My Lords, the House will be grateful to the noble Lord, Lord Darzi, for repeating the Statement. I am sure that I will not be alone among your Lordships in having mixed feelings about the announcement that he has made. On one level, the Government are to be congratulated, as is Professor Mike Richards, on having grasped a very difficult policy nettle and come up with a way forward that they believe is workable. I certainly welcome the announcements on NICE appraisals, flexible pricing for new drugs and the core principles to guide PCTs in their decision-making. On another level, we are left with the distinct impression, despite the noble Lord's assurances, that the way forward adumbrated today on top-ups amounts to nothing less than a two-tier NHS, something against which all political parties have hitherto set their faces.
We are also left asking whether the Government have focused sufficiently on the real issue, which is surely: why are NHS patients in England not able to receive clinically effective treatments that are routinely available in other European countries free at the point of need? Against that background, I have a simple query to level at the Minister: is he or is he not in favour of top-ups? Does he believe that top-ups will be good or bad for the NHS? Obviously, from the point of view of the patient, there can be no disagreement: patients in this country want to receive clinically effective treatments. If there are clinically effective treatments that the NHS is unwilling to supply, the NHS should not stand in the way of patients who want to access them. I would not for a minute argue with that. Equally, if a patient chooses to purchase a drug privately for which the NHS will not pay, it is wrong that he should then lose all entitlement to his other NHS care. The wonder is that the Government have allowed that to happen in those instances where it has been reported.
However, is creating a two-tier NHS the right way to address the issue? Do not top-ups in one important sense represent a defeat? Does the noble Lord think that by allowing an NHS patient in an NHS bed to top up his care with his own money we can successfully avoid blurring the line between private and NHS care? As he will know, to blur that line risks giving rise to enormous public resentment, as well as, for practical purposes, an abandonment of one of the founding principles of the NHS. Personally, I am fearful of that prospect in the light of today's announcement, because I do not think that the occasions on which the right to top-up is invoked will be as rare as the noble Lord suggests.
There is one thing about which we should all be clear. The announcement made today will not rid us of the postcode lottery. Unless the Government make the proposed core principles statutory and mandatory, PCTs will still be able to decide for themselves what exceptional cases they are prepared to fund and what cases they are not. That means that gross disparities in NHS-funded care are bound to remain around the country. What additional action are the Government going to take to address that issue?
I have a number of more detailed questions for the Minister. Once top-ups, in any form, are allowed, there must be a concern that patients may be at risk of exploitation. We must avoid a patient being led to invest their own money in treatments that do not deliver the clinical results that the patient expects, with the result that he spends in vain a great deal of money—money that he might not have. What does the Minister propose to do to prevent this kind of risk and to enable patients to make a genuinely informed choice? In so far as patients may be charged by the NHS for the cost of administering a drug purchased privately, what arrangements will be put into place to ensure that these charges are fair and transparent and genuinely represent only the marginal costs incurred?
On a related issue, how are patients to be protected from unjustifiably high prices for the medicines that they buy? Once pharmaceutical companies know that patients can purchase a drug privately, and that they do not have to justify their products to NICE, what is to deter them from raising their prices to a level that exploits the desperation of patients? Equally, what is to deter PCTs from deciding not to fund a particular treatment, knowing, as they will, that the patient can pay for them privately? How will the advent of top-ups not lead, slowly and quietly, to large numbers of treatments no longer being available on the NHS at a local level?
I could ask several detailed questions about how a top-up is to be defined, which is a fairly basic question, but I shall focus on more substantive practical issues. Where a privately purchased drug has been administered, who will be responsible for follow-up care, and where does the financial liability lie if the clinician is negligent or incompetent? What will happen if, half way through a treatment, the patient no longer has the money to pay for it? What happens if, having commenced a treatment privately, the patient finds that it prolongs his life for much longer than he had budgeted and that he is spending money that he has not got simply to keep the treatment going? What action will the Government take to ensure that patients are properly advised before they decide to top up their NHS care privately?
Today's announcement will certainly come as a relief to patients who have been left in a state of uncertainty about whether they will be able to access certain drugs and still remain an NHS patient. To that extent, it is good news. Equally, however, we can surely no longer argue from today that treatment on the NHS is available based solely on need and not the ability to pay. Indeed, the Government have created a potentially awful muddle here. On the one hand, they think it right to exempt cancer patients from prescription charges. On the other, they know that the cost of that exemption—some £20 million—would be enough to fund all the requests that were turned down by exceptions panels in 2007 for drugs to treat rarer cancers, drugs that patients will in many instances find themselves paying for out of their own pockets and at considerable cost.
The Statement leaves unanswered as many questions as those that it purports to remedy. No doubt much of the detail will emerge, but the national debate on these questions is only just beginning.