was an interesting point that my hon. Friend and, I think, the hon. Member for Burnley (Julie Cooper) made about the way in which costs are estimated for difficult and complex cases. We would all concede that it is right that we properly recompense people who have been damaged through negligence and so on, but one of the things that that is based on is private health insurance rates, not the NHS doing the work. I have discovered the reason for that: it is what was set out in the National Health Service Act 1948, which set up the NHS. We are looking at options around that, but the history of how that evolved and why it became the case is interesting.

[Mr Baker]

I am grateful for the opportunity to recommend an excellent book: “Working-Class Patients and the Medical Establishment”, by David G. Green, who now runs Civitas. It tells that history, and there are a great many similar examples where we might look at how we can reconnect the whole system with the patient.

[David Mowat]

I thank my hon. Friend for that intervention and for the interesting comments he made. He talked about the transfer of risk due to specialisation, which is an interesting concept. I will push back a little on that, however. Of the £50 billion of reserve that the NHS needs to hold for legal cases and compensation payments into the future, the vast majority is around maternity, because the money tends to be focused on babies who are injured and have to be supported throughout their life. I am not absolutely sure he is right about that concept.

My hon. Friend made a point about the status of partners in GP practices. Partners have unlimited liability unless they have indemnity, which potentially makes it less attractive to be a partner than a salaried GP. We are seeing that trend. There is a double edge to that, and I will not go into other aspects of how GP practices are structured, but increasingly—I do not know whether this applies to my hon. Friend’s wife—we are finding that things are working better with GP practices being put into hubs of 35,000 to 40,000 people. They are able to employ pharmacists and physios and do more things at scale than they could as a single GP practice or as a practice of two or three GPs, which has historically been the norm.

We are migrating over time from a position where we have 7,500 GP practices to one with something more like 1,500 super-hubs, but it is true to say that the contract position has not caught up with that, and it is a long road. Tomorrow, I am going to visit a hub in Dudley. Super-practices are emerging, which have tens and possibly hundreds of GPs who can provide services across much wider areas. That is a different model, and there is some evidence that such hubs can provide more career structure for GPs and the opportunity to specialise in a way that they have not been able to in the past.

[Mr Baker]

I must admit that I missed the Government’s plans to move to super-hubs. It sounds quite suitable for Wycombe. Without wishing to make this debate about my wife, she is with the Ministry of Defence. At the moment, the MOD is providing healthcare to units or stations, or whatever bases they may be. How would the super-hub proposal work with the armed forces?

[David Mowat]

I had forgotten to talk about MOD locums. My hon. Friend raised that issue, and I do not know the answer, but I will write to him and give him the information he needs, and he can talk to his wife about that. I was surprised by that example. I am sure that between the various parts of the Government, we can get an answer.

In the hour available to me, I will discuss in more detail the environment in which the NHS finds itself, the impact and the Government actions we are taking, but I will start with this: we all want access to justice. That is a fundamental of our country, and we should do or say nothing that causes people who have been badly treated to lose out. Lawyers have to be part of how they get access to justice, and that is right, but we also need to protect the viability of our NHS.

We are spending towards £2 billion a year in this area. That is £2 billion a year that we are not spending on nurses, doctors and the improvements we would all like to see. We often have debates about the level of NHS spend compared with other countries in Europe and different parts of the world, but one area in which we can say we are a leader in Europe is the amount of money we spend on litigation and all that goes with that. That is not because our NHS is less safe than other systems; it is to do with some of the points that were made earlier about the litigation culture that has built up. To an extent, that has been encouraged to build up because of our treatment of costs and some of those things. That spend of £1.5 billion to £2 billion has been increasing by something like 20% a year in the past three or four years. We cannot afford to continue to spend money in that way.

GPs are not the most expensive part of the system, but as my hon. Friend the Member for Cheltenham said, GPs typically have to spend £7,900 out of their own pocket on indemnity. That figure is increasing by 10% a year. Indemnity costs for GPs who do out-of-hours work are increasing by 20% a year, which has knock-on effects for the attractiveness of that work. As we discussed earlier, it also impacts on people in other ways, such as propensity not to become partners in GP practices.

What has made the acceleration in legal costs evident is not so much the major claims that everyone would agree need to be sorted out and dealt with—for example, babies who are damaged at birth and need to be looked after for their entire life—but the significant increase in the number of minor claims, which tend to have a higher proportion of associated legal costs. As I said, claims of around £10,000 would typically have legal costs in excess of three times the amount that the patient would receive. My hon. Friend the Member for Cheltenham said that many claims are successfully defended, and the fact is that 99% of all claims are settled out of court. There can be a tendency to settle minor claims for relatively small amounts—claims under £100,000—just because of the volume that are coming in and because it is cheaper to settle than fight to the end. All of that takes money out of our NHS.

We have talked a little bit about why this is happening. The life expectancy of people with complex needs is increasing, so if someone is damaged at birth, typically the awards they need go on for much longer than in the past. That is a good thing in terms of life expectancy, but it drives cost. There is a view that the best-quality care becomes more expensive. Technology is a part of that. We also have an environment in which, for whatever reason, there has been an explosion in small claims against the NHS, which particularly affects GPs, and there is a legal environment in which even unsuccessful claims or claims without merit can sometimes be rewarded. All of that is made worse, as we have heard, by the change to the discount rate made by the Lord Chancellor, which will come into effect next week on 20 March.

The time value of money essentially was 2.5% and is now going to be -0.75%. That will have a significant impact on all insurers in the private and public sectors. It particularly affects the health sector. The £59 billion reserve that the NHS has for central litigation costs will increase because of the change that has been made by something in excess of £5 billion or £6 billion. Those are significant and serious sums of money in the public purse. The Government’s position is that doctors will not have to pay as a consequence of the technical change in discount rate. We are working through how that will work in the central litigation authority and the three insurance companies that my hon. Friend the Member for Cheltenham mentioned. Nevertheless, the cost is significant in the context of all the other pressures on the health system.

A couple of Members talked about the fact that the issue affects not only doctors in primary care but pharmacists. Increasingly, clinical or prescribing pharmacists are working in primary care and they need indemnity, as do nurse practitioners. We need to remember that that is all part of the picture.

Oral Answers to Questions

Steve Baker Excerpts

Tuesday 7th February 2017 Commons Chamber

[Mr Hunt]

May I gently tell the hon. Lady that I do not think our debates on the NHS are helped by her taking my comments out of context? I was quoting Chris Hopson, from NHS Providers, talking about a specific week when he said there were, in that week, a small number of incidents. We recognise the pressures across the NHS, which is why this Government are backing the NHS with record funding.

[Mr Steve Baker (Wycombe) (Con)]

A small business in my constituency was driven out of business by slow payments for relatively small sums by NHS providers. Will he ensure strict compliance with the guidelines for timely payments?

[Mr Dunne]

My hon. Friend will be aware that best practice for NHS bodies is to pay within 30 days. I am pleased to be able to tell him that figures for the quarter ending in September show that the Department of Health paid 98.4% of our bills within five days—one of the best performances across government.

Breast Cancer Drugs

Steve Baker Excerpts

Thursday 26th January 2017 Commons Chamber

[Mr Steve Baker (Wycombe) (Con)]

I congratulate the hon. Member for Mitcham and Morden (Siobhain McDonagh) on securing the debate. Like other hon. Members, I am here today to represent my constituents’ concerns. I should say from the off that I join the cause to make Kadcyla more available.

When my staff and I were discussing the correspondence about the debate and particular constituency cases, we quickly agreed that this is the worst sort of correspondence that we receive—when people are terminally ill but unable to access the medicines that they need. The subject is particularly acute—I do not think that I am the first Member to struggle to keep a quaver out of my voice—because my mother-in-law died of secondary cancer. These things will stay with us all. None of us can know what ladies who are currently suffering from these diseases are going through, but when we have seen it at second hand, we all want to live in a world where the NHS does not have to practise any rationing.

I want to focus on that point because, as the hon. Member for Coventry South (Mr Cunningham) said, the problem is intractable. I know about some of the great difficulties in bringing forward Abiraterone to help men, in a similar set of circumstances, suffering from prostate cancer. In a sense, I sympathise with the Minister and with NICE because they have an extremely difficult task. While it is easy for all of us to say that of course Kadcyla should be freely available to all those who need it without restriction, I am well aware that the problem is long-standing and applies to many innovative pharmaceuticals.

I also appreciate that it is no comfort whatever to sufferers of various cancers to know that a profit-making pharmaceutical system has a far better record of innovation than the alternative planned systems. I wish the Minister every success in her crucial task of working out how to ensure that innovative medicines come forward at a lower cost and a greater rate.

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[Martyn Day]

I do indeed join my hon. Friend in those comments.

A new and ambitious Scottish cancer strategy, launched in 2016, aims to stop anyone dying from breast cancer by 2050, and breast cancer is of course a priority in the Scottish Government’s Detect Cancer Early initiative. We need to do many things to move forward in that direction.

No debate seems complete these days without reference to Brexit, and this issue is no exception. The Health Secretary has stated that the UK will not be in the European Medicines Agency. If so, there could be implications for the way in which medicines are regulated, and marketing authorisations will be required from the Medicines and Healthcare Products Regulatory Agency for the UK. I am in no doubt that the implications will be less efficiency and possibly longer processes for obtaining authorisations, resulting—I fear—in innovative drugs taking longer to reach patients. Some industry leaders predict delays in the region of 150 days, based on the examples of Switzerland and Canada.

According to a piece that appeared last year in the Financial Times, when Sir Michael Rawlins, chair of the MHRA, was asked whether it would be able to take on all the extra work registering new drugs and medical devices currently carried out by the EMA, he said, “Certainly not”. It seems that considerable investment and recruitment will be required to re-establish it as a stand-alone national regulator. I am keen to hear from the Minister how delayed drug access for UK patients will be avoided.

[Mr Baker]

I have listened carefully to the hon. Gentleman, and of course he raises a perfectly reasonable concern, but the campaign director of Vote Leave had, as one of his particular bugbears, the costs associated with the clinical trials directive and its prejudicial effect on innovation in medicines. I hope that the Government can find a better way through than the previous system and that, in leaving the EU, we will not only solve the problem of the EMA but have a better regulatory system afterwards.

[Martyn Day]

I thank the hon. Gentleman for his intervention, and I look forward to hearing the outcome.

In conclusion, with regards to Kadcyla, I hope the company’s resubmission to the Scottish Medicines Consortium is at a fair price to allow it to be considered for approval for use in the NHS in Scotland. It would give people across Scotland the opportunity to benefit from more treatment options and could give them precious extra time with their families and loved ones. The Scottish Government, the SMC and the NHS have worked hard to reform access to new medicines, but we now need pharmaceutical companies to do their bit by bringing forward much fairer prices for new medicines, so that access is as wide as possible for the people of Scotland. Cost-effectiveness is a key marker in ensuring that drugs are routinely available in the NHS, and I take the opportunity to emphasise that point to the pharmaceutical industry in general.

Oral Answers to Questions

Steve Baker Excerpts

Tuesday 20th December 2016 Commons Chamber

[Mr Hunt]

We do indeed have superb clinical leaders, such as Marianne Griffiths at Worthing, which was recently given an outstanding rating. We also have superb non-clinical leaders, such as David Dalton at Salford Royal. I would gently say to the right hon. Gentleman that if he is worried about funding, why did he stand in the election on a platform that would have seen the NHS have £1.3 billion less this year?

[Mr Steve Baker (Wycombe) (Con)]

Will the Secretary of State ensure that clinical leaders are able to apply important techniques from other disciplines, such as lean production, which can drive up productivity?

[Mr Hunt]

My hon. Friend is absolutely right. Clinical leadership is important, but so is openness to the skills of other industries—particularly engineering skills, with which he is very familiar—that can help us to get processes right so that we improve care and safety for patients.

Community Pharmacy in 2016-17 and Beyond

Steve Baker Excerpts

1st reading: House of Commons
Thursday 20th October 2016 Commons Chamber

[David Mowat]

This is the first time ever that we have given pharmacies a two-year planning horizon; usually, these negotiations relate to a one-year period. After the completion of this period, there will be further negotiations, at which point we will take forward what is right to do.

[Mr Steve Baker (Wycombe) (Con)]

I congratulate the Minister on the way he has sorted out this mess. Is this unnecessary and wasteful clustering of pharmacies not a direct consequence of the former Labour Government’s broken payment model?

[David Mowat]

I am not sure that takes us forward, but it is right to say that spending NHS money on payments of £25,000 to many pharmacies within half a mile of one other is the wrong way to spend money when we need more in cancer drugs funds, in GP surgeries and in accident and emergency—that is what we need to be doing.

Oral Answers to Questions

Steve Baker Excerpts

Tuesday 11th October 2016 Commons Chamber

[Mr Dunne]

We have provided access for seven of the worst affected trusts with obligations under PFI to a support fund of some £1.5 billion to help them with those obligations. I am not sure whether Norfolk is one of them; I suspect that it is not. I would be happy to talk to the right hon. Gentleman about this, but rather than raising his hopes inappropriately I have to say to him that many of the schemes are too costly to divert resource to pay them off completely.

[Mr Steve Baker (Wycombe) (Con)]

5. If he will take steps to ensure that clinical commissioning groups publish their proposals for implementing the NHS “Five Year Forward View”.

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

The “Five Year Forward View” will be delivered through sustainability and transformation plans which are currently being developed by clinical commissioning groups in collaboration with local authorities and providers. NHS England expects that all STPs will be published, although in some areas discussions are already taking place.

[Mr Baker]

I am led to understand that in Wycombe we should expect no dramatic changes and possibly no publication of a strategic plan. Does my hon. Friend agree that public confidence would be much enhanced by the clear articulation in public of a strategy for meeting the “Five Year Forward View”?

[David Mowat]

I agree with my hon. Friend, and I will try to give a clear answer. NHS England is determined that all 44 areas will publish their plans shortly. For those that have not already done so, publication will take place after the formal checkpoint review at the end of October. Areas are working to different timescales, but the plans will all be published by the end of November. For the avoidance of doubt, that includes the STP for Buckinghamshire, Oxfordshire and Berkshire West.

Oral Answers to Questions

Steve Baker Excerpts

Tuesday 10th May 2016 Commons Chamber

[Mr Hunt]

I can reassure the hon. Lady that we have been monitoring the situation closely and have provided extra capacity at the Royal Preston hospital. Her own Royal Lancaster infirmary has recently come out of special measures and done a really good job in turning round the quality of care after protracted difficulties. We continue to monitor the situation, and patient safety is our No. 1 priority.

[Mr Steve Baker (Wycombe) (Con)]

Following centralisation and specialisation processes to drive up the quality of clinical care, we now have patients presenting at minor injuries units and urgent care centres with conditions that need to be treated elsewhere. Will my right hon. Friend take steps to ensure that those centres own the patients’ experience once they have presented, so that we never again have a patient with a serious illness being sent out to make their own way to A&E?

[Mr Hunt]

As ever on health matters, my hon. Friend speaks wisely. The fundamental issue is a high level of confusion about what happens to patients when they are faced with a bewildering choice about what to do when they have an urgent health need that needs resolving. They can call 111, try to get an urgent GP appointment, go to a walk-in centre, go to A&E and many other alternatives. We need to resolve that and make it simpler for patients so that they go to the right place first time. Urgent work is happening to ensure that we do that.

Junior Doctors Contracts

Steve Baker Excerpts

Monday 25th April 2016 Commons Chamber

[Mr Hunt]

Let me gently tell the hon. Lady the facts about what the contract involves. It involves the maximum number of hours that any junior doctor can be asked to work in any week coming down from 91 to 72. It involves reducing the number of nights and long days they can work, as we discussed earlier. It is a safer contract. The reason morale is low is that, rather than negotiating sensibly, the BMA has gone for an outright win, which was a very big mistake. We could have had a negotiated solution a long time ago. In that situation, a Health Secretary has to do what is right for patients, and that is what we are doing.

[Mr Steve Baker (Wycombe) (Con)]

I have long found that the BMA is not universally admired by doctors, perhaps because of its long history of putting doctors’ interests ahead of patients’ interests. Will the Secretary of State ensure that he does not inadvertently drive doctors into the arms of the BMA, and will he look into adopting some of the old left ideas of mutuality, which would reconnect doctors to the interests of their patients?

[Mr Hunt]

My hon. Friend and I have discussed that recently, and I do think that the mutual structure is something we should be open-minded about. When junior doctors go on to the new contracts, which will happen in stages starting this August, they will find that it is safer and better and that they have more predictable shift patterns. It will enable them to have a better quality of life. Then they will realise just how badly represented they have been by the BMA.

Community Pharmacies

Steve Baker Excerpts

Tuesday 23rd February 2016 Westminster Hall

[Huw Merriman (Bexhill and Battle) (Con)]

It is a pleasure to serve under your chairmanship, Mr Streeter. I congratulate my hon. Friend the Member for St Ives (Derek Thomas) on introducing this important debate.

Some 28% of my constituents, across our 200 square miles of East Sussex, are over the age of 65. Losing our pharmacies would affect all my constituents, but I am particularly concerned about the impact on the elderly and vulnerable. I spoke today with a pharmacist in the village of Ticehurst in my constituency, who told me about his concerns. First, he is concerned that the Government might cut 6% from his dispensing fees. Secondly, he is concerned that they might withdraw the £2,500 that all pharmacists are paid annually. Thirdly, he is concerned that the Government might impose a clawback, meaning that if a budget is overspent, pharmacists might be required to reimburse their fees. Fourthly, he is concerned that the pharmacy will have to cover the welcome introduction of the national living wage and the cost of new pension arrangements.

I understand that it is essential for the NHS to make savings—£22 billion over this term—and it therefore seems reasonable to expect the £2.8 billion pharmacy budget to contribute to that. The Government rightly point out that many of our pharmacies are situated in walking distance clusters, but I am concerned that the proposed funding changes, if not sensibly targeted, could affect not just pharmacies in clusters but the rural pharmacy that is miles from another one and more than just a dispensing chemist. Because a pharmacist knows his or her customers, he or she is able to advise them on solutions more cost-effectively than if they were to utilise the wider NHS, including GPs and A&E.

[Mr Steve Baker (Wycombe) (Con)]

In an unscientific Twitter survey, which I kicked off at the beginning of the debate, 62% of respondents say they would prefer to see a community pharmacist first. Does my hon. Friend agree that the Government should be clear when making their funding allocation about the extent to which people would prefer to make use of community pharmacists before they see GPs?

[Huw Merriman]

Much as I prefer to disagree with everything that is said on Twitter, I could not disagree with that particular scientific survey.

Access to Medical Treatments (Innovation) Bill

Steve Baker Excerpts

Friday 16th October 2015 Commons Chamber

[George Freeman]

I made the point earlier that the barriers to access of innovation are much broader than the fear of litigation, and I am happy to reinforce that.

[Mr Steve Baker (Wycombe) (Con)]

The Minister will know that in the treatment of wet AMD Lucentis costs £700 an injection and Avastin £60. Does he think the Bill could help clinicians use Avastin to treat wet AMD, thereby saving the NHS, I understand, some £84 million?

[George Freeman]

My hon. Friend is quick to leap on to a very important point. The answer is no, because in law we have an important provision to protect people who invest billions of pounds in developing new innovations. Clinicians are free to use alternative off-label drugs where there is evidence they work, but not on the basis of cost. We have a presumption in law that where a drug is licensed or on patent for a particular indagation, which is the protection for the company that has invested to bring the drug to market, we allow an alternative to be used only where there is clinical evidence, not on cost grounds. The price falls dramatically when drugs come off patent and the generics industry picks them up. There is price protection for a short period of patent life to create the incentive for people to make the extraordinary investments up front. We then get the benefit of cheap drugs through the generics sector.

[Mr Baker]

The Minister raises a critical point. I am concerned that cost grounds do matter and that some people might be going without early treatment for wet AMD, because they cannot, for a range of reasons, access Avastin. My concern is that people might be going untreated for wet AMD at a point when the relevant drug, Avastin, might help them more than Lucentis at a later stage.