§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Wills.]
§ 10.11 p.m.
§ Dr. J. Dickson Mabon (Greenock)
I wish to raise the matter of multiple packs particularly in relation to four categories of patients. On 1st December, 1956, the new National Health Service regulations, involving a basic charge of 1s. per item, became operative. In the debate in the House on 29th November, we received assurances on all sides of the House—because this is a matter which concerns hon. Members on all sides—that the effect of the new regulations on the chronic sick would be kept under review by the various Government Departments—the Department of Health for Scotland and the Ministry of Health covering England and Wales.
We were also told that, wherever possible, any further suggestions abut multiple packs—in particular ones made in the debate on 29th November—would be considered. I understand that up to the present time we have seen adopted, or proposed to be adopted, one more new multiple pack and that is concerned with the treatment of boils and carbuncles. I believe that it will come into operation in the spring of this year, but I have no doubt that the Joint Under-Secretary of State for Scotland, who will be replying to this debate tonight, will give us some precise indication.
1388 It is legitimate for hon. Members on both sides of the House to complain about the long delay there has been in giving us some idea of what was happening in relation to multiple packs. Fourteen months is a long time when one considers the effect this is having on quite a number of people who suffer from chronic sicknesses. I personally do not agree with the concept of multiple packs. I think that this idea is not good for the practice of medicine. Clearly, it puts into a strait-jacket the kind of régime which different doctors might wish to apply in varying ways to particular patients. After all, the concept of multiple packs was really a mechanism resorted to by the Government to alleviate the hardship which they feared might fall consequent on the passing of the regulations on 29th November.
I am mentioning in this debate four categories of patients not because they are the only ones embraced in the phrase "chronic sick", but because they represent, fairly I think, the different kinds of sicknesses that have to be looked at in terms of a multiple pack. The common factor about the four kinds of patient which I have mentioned—the diabetic, tubercular, colostomy and cardiac patients, is that they are chronic sick and can reach a state of stabilisation in their régime where they are getting the same drugs and materials for two or three months at a time. That lends itself to the idea that if a quantity is being regularly prescribed and, in medical terms, the patients are stabilised, it may be administratively possible to prescribe for long periods, or for a number of commodities collectively at any one time.
I should like specific answers, if it is possible, about these four categories, because they are varied. I could have mentioned cancer and other diseases, but I have omitted them because of lack of time. For instance, colostomy requires four things. There is, of course, replacement of the colostomy belt, and I have no quarrel with the provisions for that, but a colostomy patient also requires 1389 cotton wool, plastic packs and cellulose wadding. Surely it does not defy our administrative ability here to find a way of securing a multiple pack which would cost 1s. a time instead of, as at present, paying 1s. an item.
Similarly with diabetics. I am told that there are so many kinds of insulin that it becomes difficult to find ways and means of putting them into a multiple pack, but a stabilised diabetic has the same kind of insulin for two or three months. If he breaks down, he naturally returns to his diabetic clinic or to his physician to be reassessed, and if he does not break down he receives the same dosage every day or so and follows the same regime. At present, he has to purchase syringes and needles at 1s., urine testing set for 1s., pays 1s. for cotton wool, 1s. for surgical spirit and 1s. for the insulin, which is not always supplied in large quantities. It would not be desirable to supply it in very large quantities, but a month's supply could be given.
I have asked about tuberculosis specifically because of the Scottish context. I am glad to say that in Scotland we have a very lively campaign at present for picking up tuberculosis contacts. A large number are treated at home and because of that we are having to use three new tuberculosis drugs in very large quantities. In Scotland—it may not be the case in England—it might be feasible to have multiple packs of these drugs, particularly those which are taken orally as distinct from those prescribed for injection.
I have included the last category of cardiacs because I feel that here is a subject which administrative endeavour has left unexplored. There are two kinds of chronic cardiac. Some require a régime of digitalis and a mercurial diuretic. Those two drugs, prescribed regularly, might be given in a multiple pack.
In the debate to which I have referred, my hon. Friend the Member for Kirkcaldy Burghs (Mr. Hubbard), who has suffered from coronary thrombosis, outlined the six drugs which I know he takes regularly and which fend off any future attack which might occur. In a most interesting speech, he discussed diabetes in the same context, because he is also a diabetes sufferer. I can confirm that he takes the six drugs he mentioned. There must be a number of people with 1390 coronary thrombosis, which is so widespread that it would be very important for them to have multiple packs.
I began by saying that I do not agree with multiple packs, but the point of it all is that the premise upon which we have to have multiple packs is one that was offered to us by the Government. I do not want to quarrel with the idea, because I wish to hear what the Government have to say in relation to these four categories, but if we are to have multiple packs or some other form of removing the hardships consequent on the passing of the regulations fourteen months ago, may not some other suggestion be considered?
I should like to put forward two possible alternatives to help the Government, which, at the same time, might possibly meet the difficulties arising in the cases of the chronic sick. Is it not possible for the Department and the Ministry to lay down a rule that doctors can prepare a multiple pack from lists of variants? That is to say, that the doctor will have a list of the commodities which he is able to prescribe, and the various items could, in effect, be prescribed as a multiple pack. All the patient would have to do would be to go to the chemist, who would have all the items listed on the form E.C.10, and be able to work out the permutation of the permitted items.
There is a host of such variations, and I think it is well worth while looking at whatever administrative difficulties there may he so that a doctor should he allowed, from the list of drugs, bandages, and so on, to prescribe them in a certain series which will be considered by the Department and the Ministry to be, in effect, a multiple pack. From the point of view of the chemist, there should be no difficulty, because the chemist will be taking these items from the stock in his shop. May I make another suggestion?
Would it be possible for the Department to think about the position where a doctor could certify that a patient is a chronically sick patient, and that he will be for the next two or three months on a certain régime of medicine and materials? The doctor could so certify that, and the certificate could be sent to the National Health Service executive committee, which would issue a registration card to the patient showing that he 1391 is chronically sick and giving him a number. This would be marked on the form E.C.10, so that the prescriptions regularly given by the doctor will clear him of any charge, or, at any rate, make him eligible only for the charge of 1s.?
I do not know whether these suggestions are particularly good, but I certainly would like to think that something like that was being considered. Either the Government are sincere in trying to get the multiple pack or some other system in operation to relieve hardship or they are not, and I should like to believe that they are genuinely trying to find a way out of the difficulty. If it is true that there is a difficulty in getting the medical profession, through the British Medical Association, to agree—though it is difficult to get agreement here, and I can quite understand why that is so—surely it is not impossible for the Department to suggest other solutions which might find acceptance with medical people.
The whole idea of this multiple pack and of the regulations concerning it which caused this development to emerge, was economy. While I do not have with me the figures for Scotland and Wales tonight, and I regret this, I have the figures for England in relation to comparable periods of nine months in 1956 and nine months of 1957 up to September. The period of nine months in 1956 was free of the charge and only carried the single 1s. charge, but the period of nine months in 1957 carried the charge of 1s. per item.
It is interesting to look at the figures for England. I do not think that England will necessarily be a bad reflection of performance in Scotland, although that may be a point of comment. I am prepared to accept the fact that England is a mirror of reflection of performance in the whole of Great Britain in this matter. The Minister may say, "This system and these regulations have reduced the total number of prescriptions from 160 million in the nine-months' period of 1956 to 139 million in the comparable nine months of 1957." That would be a legitimate point for the Minister to make.
But if he takes the real figure—and the Health Departments must know that this is true—he will find that the average total cost of each prescription for the two nine months' periods are 55.96d. and 70.16d. 1392 respectively for 1956 and 1957. That shows a substantial increase in the actual cost of the prescription. In other words, we are not defeating the rising costs of prescriptions in the National Health Service, which was what the Government intended to do. I am at one in this respect with the Government; I think that we can make an earnest effort to delimit the cost of drugs in the National Health Service.
I think that there is a great deal of hidden abuse, but it is not at the patients' end, nor do I think that these are difficulties which doctors experience because of a voluntary non-salaried service. I believe that the weaknesses lie within the operations of the drug companies. The waste in the field of competitive research is terrific, as is the advertising. That is what the Government should tackle. I do not want to raise the general context of the whole matter, although I have to do so to some extent to provide the background for the debate. I am interested to know—as are many of the chronically sick—what has happened about the multiple packs that were going to be made available under this or some other system.
§ 10.27 p.m.
§ Dr. Edith Summerskill (Warrington)
I should like to emphasise the importance of this matter. Like my hon. Friend the Member for Greenock (Dr. Dickson Mabon). I cannot understand the delay. I raised this matter months ago. This is a plea on behalf of some of the most tragic patients in the country—people suffering from diseases which must necessarily shorten their expectation of life. Consequently, they are just the people who cannot wait. Yet, although the Government have had this matter brought to their attention time after time—not only the Joint Under-Secretary, who is new here, but previous Ministers of Health—and although we have been given a half-promise, still nothing is done. I should like the Minister to tell us why there has been this delay, and when we may expect action to be taken.
§ 10.28 p.m.
§ The Joint Under-Secretary of State for Scotland (Mr. J. Nixon Browne)
I am grateful to the hon. Member for Greenock (Dr. Dickson Mabon) for providing this opportunity to discuss the question of packs for colostomy, diabetic, tuberculosis 1393 and cardiac patients, with whom we all have great sympathy. At the start I should like to make it clear that there is no question of these patients not having prescribed for them the medicines and equipment that they need. The doctor can and does prescribe all that they require. The question of packs concerns rather the 1s. charges that the patient has to pay: if what he needs is prescribed as a series of single items then he has to pay 1s. for each: if they are included in a multiple pack they are prescribed as one item and only 1s. is, is payable.
On the general question of the 1s. charge the justification for that was, as the hon. Member will remember, very fully debated in November, 1956, when the Regulations concerned were before this House. In our view these 1s. charges, together with the arrangements—which are very important—for refund in needy cases, represent a reasonable way of obtaining a contribution from patients who benefit; a contribution which goes some way to meeting the rising cost of the drug bill, about which we are all so concerned.
At the time the charges were introduced in December, 1956 ten multiple packs were already on the market and we provided for these composite packs being charged at 1s. each. Therefore it is not correct to say as the hon. Gentleman says that these multiple packs were devised as a consequence of the change to the 1s. charge per item.
§ Dr. Dickson Mabon
All these multiple packs are really dressings. They do not face up to any disease. They are really surgical dressings.
§ Mr. Browne
I am simply saying that they were not devised as a consequence of the 1s. per item charge.
Examples of these packs are the syringe and spare needles for diabetics, the vaporiser set for bronchitis patients and the multiple pack dressings for minor wounds.
My right hon. Friend the Member far Thirsk and Malton (Mr. Turton) who was then Minister of Health said:The conditions governing the creation of multiple packs are that the articles must be frequently prescribed at the same time and sufficiently often prescribed to make it worth 1394 while for the manufacturers to make up the packs."—[OFFICIAL REPORT, 29th November, 1956; Vol. 561, c. 716–7.]He also said that the British Medical Association had been asked whether it could suggest any further multiple packs, and that if any were suggested he would at once approach the manufacturers.
The Health Departments have since been trying to devise further packs for chronic sick patients and in this they have had the help of the British Medical Association which, I believe, consulted some of the local medical committees. Since my right hon. Friend made this promise, this question of multiple packs has been constantly under examination by the Health Departments and the General Medical Services Committee of the British Medical Association.
These discussions have been conducted on a Great Britain basis, because the needs of the patients are, of course, the same in both countries, and, indeed, the vast majority of the manufacturers in the pharmaceutical industry, who are closely concerned, are domiciled in England. The only new pack that we have been able to devise that would seem likely to benefit a sufficient number of patients to make its production useful is a larger pack of dressings for general use; and this proposal is at present before the manufacturers who are considering the production arrangements.
I cannot give the hon. Member the exact date when we hope to have it, but we hope it will be in chemists' shops within eight or twelve weeks' time. We are disappointed that it was not found possible to devise new packs for the types of patients the hon. Member has mentioned, but I am sure it was right to persevere with the examination of possibilities, rather than dismiss the task at an earlier stage. The British Medical Association which, indeed, originally suggested the possibility of further packs for colostomy, diabetic and tuberculosis patients, has shared with us in our efforts and in our disappointment.
The main difficulty is the varied needs of different patients. Before a pack can usefully be manufactured and marketed, it must be established that the standard contents will be suitable for a reasonably large number of patients, otherwise it would be impossible for the manufacturer to support its production and the 1395 packs would lie unused either on his shelves or on the chemist's. It is, of course, in the manufacturer's own interest to produce an acceptable pack. The hon. Member will appreciate that it would not be any convenience to the patient to be given a standard pack in which there was more of one item than he needed and not sufficient of another. The patient would, I am sure, much rather have the items he needed precisely prescribed for him separately, rather than be given a standard pack which did not really meet his particular needs.
Perhaps it would be helpful if I mention the suggestions for new packs which have been carefully considered, but which have not been found practicable. First of all, for colostomy patients there is already available a multiple pack—a colostomy replacement set—so that the patient can obtain for 1s. the replacement of all or any of the various pieces of apparatus which he requires.
We have considered the possibility of devising a special dressings pack for these patients. It seems, however, that the types of dressings required for different colostomy patients do not fall into one pattern on which a useful pack could be based. These patients need different types of dressings in different quantities to suit their particular conditions. This is indeed a matter on which doctors themselves have individual preferences.
The diabetic patient needs a syringe, needles, a urine sugar analysis set, supplies of insulin, spirit, wool and reagent. Two packs have already been produced for diabetic patients, one containing the components of the urine sugar analysis set that they must have, and the other containing a syringe and needles. Each of these packs attracts only the 1s. charge.
We have tried to devise a pack containing insulin, wool and so on, but the fundamental difficulties are, first, that insulin has to be stored in proper conditions, either in the factory or the pharmacy, and, perhaps more important, that diabetic patients have widely varying needs for different types and strengths of insulin. The hon. Member will, I am sure, appreciate these difficulties even better than I can—in fact he mentioned them—and will know that there are no less than seven different types of insulin, each available in different strengths.
1396 For tuberculosis patients, the possibility of a pack containing quantities of the anti-tuberculosis drugs was considered. Once again, when the prescriptions were examined, they did not seem to indicate a sufficiently common requirement on which to construct a pack that would be a practical proposition for patients and manufacturers.
I must say quite frankly that we have not considered, so far, any suggestion for a multiple pack for cardiac patients. But we shall certainly consider carefully the suggestions which the hon. Member has made. I am grateful to him for them, although I am sure he would not expect me to comment learnedly at this stage.
I can assure the hon. Member, and the House, that the Health Ministers and the British Medical Association will be only too willing to consider any suggestions for further packs for chronic sick patients that may be put forward from any quarter. None of us wishes to add unduly to the burdens of these unfortunate people; we all have the greatest sympathy for them and we would all, I know, do all we could to help. I know that, to help them, doctors have been prescribing larger quantities of medicines and dressings at a time than formerly they used to do, because this reduces the 1s. charges payable by these patients over a period. This is another way of helping them, and it does not, of course, increase, overall, the amount of any drug or dressing required by the patient.
I wish to explain quite clearly that this is not overprescribing. The quantity prescribed depends on the judgment of the doctor. He will know the largest quantity that can safely be given without any wastage resulting, and without deterioration of the drug itself. The hon. Member will, I am sure, know, that to make it possible for doctors to prescribe larger quantities of drugs and dressings especially for the benefit of chronic sick people my right hon. Friend the Secretary of State, in the regulations which introduced the current charges, specifically provided that any quantity of the same drug, even if it is supplied in a number of saparate containers, would attract one single 1s. charge only.
Lastly, the hon. Member spoke of hardships, and, of course, it is idle to deny that any charge, however light, must create some hardship to someone, 1397 but I think it is wise to conclude by looking very shortly at the extent of the hardship. Since 1st December, 1956, when the current charge of 1s. per item was introduced, a total of about 60 representations or complaints of hardship have reached the Scottish Office. In the same period about 19 million prescriptions, covering about 24 million separate items, have been dispensed. Medical officers in my Department have regular contacts with family doctors, when one would expect cases of hardship, if they occurred at all frequently, would be mentioned. No mention has, in fact, been made of such cases at these routine visits, which would suggest that they must be exceptional occurrences.
That general picture is in line with another set of facts. During the whole 1398 of 1957, which included the heavy influenza epidemic of last autumn, only 2,500 people in Scotland, apart from those already in receipt of National Assistance, found it necessary to seek a refund of their prescription charges from the National Assistance Board, a refund which amounted, in all, to between £700 and £800.
The hon. Member has done a great service in raising this important question and in giving us valuable ideas, which, can assure him, will be considered, and in giving me this opportunity to tell him, the right hon. Lady and the House exactly what the present position is.
§ Question put and agreed to.
§ Adjourned accordingly at nineteen minutes to Eleven o'clock.