HC Deb 17 March 1958 vol 584 cc1003-38

7.14 p.m.

The Minister of Health (Mr. Derek Walker-Smith)

The net amount of this Supplementary Estimate is £7,428,720, which is an increase of just over 1½ per cent. of the revised July Estimate of £477,876,365. This Supplementary Estimate is made up of excesses of £10 million, partially offset by savings of £2 million, mainly on hospital capital, general dental services and superannuation, and of £600,000 on appropriations in aid.

There are three main items in this excess exceeding £1 million apiece; that is to say, hospital revenue £5 million, pharmaceutical services £1,800,000 and grants to local health authorities £1,400,000. These items involve the convenient grouping of the various subheads which collectively compose them. I would add that the excess on hospital revenue of £5 million would have been £8 million but for the effect of a once-for-all saving of £3 million in the current year due to a change in the system of Exchequer advances to hospital authorities from a monthly to a weekly basis.

This increase for which I am asking the House today is accounted for largely by increases in prices and remuneration, for which no provision was made in the earlier Estimates. This price and remuneration increase is really part of the general point I made recently during the Second Reading debate on the National Health Service Contributions Bill. There is, of course, this year a special reason which contributes in part to the increase; that is to say, the effect of the Asian flu epidemic.

I should perhaps also add the general point that many items in the large National Health Service Vote relate to expenditure the course of which is inevitably difficult to predict. This Supplementary Estimate was prepared in January and submitted to the House early in February, and it represents the best estimate which could be made at that time. The latest expenditure returns suggest that at the end of the financial year there may conceivably be some net overall under-spending, but in view of the difficulties of predicting so much of the expenditure we cannot even now be sure how much this may amount to.

I will now say a word about the first of the main items, the hospital revenue item. The total of this in the July Estimate was £335 million, split as to £290 million for non-teaching hospitals and £45 million for teaching hospitials. Of this £335 million no less than £215½ million was for the salaries and wages of medical, nursing and other staff directly employed in hospitals. Other large items comprised in the total were: provisions at £40 million, drugs, dressings and appliances at £22¼ million, and fuel, power and light at £25¼ million.

The earlier Estimates were based on costs current at the time when they were settled, but the hospital authorities were told that additional amounts would be made available, if necessary, to meet increases in remuneration following from Whitley awards and to meet increases in the prices of goods and services taking effect during the year.

What the House is now being asked to do is to vote additional money solely to meet such increased costs. I will indicate the analysis of the make-up of the figure of £8 million. The Whitley awards amount to over one-half at £4¼ million. price increases to £3 million, rates to £300,000, and increased National Health Service and National Insurance contributions to £400,000. That total of £8 million is reduced by the once-for-all saving of £3 million to which I have referred already, making a net addition of £5 million.

Of the major increase, the Whitley awards, two awards account for about £3¼ million out of a total of £4¼ million. Those are respectively the award to nurses, amounting to £2½ million, and the introduction, with effect from 1st October last, of a shorter working week for ancillary staffs, costing £¾ million.

I come to the second main item, the pharmaceutical service, about which there has already been a good deal of discussion on the various stages of the National Health Service Contributions Bill, which is still before the House. On this item, the estimated increase of £1,770,000 is based on the latest assumption of an outturn of 216 million prescriptions, instead of an estimate of 237 million, at an average cost, however, of 5s. 10d. per prescription instead of an estimated average cost of just over 5s. 3d.

I should add that the expenditure on the pharmaceutical service is necessarily very unpredictable because, for example, of the effects of epidemics and of changes in prescribing practices due to the introduction of new drugs and so on; and for those reasons it is possible that the actual outturn may still be significantly different from that now assumed.

The general reason for the part of the Supplementary Estimate which relates to the pharmaceutical service is an increase in the average cost per prescription above that originally estimated, with a partial offset due to the falling off in the estimated number of prescriptions. Taking the average cost, the original estimate, as I have said, was just over 5s. 3d., but the increase in prescription charges to 1s. an item, with effect from December, 1956, had the effect of leading some doctors to prescribe larger quantities of drugs but at less frequent intervals. We would therefore expect an increase in the cost of prescribing and a reduction in the number of prescriptions, and that is exactly what has happened.

The average cost rose to just under 6s. 2½d. per prescription in August last, and in December, which is the last month for which figures are available, the figure was 6s. 1d.

Mrs. Lena Jeger (Holborn and St. Pancras, South)

Does not the right hon. and learned Gentleman agree that when doctors prescribe for longer periods in an effort to help their patients financially, there is more danger of waste and that it is more difficult to prescribe accurately over a longer period? Will he bear that problem in mind?

Mr. Walker-Smith

As I think the hon. Lady knows, the only circumstances in which I am encouraging general practioners to prescribe in larger quantities to last a longer time is in respect of chronic conditions, a subject in which the hon. Lady has displayed an especial interest in the House. I am not encouraging them to do it in ordinary cases, because, I agree with the hon. Lady, there are dangers of waste in that. That, no doubt, is one of the aspects of the matter to which Sir Henry Hinchliffe and his Committee are devoting their attention.

The 6s. 1d. figure is the figure which I gave to the House in the course of my speech on the Second Reading of the National Health Service Contributions Bill the other day. The Supplementary Estimate, which I am now commending to the House, assumes a figure of 5s. 10d. per prescription as the overall figure for the current financial year 1957–58.

I should add that another reason for the increase in the average cost is the availability of expensive new drugs which have come upon the scene and which were not previously available. Ever since the inception of the National Health Service, the number of prescriptions in any given financial year has tended to fluctuate. The Estimate for 1957–58 was based on a figure of 237 million which appeared to be the right figure in the context of that time. It now seems that the total number of prescriptions in this financial year will not exceed 216 million.

That is the figure which has been used in framing the present Supplementary Estimate. However, but for the influenza epidemic. the number of prescriptions might not have exceeded 204 million, instead of the 216 million which we now expect and the 237 million which was the basis of our Estimate. The reduction in that case would have been more than enough to offset the effect of the increased average cost of a prescription about which I have been speaking.

Having given that explanation of the reason for this part of the Supplementary Estimate, I must say that the Government are well aware of the problems of the mounting drug bill and, as the House knows, much action has already been taken in that regard. In addition, the question is currently under the review of an independent professional committee, the Hinchliffe Committee, to which I referred in answer to the hon. Lady's intervention a moment ago. I hope to receive an interim report from Sir Henry Hinchliffe fairly soon.

Finally, on the third main item of the Supplementary Estimate, the grants to local health authorities——

Mr. Albert Roberts (Normanton)

It used to be said that the cost of prescriptions in non-industrial areas exceeded that in industrial areas. Can the Minister tell the House whether that is now the case?

Mr. Walker-Smith

I do not know that it is, but it may be that I shall be able to form a more precise view in the course of our proceedings, in which case my hon. Friend the Parliamentary Secretary will be happy to communicate it to the House.

Local health authorities are at present entitled to a 50 per cent. Exchequer grant on their net expenditure on health services under Section 53 (1) of the National Health Service Act, 1946, as amended by Section 7 of the Local Government Act, 1948. There are ten main services involved, each with a separate subhead, and a further miscellaneous subhead. The amount of the Supplementary Estimate for the local health authorities is £1,400,000 in respect of all those services taken together. The Supplementary Estimate in respect of the services is necessary, because both the autumn revised Estimate of the net expenditure of local health authorities in the current financial year and the actual net expenditure in 1956–57 were higher than had originally been expected. As a result, the advances for the current year have to be increased by £1,079,000 and the balance due for 1956–57 by £323,000.

The House will appreciate that I cannot give the same detailed analysis in respect of local authority health services as for the other services, because local health authorities are not subject to detailed control. Broadly, however, the increases are due to three factors: first, wage and salary awards: secondly, rises in prices, and thirdly, staff increases and expansions of the services. Examples which I would quote in this connection are the salary increases to nurses, midwives and health visitors, wage increases for domestic helps, and, in the mental health sphere, increased wages and prices, and the expansion of occupation centres for mental defectives.

With that explanation of the main items of which the Supplementary Estimate is made up, I hope that the House will agree that it is necessary—and, in the circumstances, even moderate—and will be prepared to vote it accordingly.

7.32 p.m.

Mr. A. Blenkinsop (Newcastle-upon-Tyne, East)

We all welcome the further information that the right hon. and learned Gentleman has given us in introducing this Supplementary Estimate, and at any rate, hon. Members on this side of the House also welcome a very large part of the increase. We would not wish to challenge the increases which have taken place in respect of hospital authorities, or the modest increases in respect of local authority health services, although it would be more appropriate to discuss those matters when the full Estimates are presented later on.

Although my hon. Friends may wish to raise certain points, I want to follow up some of the points which have been raised in connection with the pharmaceutical services. It would be useful to the House if more information and elucidation were given by the right hon. and learned Gentleman or the Parliamentary Secretary. Many of us feel that we are being asked to make a judgment about the Supplementary Estimate—especially in regard to the pharmaceutical services—on very inadequate information and evidence. I do not blame the right hon. and learned Gentleman exclusively; this situation has persisted for a long time. But it seems to me that if we are to decide whether or not we are getting reasonable value for our expenditure on the pharmaceutical services we ought to know far more about what is being done for the health of the nation in return.

All that we can do at present is to make some snap judgments from our own experience and the evidence that we have been able to gather, which may be misleading. A very considerable part of the pharmaceutical expenditure of the Health Executive Council in Newcastle is taken up by drugs used in the treatment of tuberculosis. The pharmaceutical expenditure for the last full financial year in the area was about £450,000, and on the best estimate that can be made, taking into account the number of patients under regular treatment and the average cost per patient—which can amount to about £1 a week—there is an expenditure of between £50,000 and £100,000 on tuberculosis treatment alone in Newcastle. Whatever view we may take as to whether prices for drugs can be reduced, none of us doubts for a second that the expenditure is well worth while, both in reducing hospital attendance and enabling many people to carry on with treatment while at work.

Unfortunately, however, we know far too little about the rest of the matter. We have no estimate of the cost of the treatment for bronchitis, which is a very high figure in many industrial areas. We do not know to what extent the drug bill represents useful work in the treatment of children, although we know that great advances have been made and that hospital beds are becoming available in children's units. All this is encouraging, but we know extraordinarily little about the effectiveness of the use of these drugs, and we should know if we are to make a fair judgment.

The Guillebaud Committee called upon the Ministry to improve its investigation units and establish a statistics department. I know that the Ministry has taken some action along those lines, but we have not yet seen much evidence of its work. I was glad that the right hon. and learned Gentleman was able to say that he was hoping that further information would be coming forward for the public. The Guillebaud Committee said: we need to know more … about the nature and causes of difference of morbidity in different Hospital Regions; about the changing patterns in the use of drugs in the National Health Service, and also about their cost; about the incidence of charges on particular sections of the community … I should be glad to know whether anything has been done on those lines.

Many general practitioners and probably the College of General Practitioners would be willing to help in collecting evidence about the value and efficacy of the treatments being carried out today. The only such investigation that I know of was carried out privately by a Mr. Martin who wrote a book called, "Social Aspects of Prescribing", an interesting book which, unfortunately, is rather out of date, since it relates to the position in 1951. Although the findings are of interest, we should like to have the views expressed brought more up to date.

One thing which the author says, which relates to the interjection of my hon. Friend the Member for Holborn and St. Pancras, South (Mrs. L. Jeger) a few moments ago, is: Expensive prescriptions occur most frequently in well-to-do areas. It is important for us to know whether that is still true. He also says that it is a sobering thought that the areas with the highest rates of morbidity as indicated by infant mortality are the ones with the cheapest prescriptions. These are important social factors.

Sir Keith Joseph (Leeds, North-East)

The hon. Gentleman might also bring out the interesting point that often where prescription unit cost is cheapest the number of visits to the doctor are most frequent.

Mr. Blenkinsop

I was going to refer to the relationship between the cost item and the frequency of visits.

We need a great deal more information in order to make effective judgment. There are some matters about which we have the right to inquire. One is the question of price. A good deal has been said about this already, and I do not wish to go over the ground which has already been covered in other debates. It is a striking fact that we have had this considerable rise in the cost per prescription which coincided with the introduction of the additional Health Service charge; although I agree that, as one might expect, there has been some reduction in the total number of prescriptions. That has not wiped out the effect of the larger quantities.

The right hon. and learned Gentleman made the point about the effect of the influenza epidemic, and the total number of prescriptions has for some time tended to vary, as we would expect. This must depend on the actual experience regarding health in the country over a period. One would expect variations. But this increase in the quantity prescribed is striking. Although, almost for the first time, the right hon. and learned Gentleman tried to distinguish between the types of drugs which he wishes general practitioners to prescribe in larger quantities and those he does not, evidence from the medical profession shows that there is encouragement to increase the quantities prescribed and not purely in the limited scope to which the Minister referred. Even in that case one is doubtful whether this is a good practice, except, of course, as a means of saving the chronic sick and the elderly from having to pay extra charges. But the fact that they have to pay extra charges is the fault of the Government for imposing them. The answer is not necessarily to encourage the prescribing of larger quantities but to withdraw the charge.

No notice was taken by the right hon. and learned Gentleman and his predecessors of the recommendations of the Guillebaud Committee, which did not recommend any increase in charges for prescriptions. Hardly was the ink dry on that Report than the Government proposed an increase, with the ill effects which we have seen. We cannot emphasise too strongly not only the waste which attends the prescribing of large quantities, but the danger of so doing. I do not think there is a single pharmacist in the country who would not say the same.

We know from experience what happens. There are few houses in the country where it would be impossible to find a number of bottles of medicine or packets of pills of one sort or another which are used by different members of the family or passed over the garden wall to be used by other families. This practice makes nonsense of effective medical control of states of illness. It is a cause of danger as well as being a waste, and it would be a good thing to recommend that at the end of a treatment the medicine left over should be disposed of by pouring it down the drain or by getting rid of it in some other way as rapidly as possible. I ask the right hon. and learned Gentleman to look at this matter. In our anxiety about what has happened, we are supported by a good deal of medical evidence. Not only are we wasting money by providing larger bottles of medicine and bigger packets of pills, but danger is being caused.

Ministers of Health come and go rapidly, and sometimes one is sorry for the reason. I am not sure which Minister it was, but not so long ago one announced the conclusion of an agreement with manufacturers regarding the prices of drugs, particularly the proprietary medicines. It was a very complicated agreement. The last Report of the Public Accounts Committee gives us cause for anxiety. The right hon. and learned Gentleman himself suggested that we should not get the economy we had originally hoped to secure through that agreement. Many of us believe that we shall have to look again at the question of prices. There is no doubt that doctors should know far more about prices even than they do now after the modest efforts of the Ministry and the prescribers' notes which have been sent out.

We have to reach the state where manufacturers are required to put prices on any material they issue. I had sent to me a large bundle of advertising matter which had been received by a doctor in a particular fortnight; and of that mass about one-third included prices and the other two-thirds did not. I consider that some action must be taken about this. It has been suggested that doctors should have a standard card index of drugs and prices. It would not matter about having detailed prices, because the doctors would not be doing the work of the pharmacists in making up the actual accounts, but they would have some evidence of the average cost of the treatment of a patient for a week. Every doctor should possess some such evidence. It is wrong that the Government should pay twice for the cost of advertising, but, in effect, that is what happens today. The Treasury makes its concession for tax purposes, and a very considerable concession it is, and then that cost is bound to come into the total figure of drugs that the Government have to meet for the Health Service. In a sense, the Government pay twice. There again, there must be a very serious further review. We cannot accent the present position in which advertising is in effect encouraged, even though a very large part of it is to the detriment rather than for the benefit of the National Health Service.

While I am dealing with prices, I would refer to one further factor. I do not expect the Minister to give me an answer immediately about it. Nobody has been able to do so yet, and I am not very hopeful of the right hon. and learned Gentleman's being able to do so, although he might be able to find something to tell us before the end of the debate. We know that a considerable proportion of the proprietary medicines supplied today originates from the United States. Very valuable many of them are, yet we have to face the fact that included in the cost that we pay are quite heavy additional charges for patents and royalties which we should not have to pay if the drugs were produced in this country.

Different suggestions are made about how much this cost amounts to; I do not pretend to know. I only know that a very substantial proportion of the drugs and proprietary medicines commonly used comes from the United States, I do not mean that they are necessarily manufactured there. Very often they are manufactured under licence in this country. Nevertheless, those external charges are imposed before the medicines can be sold here. That is a matter that we are bound to take note of, because it may affect substantially the total drug bill.

The Government should step in to see whether we can get more favourable terms. We remember the situation about penicillin. Many of us feel that we could reach more satisfactory agreements if the Government could step into the negotiations on these matters. I will ask the Parliamentary Secretary to say a word on this matter when he replies.

We all agree that the cost of drugs is under the control of the doctor and of no one else. The Labour Government, when instituting the Health Service, and subsequent Governments, have said that we must guarantee to the doctor freedom to prescribe what he thought was necessary for his patients, but there have been, by agreement with the profession, arrangements that in certain fields, for example in the proprietaries, doctors would not prescribe if there was any equivalent in our pharmaceutical list. The doctor still retained the right in the last resort to prescribe that special form of drug if he thought it necessary for his patient, knowing that he might be asked to explain why. The doctor still insists, and I think rightly, on his right to prescribe what is necessary for his patient.

If that is so, we have to face the unhappy fact, of which we have had experience, that there has been a very great deal of excessive prescribing over the years, of some of the antibiotics for example, for minor conditions for which they were not necessary which has endangered their use for the more proper purposes. We are facing acute problems in relation to this matter today simply because of the many costly drugs which have been used for conditions for which they were not necessary, although they might have had dramatic effects.

If we say that the doctor should be given complete freedom to prescribe what he thinks fit, there is the corollary that the doctor, while he should receive training about prescribing, must have all the necessary information. We are very clever about saying what shall be put into a curriculum but not so clever in suggesting what shall be left out. The education of the doctor should help him to exercise his proper judgment.

How can that be done? We must consider whether the present set-up of the committee, which has done valuable work in the classification of drugs, is now adequate as a permanent part of our Health Service system. One wonders whether it is not necessary to have some even more thorough check on new drugs coming on to the market before they are made fully available for general use. This matter will have to be discussed with the medical profession, but there have been suggestions that there should be a kind of testing before the drugs are made generally available. This is obviously another matter for the committee to consider. I hope that the medical profession will join in and help in this matter.

We must not look at these problems too much in isolated and separate compartments. The real hope of getting stabilisation and reduction in the drug bill will come from the doctor becoming far more of a health educator and leader of a team, which ought to include the health visitor and others, of people who realise that their main job is health education just as much as treatment. They will try to effect some change from the assumption that the bottle of medicine and the packet of pills are the essential corollary to a visit to the doctor.

If progress is to be made in this direction, there must be some reduction of prices such as is now under consideration. We want greater impetus to group practice and health-centre work to encourage the doctor to use a more independent judgment. It is said that many doctors say, in explanation, that they are pressed to prescribe particular drugs. They are afraid that if they do not give the prescriptions their patients will go down the street to another doctor. I must say that in that attitude there is not an awful lot of trust shown in the professional standard. If we are to get a better standard, we must move away from the isolation in which too many doctors still work. That will come if we encourage this wider development of the group practice.

Can we not here bring in more actively the Central Council of Health Education? I should have thought that the right hon. Gentleman the Chancellor of the Duchy of Lancaster would have encouraged that, because I believe that at one time before he came to this House he was very actively interested in it. In any case, there is a need for a really vigorous drive for public education in health, and the proper use of drugs. None of us doubts for one moment the value of drugs. What we very sincerely doubt, as my right hon. Friend the Member for Warrington (Dr. Summerskill) has said on many occasions, is the wisdom of the way in which they are being used at present. We ask the right hon. and learned Gentleman therefore to make some of the inquiries that we think important.

We think that the Ministry itself has a very real part to play here and that it must, as it were, break out of its confinement. I do not blame the Ministry, but it is true that it is too narrowly confined to the recovery side to tackle effectively the reasons, in a sense, for these high drugs bills. What is the Minister doing, for example, to get ahead more rapidly with the Clean Air Act? I believe that the more quickly he can get the clean air zones the less bronchitis we shall have and the lower, eventually, will be our bills for many of the drugs that are being continually poured out for such conditions.

In the same way, if the right hon. Gentleman could stir some of his laggard Ministerial colleagues who are denying us the opportunities to develop our sewerage schemes and to carry out house improvements, it might very well make a very real dent in our drug bill. We want to know what he is doing in all of these sectors—and I make no apology for, perhaps, widening the debate rather more than the right hon. and learned Gentleman may have expected, but if I had not been strictly in order I am sure that I would have been told.

I make a final suggestion which I am sure will appeal to the Minister. On this side, we have been worried—and I have asked Parliamentary Questions—about the developing costs of these tranquilliser drugs. Again, these drugs can be of undoubted value if properly controlled, but medical opinion is very much seized of the dangers of their general use, particularly if we are ever to use these drugs as widely as they are used in America. There are these anxieties and dangers, and if we do not help in some way to control the use of these drugs through education of the public, the bill may go on expanding more and more and we may still be without the real, effective ways of judging just how much of the drug bill is valuable and how much is not.

I said that I would make a final suggestion that the right hon. and learned Gentleman would welcome. We would, of course, secure a very considerable reduction in our bill for tranquillisers if we could only persuade the whole of Her Majesty's Ministers to resign at an early date and to give us the date. It would relieve the country very greatly and might even relieve many of Her Majesty's Ministers as well.

8.5 p.m.

Vice-Admiral John Hughes Ballet (Croydon, North-East)

It would be very difficult indeed to challenge any of the specific items in this Estimate, and I certainly do not intend to do so. On the other hand, the fact that we have this big Supplementary Estimate confronts Parliament with a problem of priorities that is becoming ever more acute, and a problem as to whether or not, as the hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) said, we are really getting full value for the money being spent on the National Health Service. As he said when at the start of his speech, these are matters that could more appropriately be discussed when we come to the main Estimates, and I assure hon. Members present that I intend to follow that precept.

I want to refer to four ways that have been suggested from time to time by which the rising cost of the Health Service can be kept in check, and to ask my right hon. and learned Friend whether they are being carefully studied. More than six months have passed since the Select Committee on Estimates recommended that some sort of training on the finances of the National Health Service should be given to medical students. I believe that suggestion to be one of the greatest importance. It is something that must be done if we are to keep under any sort of financial control a Service which, after all, costs more than any single one of the fighting Services.

When hon. Members read the evidence given before the Committee they will observe that not all the doctors who appeared before us agreed with this proposal. There were some who said. "Oh, health is something for which there is no price too high to pay." To that, I would say only that any price is too high if one has not the money. I ask my right hon. and learned Friend to do what he can to implement that proposal.

Secondly, there is the question of closing some of the smaller hospitals when they become uneconomical. I understand that, from time to time, regional boards put forward proposals to close a hospital, in a group, perhaps, where they feel that the patients can be properly looked after in the remaining hospitals. Obviously, the savings resulting from such measures are real, the economy produced is a genuine one, and I should like to be reasurred that such proposals, when made, are not lightly set aside.

Thirdly, is my right hon. and learned Friend entirely satisfied that we are doing all we can to educate the public in preventive measures? I am not here talking of the use of drugs and so on, but of ordinary common-sense preventive measures. I ask him, in particular, because one of the reasons given for this Supplementary Estimate is the influenza epidemic Few things were heralded so widely or for so long than was the arrival of that epidemic in this country. Its progress from the East across the world was followed almost from seaport to seaport until it arrived here. It is rather disappointing that it should, none-the-less, have taken such a toll.

While there may be a great deal of controversy, and a number of views on whether or not it is desirable to televise major operations, surely there can be no two opinions that any time that television can devote to a little homely advice about not going into crowded trains when one has a bad cold, about not going into places of entertainment when one feels that a fever is coming on, would be well spent. I suggest to the Minister that millions of pounds might be saved on the Estimates if people could be educated to use just a little common sense in looking after their own health.

Lastly, is my right hon. and learned Friend entirely happy that the general practitioner service is working as it should? After all, the expensive thing in the Health Service is the hospital service. Are we sure that as many cases as possible are treated by the general practitioners in the patients' own homes? I know that this is a very big question, and I am not asking for a reply tonight, but it is very much in my mind that one of the radical steps that could be taken to prevent Supplementary Estimates of this nature, and to keep down the cost of the Health Service, would be to try to ensure that as many people as possible were treated in their own homes, without having to go to hospital.

8.11 p.m.

Mr. Somerville Hastings (Barking)

I should like to refer to one point made by the hon. and gallant Member for Croydon, North-East (Vice-Admiral Hughes Hallett) in his interesting speech, and that is his suggestion about the closure of some small hospitals. I am in complete agreement with him, because small hospitals are not economic and, in many cases, are not efficient. I shall be glad when special hospitals are abolished and are fused for operational purposes with general purpose hospitals.

I should like to extend what he said. Not only do we want the closure of small hospitals and the fusion of hospitals, but we also want a greater fusion of hospital management committees. In each case we have not only a management committee but also staff, including financial officers, engineers and supply officers, responsible for purchasing. In the regional hospital board to which I am attached there are two or three management committees with only three or four hospitals in each. Not only is that uneconomic but it tends to be inefficient, because when we have a group of hospitals it is very much better to centralise special departments in one of these hospitals and not to let every small hospital have a department with inpatient beds for every specialty.

The debate has been largely directed to the question of pharmaceutical products. I have no regret whatever that more is being spent on drugs, assuming that it is being well spent. The public insists on having medicines, and it is very much better that those medicines should be ordered by a doctor who understands what he is doing than be bought straight from a chemist. I do not think that this increase is such a disaster. It is fashionable to blame the drug houses for everything that has happened, but I believe that the cost of the standard drug has not risen within the last few years in anything like the same proportion as have many other things which we use.

It must be admitted, too, that the drug houses spend a good deal of money on research. I think that they could fuse their research departments usefully and that money could be saved in that direction, but I am convinced that money must be spent on research into pharmaceutical products and that we are getting benefit from it.

Perhaps these drug houses advertise too much. I have not seen a patient since 1945, when I returned to this honourable House, but I still receive samples—I will not say daily, but at frequent intervals—of different drugs from the various drug houses. To some extent that is regrettable, but it has another side to it, because a busy general practitioner who is seeing a large number of patients, many of them with the same disease, may lose interest in his work unless he is able to try out new methods of treatment. These new drugs which are coming out increase the general practitioner's interest and keenness and, therefore, the quality of his work.

Mr. Blenkinsop

I am interested in my hon. Friend's remarks, many of which I agree with, but I am sure that he agrees that the drug houses should state prices on their documents.

Mr. Hastings

I agree entirely, and I also agree with my hon. Friend's suggestion that medical students ought to be taught to some extent the relative costs of the drugs which they propose to order.

Nevertheless, I believe that it is inevitable that we shall spend more money in the National Health Service on drugs. There are two reasons for this. First, although the maximum age to which people live is probably not increasing appreciably, there are many more people over the age of 70. When people reach old age they are more subject to disease and need more treatment. Moreover, the object of treatment is not necessarily in every case to cure. It may be to make the patient comfortable and to relieve symptoms. Because we have an ageing population it is inevitable that we shall need more medicine.

In addition, much more can be done with drugs today. When I was a student there were no drugs which would kill germs without first killing us. Now we have the large group of antibiotics. It is true that germs are beginning to get the better of them, because they are themselves becoming immune to many of our antibiotics, but we are reacting by discovering others. Among these drugs are the very valuable ones used for the treatment of tuberculosis which have been responsible to a large extent for the reduced mortality from this disease. For these reasons we shall use more drugs in the future, apart from the fact that research is constantly being carried out and new uses for drugs being found.

I agree that we should urge on doctors care in prescription and care not to use the proprietary drugs while others which are equally good are available. But I suggest to the right hon. and learned Gentleman that he should be a little careful about how doctors are approached on this question. One doctor whom I saw recently told me that he had had two visits from people from the Ministry urging him to reduce his drug bill, and he resented it very much indeed. I have asked other doctors about it, and they have told me that they have had visits on the same lines, but they rather liked it and did not resent it at all. There are those two sides to the question. The important thing is that the approach by officers of the Ministry should be as tactful as possible in order to obtain the best results.

8.21 p.m.

Mr. Reader Harris (Heston and Isleworth)

I have been most interested in the debate, though it is a subject on which I am no expert. I listened with great interest to the speech of the hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop), who certainly widened the debate and ranged over many subjects, even suggesting that more should be done to implement the Clean Air Act. If we are to widen the debate to that extent, there are many things we could suggest. I hope that we shall one day have a Government having the courage to pass a law making it compulsory for everyone to have a bath every day; that would do as much as anything——

Mr. Deputy-Speaker

That is a little beyond this Supplementary Estimate. The hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) went to the periphery of the bounds of order. I hope that the hon. Member for Heston and Isleworth (Mr. R. Harris) will not go further.

Mr. Harris

I would try to keep within the bounds of order, Mr. Deputy-Speaker. I wish to raise the question of drugs and support what the hon. Member for Newcastle-upon-Tyne, East, said about the prices of some of them. This is a very important matter. A little time ago I wrote a letter to the Parliamentary Secretary to the Ministry of Health about the price of a drug called Terramycin. The answer which my hon. Friend very kindly gave me does not, I am afraid, entirely satisfy me. A pharmacist of my acquaintance drew my attention to this particular drug and sent me one of the actual cartons showing that it contained 100 tablets. He told me that these hundred tablets cost £14 10s. This raises many questions, the first of which is this. What control is the Minister able to exert over the drug houses which produce drugs of this sort?

I am not in any way trying to comment on the use of any drugs which may be necessary for the saving of life, and I am certainly in no position to say whether there is any drug other than Terramycin which is as effective. But, if a drug like this is to be produced, 100 tablets of which cost about £14 10s., one wonders whether the Ministry is able to exercise any control over the size of carton in which they are distributed. The situation may well arise—it has, in fact, arisen, my pharmacist friend tells me—of a drug like this being prescribed and the chemist having to obtain it. A certain number of tablets may be used and the rest may remain on the chemist's shelf, and may, I am told, be there for a very long time without being used. In his reply to me, my hon. Friend the Parliamentary Secretary said that about twenty tablets would be the normal number in one prescription. Even that makes it a very expensive prescription, something in the region of £3, although my hon. Friend said that it would, in fact, cost 47s. 6d., this amount including chemist's dispensing fee and a sum to cover overhead expenses. However, one-fifth of £14 10s. is more than 47s. 6d.

Can the Minister control the size of the package in which the drug houses distribute these things? When one considers the terrific barrage of advertising which goes out, the matter assumes even greater importance. I do not say that this advertising is entirely wrong; obviously, there must be some advertising by drug houses, though I can name one particular American firm which reckons to circularise all the doctors in the country twice a week. It may be done only by postcard, but it seems quite fantastic that any firm should reckon to reach each doctor in the country twice a week by any form of circularisation.

Inevitably, with this tremendous pressure upon doctors, they will occasionally prescribe a drug which is, perhaps, a little more expensive or they may prescribe in a quantity slightly greater than is necessary. Obviously, doctors being hopelessly overworked in many places, there is always a tendency to prescribe for a little more than is necessary, perhaps in order to prevent a patient having to come back.

I have been informed that there is a tendency today for doctors to prescribe for larger amounts than in the past. For instance, a liquid medicine which used to be prescribed in what were known as doctors' bottles, 6 oz. bottles, are very often prescribed now, according to my pharmacist friend, in 40 oz. bottles. Has the Ministry any control over things like that?

I hope that it will be possible to have the advice of well known and reputable British firms who exercise restraint in these matters. Their advice on how to control the activities of what are, usually, American firms with high pressure sales methods would be useful. I do not altogether condemn those methods. I have an American pharmaceutical company in my constituency, Parke Davies and Co., a very reputable company, which has progressed steadily and gradually over the years; but there are other firms which are bringing to this country the methods they use in the United States. One firm which I know in the United States has travellers on the road and reckons to get round to every doctor once a week. If there is to be that sort of personal visit once a week in this country, life will become intolerable for doctors.

Colonel Tufton Beamish (Lewes)

I appreciate what my hon. Friend is saying, but does he realise that a great many doctors like these visits and that, if a doctor should say he does not want to be called on again, he will not be called upon?

Mr. Harris

I am glad to hear that and to think that some notice is taken of what the doctors say in these matters; but, from what I know of some of the firms, I am not sure that they would be taken off the list quite so readily as that.

In the letter I received from the Parliamentary Secretary, he told me that information and advice on the use of these drugs has been made available to doctors in the British National Formulary and in the Prescribers' Notes. Do the Formulary and the Notes put the prices of these drugs against them? Perhaps they do; I do not know. If some assurance can be given by the Minister on this very important point, I should be very glad. I know that it would give some reassurance also to chemists, many of whom may be doing extremely well out of it but who, nevertheless, are genuinely desirous of keeping the cost of the Health Service down as much as possible.

8.29 p.m.

Mr. James Harrison (Nottingham, North)

My contribution to the debate takes the form of a very short question, but it is a question which ought to attract the serious notice of the Minister. If he can contribute towards an answer, I for one would be much obliged.

I wish to refer to the increased cost of our hospital services as a result of the universal treatment that is offered. Any person who is in these islands, or who comes to these islands especially for hospital treatment, can obtain treatment free under the National Health Service.

Can the Minister give us something rather more than the stock reply to this question? Whenever we raise this matter we are told of the administrative cost of making the service selective. We are told of the difficulty of limiting it to residents in this island and those people whose countries offer reciprocal services and give our citizens the privilege of free treatment in their hospitals.

Can the Minister tell us what schemes he and his officers have examined when they say that the administrative cost would exceed by far the amount saved by the exclusion of people whose countries do not offer similar facilities and who are non-resident in these islands? The premise of these arguments is usually that it would be a good thing if we could limit the services and thereby save considerable money, but that to do that we should have to introduce an administrative scheme of selectivity that would cost more than the amount which might be saved by its introduction.

I have never heard any of these schemes described. I wonder if the Minister would indicate some of the schemes that he has examined and tell us where the extra cost would fall if a scheme were adopted. That would help us to understand the position and to argue the question should it be raised in our constituencies.

8.32 p.m.

Dr. Donald Johnson (Carlisle)

There are two points that I want to raise on this Supplementary Estimate. They are on the general lines that the debate has pursued. I wonder whether the Minister can say something about the general plan of expenditure on the development of mental hospitals.

I was very pleased to hear on my last visit to my constituency that, at last, our local mental hospital, The Garlands, is getting very much needed improvements. Nobody is more pleased about that than myself. On the other hand, looking at the other point of view, in answer to a Question that I asked the Minister a week or two ago about the development of psychiatric units in general hospitals, he told me that about 12 to 15 psychiatric units in general hospitals had been initiated over the last two or three years.

We all know that because of our restricted resources we cannot do everything. We cannot spend the money in every way that we would like. I think it is generally accepted now that the idea of psychiatric units attached to general hospitals and the beginning of small psychiatric units nearer to the community are more in line with modern thought.

I wonder, therefore, whether the Minister can tell us something about the policy of development and expenditure in this respect. Will the money be spent more on these older hospitals, or will he let them go to some extent, realising that they have had their day, and make a drive forward on a newer line? We all know how thought has changed very much in this respect over the last two or three years, and it is changing rapidly at present.

Three or four years ago it was the wish of many hon. Members to hear the Government bring forward a policy for building more and more mental hospitals. Now, many of us look forward to the day when the Minister can introduce a policy for the demolition of the older hospitals and the building of newer units more in line with modern thought. I do not expect my hon. Friend to develop this discussion in any great detail tonight, but can he give us some indication of his views about it when he replies to the debate?

Whether my right hon. and learned Friend is spending the money on the older hospitals or on the newer units, I urge that the money should be spent especially on admission wards and observation wards. I do not want to go into a discursion on admission procedures and that sort of thing, but the most distressing stories we hear from former mental hospitals patients, such as ladies with nervous depression who may go as voluntary patients for treatment and who, because of lack of accommodation and lack of facilities, have to be put in a ward with chronic and deteriorated patients, so that whatever treatment was given, the surroundings in which they find themselves are apt to do them much more harm than good.

The second point which I want to discuss has already been mentioned—the intractable problem of drugs, a subject on which I made some comments in the debate ten days ago. As a former general practitioner, I am the first to maintain that doctors must always have the right to prescribe what they like. None the less, doctors are the same as other people, very susceptible to pressure by suggestion and pressure by advertising.

In discussions about advertising with representatives of drug companies and others, one has to admit that a measure of advertising is both legitimate and necessary, with a view to introducing doctors to new drugs, in the way about which we have heard. The visits of repre- sentatives from drug firms are among the better features of this advertising. When I was working in general practice, before becoming a Member of Parliament, three years ago, I always welcomed the visits of these gentlemen. I found them quite inoffensive and they never used high pressure methods. They were always reasonable and I welcomed their visits for discussion with a view to hearing about newer methods and drugs which had been developed.

However, one wonders whether some of the more florid forms of literature which come through the post are really necessary and whether they are not wasteful. My hon. Friend the Member for Heston and Isleworth (Mr. R. Harris) referred to an American firm which sent out a small brochure to doctors twice a week. He said that it might be a postcard. I can assure him that it was considerably more than a postcard. I know the firm, because I have received these things myself. Some of the brochures are tasteful and expensive half-tone publications. One wonders whether that sort of thing is necessary.

One wonders whether the kind of publication which I received only a couple of days ago through the post, and which I now show to the House, is really necessary. It has been most expensively prepared and contains many pages of coloured advertising of a number of new products. It was sent to me, although the last time I had occasion to practise was three years ago. Therefore, in my case, it is a complete waste of money. One cannot help thinking that expenditure of this kind is running to waste and obviously coming out of the money which we vote in the House for the National Health Service. We give the drug firms fair play when we discuss these matters in the House and I think that they should get together in the national interest and arrive at some self-denying ordinance in advertising so as to ensure that this immense amount of money is not squandered on sending these highly-coloured and expensive publications to doctors.

There still remains the main question of what is to be done to tackle the mounting drug bill. Various suggestions have been made and the hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) has said that by various methods doctors should be perpetually reminded of prices. He is more optimistic than I am about the economy-mindedness of my profession. I do not think that we can really remind people of prices effectively unless we have some sort of sanction over them to keep them up to scratch. Then, if we adopt a method involving sanctions we shall get into trouble straight away.

The hon. Member for Barking (Mr. Hastings) mentioned the possibility of visits from the Ministry's officers. Some doctors take those well. Others do not take them particularly well, and again we should run the risk of creating resentment and trouble among the doctors. A third suggestion is that we should teach doctors something about economy and prices and put that subject into an already overcrowded curriculum. It is no use putting these things into a medical student's curriculum, however, unless he knows that he will have an examination at the end. I question whether he would seriously suggest that before qualifying a medical student must undergo an examination on the prices of drugs. Unless there is an examination, any amount of trying to teach medical students about prices will be ineffective. I can assure the House from memories of my own student days that if there is no examination they will be elsewhere when the lectures take place.

I suggest, therefore, that the drug firms might get together and devise some self-denying ordinance on advertising expenditure. I would go a little further and suggest that the Minister might go into competition with the drug people in a little advertising on his own account, by drawing the attention of doctors to the cheaper, simpler pharmacopeia preparations which are identical with the proprietary medicines.

It is useless to do that, however, unless the Minister does it in an attractive and arresting way. I do not think that the average ministerial circular would compete very much with a publication such as the one which I now have in my hand. If the Minister will publish attractive brochures and leaflets periodically to circularise among doctors, spending a little on typography and layout so as to to make the presentation attractive and easy to read, they might well yield him excellent dividends.

8.45 p.m.

Dr. Horace King (Southampton, Itchen)

I wish to continue this debate for a few minutes only, in order to press a point about drugs. I agree with every word said by the hon. Member for Carlisle (Dr. D. Johnson). I think he stated a magnificent case temperately.

Obviously, we cannot prevent doctors from prescribing drugs that save life or preserve health, but my hon. Friend the Member for Barking (Mr. Hastings) was quite right in the tribute which he paid to all the modern discoverers of drugs, who get a little bit of money for what they have discovered, as compared with the manufacturers and exploiters of drugs, who get much more for the brain-child of some eminent scientist, or the advertisers, who probably get more than the manufacturing druggists for bringing these drugs to the notice of the medical profession. I do not think we can do very much about that. I do not think that we can build a shield round the medical profession to protect it from this barrage of publicity that the manufacturing druggists impose upon them.

I have always thought that the chemist himself had a claim. He has asked for a long time that he should be able to substitute the pharmaceutical equivalent for any prescription, but no doubt the medical profession would be up in arms if we gave that privilege to the practising chemist.

There is something which the Minister can do. It is now three or four years since the Select Committee on Estimates examined the National Health Service and pointed out, among other things, that there were manufacturing druggists or chemists who were getting their working capital back within four years, and who were making an average annual profit of about 25 per cent.—and this after all the apparatus of advertising, which has to be paid for ultimately by the National Health Service.

At that time, the Ministry was in consultation with the manufacturing chemists, and I would hope that by now we have narrowed the field of difference between the Minister and private enterprise in the drug manufacturing industry. No one denies that the labourer is worthy of his hire. Having visited the factories of the manufacturers of some of these American so-called ethical products, I can say that they are manufactured under ideal conditions. The doctors are satisfied because they know that the drugs they obtain from one of the reputable firms are all that they purport to be, and that they are manufactured under the best of conditions. All that is worthy of the hire of the labourer. What the Select Committee found three years ago was that the labourer was making an unreasonable charge for his labour, and I think we have a right to demand from the Minister that he should exercise some control on the profits made by these manufacturers.

At the same time, I would press upon the right hon. and learned Gentleman another point which has arisen casually and incidentally in the debate. It should be possible in time for British manufacturing chemists to take over the manufacture of products now made by the Americans. There was a time when, penicillin, having been invented in this country—Fleming was one of the greatest men of our century, and there are hundreds of thousands of people in the world today who owe their lives to him—it was manufactured in America, and we were paying a royalty year after year from the National Health Service to American druggists for a drug invented by a great Englishman.

Mr. E. G. Willis (Edinburgh, West)

A great Scotsman, surely?

Dr. King

I hope that the Minister will be able to tell us what steps he is taking to take over from the Americans the manufacture of British products.

8.50 p.m.

Mr. Raymond Gower (Barry)

I wish to make one comment on what was said about charging for the services administered for the benefit of people from abroad. I quite agree with the view that has been expressed that this is both desirable and needed, but I think it would be most difficult to do. I think, however, my right hon. Friend recognises that the number of questions addressed to us as hon. Members of this House, and indeed to him, indicate that among the general public there is a good deal of misunderstanding about this issue. It is the kind of thing that can easily arouse a hearty roar of approval at any meeting. I hope he will find it possible to get some more definite information about the difficulty and the cost than he has yet been able to give the House.

My only other point concerns Wales. The figures indicate that the miscalculation in respect of expenditure in Wales was proportionately rather more serious than in England. I wonder to what extent as regards teaching hospitals, if at all, this is due partly to the antiquated nature of the hospital in Cardiff, which involves a great deal of capital and revenue expenditure each year. The maintenance expenditure is necessarily heavy owing to the age of the building, which has given great service but obviously should now be replaced.

My right hon. and learned Friend will recall that one of his predecessors promised us in the relatively near future one of the new hospitals as a teaching hospital in South Wales, the first to be built since the war. I would like to know whether even the current expenditure on the maintenance of existing buildings, apart from other reasons, indicates that this matter should now receive his earnest attention. We need this hospital for other reasons also. Cardiff has established in respect of its population an enviable reputation, and a new teaching hospital would be a facility which would give greater opportunities to the large number of young people in South Wales who are entering the practice of medicine.

I hope my hon. Friend will find it possible to comment on this point when he replies to the debate.

8.53 p.m.

The Parliamentary Secretary to the Ministry of Health (Mr. Richard Thompson)

When my right hon. and learned Friend the Minister of Health opened the debate he made the case for the Supplementary Estimate in general terms, and I can best serve the House by dealing with some of the points of detail which have arisen during the debate. To a great extent it has turned on the question of drugs: how we can effectively control the size of the drug bill, and similar matters. I will answer a number of hon. Members at the same time by dealing with the question in some detail. First, I will outline the measures we take now to limit the size of the drug bill.

We try to encourage doctors to be economical and we keep them cost-conscious by means of letters from the Chief Medical Officer of the Ministry of Health, through comparative lists of prices supplied to them by the Ministry, through the British National Formulary, through Prescribers' Notes also issued by the Ministry, and through arrangements whereby a doctor can compare the cost of his prescribing with that of his colleagues.

There are also arrangements under which the Ministry's regional medical officers visit doctors, where necessary, to inquire into possible excessive prescribing. Eventually, reference may be made for formal investigation by the local medical committee, and the Minister has power, in appropriate cases, to direct that money be withheld. Of course, that is exceptional and only in the last resort.

My hon. and gallant Friend the Member for Croydon, North-East (Vice-Admiral Hughes Hallett) referred to the recommendations of the Select Committee on Estimates that the Minister should urge on medical schools that medical students should be required to satisfy examiners about their knowledge of the financial structure of the National Health Service and the costs of the treatment for which they may be responsible. That recommendation is under active consideration, and I can say that earlier approaches have been made by the Ministry's Chief Medical Officer to deans of medical schools on the subject of instruction on economic prescribing. This is an aspect of the cost of prescribing which no doubt will be brought under review by the Committee under the chairmanship of Sir Henry Hinchliffe.

The prices of proprietary preparations which were not, in the view of the Cohen Committee, therapeutically superior to the standard preparations are now regulated by a voluntary price regulation scheme which has been agreed for a trial period with the Association of British Pharmaceutical Industries. The latest figure for 1956 of the proportion of preparations in this category is 91 per cent., but I shall have a word or two more to say about that in a minute.

The question of giving advice to doctors is extremely thorny and "sticky." No one can reasonably expect a doctor, simply to oblige the Treasury, to utilise the methods of treatment appropriate to a generation ago. Naturally, he will wish to use the latest aids and devices known to science, and he would not be a proper doctor if he did not. Having said that, however, there is the other aspect that it is possible to over-prescribe, all with the very best intentions, as the hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) said.

It is reasonable to assume that the aggregate effect of these measures has been to help to keep the costs of the drug bill below the level which they might otherwise have reached. We shall set considerable store by the Report of the independent professional committee under the chairmanship of Sir Henry Hinchliffe, which is looking into all this.

I said that I would say a word or two about manufacturers' prices. In 1953, we began a systematic investigation of manufacturers' prices and in 1955 we concluded that prices of standard drugs and preparations were reasonable. This conclusion was based on an examination of costs and profit margins which may be renewed from time to time. On proprietary preparations which, in the Cohen Committee's view, are not superior to the standard preparation, long and difficult negotiations with the Association of British Pharmaceutical Industry led to the Government's acceptance of three years' trial of a scheme under which manufacturers voluntarily accepted regulation of their prices.

This scheme began to come into operation on 17th June, 1957, and has so far been applied over nearly 70 per cent. of the total field, which covers 4,000 preparations produced by nearly 200 different manufacturers. Its application has so far resulted in 237 price reductions at a very substantial saving to the Exchequer. Naturally, this is a process which we want to see continue.

In view of the importance which hon. Members have attached to this question, I should say a word about the three main provisions for regulating prices. Under the first, the price in the United Kingdom shall not exceed that which the product commands in adequate volume in overseas markets in face of international competition. The second consideration, which applies when a drug is not exported in significant quantities, provides that if an identical non-proprietary standard drug is available in the United Kingdom the price of the proprietary shall not exceed the price of the standard drug. Thirdly, if it is impossible to apply either of these two provisions, a maximum price should be determined by using a detailed formula, comprising an ingredient allowance based upon recognised trade prices and processing and packaging allowances according to a schedule covering different types of drugs. I should add that the scheme also provides, in special cases, that where a manufacturer prefers this course, a fair and reasonable price may be negotiated with the Health Departments.

We are also inquiring into prices of basic drugs, such as antibiotics and hormones, which are important basic ingredients used in both standard and proprietary preparations. Investigations in this field were necessarily held up whilst we were negotiating on proprietary preparations because of the close interaction between the two fields. They are now being resumed.

The hon. Member for Newcastle-upon-Tyne, East made a general plea for a more detailed breakdown of the drug bill and information as to the way in which various conditions were responding to the use of drugs. He probably had in mind such a condition as tubercular meningitis which, once uniformly fatal, is now curable. Indeed, the morbidity and mortality of adult tuberculosis has fallen dramatically over the past ten years because of effective drug treatment.

On the other hand, as at present organised—as the hon. Member well knows—it is difficult for us to isolate these items in the drug bill. I shall certainly bear in mind what he has said about this matter because, if it is possible for us to enlarge our knowledge by some such operation as he suggests, we will certainly consider doing so, but for the present I cannot say more than that we will give the matter consideration.

Mr. Blenkinsop

Will the hon. Gentleman follow up my suggestion that he might contact the College of General Practitioners to see what help it might give in any special inquiries into diseases such as bronchitis?

Mr. Thompson

We would certainly see whether its experience and knowledge could be of help to us in that respect.

The hon. Member went on to talk of the danger of prescribing large quantities. In all good temper, I must say that I take leave to doubt whether the removal of the prescription charge would make any difference to the formidable arrays of medicine which accumulate on family shelves. I do not think that it would make the slightest difference.

The hon. Member went on to ask what was the value of the royalty element on foreign drugs imported into this country in large quantities. As he surmised, that is a matter which I certainly cannot answer "off the cuff", if, indeed, it can be answered at all. It involves a complicated statistical exercise in trying to separate the drug royalty element from all the other royalty elements which we pay to foreign countries, but I shall look into the matter and see whether it is possible to get even an approximation of that kind of information.

The hon. Member referred to tranquillisers. We have no general power to control the marketing of a drug in relation to its efficacy or safety, but in their own interests manufacturers do not introduce drugs without a preliminary test and trials. The Health Service Act provides that a general practitioner shall prescribe proper and sufficient drugs and medicines. Our advice is that this gives no authority to exclude a class of drugs from supply under this service.

As regards the question of limitation to prescription, the dangerous drugs legislation applies to specified drugs of addictions, but there is not sufficient evidence on which the Home Office can bring tranquillisers under this kind of control. The Pharmaceutical Society has recommended chemists not to supply transquillisers without prescriptions and such a recommendation would command special weight.

Information about types of tranquillisers and the advice available as to their use and cost was given to National Health Service doctors in March, 1957, in an edition of Prescribers' Notes. For the future, my right hon. Friend the Home Secretary has asked the Poisons Board to consider the general question of the need for controlling the supply of drugs which may be harmful if taken in excess, but it was said that an early report could not be expected and it is likely that further control would require fresh legislation.

Arising out of the matters quoted by certain hon. Members about the misuse of a particular proprietary tranquilliser, the Department is consulting the Home Office about whether reference to the Poisons Board of bromvaletone and carbromal would be desirable in the light of such general information as is now available.

One matter referred to by the hon. Gentleman with which I have not dealt is the disparity in the prescribing returns as between industrial and other areas. There are unexplained differences in the cost of prescribing per person between apparently similar areas, which apply to industrial areas as well as others. There has been no fundamental change since the increase in the charge. It is true to say that prescribing is less expensive in rural than in industrial areas, but no such generalisation is true as between industrial and other urban areas. The figures are being studied by the Hinchliffe Committee.

Mr. Blenkinsop

Can the hon. Gentleman do anything about the idea of developing a special standard of price indications for general practitioners? That proposal is being aired at present.

Mr. Thompson

I will look into that.

My hon. and gallant Friend the Member for Croydon, North-East referred to several matters. I have dealt with the recommendation of the Select Committee on Estimates, but he referred to the question of economies arising from the closure of small hospitals and matters of that kind. I am glad to say that quite a number of small hospitals have been closed over recent years, 70 or 80 in England and Wales in the past five years.

The small hospitals are, however, providing an essential local service and they attract much local interest and support. It is not infrequently the case that while the economic and medical arguments for closing a small unit may be powerful, or indeed overwhelming, as soon as they are put into practice, an immense volume of local opposition develops and finds political support in this House. However, we are alive to any possibilities of economy and a more rationalised system of working through the closing of small outlying units that are difficult to staff and otherwise inefficient.

My hon. and gallant Friend referred to the influenza epidemic. It was his view that as we knew that this epidemic was coming—its progress across the world was dramatic and well advertised—would it not have been practicable to take forestalling action rather than to deal with the cases when they actually arose? It would not have been practicable to inoculate 48 million people, which is roughly what we should have had to do, within the time available. We could not have made enough vaccine, and we could not have had enough doctors to give the necessary shots within the time. I cannot think it would have been justifiable to devote to it such a large percentage of our medical effort, although the alternative was that we had to accept epidemic when it came.

Vice-Admiral Hughes Hallet

My point was not connected with vaccination or inoculation, but with the education of patients, telling them on television, and so forth, the simple rules by which one avoids getting this infection.

Mr. Thompson

As a matter of fact, an effort was made in that direction and we received a number of angry calls from doctors who said that they objected to the Ministry of Health setting itself up as doctor and telling patients what steps they should take to meet a not very specifically defined complaint.

My hon. Friend the Member for Heston and Isleworth (Mr. R. Harris) had a question on the prices of drugs with which I hope I have dealt in my general reference to the subject earlier. In particular, he asked whether we could control the size of packages. My advice is that we cannot, more particularly in the case of American drugs.

Mr. R. Harris

On the question of prices, I understand from my hon. Friend that there have been 237 price reductions. Is that out of the total of 4,000 possible, since he said that there were 4,000 drugs? What special steps are taken in the case of a drug like Terramycin, which is a monopoly? I was at a loss to understand what a trade association can do in getting restriction or reduction in prices.

Mr. Thompson

Inquiry into these prices is still going on. Although I mentioned the figure 237, which my hon. Friend correctly quoted, that is not the whole story. We have not stopped there. On the particular point about terramycin, I could not tell my hon. Friend whether there is any alternative supply. If the doctor chooses to prescribe this drug we cannot stand between him and his patient. I agree that if we can provide the means of a more economical source of supply, it would be very desirable indeed.

The hon. Member for Nottingham, North (Mr. J. Harrison) had a point about what he thought was the indiscriminate admission to hospital of patients of foreign origin not resident in this country, as the result of which beds were taken up and expense was devoted to the care of those patients. The hon. Member asked me, I think, what force lay in the argument that the administrative procedures necessary to stop this were so complicated that it was not worth while to do so.

I would make two replies to that. The first is that one of the administrative procedures is already at work, and, I think, functioning satisfactorily. The immigration officials at the ports have instructions to resist as far as possible, people coming here whom they are able to show, or whom they have reason to think have come here specifically for the purpose of going into hospital to have an operation. I am sure that the hon. Member will be pleased to know that.

The rest of the argument probably applies more particularly to the general practitioner service but is also relevant to the hospitals, to which the hon. Gentleman wished to confine it. I think that he will see—and this is the answer to my hon. Friend the Member for Barry (Mr. Gower), also—that if we are to erect a nationality bar to these people, someone has to do it for us, and that, in practice, will be the doctor, who will have the duty of satisfying himself that various patients coming to his surgery are foreigners. We take the view that that is putting an additional, unsought and unwelcome duty on the doctor, and that, if it is performed efficiently, it will make the treatment of our own people more difficult than it is now.

Mr. Gower

I certainly did not advance any argument that was at all contrary to what my hon. Friend has just said, but I did suggest that public opinion obviously demands a rather clearer answer on this subject than has yet been given.

Mr. Thompson

Perhaps my references, and my hon. Friend's intervention, may enlighten public opinion. I hope so.

My hon. Friend the Member for Carlisle (Dr. D. Johnson) asked a number of questions about the future of psychiatric medicine—about which he has been asking Questions recently—which, I think, went a little outside of the scope of this debate. It is a fascinating subject but, with great respect, I would have thought that the proper time to raise it would be during a general debate on the Estimates which, no doubt, we shall have before long.

I know that hon. Members for Scotland are anxious to have a debate——

Miss Margaret Herbison (Lanarkshire North)

Not now.

Mr. Thompson

We seldom hear them admit defeat. However that may be, they must admit that I did my best to get them into the debate.

I have no intention of minimising an increase of even the 1½ per cent., which we are asking on our original Estimate of £477 million, but it has been shown by my right hon. and learned Friend that most of this arises from higher wages and salaries and increased prices. Consequently, the increase in real terms is smaller, although, of its nature, the Service is an expanding one, because we have an increasing population, old people are living longer, and drugs are getting more costly.

Clearly, the National Health Service will be a major beneficiary if the efforts of Her Majesty's Government to stabilise prices prove successful, and, although we need to look with the greatest care at such a great consumer of public money as is this Service, and not pass lightly any demand for additional provision that is made, I feel that we have made out the case for this Supplementary Estimate, and I hope that hon. Members may feel that the money can now be voted.

Question put and agreed to.

Fourth Resolution read a Second time.

Motion made, and Question proposed, That this House doth agree with the Committee in the said Resolution.