Branded Health Service Medicines (Costs) Regulations 2018

Lord Lucas Excerpts

Wednesday 20th June 2018 Lords Chamber

[Lord Turnberg (Lab)]

I want to restrict my observations to the case of the treatment of hypothyroidism, and elaborate just a little on the wise words of my noble friend Lord Hunt of Kings Heath.

We have here an unhappy coincidence of bureaucratic errors on the one hand and what can be described only as corporate greed on the other. The end result is that patients with hypothyroidism are suffering. I suppose that I should just say a little about this condition, in which these patients fail to produce enough of their own thyroid hormone, for one reason or another. Although I am no longer on the medical register, I do not feel too constrained: it causes a range of unpleasant symptoms and can be life threatening. It causes symptoms, some of which may sound familiar to your Lordships, including extreme tiredness and a general slowing down, which makes you gain weight, thickens your skin and makes you lose hair. It comes on insidiously, so that it can sometimes be difficult to diagnose. It is worth noting, as I think my noble friend said, that up to 5% of the population, or one in 20, are said to suffer from hypothyroidism—and, worst of all, it can cause heart attacks, if not treated.

Yet treatment is very easy indeed—just one tablet a day of the hormone thyroxine gets rid of all the symptoms and can make people normal again, which works for the vast majority. But here is the rub: a few patients do not feel better, and they need to take the more active metabolite of thyroxine, liothyronine, or T3, to make them well. There is some controversy over why some patients need that more expensive treatment. Do they have a problem with converting thyroxine to the active principle or not? That has not been resolved scientifically, but there is little doubt that, clinically, some patients get better only on the active metabolite, T3. That being so, clinicians should be able to prescribe it. Certainly, that is the case in many countries around the world.

Prescribing T3 here in the UK was never a problem until 2007, when the Canadian manufacturer, Concordia, got hold of it and was given the sole contract by the NHS to produce it. It was then that, as a monopoly supplier, it put the price up several-thousandfold, as we have heard, so that now the price has risen to over £900 for 100 tablets. Then, of course, NHS England found it increasingly unaffordable. So instead of trying to find cheaper suppliers, it put in draconian conditions on doctors under which it may be prescribed. On top of that, those conditions are so ambiguous that CCGs, GPs and consultants are fearful of prescribing it, so they have stopped. As we have heard, patients who have been on it for years now cannot get it and suffer the consequences. So what do the patients do? They go online and buy it privately in Europe for around €30, instead of £900 for 100 pills.

I have three questions for the Minister. Will the Government try to move the Competition and Markets Authority along after its preliminary hearing that the manufacturers should repay the several million pounds that they owe to the NHS? Will they consider purchasing the medicine from an alternative supplier, possibly elsewhere in Europe, for a fraction of the cost? Will he press NHS England to produce some straightforward, unambiguous guidance for patients and doctors about how it can and should be prescribed? I would be happy to help, if he would like that.

[Lord Lucas (Con)]

My Lords, I ask my noble friend to turn his intelligence and attention to how the NHS can get best value in the purchase of out-of-patent medicines, branded and generic. I have had the pleasure of reading the 2014 pharmaceutical price regulation scheme. If any noble Lord is in need of tickling his belly button with his jaw, I suggest that he does the same. It is the most astonishing system, guaranteed to produce lush profits for manufacturers, giving the NHS almost no purchase whatever on the price being charged. It is done in the name of promoting innovation and promoting the UK industry, but there does not seem to be the level of intelligence—meaning not mental intelligence but investigation and the understanding— that would be necessary to make sure that that was the case.

Health and Social Care Bill

Lord Lucas Excerpts

Monday 7th November 2011 Lords Chamber

[Lord Walton of Detchant]

My Lords, I shall be extremely brief in my contribution. As a former practising doctor and neurologist, I am fully aware of the immense distress and concern that patients, and often their families, have experienced as a result of medical accidents in the broad. It is clear that there are certain circumstances in which episodes construed as being so-called medical accidents have been the inadvertent effects of treatments that have had completely unforeseen complications, for which no one could possibly be held responsible.

When I was a young doctor, the medical protection groups—the Medical Defence Union and the Medical Protection Society—always recommended that if an error occurred, under no circumstances should one apologise in such terms as to constitute accepting liability. However, when I was president of the General Medical Council, the concerns that have been so eloquently expressed around this Committee, particularly by my noble friend Lady Masham in her opening speech, led to a gradual and significant change in attitude. After regular consultations with the medical protection bodies, the General Medical Council eventually recommended, and still recommends, a duty of candour on doctors to apologise and explain in depth if accidents and errors have occurred. This is, I believe, still part of the advice that the GMC gives.

Having said that, I understand and sympathise deeply with the purpose that underlies this amendment. However, in several respects it is very difficult to make its wording the basis of a statutory requirement. In particular, proposed new paragraph (b) states that,

“regulations are introduced to enable the Care Quality Commission to take action against a registered person or body who fail to disclose details of such incidents as set out in those regulations”.

This could cut across the responsibilities of the statutory regulatory authorities—the General Medical Council, the General Dental Council and the Nursing and Midwifery Council—and I simply could not accept the wording of that part of the amendment. Therefore, I have great sympathy with the view that something might well be done to reinforce the advice that is being given by a regulatory authority such as the GMC to enforce the duty of candour. However, sadly, the amendment in its present terms would not fulfil that very worthy objective.

[Lord Lucas]

My Lords, an apology is not, of itself, an admission of liability. I am very grateful to the noble Baroness, Lady Masham, for allowing me to put that into English law, if I can update the noble Lord, Lord Marks, on it.

I come at this question from a slightly different angle. My familiarity is with doctors who have blown the whistle and had their careers destroyed as a result. That, too, has its roots in a lack of internal candour. I want to see the health service become more constructively self-critical, and for the mistakes and wrong judgments that have been made to be the subject of ordinary conversations within a hospital or other medical organisations, so that better care is provided in the future. This is the way it is in schools. Teachers are generally pretty open about things that have gone wrong and look to find ways of doing things better, but they do not tell parents about it. You can look at schools that have improved from 20 per cent to 80 per cent of students achieving five GCSE grades of between A and C. The kids are the same and the intake is the same. That school has failed thousands of children but no one has ever admitted that to the parents, which is very hard to do. In fact, it would tend to freeze any kind of internal self-critical attitude, particularly if the duty was drawn as widely as it would be in this amendment.

I therefore find myself siding with the noble Lord, Lord Winston, in this, although I am very committed to candour. Candour needs to be there, particularly in something as dangerous as medicine, where you are skiing down the edge of a precipice for half the time. You cannot be blamed when things go wrong because mistakes are bound to happen under those circumstances. Downhill skiers crash; they do not intend to do that and are well trained not to—but it happens. This spreading of blame for every slight mistake or wrong judgment taken in the circumstances of surgery or something with a longer timescale, such as pharmacology, is not the right way to approach the issue. We need to find ways of being open and of encouraging professionals, in particular, to be open with each other in a culture of self-improvement. To expose all this to litigation and in effect to encourage patients to go to law whenever something goes wrong, under circumstances where it is inevitable that a large number of things will go wrong, would be a mistake.

[Lord Harris of Haringey]

The experience within the NHS is that people go to law only because they feel that that is the only way in which they are going to get some clarity into what has actually happened.