Hypothyroidism

Steve Brine Excerpts

Monday 21st May 2018 Commons Chamber

[The Parliamentary Under-Secretary of State for Health and Social Care (Steve Brine)]

I thank the right hon. Member for Twickenham (Sir Vince Cable) for giving us the opportunity to debate this issue. It is unusual for a party leader to lead an Adjournment debate; indeed, this is certainly a first for me. I just note that point. I pay tribute to him and the hon. Member for Strangford (Jim Shannon), who as always is in his place and intervened in the debate. They spoke passionately on behalf of their constituents affected by this condition.

Hypothyroidism—hypo is different from hyper, as the right hon. Gentleman rightly said—is a debilitating condition, caused by a deficiency of thyroid hormone that affects at least two in every 100 people. It is therefore not rare, and it can lead to depression, severe tiredness and weight gain, with all the associated health implications that we know about. The symptoms can affect every area of someone’s life, affecting their ability to work, to play a role in society and to lead any sort of full social and personal life.

It is important for people to have the drug that is most effective in treating their condition. Levothyroxine is beneficial for the majority of patients with the condition but does not treat the condition in all patients. For some, the alternative drug at the centre of the right hon. Gentleman’s opening remarks—liothyronine—better alleviates symptoms.

Let me say up front that, if people have a clinical need for a medicine, it is right that they get the most appropriate medicine for their condition. It is certainly not the Government’s intention to deny someone the correct treatment. Indeed, the basic principles of our national health service are based on the provision of the right care and treatment, free at the point of delivery, paid for by general taxation. That is correct and how it will remain.

Under their terms of service, GPs are allowed to prescribe any product, including any unlicensed product, that they consider to be a medicine necessary for the treatment of their patients under the NHS, subject to three provisos, the first of which is that the product is not included in what is commonly referred to in the NHS as the grey and black lists—the list of drugs which have national prescribing restrictions placed on them. The second proviso is that the local clinical commissioning group is prepared to fund the treatment. They are the commissioners of treatment, which the House decided through the Health and Social Care Act 2012, under the Government in which the right hon. Gentleman served. The third proviso is that the GP is prepared to provide a clinical justification to any challenges to their prescribing.

Although prescribers such as GPs should consider the cost of a medicine, their first consideration is the individual clinical needs of patients and the most effective options for meeting those needs. However, it is in all our interests that the NHS drives maximum value in delivering its essential services, including by using the most cost-effective and safe medicines for patients. As has been mentioned this evening, NHS England guidance following its consultation on

“items which should not be routinely prescribed in primary care”

said that liothyronine should not be prescribed routinely due to its significantly higher cost. I should make it clear that that decision was also based on insufficient evidence of the clinical effectiveness of liothyronine, either alone or in combination with levothyroxine.

The NHS England guidance was developed, as we would expect, in partnership with NHS clinical commissioners on behalf of the clinical commissioning groups that they represent, based on the latest clinical evidence, including that from the National Institute for Health and Care Excellence. Practising doctors and pharmacists were involved in the development of the guidance throughout.

The proposal that liothyronine should not be routinely prescribed caused significant and understandable concern among patients who had been prescribed it. NHS England listened carefully to those concerns during its consultation on the guidance, and as a result, the NHS England board has decided that liothyronine should continue to be prescribed for a small cohort of patients for whom the first-line treatment—levothyroxine—does not alleviate symptoms and has advised that it should be initiated in secondary care only.

NHS England’s final commissioning guidance is addressed to clinical commissioning groups to support them to fulfil their duties on the appropriate use of prescribing resources. As part of issuing the final guidance, I am assured by NHS England that careful consideration was given to all responses to the consultation to ensure that particular groups of people are not disproportionately affected and that principles of best practice on clinical prescribing are adhered to.

NHS England expects, as do the Government, clinical commissioning groups, which have responsibility for commissioning services, to take account of the guidance when determining their local prescribing policies. I cannot comment on the situation in Strangford, but I understand that the south-west London clinical commissioning groups are reviewing local arrangements. The review will include close working with consultants in south-west London hospitals and build on the recent NHS England guidance. It will consider whether GPs as well as hospital consultants—primary as well as secondary care—should initiate prescribing of the drug. It will also consider which categories of patients should be prescribed it. I am sure the local clinical commissioning groups will ensure that the right hon. Gentleman is fully apprised of the outcome. I will ask them to ensure that he is fully apprised every step of the way.

Let me now turn to the other issue raised this evening concerning liothyronine: the significant increase in its price. Liothyronine is an unbranded generic medicine. For unbranded generics, the Government encourage competition between suppliers to keep prices down. However, as we know, Concordia—the manufacturer—is currently the subject of an investigation by the Competition and Markets Authority over how much it was charging the Government and taxpayers. As the right hon. Gentleman said, the CMA has provisionally found that Concordia abused its dominant position, overcharging the NHS millions of pounds for its tablets.

As the right hon. Gentleman rightly put on the record, the CMA’s findings are provisional at this stage. There has been no definitive decision that there has been a breach of competition law, and the CMA will carefully consider any representations from the companies concerned before deciding whether the law has in fact been broken. Where companies have breached competition law, the Department of Health and Social Care will seek damages and invest that money back into the NHS. That was one of the right hon. Gentleman’s questions, and the answer is an unequivocal yes. This is why we refer such issues to the CMA.

I am pleased to note that there are now multiple marketing authorisations for this drug. Increased competition usually leads to a more resilient supply chain and lower prices—one of the right hon. Gentleman’s other concerns. However, we will watch this carefully and will consider referring the matter to the CMA again if competition does not bring the price down.

It is not often that we hear a Liberal in this House quote the qualities of Enoch Powell—he is not often talked about in new Richmond House—but I take the right hon. Gentleman’s point. I will look into the issue of overseas imports and write back him on it. He also mentioned the Health Service Medical Supplies (Costs) Act 2017, which does not come into force until this summer. Officials who report to me are very much ready to go when that legislation comes into force. I thank the right hon. Gentleman for speaking on behalf of his constituents and many others. This subject has not had a hearing in this House during my time here.

The total medicines spend in England for the years 2016-17 was £15.4 billion. That is the second biggest area of NHS spending after pay. Access to treatment is, and always will be, a priority for this Government. I hope that some of the answers that I provided tonight have helped the right hon. Gentleman in his investigations; I will write to him with more.

Question put and agreed to.