Motion made, and Question proposed.
That a Supplementary sum, not exceeding £16,589,706, be granted to Her Majesty, to defray the charge which will come in course of payment during the year ending on the 31st day of March, 1959, for the provision of a comprehensive health service for England and Wales and other services connected therewith, including payments to Northern Ireland and the Isle of Man, medical services for pensioners, &c., disabled as a result of war, or of service in the Armed Forces after the 2nd day of September, 1939, certain training arrangements including certain grants in aid, the purchase of appliances, equipment, stores, &c., necessary for the services, and certain expenses in connection with civil defence.
§ 3.41 p.m.
§ The Minister of Health (Mr. Derek Walker-Smith)
The amount of this Supplementary Estimate for the National Health Service represents an increase of 1463 just over 3½ per cent. on the original Estimate of £472,459,430 for the year. There are four main items, each of £1 million and upwards, that go to make it up. The first is hospital revenue expenditure, at £8,700,000; the second, general medical services, at £2,200,000; the third, pharmaceutical services, at £2,200,000; and the fourth, poliomyelitis vaccine, at £1 million. For the information of the Committee I will, if I may, deal shortly with each of these four items in turn, but perhaps I may say, first, a few general words.
Many of the items in this large Vote for the National Health Service relate to a type of expenditure, the course of which is, in the nature of things, very difficult to predict, and even the figures now appearing in the Supplementary Estimate do not pretend to give a certainty beyond peradventure. The Supplementary Estimate was prepared in January. It represents the best estimate that could then be made, but because of the difficulties of predicting so much of the expenditure we cannot, even now, be certain that it forecasts within precise or narrow limits the expenditure that will, in due course, be shown to have been incurred.
Having made that preliminary and precautionary observation, perhaps I may now come to the first main item—the £8,700,000 for hospital revenue expenditure. The original Estimate for hospitals was £354,566,000. The revised Estimate is £363,262,000—an increase of £8,696,000, which I have rounded up to £8,700,000. In considering this item, the Committee should have in mind the very large proportion of this expenditure that is devoted to the salaries and wages of medical, nursing and other staff directly employed in the hospitals. Thus, in this connection, in the original Estimate of £354½ million, wages, salaries, and so on, account for no less than £228½ million. As a matter of proportion, this means that well over 60 per cent. of the hospital revenue account is for wages and salaries.
For the information of the Committee, I would like to analyse this hospital item. The £8,700,000 is made up of Whitley awards, £3½ million; price increase, £½ million; acceleration of maintenance work and replacement of equipment, £4,600,000, and plant replacement—among smaller items—£100,000. 1464 That totals £8,700,000. Of that amount, increases in wages and prices together account for £4 million, but that increase of £4 million compares with an increase, in respect of the same items, of twice as much—that is to say, £8 million—in the last financial year, and of £13 million in 1956–57.
The Whitley item comprises, in the main, three large awards, accounting for nearly £3 million of the total. The first was the award of £1,626,000 for the domestic and ancillary staffs; the second was for the administrative and clerical staffs—being the regrading exercise which we successfully achieved—£927,000; and the third was for the medical and dental staff—£325,000. The total for the three is £2,878,000.
The third of the component parts of the hospital amount is the £4,600,000 for acceleration of maintenance work, replacements, and so on. I think that the Committee will agree that this is obviously worthwhile expenditure. I am glad to say that it also reflects the strength and position of sterling. In August last, the £ was so fortified by the efforts of my right hon. Friend the Chancellor of the Exchequer that it was possible to make available additional funds for building maintenance, domestic repairs, and renewals. I do not suppose that any hon. Member quarrels with expenditure on this good and worthwhile work—
§ Dr. J. Dickson Mahon (Greenock)
Would the right hon. and learned Gentleman be good enough to give us the breakdown of the price increase of £1 million in terms of equipment, and so on?
§ Mr. Walker-Smith
I am not quite sure that I caught what the hon. Gentleman is asking for. The total of price increases within the £8,700,000 is only £½ million. That is only one-eighteenth of the item for hospital revenue expenditure which, in turn, is only half of the total Supplementary Estimate with which we are dealing. Therefore, the total of the price increase is only about one-thirty-sixth of the Supplementary Estimate overall. I gave the comparative figures to show how wages and prices compare with those in previous years, and if the hon. Gentleman wants a breakdown of the small figure of £½ million my hon. Friend will seek to provide it when he replies.
1465 The second main item is £2,200,000 for general medical services. This sum arises from two main causes. The first cause is the advance payment on account of the balance of the central pool for 1957–58, which otherwise would not have been paid until next year, and the second cause is money paid on account of the further interim increase of 4 per cent. given to general practitioners with effect from 1st January. The first figure, of course, only represents, in effect, an advance payment of sums already due, and the second relates to an increase of which I heard no criticism when I announced it to the House. I am glad to say that I have heard no criticism since, and I am optimistic enough not to expect any criticism today.
The third main item is the pharmaceutical services. The Supplementary Estimate provides for £2,200,000, bringing the total cost to about £69 million for these services. This includes the cost of drugs and the payments made to chemists and dispensing doctors for their professional services and to meet their overheads. The total of £69 million, of course, is a large amount, but I think that it should be kept in perspective. The revised estimated total cost for the National Health Service for England and Wales this year is £675 million, of which the pharmaceutical services represent about one-tenth. That proportion, as the Committee may recall, has remained more or less constant over the last three or four years.
If I may say a word about the place of prescriptions in this matter, the expectation of the original estimate in respect of prescriptions was that there would be about 216 million prescriptions at an average cost of 6s. each. Our present expectation is that there will be fewer prescriptions at a higher cost, that is to say, that there will be 205 million prescriptions at an average cost of 6s. 5½d.
The charge of 1s. per item which was introduced in December, 1956, as the Committee will recall, in lieu of the previous charge of 1s. per form, had the result that some doctors prescribed larger quantities of drugs at less frequent intervals, as I think we have noticed before in the House. The number of prescriptions fell accordingly. But then a corrective influence came on the scene, 1466 operating in the reverse direction, to wit, the Asian 'flu epidemic of the autumn of 1957. That, of course, in the nature of it, had the reverse effect, increasing the number of prescriptions and reducing their average cost, because it is a fairly elementary disease.
This corrective tendency introduced by the Asian 'flu epidemic was taken into account at the time of the original estimate. Of course, the incidence of epidemics, it goes without saying, is a notable cause of fluctuation in the numbers and prices of prescriptions. There has always been a considerable fluctuation in the number of prescriptions. If I may take an example from some years back, when right hon. and hon. Gentlemen opposite were in office, there were, in 1949, 202 million prescriptions, rising in two years to 228 million, an increase of 13 per cent. I quote that example to illustrate that there is always a considerable margin of fluctuation in these things, and there is, therefore, no possibility of having the precision of estimation which one would otherwise wish.
As to the reasons for the increase, there is, first, the general upward trend of costs which has been reflected in drug costs as in other things. Secondly, there has been the introduction of new drugs and preparations. The newer drugs, for example, antibiotics, corticosteroids, and certain cardiac preparations now account for about 40 per cent. of the total ingredient cost of prescriptions. One single new drug introduced early this year, which is of particular value in the treatment of elderly patients, may now be costing £1 million a year.
This illustrates how, when we have a new drug of great therapeutic value, it may have the effect of increasing the outlay on the pharmaceutical services. But the cost of these new drugs must obviously be balanced against their value to the community, not only medically—that is important, of course—but also for the contribution they make indirectly but none the less powerfully to the national economy by shortening illness and thereby promoting a speedier return to work. The pharmaceutical industry has considerable achievements to its credit for which the nation should be grateful.
The third main reason for increased costs in this respect is the prescription of increased quantities, with which I have 1467 been dealing, but I should like to say that this is not necessarily uneconomic. In many cases of chronic illness, it is a perfectly proper practice and not necessarily wasteful at all. As a general tendency, it was particularly marked, as I said, in 1957 following the change in the basis of the prescription charge. But this tendency to prescribe larger quantities does not seem to have gone significantly further since that time and does not appear to have been increasing further this year.
It is clearly right that the Committee should scrutinise these figures keenly. I certainly approach the matter in no mood of complacency. As the Committee will know, we have devised many useful methods of keeping the drug bill within reasonable bounds. There is an agreement about the prices of most preparatory preparations which was negotiated with the industry to operate for a trial period. That trial period is now going on; we are rather more than half way through it. We are watching its progress very closely in the context of what the position will be and what it should be at the end of the trial period.
At the same time, we are doing all we can to encourage economy in prescribing among doctors. I am glad that the Hinchliffe Committee, on the Cost of Prescribing, in its interim Report, found that, on the whole, doctors are careful in prescribing at the public expense and exercise due responsibility. I am adopting the Committee's recommendations made in its inteim Report designed to secure that fuller information is put in the hands of doctors to help them in discharging this duty. I am looking forward also to receiving the Committee's final report, perhaps next month, and I shall at once, on its receipt, devote careful and constructive consideration to its further suggestions.
§ Mr. A. Blenkinsop (Newcastle-upon-Tyne, East)
Will the Minister make any comment on that very interesting analysis published in the Lancet as to the effect of the increased charges on drugs?
§ Mr. Walker-Smith
I did deal with that rather fully at Question Time in the supplementary answers I gave, I think, to the hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) or to one of 1468 his hon. Friends. I made the position clear at that time. If the hon. Gentleman wishes to pursue the matter, in the light of that, no doubt he will have an opportunity to catch your eye, Sir Charles, and then my hon. Friend will deal with any further points which the hon. Gentleman cares to make about it. I did say then that we felt that the comment was not entirely appropriate—I do not say misconceived—for the reasons I then gave.
I now come to the last main item. It may be the smallest financially, but it is important. It concerns the £1 million for the purchase of poliomyelitis vaccine. We have made considerable strides, I am glad to say, with our immunisation programme in this year, 1958–59. At the end of 1958, over 6 million children had been vaccinated twice, and nearly a quarter of a million who had had one injection were awaiting their second injection. Over three-quarters of a million received a third injection as a result of the expanded programme which I was able to announce to the House last July. There is at present plenty of vaccine available for late registrants, and, therefore, parents who have failed to register their children should not delay longer if they want to ensure that they are vaccinated before the start of the next season of poliomyelitis.
Unfortunately, young adults, the 15 to 25s, who also figured in the extended programme which I announced in July, instead of showing the traditional impetuosity of youth, have been dragging their feet. I would, therefore, through the Committee, tell them that they should now come forward at once in their own interests. It is true that the incidence of poliomyelitis in this age group is not quite as high as it is with the younger children with whom we were previously dealing, but, on the other hand, for those who contract it at that age the severity of the attack and the degree of paralysis are alike much greater.
I therefore sent letters to local health authorities making suggestions about arrangements that might help to improve the response of this age group. I am glad to say that the authorities, with the co-operation of general practitioners, employers and others, and with the help of publicity measures, are making strenuous efforts to bring this group in. I hope, also, that hon. Members will use 1469 their influence and good offices to advise these young people to act now in their own interests.
I have covered the four main items of the Supplementary Estimate, and I trust that what I have said will show clearly that this Supplementary Estimate is not in any way due to extravagance, but rather reflects valuable results in terms of the progress of the service and the well-being of those who work in it.
§ 4.3 p.m.
§ Dr. Edith Summerskill (Warrington)
I am sure that the whole Committee would like to thank the Minister for the detailed manner in which he has dealt with this Supplementary Estimate. I intend to address myself to two items, namely, the one dealing with the additional sum needed for hospitals, and the other the pharmaceutical services.
To take the hospitals first, this sum is additional to the revised Estimate, and I think that the House will agree that it is a very large sum of money. It always seems to me that the sum used by the hospital service is disproportionate to some of the other services—for example, the general medical services. I do not propose to pursue that point, except to this extent. I remind the Minister—it has been said time after time in the House—that the expensive hospital service is being used in some measure as an alternative to a less expensive welfare service.
A hospital working at a cost of £25 a bed may well contain many aged patients who could be accommodated comfortably and less expensively elsewhere. Indeed, they could be accommodated even more pleasantly than in a hospital. The House must address itself to that matter. As the Minister said, this very large sum of money which is needed for the hospital service is in a large measure spent on wages and salaries, which are embodied in the very large sum of £25 per bed.
Apart from wages and salaries, the Minister has mentioned the higher prices for new equipment, maintenance, and so on. Not for one moment would I question the cost of the equipment, the necessity to pay the staff adequately or the high cost of maintenance. It may well be argued that the additional sum for which we are asked is a small proportion of the original Estimate, but it is the time-honoured right and duty of this House 1470 to inquire into how these sums are arrived at and by whom, and particularly the criterion which the Minister adopts when he decides that an additional sum is needed for the hospital service.
I have with some effort, owing to the small size of the print, examined some of the costing returns of hospitals which operate the alternative and the main scheme. No doubt, when these schemes have been in operation a little longer, we shall be able to make further comparisons between the costs of comparable hospitals. That is absolutely fundamental. It is of little value to the House for the Minister to say that something costs either less or more than something else. We must always have comparable costs. No doubt we shall be able to promote further economies and improve efficiency. Consequently, the recommendations of the working party on hospitals costings which have been implemented have proved extremely valuable.
While these very detailed summaries of hospital costs will provide important statistics for regional hospital boards, teaching hospitals and the Minister, a real assessment of the efficiency and effort to promote economy can be made only by somebody in authority on the spot who can see for himself precisely what is happening and what is needed. For six years I served on the committee of a hospital where the medical director combined first-class surgical skill with an administrative flair and a social conscience for the taxpayers' money.
I am well aware that that is an unusual combination of qualities and I know that it has been decided to change that arrangement for a greater degree of lay administration. However, those who understand the day-to-day working of a large hospital know that only good medical administration can ensure efficiency combined with economy in the medical sphere. I will go so far as to say that only a doctor can speak to a doctor. Therefore, before granting these additional sums, I should like to know the criterion which the Minister adopts regarding efficient administration.
It is five years since the Bradbeer Committee reported on the internal administration of hospitals. It produced a good Report, but we do not hear very much about it. I should like to hear more 1471 about how this Report being implemented from the Parliamentary Secretary when he winds up the debate. The Committee made various recommendations and I should like to know how they have been put into effect. They are closely related to the efficiency of the service and the related costs which are reflected in a limited measure in the Supplementary Estimate before us.
The Minister will recall that the Bradbeer Committee recommended that a medical administrator should be appointed in the larger hospitals. The cost of many of the things about which the Minister has spoken would come within the purview of the medical administrator. That Committee also recommended that he should be a consultant, combining clinical with administrative duties and working in close association with the matron and lay administration.
The Bradbeer Committee envisaged the medical administrator as giving advice to the governing body on the available use of beds. I remind the Minister that many of my hon. Friends have raised the problem of waiting lists. He will recall that we had a most interesting debate the other night when my hon. Friends representing constituencies on the North-East Coast drew the attention of the Parliamentary Secretary to the long waiting lists of that area. My hon. Friends representing constituencies in Birmingham and Manchester have also drawn the Government's attention to long waiting lists in those areas.
The Bradbeer Committee said that if an administrator of the kind I have described were introduced into those hospitals one of his functions would be to observe the waiting lists and try to keep them down.
§ Sir Keith Joseph (Leeds, North-East)
The right hon. Lady has not referred to a much more recent Report than that of the Bradbeer Committee, the Boucher Report, which draws attention to the fallacy of comparing waiting lists with each other, although some of them in some areas are compiled on out-of-date principles and do not reflect the true current needs of the local population. Surely the right hon. Lady should be asking that waiting lists should be realistic before being compared with one another.
§ Dr. Summerskill
I assure the hon. Member that waiting lists are realistic. If he had troubled to be present at our most recent debate, only two weeks ago, the debate on the position on the North-East Coast, he would have heard hon. Members being completely realistic in their approach to this matter and the Parliamentary Secretary's reply to the debate.
My point is: is there proper supervision of these important aspects of medical work? It was also recommended that the administrator should undertake liaison work with the regional board, the local health authority and the local executive councils. That approach would also ensure the more efficient conduct of hospitals. It is said that the administrator should be responsible for the supervision of admissions and discharges and, as I have already said, the survey of the waiting lists, which would put him in a position to advise on the employment of whole-time or part-time consultants—and I am very pleased to see my hon. Friend the Member for Birmingham, All Saints (Mr. D. Howell) in his place, and I hope that he will raise this matter again. There is a difference of opinion about whether the part-time consultant approach is wasteful. I am sorry that the Minister did not deal more with those day-to-day problems which have been brought to his notice during the year by hon. Members from different parts of the country.
It has also been recommended that the administrator should survey medical staffing. The Minister has told us again today that a large proportion of the amount spent by hospitals is devoted to medical staffing, but we should have been very pleased to learn just how medical staffing is determined. In our most recent debate, we were told that the number of medical staff per 1,000 of the population on the North-East Coast was very much lower than the corresponding figure for the South. We were not given any reason for that, for which I do not blame the Parliamentary Secretary, because he cannot know all the answers. I specifically asked what the pattern of staffing was and how it was decided that there should be one pattern in one area and a different pattern in another. That sort of difference causes hard feelings and gives rise to Questions in the House.
1473 Another recommendation—I think by the Bradbeer Committee, although it might have been in a more recent report—was on the employment of lay workers, another wry important matter. It was brought out in a recent report on maternity, when the Minister was advised that wherever possible midwives and nurses in hospitals should he helped by lay workers who could do domestic work which would otherwise take the time and effort of professional workers. This is a means whereby great economies could be effected, and I hope that we shall hear more about it. It is an important approach to the staffing of our hospitals.
It was recommended that the medical administrator should supervise the medical equipment and medical supplies in cooperation with the chief pharmacist. In discussing the whole subject of pharmaceutical services, the Minister reminded us of the drugs which have been put on the market, and of their dramatic therapeutic results. Nobody denies that, and there is no doubt that there are hon. Members listening to me who have benefited from those drugs. We all welcome that contribution to medical science in this century.
Nevertheless, at the same time, we must examine the cost of those drugs and discover how those responsible for ordering large amounts of drugs for our hospitals are supervised. Again, it has been recommended that chief pharmacists in hospitals should be carefully supervised. It is not enough to say, as we are often told, that a medical advisory committee is functioning and that it examines demands for and costs of new medical equipment. I have friendly feelings towards those medical committees in hospitals, committees of doctors. However, a member of such a committee is not always prepared to demur at some expenditure which he may think unjustified, because he might find a future request of his own refused.
I attach great importance to the overall authority of one person who can make decisions and recommendations in the interests of economy and efficiency. I want to know, therefore, how far the recommendations of the Committee on Hospital Administration, set up by the 1474 Central Health Service Council, have been carried out.
I want now to refer to the sum additional to the revised Estimate for pharmaceutical services. The Minister has been very frank about this in the Explanatory Note, which says:A saving, resulting from an expected reduction in the number of prescriptions below that assumed in the original estimate, is more than offset by higher average costs per prescription attributed largely to new drugs and preparations.I am surprised that it does not say that it is also attributed to over-prescribing, because the Minister has not attempted to hide that fact.
What the Minister said and what is paraphrased in the Supplementary Estimate is precisely what I and my hon. Friends warned the Government would happen when they imposed a charge of 1s. per item on a prescription. I do not like to say "I told you so", but here we are dealing with Estimates of a very high order and it was clear that when the Government decided to change their policy they were making a mistake.
A few years have passed and now the Government say that the country must be prepared to pay for the Government's mistake, because that is the one explanation of the Supplementary Estimate. On that occasion, I went into considerable detail, giving examples to show how proprietary drugs with no proven therapeutic value would increase the drug bill. Many of my hon. Friends who were here at the time said that this would encourage over-prescribing.
The recent article in the Lancet has been mentioned. Nobody inspired this article. The people who wrote this article are quite unknown to me, and do not belong, as far as I know, to any political party. After they had analysed the Government's policy, the authors of the article in the Lancet of 3rd January this year—J. P. Martin, who is Lecturer in Social Science at the London School of Economics, and Sheila Williams—on the effects of imposing prescription charges, reached this conclusion:The charge on each item prescribed led to a sharp fall in the number of prescriptions issued, coupled with a drastic increase in the cost of prescriptions. It appears that about 40 per cent. of this increase was due to doctors prescribing in larger quantities. The strength of this reaction was such as to increase the 1475 net total of the prescription bill by just over£1¼ million, instead of reducing it by £4½ million.We were told in a most dogmatic fashion that the 1s. tax on the sick, because that is what it comes to, was to raise £5 million, and that very action has resulted in the drug bill soaring. This is borne out by what the Minister said, by what is said in the Explanatory Note and by what is said by people who have examined the situation but who have nothing to do with the House.
In 1956, when the 1s. charge was imposed, the cost of a prescription was 4s. 6d. This afternoon, the Minister told us that the cost is 6s. 6½d.
§ Dr. Summerskill
All right, 6s. 5½d.; I will give the Minister a penny.
The Minister of Health at that time, the right hon. Member for Thirsk and Malton (Mr. Turton) said:I have to see that there is no extravagance … I can assure the House that we are actively considering ways in which we can reduce the cost … I believe that we must do more. I am sure that we must educate the young doctor so that he knows more about economical prescribing. I believe we have also to go into the question … of the pressure of the salesmanship of the drug houses and the other pressures to which a doctor is subjected. I shall give early consideration to further ways of dealing with that part of the problem."—[OFFICIAL REPORT, 29th November, 1956; Vol 561, c. 710 and 712.]Here, today, after these promises and after this recognition of the problem, the Minister has to come here and tell us that the cost of prescriptions has gone up by 2s.
The Minister may say, "Well, here was the Opposition dealing with this in a perhaps aggressive spirit." May I tell him what the British Medical Association said—and the B.M.A. is not composed of Socialists, I can assure him. The B.M.A. said:The composite packs of medical supplies which the Minister said he would introduce and save a shilling or two was not the answer. The B.M.A. warned them that it would create wastage. A further result would be a tendency to over-prescribe which might result in waste and more expense to the Service than ever before.I must say that I have never before said in this House that the British Medical Association was absolutely vindicated.
What did the Lancet say? On the charge of 1s. per item, it said this: 1476This decision … will be welcomed by neither patient nor doctor … Given that some further reduction in national spending is required, it is by no means clear why this should be paid by the sick consumer rather than the healthy consumer … More of this new levy will be paid by the average woman than the average man … The average aged person will pay half as much again as the younger person … will bear more heavily on the family man than the individual wage earner.It is quite clear that the Government were given warning, yet now we are invited to pay a colossal price for drugs. The Government were warned that the charge would be against the interests of the patient and would not reduce the drug bill. In fact, again and again, we have said that it would encourage over-prescribing, and the prescribing of proprietary drugs. In view of this, I ask the Minister, since this act of the Government has increased the price of the prescription and has put up the drug bill, will the Government now abolish the prescription charge in order to reduce over-prescribing?
I can assure the Minister that this is not a political point, because at that time the present Minister's predecessor advised the doctors to over-prescribe. I remember the details so well, when we told the Minister, "If you charge an old person 1s. for, let us say, an 8 oz. bottle of cough mixture in the London smog, the old person living on an old-age pension will say that 1s. is a large amount, and the doctor will say that he will give him a 16 oz. bottle, which will last him two or three times as long." The Minister at that time then said that we should encourage doctors to over-prescribe, and, indeed, that he would allow them to over-prescribe in those circumstances.
If any hon. Members think that that is an exaggeration about over-prescribing, I would ask them to look at their own medicine cupboards in the bathroom, and see the bottles of tablets, the boxes of powder, the ointments, expensive ones, all of them. If the Minister will do me the honour of looking up what I said, he will find that I said that all that the Minister was doing was cluttering up the medicine cupboards of the country. Here is the cost of it—the cost of the clutter. I am not asking everybody to swallow these pills. I would much prefer them to clutter up the cupboards rather than that people should be taking antibiotics 1477 which are not doing them any good. The point is that the country has to pay for that clutter. I therefore hope that the Parliamentary Secretary will tell the Committee whether, in view of this over-prescribing, the Government will now abolish the 1s. charge.
I should also like to ask what other advice from outside this House has been heeded. I remind the Minister of Lord Cohen's advice. Lord Cohen served on the Committee on General Practice within the National Health Service, which said this:In order to influence students' training in methods of prescribing, the National Formulary and all official published documents on prescribing (including Prescribers' Notes), shall be issued to medical students during their clinical training …This was also one of the recommendations in the interim Report of the Hinchliffe Committee on the Cost of Prescribing, the Committee which the right hon. and learned Gentleman mentioned. The Hinchliffe Committee also recommended that if doctors are to be encouraged to prescribe official preparations, additional lists should be provided in which proprietary names are arranged alphabetically, together with their official equivalents.
The Minister told us that he was implementing these recommendations. I should like to know specifically from the Parliamentary Secretary which of the 10 recommendations in the interim Report of the Hinchliffe Committee have been implemented. It may be that the medical student to whom I spoke yesterday had perhaps been badly served, but he certainly had not been told, or been given the advice which Lord Cohen said he should be given.
There is one aspect of prescribing which I hope the Committee will examine, and perhaps the Minister himself could help. While the prescription of the general practitioner is examined, may I ask whether the hospital prescription is subjected to the same scrutiny? Is the consultant who likes to prescribe expensive proprietaries, when much cheaper standard preparations are equally efficacious, communicated with? The Minister will know that if a general practitioner is shown to be over-prescribing, he receives a communication and is asked to give an explanation.
1478 I should certainly like to know precisely what treatment is meted to those specialists who are known by general practitioners to favour always the latest proprietary drugs. Is any examination made of the prescribing costs of consultants in the same specialty in different hospitals, particularly in relation to outpatients?
I come now to new drugs and preparations. Every doctor is reminded, as he opens his letters every morning, that the market is still being flooded with new proprietary drugs. The Minister has had questions put to him from both sides of the House about the high charges made by American firms operating in this country. I would remind the House that the most flagrant recent example was raised by my hon. Friend the Member for Islington, East (Mr. E. Fletcher). For two years before July. 1958, the Minister agreed that the prices submitted for corticosteroids were fair and reasonable. He confirmed that in July, 1958. In the four months following July, 1958, there was a drop in price on one item from £56 to £12 per 1,000 tablets. The price reduction was by stages which were all followed simultaneously by the American-owned or American-licensed companies in the United Kingdom.
My hon. Friend the Member for Islington, East was not alone in showing his concern at what appear to be the activities of an American drug ring. The hon. and gallant Member for Knutsford (Lieut.-Colonel Bromley-Davenport), who always amuses the House, is a very vocal supporter of the Government. He has asked Questions of the Minister on this subject. So has the hon. Member for Heston and Isleworth (Mr. R. Harris), another Government supporter. My hon. Friend the Member for Willesden, East (Mr. Orbach), who is associated with six hospitals, has also shown concern.
I think that the Minister will be rather shocked by my next comment. The other day, when this matter was raised in the House, the only support which the Minister received when asked about this matter was from the hon. and gallant Member for Lewes (Colonel Beamish). The hon. and gallant Member was asked to declare his interest. He said nothing. I understand that the hon. and gallant Gentleman, last November, was made a 1479 director of the drug firm, Smith, Kline and French, a private American company. If I have been wrongly informed I shall be only too happy to withdraw this remark, but the source of my information, and the fact that when the hon. and gallant Member was asked whether he had an interest he declined to reply, make me think that the information I have been given is absolutely accurate.
§ Sir K. Joseph
I am sure that my hon. and gallant Friend the Member for Lewes (Colonel Beamish) has never concealed his interest at all.
§ Dr. Summerskill
The hon. Member is very rarely here. He comes perhaps to a major debate on health problems. He interrupted me just now with a question which was entirely irrelevant. If the hon. Member was not here and is completely ignorant of the facts, he must not continually interrupt. I am sure that the Minister would agree that this question of a decrease in price from £56 to £12 per 1,000 tablets needs investigation. On that day when this matter was raised the hon. and gallant Member for Lewes was asked to declare his interest. He leapt up with fervour, but he said nothing. Since then, I have been given the information which I have just passed on to the Committee.
§ Sir Hugh Linstead (Putney)
Did the right hon. Lady, as a matter of the ordinary courtesies of the House of Commons, inform my hon. and gallant Friend the Member for Lewes (Colonel Beamish) that she intended to raise this matter today?
§ Dr. Summerskill
In view of the importance of this matter and the fact that drugs were being discussed, I was quite certain that he would be here.
§ Dr. Summerskill
When there is a debate and one pursues some matter at length, of course, one notifies an hon. 1480 Member, but does one otherwise inform an hon. Member? I have been a Member of the House for twenty years and I have heard hon. Members time after time mention the names of my hon Friends and continue to pursue a topic without informing them beforehand.
This is one simple question. If I have been misinformed I shall certainly withdraw my remarks. I should not have mentioned it had we not been on the subject of American supplies of drugs at very high prices and this debate had not been on a Supplementary Estimate and I had not believed that hon. Members on both sides take an interest in the matter
§ Dame Irene Ward (Tynemouth)
Is not the point that on matters of this kind, when it is a sort of personal allegation, it is common practice to notify the hon. Member concerned that the matter will be raised? On general issues, when one is talking of political philosophy or general behaviour, of course it is not. I also have been a Member of the House for a very long time, and I have always understood that it was common practice if one intended to make a direct allegation, to take steps to inform the hon. Member concerned.
§ Dr. Summerskill
I have the greatest admiration for the intelligence of the hon. Lady the Member for Tynemouth (Dame Irene Ward), but I am surprised that she should feel it necessary to intervene at this great length on such a minor matter.
§ Dr. Summerskill
If the hon. Lady is fortunate enough to catch your eye, Sir Charles, she should try to make a contribution to the debate of much greater value than her intervention.
§ Mr. Maurice Edelman (Coventry, North)
Is it in order, Sir Charles, for the hon. Lady the Member for Tynemouth (Dame Irene Ward) to describe my right hon. Friend the Member for Warrington (Dr. Summerskill) as an ass?
§ Dr. Summerskill
It shows the paucity of the hon. Lady's argument that she has to descend to vulgar abuse. It shows that she has little left to say.
§ Dr. Summerskill
I am surprised that the hon. Lady should be so feline on this occasion.
To return to the subject. The consumption of certain so-called medicines, particularly in the form of tablets, is an insiduous process. I ask the Minister to take this matter seriously. The country must be vigilant. I would call attention to an artcle in yesterday's Financial Times, a serious newspaper. It was headed: "'Happy Pills' become big business in the United States." It said:Last year an estimated 225 million dollars"—equivalent to £80 million—was spent in America on pills to reduce the tension and anxiety of living.Apparently, these tranquillisers and energisers—the so-called "happy pills" and "lift pills" respectively—are part of the American way of life. The greater part of this colossal sum was spent on "happy pills", but the "lift pills" are gradually catching up. I do not know whether Abraham Lincoln had "happy pills" and "lift pills" in mind when he talked about the pursuit of happiness.
This question of American firms operating in this country and producing these tranquillisers and advertising them extravagantly in the way we all know they do, must have been brought to the Minister's attention. Every day, every doctor receives leaflets, pamphlets, pills and tablets from American firms. It may be that this pattern of life, which is acceptable in America, may be imposed in this country.
The Financial Times continued:The happy pill consumption has risen sharply in five years, partly as a result of the promotional activity of the drug companies … This mass consumption of pills that sell for about five dollars to six dollars for fifty, with a daily dosage of three to eight pills, has increased the sales and profits of drug companies substantially.When we have put Questions to the Minister about excessive prices, inevitably he or his predecessors have assured us that the money is being spent on research, and that research in this country is so limited that we have to depend upon the research in America. If that were so, would his hon. and gallant Friend the Member for Ripon (Sir M. Stoddart-Scott), who is a doctor and 1482 a steady-going supporter of the Government, ask for information about the activities of certain United States companies if he had no good reason?
Yet the hon. and gallant Gentleman alleged the other day that these corn-panics are extracting high prices from the Minister's Department for research, the cost of which is already included in royalties payable to their mother companies in the United States of America. I ask the Minister to investigate this matter. This is imperative, in my view, when a highly responsible Member feels it necessary not to write the Minister a private letter, but to ventilate the matter in a Question.
On other occasions I have given instances of gross overcharge by American firms in this country. It is clear that hon. Members on both sides of the Committee are uneasy about the high prices of proprietary drugs which, the Minister tells us on this Supplementary Estimate, are largely responsible for the rise in the cost of the pharmaceutical services. In fact, £2 million more are being asked for the pharmaceutical services today, chiefly for proprietary drugs, which means that the Minister could not anticipate the rise. The firms in question are now bringing such pressure to bear that a great Government Department such as the Ministry of Health cannot even anticipate an increase of £2 million for proprietary drugs. In view of this fact, I ask the Minister to respond to our request, which has been repeated time after time, for an inquiry into this aspect of the service.
This is the last point I want to raise on the Supplementary Estimate. I am apprehensive that next year we may again be asked for an additional sum for proprietary drugs, and because of that I believe that the whole Committee should now demand an inquiry.
§ 4.44 p.m.
§ Mr. James Dance (Bromsgrove)
I intervene in this debate only for a few minutes, and I can assure you, Sir, that I shall not be controversial.
A statement has been made by the Mid-Worcestershire Hospital Management Committee which has caused great indignation to many thousands of my constituents. It may be that the same kind of decision has been made by other 1483 hospital management committees, and, if so, it will affect other hon. Members of this Committee and their constituents. I refer to their decision to end all local house committees by the end of the month.
These committees have done excellent work in the past, and so I hope that my right hon. and learned Friend will take some action and allow them to continue. Since the State took over hospitals these committees have been the only close contact between local people and their hospitals. On the principle that a man or woman on the spot knows best what are the local requirements, many public-minded people who have been members of those committees have made many recommendations which have brought great benefits to the smooth running of their local hospitals. Above all, and this is vitally important, they have fostered the human relationship between staff, patients and their friends and relations.
It was not only the decision—though that was of paramount importance—but the way it was announced which caused great indignation in my constituency. The suggestion was kept a close secret, and no reason was given for the decision. There was merely a high-handed announcement that this excellent committee was to be abolished, with less than six months notice. I can bear out what I have said by quoting the Redditch Indicator of 6th March which stated, "Hospital committee closing a bombshell". And it was. It was a complete bombshell to my constituents. I submit that this is not democracy. It is a form of dictatorship.
The town of Redditch in my constituency is particularly affected. Redditch is a very well-run and progressive town on the borders of Worcestershire and Warwickshire. For some time its people have felt that they have been left out in the cold in connection with hospital services. Indeed, some time ago I had an Adjournment debate in the House in which I protested against the closing of their maternity home, and this recent decision of the Mid-Worcestershire Hospital Management Committee is the last straw. The people of Redditch feel strongly that this is their last personal contact with their excellent Smallwood Hospital, and it is to be taken away from them. In 1484 conclusion, therefore, I hope that my right hon. and learned Friend will use his good offices to persuade the management committee to reconsider its decision which, I am convinced, will not only be detrimental to the efficient running of the hosiptal but, as I have already stated, will cause bitter resentment to thousands of people who will not tolerate this form of dictatorship.
§ 4.48 p.m.
§ Mr. Maurice Edelman (Coventry, North)
May I turn to some of the wider considerations raised in the course of the Minister's presentation of this Supplementary Estimate? The right hon. and learned Gentleman rejected in anticipation the charge that he might be thought to be complacent, but I could not help feeling that he was smug in dealing with the startling rise in the cost of the pharmaceutical services. I wish briefly to rehearse the development of the cost of those services in the last ten years or so.
The Minister will recall that, in its Report of 1956–57, the Public Accounts Committee drew attention to the continuous increase in the cost of those services, pointing out that between 1949 and 1956 there had been a rise of from £34 million to £63 million in their cost. Today the Minister tells us that the cost has risen still further to the order of £69 million. Also, whereas in 1949 the average cost per prescription was about 3s. 1d., today it has gone up to more than double, to the startling figure of 6s. 5d. per average prescription.
I speak as one who has no connection with the pharmaceutical industry except perhaps as a potential consumer of its products, but I share a widespread anxiety about the startling rise in the cost of those products and its effect on the public, which I would describe as holding up the consumer to ransom. I hope in due course to develop this point and to give one or two illustrations of the way in which this takes place.
I observe in the Report the suggestion that one of the chief reasons for the rise in costs was over-prescription, which my right hon. Friend the Member for Warrington (Dr. Summerskill) has dealt with from the Front Bench, and also the suggestion that doctors have been rather rashly prescribing expensive drugs.
I had the feeling, when reading this Report, that the whole onus of cutting 1485 down the cost of the pharmaceutical service was, in fact, being laid upon the doctors. I want to show this afternoon that, so far from the doctors being at fault, the actual responsibility for the substantially increased cost, particularly in proprietary medicines, lies in the fact that these drugs have fallen into the hands of what I can only describe as a ring of producers which is, in effect, demanding of the consuming public prices which, if they were translated into terms of other products, would cause a tremendous wave of protest all over the country.
Of course, the fact is that the average layman, knowing nothing about the cost, benefiting from the inventions and discoveries of doctors and enjoying the advantages which come from the provision of new and effective drugs, is naturally grateful to enjoy these benefits, while at the same time he must, if he examines the cost of the pharmaceutical service, be appalled at the way in which the pharmaceutical industry is profiting at the expense of the community.
I should like to deal first of all with the question—a matter which I have been interested in for some time—of the cost of anti-poliomyelitis vaccine. The Minister has made a passing reference to the Supplementary Estimate and to the fact that the sum of approximately £1 million is involved. We have not heard from the Minister how much of this money is going for imported vaccine and how much for domestically produced vaccine. We have not heard to what extent, in producing domestic vaccine, he submitted contracts to competitive tender. All we know is that the Minister has come to tie House and asked for another £1 million of vaccine in order to pay for this very desirable object of inoculating a large new class of young people.
Let me say straight away that I believe that only the very best National Health Service is good enough for the people of this country. Let me make it quite clear, in anticipation of what might be said, that in my opinion these remarkable new antibiotics, these corticosteroids which have recently been produced in increasing quantities, are all highly desirable and should be made available to everyone without exception who requires them, and that the test in these matters should 1486 not be the capacity to make contributions but the test of need.
I see that the hon. Member for Leeds, North-East (Sir K. Joseph) has fled from the Chamber before the attack of my right hon. Friend, but I must say that when last year he brought the ladies at the Conservative Conference to their feet in frenzied applause at his suggestion that there should be increased charges for die National Health Service he was doing a great disservice to all those people who have benefited from the National Health Service, because until the present it has been either free or at least almost free.
I want, therefore, to make it quite clear that in my opinion the National Health Service should not only be a free service but the best service available to the people of this country. I want to add that any suggestion that there should be increased charges and increased payments by the patients for pharmaceutical products made available through the Service is merely a suggestion which will benefit the pharmaceutical industry and encourage the very powerful lobby which exists in order to promote the interest of that industry.
The anxiety which I feel about the cost of the anti-poliomyelitis vaccine, the, anxiety which I feel that the market has not been adequately tested, and the anxiety which I feel about the investment that has been made and the manner in which it is being recouped, is nothing compared with the anxiety felt in the United States of America about some of the activities of the companies producing the Salk vaccine, which supplied something like £45 million worth of vaccine to the American health services last year.
I think it is not generally known among the suppliers to this country, suppliers which, no doubt, the Minister has under contract—he will correct me if I am mistaken—that on 12th May last year, and I now quote from the report in The Times, a report which I have confirmed from another source:Five big American drug firms were indicted today on charges of violating the laws against monopolies in the supply of anti-poliomyelitis vaccine to Federal state and local authorities. The indictment, announced by Mr. Rogers, the Attorney-General, named Eli Lilly and Co., of Indianapolis; Allied Laboratories, Inc., of Kansas City; American Home Products Corporation of New York; Merck and Co., of New Jersey; and Parke, Davis 1487 and Company, of Detroit. The companies were described as the sole producers of poliomyelitis vaccine in the United States from the time the success of the Salk formula was announced in April, 1955.I quote this in order not merely to suggest that this charge was initiated, as the Minister will know, by the House Committee of Congress, not merely in order to show that Congress is aware of what has been done, but to raise a matter directly relevant to the Supplementary Estimate before the House.
I want to ask the Minister this question directly—and I hope that he will reply to it in direct terms—whether the prices quoted by the five American companies have been uniform prices. If so, it means that we here are enduring the consequences of an activity which in the United States has resulted in a charge of conspiracy.
I must say in fairness that one of the companies charged, Merck and Company, said in a statement that they had charged the market price and thatpricing decisions were made independently, in conformance with the law and the public interest. A statement by Parke Davis said: We have never conspired with other manufacturers to fix or control the price or the market for this or any other pharmaceutical product'.This is extremely interesting, because it shows a certain amount of simultaneous inspiration, if that is the right term, among all those firms supplying pharmaceutical products, because, according to the report of the house committee which studied this matter, the House Committee, which was headed by Representative L. H. Fountain of North Carolina, a price conspiracy was indicated by the fact that not one but hundreds of identical bids within a fraction of a cent. were received on polio vaccine by Federal and State agencies. I was interested in the activities of some of these companies, and especially in their application to other products which were being bought by the Minister.
Quite recently, I have been interested in a product, which the Minister I believe by inference referred to, called mecamylamine hydro-chloride, marketed in this country under the name of "Inversine" by one of the companies which were named in this indictment as one of the alleged conspirators to keep up the price of anti-poliomyelitic vaccine. The com- 1488 pany which markets "Inversine" is Messrs. Merck, Sharp & Dohme, Limited, a company which, no doubt, is known to the Minister. It is perfectly true—the Parliamentary Secretary has written to me on the subject, and I am obliged to him—that companies which develop pharmaceutical products, particularly if the product is the result of many years of research, are entitled in some way to recoup, either privately or from the Government, their research costs. It is in the national interest that research should be stimulated, whether by means of royalties or by means of an inclusion in the direct price of the product.
On the other hand, having established that, it is utterly wrong that any company should derive from the public a profit of 1,990 per cent. for a corticosteroid drug, a drug designed against hypertension and which is of benefit, possibly, to millions of people throughout the country. It is absolutely wrong that the public should be fleeced in this way—that is the only term I can use—when it is possible for a comparable drug to be produced considerably more cheaply.
When I asked the Minister Questions about it, he replied in two forms. First, on 9th February, when I asked him about corticosteroids generally—that is, drugs against hypertension—he replied:The original tenders obtained in 1955 showed some price differences, and the subsequent downward movement of prices to uniform levels was, in my view, the result of competition."—[OFFICIAL REPORT. 9th February, 1959; Vol. 599, c. 141.]In other words, the Minister was arguing that as a result of competition the competitive prices eventually were brought down to a uniform level and that this uniform price was not the result of collusion but was merely the effect of his pressure upon the companies to bring the prices down.
I want, however, to go further than that. I have grave doubts whether this uniform level of prices was the result of competition. In my opinion, it is the result of collusion, that kind of price collusion which can be found throughout the whole of the pharmaceutical industry and about which the public, generally speaking, is little informed.
On 16th February, I went further and asked the Minister a Question which I will not repeat in detail, because it is highly technical, although it has direct 1489 reference to this subject. I asked him whether he would look into the matter in view of the fact that the raw material of mecamylamine hydrochloride, from which the drug "Inversine" is prepared,is available in Europe at £100 per kilo and that the profit on the price to the National Health Service, after allowances for manufacturing costs, is approximately 990 per cent."—[OFFICIAL REPORT, 16th February. 1959; Vol. 600, c. 4.]I was wrong in one particular, because the profit being made by the firm was not 990 per cent. but 1,990 per cent. The Minister, very properly and understandably, asked me to bring him proof and to provide the figures on which I reached that conclusion.
Usually, the result of asking the average uninformed inquiry on a subject of this kind is to conclude the matter, but it so happened that I had the figures at my disposal. The Minister will recall that I wrote presenting him with an analysis of how the figure was reached. He said, as is reasonable up to a point, that in the case of drugs it is not merely a matter of considering what are the raw material costs, but that there are many other factors, including research. I accept that, but only in part.
I believe that today there is a twofold process going on. On the one hand, we have scientists like the brilliant team at Beecham's who have recently discovered the variants of penicillin and the possibility of their development on a large scale. We have these distinguished scientists working for science. Then, there is the second stage, and what I regard as the socially immoral stage, when these discoveries are taken up by commercial companies and not used simply, directly and primarily to make them available for the healing of people, but are used instead to reinforce a price ring which is used to exploit the sick. The proof of that exploitation—I willingly use strong language in this matter—lies in the way in which the biggest customer in the whole world, the National Health Service, has steadily had to pay more and more, year after year, for the pharmaceutical products which it buys.
I hope I have said enough to illustrate the point I am making. In this case, I can merely offer an illustration, although I am quite certain that a large number of cases could he produced to reinforce this illustration.
1490 I repeat what I said at the beginning. I believe that the country is being held to ransom by the pharmaceutical industry working in a tight ring, exercising powerful pressure by means of its lobby in order to make sure that this price ring is maintained. Has the Minister investigated these matters with a view to submitting his conclusions to the Restrictive Practices Court, before whom, I believe, they should be brought? The Minister and his predecessors have made a number of well-intentioned gestures. I believe that the setting up of the Joint Committee with the pharmaceutical industry was very good, but we then come to the paragraph in the Report of the Committee of Public Accounts which is cardinal to the demand of my right hon. Friend the Member for Warrington that there should be a committee of inquiry.
The Report from the Committee of Public Accounts, 1956–57, deals with the discussions with the pharmaceutical industry with a view to forming the Joint Committee to investigate the prices of pharmaceutical products and paragraph 19 states:These long drawn out negotiations have at last resulted in an agreement which is to operate for a trial period of three years from June, 1957. The terms of the agreement and the considerations which led to its acceptance by the Government are described in a memorandum furnished by the Ministry.Now I come to the point which is fundamental to the strength of my right hon. Friend's case and which underlines the weakness of the Minister's own position. The Report goes on to say that the Ministry's memorandum to the Committee of Public Accountsexplains that the agreed formulae which will govern the prices to be paid have not been built up in a way which allows normal tests to he applied but have been constructed empirically with the object of reflecting the current prices of reputable firms.Is not the use of the word "reputable" a question-begging adjective? Is it reputable to enter into a conspiracy to keep up the price of poliomyelitis vaccine? In the case of the poliomyelitis vaccine, did the Minister take his prices on the empirical basis of reflection of the current prices of reputable firms? Did he include the firms mentioned in the report from The Times in connection with their indictment before a Grand Jury in the United States of America?
1491 I ask these points because it seems to me that as matters stand today the Minister does not have the means of checking prices. I believe that prices have soared and will continue to soar, and that that is illustrated by the fact that the hoped-for saving of £750,000, mentioned in the same Report, has not materialised All this goes to show that the country has paid substantially more than it should have for its medical services; the Minister has shown himself to be weak in tackling the pharmaceutical industry, and that until we have a strong Minister who is capable of standing up to the powerful interests inside the pharmaceutical industry the prices of pharmaceutical products will continue to soar and the country will continue to be held to ransom.
§ 5.10 p.m.
§ Mr. Percivall Pott (Devizes)
The right hon. Member for Warrington (Dr. Summerskill) referred to the use of -domestic staff in the maternity homes to ease the staff shortage there. I am sure that the experience of the recent year or two in our big hospitals shows that that is absolutely correct, but I hope that when we consider this matter we shall not forget the many small maternity units in the rural areas, which are playing an equal if not bigger part in the global picture, because the production of domestic staff will not help them. I am thinking of the small maternity unit of which I have a first-class example in my constituency. On more than one occasion I have asked why its records are so much better than the national record, and I am assured by one of the most senior doctors in the area that the only reason is that it was built not as a maternity unit but for a quite different purpose, but that it is the perfect maternity unit.
I have no objection to the Supplementary Estimate, but I am very concerned that we have failed in our endeavours to obtain State-trained, highly qualified nurses, although we have had two committees to tell us how to do it. We are still having to close small units all over the country. We almost had to close the unit in my constituency last autumn, but owing to the terrific drive of the local people we succeeded in obtaining enough trained midwives to keep it going. I understand that we may have to close it in the next few months because of this same difficulty.
1492 If we do close it we shall be putting a load on the domiciliary service which that service cannot carry. In the rural areas, where conditions are more difficult and homes are generally less suited for the birth of children, it is essential to do more than we are doing now to ensure that the small unit is kept available to the people. If it were true that there were not enough trained midwives we should have to face the fact. Various industries have experienced a shortage of qualified people. The horrifying thing is that that is not the position in this case. Less than 20 per cent. of those who qualify as midwives ever practise in midwifery. In other words, we have a large surplus of trained midwives who are not making use of their qualifications but are doing general nursing instead.
I suggest that this proves that we are not making the conditions of service attractive enough to draw into this kind of unit the qualified people we require. We should face this situation and try to attract trained staff into those areas, even if we have to introduce a very high differential. It is not extremely difficult to do this, because we are not considering a specialist staff. A baby born in London is very similar to one born in my constituency. If we make the differential high enough, therefore, we should be able to persuade many qualified people who are now serving in London to help maintain the small units in rural areas, even if they go there only for short periods.
We know that they will carry more responsibility than they would in the great teaching hospitals. They will not have ward sisters, matrons, night matrons and senior matrons above them; they will have to carry the responsibility themselves. But I have no reason to believe that the nursing service has ever been afraid of taking that responsibility, and I would ask my right hon. Friend to realise that he must compensate for the fact that if they go to these small units these people will be living in country districts where they will be strangers, and where the opportunity for promotion will not exist. For that reason we must do something special to ensure that our small maternity units are not closed, thereby throwing a quite unfair load upon the domiciliary service.
§ 5.17 p.m.
§ Mr. W. Griffiths (Manchester, Exchange)
As I listened to the interesting speech made by the hon. Member for Devizes (Mr. Pott) I thought how characteristic his attitude was of the schizophrenic attitude of Government supporters generally towards the National Health Service. The hon. Member was quite right to plead with the Minister that in the individual instance to which he referred the Government should find more money. Hon. Members opposite, like hon. Members on this side of the Committee, have always pleaded with successive Ministers of Health that the Government of the day should find more money to help their particular interests. The trouble with hon. Members opposite is that they want more money to be spent on individual items, but at the end of the year they expect the total expenditure to be lower.
§ Mr. Griffiths
No. I noted that the hon. Member said that he did not begrudge the £16 million for which the Minister is asking in this Supplementary Estimate. Nevertheless, it is within the recollection of many hon. Members that for year after year, while hon. Members opposite were pleading on behalf of individual constituency cases in Estimates debates, in general debate and outside the House they perpetually sneered about Health Service expenditure on wigs, the dental service, and the wasteful level of Government expenditure in general. That is why I say that hon. Members opposite have always had a schizophrenic attitude towards the Health Service. But good luck to the hon. Member for Devizes; I hope that he persuades the Parliamentary Secretary to meet his request.
How different this debate is from some that we have had in past years. In the early days of the Health Service, when there was nothing like the amount of statistical information that we have now, incomplete as it may still be, Ministers of Health were assailed by hon. Members opposite for being squander-maniacs, dissipating the national wealth in an improper way year after year. I 1494 am glad that experience of the working of the Health Service over the last ten or twelve years has not only persuaded hon. Members, quite properly, to argue for special constituency interests, but has also persuaded the hon. Member for Devizes to tell the Minister that he does not complain about the £16 million for which the Committee is being asked today. Let us hope that that attitude will be maintained.
Like the hon. Member for Devizes, I wish to refer to a matter which affects my constituency, though, so far as I know, similar problems may face other hon. Members. I refer to the increased difficulty experienced by my constituents and other people in the Manchester area in getting a bed in a maternity hospital. Although we have had the Health Service for eleven years, it is my impression—one which is shared by my colleagues in the Manchester area—that it is more difficult now for a an expectant mother to get a bed in a maternity ward in that area than it was six, seven or eight years ago. At that time a woman who was having her first child was almost invariably able to secure admission to a maternity hospital, but that is not so now.
Every week I receive complaints that expectant mothers who may be living in the most deplorable housing conditions, are obliged to have their first child at home. So far from there being any extra facilities made available in our area, the Prestbury Maternity Centre has been closed, resulting in a substantial reduction in the number of beds available. It is a serious matter. I do not blame the administrators, because they are hard pressed. But, nowadays, an expectant mother is closely cross-examined about her medical history, home circumstances, and so on, and unless the birth is likely to be of great clinical interest, unless there is a possibility of some extraordinary abnormality, an expectant mother has little chance of getting into a hospital.
As one of my constituents remarked wryly to me recently, "If I had been having a two-headed monster, I should have had no difficulty in getting a hospital bed. But because, thank God, I am a healthy woman, and my child will be all right, I do not stand any chance of getting into hospital". The situation is 1495 serious, and I should like the Parliamentary Secretary to say something about it, and if possible, something specifically about the problems in the Manchester area.
I wish to refer to the question of superannuation, and as I shall be speaking of something about which I have an interest I had better declare it. When my Parliamentary duties permit, I engage in my profession as an ophthalmic optician. During the last Session, Parliament accorded statutory recognition to opticians, and one wonders whether this would be the appropriate time to accord to opticians the same advantages of a superannuation scheme as those enjoyed by dentists and doctors. It is true that when this matter was raised originally, the view of the Minister at the time was that it was not possible to accord a superannuation scheme to opticians on two grounds: first, because originally the supplementary ophthalmic service was envisaged as being only a temporary scheme which would be wound up in the unforeseeable future and the ophthalmic service would be carried out through the hospital eye service.
No one who is interested and informed about the service would now argue that the supplementary ophthalmic service will be replaced in the foreseeable future by the hospital eye service. In fact, my right hon. and hon. Friends have declared categorically on recent occasions that they envisage a continuance of the supplementary ophthalmic service. As the situation has changed, perhaps the Government will look at this matter again. There is, consequently, a change in the status of opticians and the part which they can play in the Health Service as a whole. Therefore, without going further into this rather narrow subject today, I hope that the Parliamentary Secretary may be able to refer to it.
I hope that in future, when examining the National Health Service, Parliament will reveal the same spirit of optimism which has characterised the debate today. I hope that after the General Election, when we have a Labour Government in office, the then Minister of Health will implement the policy of the Labour Party which, let me remind the Committee, is to remove all the financial barriers now existing between the patient and the 1496 service he requires. When the Minister of the day is engaged on that duty and asks Parliament for the money necessary, I hope that hon. Members, who by that time will have changed sides in the House, will be as enthusiastic in acceding to this worth-while expenditure as they have been today.
§ 5.27 p.m.
§ Dr. Donald Johnson (Carlisle)
Listening to the right hon. Lady the Member for Warrington (Dr. Summerskill), I am able to follow her as far as agreeing that one of the main anxieties in connection with these Estimates concerns hospitals and the pharmaceutical service and the cost of drugs. We welcome the publication of the costing returns which provide us with something to work on inasmuch as they reveal the strange anomalies to which I drew the attention of my right hon. Friend by means of a Parliamentary Question a short time ago. Apparently, in the case of similar hospitals in Middlesbrough and in London, the figures were £16 per in-patient each week for Middlesbrough and no less than £32 for London, with all kinds of variations in between.
Having ascertained that this is happening, we are able to examine the matter and draw our conclusions. It is not only a question of a sum of £25 for a bed in a hospital when the patient could be elsewhere, but there is also the question of out-patients. To my mind, one of the most disturbing of the figures published is the estimation of the cost per outpatient per hospital which, I think I am right in saying, works out at about 17s. 6d. per out-patient attendance. That is almost as much as a National Health doctor gets for attending that patient throughout the whole year. I realise that it is not entirely comparable; there are all sorts of factors in it. There is no question, however, which is the cheaper and more economical way of getting patients attended.
It is not only a matter of expense but of duplication of effort with the hospital out-patient service. I talk with some experience of the matter as a former general practitioner, and I cannot help feeling that too many trivial, minor cases are sent to the hospital out-patients department. In the first place there may be some excuse for that, but the disturbing thing is that when the patients get 1497 there the hospitals hold on to them and do not send them back to the general practitioner.
I repeatedly know of cases of people who went to hospital for minor injuries or cuts to hands and wrists. They were perhaps properly sent to the casualty department and then the hospitals held on to them for repeated attendances over a week or a fortnight, when they could quite well have been sent back to the National Health doctor.
§ Mr. R. J. Mellish (Bermondsey)
This generalisation is a little bit too much for us to stand on this side of the Corn-mince. It is not true within my experience. Out-patients' departments in fact send people back as quickly as possible.
§ Dr. Johnson
I am pleased to hear that, but it did not happen within my experience. [Interruption.] Excuse my saying that I have been a general practitioner and the hon. Gentleman has not; he must give me the credit of talking from experience in these matters.
§ Mr. Denis Howell (Birmingham, All Saints)
Is the hon. Gentleman saying that because he is a doctor that is the end of the matter? That is one of the troubles with the National Health Service.
§ Dr. Johnson
I was talking from my experience of what happened. The hon. Member for Bermondsey (Mr. Mellish) said that it did not happen. Perhaps it did not happen within the hon. Gentleman's sphere of knowledge, but it happened within my sphere of knowledge. I am satisfied that there are cases where it happens, so perhaps the matter could be looked into and tidied up for the benefit of us all.
Duplication of effort and divided administration between the general practitioner, the local authority services and the hospital services are a major drain of expenditure in the National Health Service. That is a matter upon which I could talk at length but do not propose to do in this debate. I hope, nonetheless, that the Minister will look at the matter from the point of view of expense. This overlapping and duplication of effort in the Service is serious. Perhaps my right hon. Friend, when he issues the directive which he has promised us under the new Mental Health Bill, will look 1498 into the question of cross-appointments by hospitals and local authority services. I hope that he will keep this whole matter under review.
I pass to the pharmaceutical service. I shall not do as an hon. Member opposite did and delve into the mysteries of the pharmaceutical industry but deal with the matter from a slightly different angle. It is only proper that we should have new drugs, and perhaps more expensive drugs if they are worth while, as they are in many cases. But we have to ask the question, which I have asked in this Chamber before, whether we are not getting into the habit of thinking that because drugs are expensive they must be effective. That is a very easy habit to get into when prescribing drugs and dealing with them. I have confessed on previous occasions that I am old-fashioned in these matters. I have recommended while speaking here such very worthy drugs as sodium bicarbonate, Epsom Salts and other simple remedies like that, which are still as effective as they were fifty years ago. Their effectiveness seems to have been forgotten. It is forgotten to such an extent that lanolin, for instance, a very worthy thing for cuts and bruises, is sometimes difficult to get.
What disturbs me is that when I go to a chemist's shop and ask for a simple drug like that, or for Dover's Powders, which are very good things to have for a cold, I always find difficulty in getting them because the shop is so filled up with more expensive drugs. We should do something to prevent simple drugs being driven out of the chemists' shops where we ought to be able to obtain them. I hope that my right hon. Friend will, as I have urged before, make every effort to remind prescribing doctors of the worth of these very simple remedies.
I want to come back to the hospital question. At the bottom of the first page of the Supplementary Estimates is one very low figure for capital expenditure on hospital buildings. I am sure that there are valid reasons, of which I do not understand the intricacies, why this figure is so low. But it cannot but remind us of the need for hospital building and of the difficulties we have experienced under the National Health Service in the building of new hospitals.
§ Mr. Walker-Smith
My hon. Friend appreciates, of course, that this is a Supplementary Estimate only and that our Estimates for the total sums of capital for hospital building are going up in a gratifying and steady acceleration.
§ Dr. Johnson
I apologise to my right hon. and learned Friend if I seemed to imply in any way that these rather meagre figures represent the total capital. I did not wish to make any such implication at all. I was merely using the figure as an illustration. We welcome the move that is being made towards getting new hospitals built, but nonetheless, looking at the whole range over the past twelve years of the National Health Service, we cannot have any great reason to be satisfied with the number of hospitals being built. I am sure that my right hon. and learned Friend would agree that there are difficulties in providing capital for the number of hospitals that he himself would like to see built. It is not a question of not being willing and anxious to build them, but of providing capital within the limits of our finances.
In that connection, I would repeat what I said the last time I spoke on this subject, at the risk of defying the lightning, so to speak. I consider that the time has come when we might consider whether hospital building efforts might be thrown open to voluntary contributions on a local basis, to supplement what the National Health Service can do. When I mentioned this matter before, I was accused by the hon. Member for Manchester, Exchange (Mr. W. Griffiths) who has just spoken, of producing antideluvian ideas on the subject. He interested me very much. He must have known that I was going to talk about him because he is in the Chamber at the moment. After chalking me off on this matter, he went on to talk about the sparsity of thoracic units in Manchester. Today he has been talking about maternity units. While he was speaking, I thought how nice it would be if the Manchester people could only collect voluntarily to provide capital for their own thoracic units. How nice it would be if we could open this up again on a voluntary basis.
I know that in the past hon. Members opposite have had very good reasons for their antagonism to this voluntary system. They have said that Bournemouth and other wealthy parts of the country had 1500 all the money and could provide fine hospitals whereas the more industrial parts were poorer and would have second-best, but that is no longer true. It is certainly no longer true to the same extent. Wealth is spread more evenly through the country. Manchester is a wealthy place, but there are places like West Cumberland, nearer to my constituency, which in the thirties was one of the poorest places in the country and has been one of the most prosperous since the war. If the question was opened to them they would willingly find capital funds that supply their own needs, whether for general hospitals or special departments.
§ Mr. Mellish
What is to stop the very virile League of Friends going into a campaign to raise money to erect such a building? That goes on in some areas. Having got the capital, the question is whether the Minister would then make an allowance for the maintenance.
§ Dr. Johnson
I am open to contradiction, but what I think would stop the League of Friends doing that is the National Health Service Act. I understand it is not legal—I hope I shall be corrected if I am wrong—for funds to be contributed for any purpose directly connected with the therapeutics of a hospital. Funds can be provided for patients' comforts, for telephone trolleys, perhaps for curtains in a ward and amenities of that kind, but I think I am right in saying that they cannot be provided for such things as a thoracic unit, an X-ray department, or anything to do with therapeutics.
§ Mr. Mellish
I happen to know of a voluntary body which is donating £¼ million as a consequence of which it has given a spur to the Minister to do a little more, and in the South-Eastern Region a new department is going up.
§ Dr. Johnson
I am pleased to hear that. I hope my right hon. and learned Friend will bring that example to the attention of the rest of the country. As I say, I am entirely open to correction on these matters, and if my impression is wrong I am willing to have it corrected by anything my right hon. and learned Friend or the Parliamentary Secretary might say in reply. I am quite sure there would be great willingness on all sides for voluntary efforts of this kind to be organised on a much wider basis than at present.
1501 I have only one thing further to say. During the course of these debates many of us are a little disturbed by some aspects of the National Health Service. One does not want to be too extreme in any remarks or too critical, nor does one want to derogate from the splendid work done by all who are working in the Service. Nonetheless, anxiety crops up from time to time over the general working of the Service. That was evidenced as recently as 28th February in an editorial in the Lancet, which was consequent on the report on sterlisation practices in hospitals, about which there has been a measure of anxiety. An interesting thing about the article was that it endeavoured to generalise and diagnose the malaise in the Service and spoke of "failure by committee".
The subject of committees in the Service is one we ought to consider. We should consider whether perhaps in the development of the Service we tend to have too many committees rather than too few. Have we not perhaps to some extent "gone to seed" with committees in the administration of the Service? These committees tend to disagree with each other, as The Lancet article said, and at times they tend to quarrel with each other. There are many places in the country where the hospital management committee and the medical committee are at loggerheads. They cannibalise each other and, as my hon. Friend the Member for Bromsgrove (Mr. Dance) said earlier, they commit mayhem and murder on each other. This quarrelling and disagreement among committees is a cause of anxiety throughout the Service. Perhaps my right hon. and learned Friend can look at this committee aspect and, a; a contrast, endeavour to stress the individual responsibility which has always been the historic basis on which British medicine has been founded.
§ 5.48 p.m.
§ Mrs. Joyce Butler (Wood Green)
I want to say a few words about one aspect of the hospital services and to ask two questions of the Minister, both of which relate to the code of practice which was issued by the Ministry of Health in 1957 for the protection of persons exposed to ionising radiations. That code of practice has no legal status, and it is not intended to have any; but it means that since workers in the Health Service have 1502 no legal protection when they are liable to be exposed to radioactivity or X-rays it is important that this code of practice should be implemented.
I believe the Ministry is very anxious that the code should be implemented, because a number of memoranda have been issued over the last two years since it was published and, in December last year, the Minister requested that progress reports on its implementation should be submitted to the Ministry by the end of February this year. The questions I want to ask the Minister arising out of the Estimates in this respect are these: Does his provision for increased remuneration provide any increase for radiographers and hospital physicists? I assume it does not. I listened very carefully to the various awards he mentioned which this item covers. I could not acid them all together and discover whether there was anything left to cover this particular category, but I think there was not. The important thing about the rate of remuneration of these two categories of workers is that the rates of pay are not sufficiently attractive to bring in enough workers of this kind.
This, together with the conditions of service, which are also not as good as they should be, has caused an acute shortage, especially of radiographers. The Minister will have seen in a recent number of the British Journal of Radiology a report by workers of the Royal Cancer Hospital, and the experience quoted in that Journal is by no means unique. It is estimated that whereas the average exposure of Atomic Energy Authority radiation workers is 0.4 roentgen a year, in the case of radium workers it is difficult to hold them down to 0.1 roentgen a week.
This is entirely due to the shortage of these workers. It is an important point and it illustrates the desirability of increasing the remuneration of this grade of worker and improving the conditions of service in order that sufficient can be employed to make sure that the Health Service code for these workers can be implemented. This matter is causing grave concern to many people associated with these workers and to the workers themselves. Is the Minister making any provision for this or considering any way in which something can be done about it?
1503 My second question concerns capital expenditure. If the Minister wants the hospitals to implement the code, does he intend to meet sympathetically any requests which they make for capital grants to enable them to implement the code? If he does not, and if he is expecting them to find the money out of their grants, it may be very difficult for hospitals, which with the best will in the world recognise the importance of implementing the code and are anxious to carry it out, to be able to do so, because it will be a very costly matter. Has the Minister made any provision in the Estimates for capital expenditure of that kind? If not, will he indicate how he expects that kind of capital expenditure for new equipment and all that is associated with it to be met? Does he expect the hospitals to do this out of their grants or will he help them in any way? This is a specialised problem, but it is a matter of great interest and it seems to be one for which the Minister should assume some financial responsibility in his Estimates.
I hope that in his reply the Parliamentary Secretary will be able to make some comments about the two questions which I have asked. If he cannot do so tonight, will he let me know later what is the position?
§ 5.53 p.m.
§ Sir Hugh Linstead (Putney)
The first of the two questions which were asked by the hon. Lady the Member for Wood Green (Mrs. Butler), dealing with the supply of radiographers, is particularly important and I shall refer to it later in my speech.
Before I do so, however, I want to refer to the speeches of the right hon. Lady the Member for Warrington (Dr. Summerskill) and the hon. Member for Coventry, North (Mr. Edelman). Once again, we had from them criticisms, in extremely strong and sometimes unrestrained language, about the cost of drugs to my right hon. and learned Friend. I am the secretary of a professional society connected with pharmacists, and I have no connection at all with any firms in the drug industry, but I nevertheless feel that it is a pity that the duty which the House has of keeping a very jealous eye on expenditure on such items as drugs in the National Health Service should be so overladen by the strength of the attacks which are made on my right hon. and 1504 learned Friend as to lose a great deal of their value and force.
Listening to those two speeches one would have imagined that my right hon. Friend was sitting back and allowing himself and the Ministry to be exploited by the industry. In fact, very few industries are more closely under financial scrutiny than is the pharmaceutical industry. The Ministry's accountants are practically sitting in the accounts offices of these manufacturing firms and I doubt whether there is any information about their financial and internal working which is not fully known to my right hon. and learned Friend.
In my opinion, less than justice has been done to the Ministry of Health, the British Medical Association, and the Pharmaceutical Society of Great Britain for the publication of the British National Formulary, which has had a remarkable effect in keeping down the cost of drugs in this country. In Canada and the United States about 90 per cent. of the prescriptions are proprietary medicines, whereas in this country, under the National Health Service, the figure is about 50 per cent. That is very largely due to the publication under my right hon. Friend's auspices of the National Formulary, which is a guide to prescribing.
I am glad that the right hon. Lady the Member for Warrington is still in her place. She made what I felt was an unfortunate attack upon my hon. and gallant Friend the Member for Lewes (Colonel Beamish), without notice, to him and in his absence. If I understood her correctly, she alleged that in a debate in the House he made no disclosure of his interest in the subject—no disclosure of the fact that he was connected with a pharmaceutical manufacturing firm. I have a copy of HANSARD here. I assume that the right hon. Lady was referring to the debate in Committee of Ways and Means on 25th February last year.
§ Dr. Summerskill
No. I was referring to Questions last week, when the hon. Member for Putney (Sir H. Linstead) was not here.
§ Sir H. Linstead
In the debate to which I referred my hon. and gallant Friend quite properly made a statement of his connection with the industry, but what was said during Questions is another matter.
1505 At the risk of taking up the time of the Committee I will also refer to some remarks which the right hon. Lady made about the Bradbeer Committee. Here I believe that her memory is somewhat at fault. I had the honour of being a member of that Committee, and I must say that I hardly recognised our recommendations in the form in which the right hon. Lady put them before us today.
§ Dr. Summerskill
I obtained a copy of the Report of the Bradbeer Committee from the Stationery Office yesterday. I therefore think that my memory is fairly fresh.
§ Sir H. Linstead
The right hon. Lady must have done a great deal of homework last night. I accept that she did, but she must accept it from me that the Bradbeer Committee never intended to give the impression, and certainly never made any recommendation, that we should embark upon a régime of medical administration of hospitals in the sense in which the right hon. Lady referred to it when she said that it was high time that in hospitals there was one medical person who could take decisions instead of our having to rely upon committees. The essential finding and recommendation of the Bradbeer Committee was what has been called the tripartite system of hospital administration whereby the matron, the chief administrative officer and the senior doctor are all responsible for the general administration.
§ Dr. Summerskill
The hon. Gentleman is completely misrepresenting me. If he reads my speech in HANSARD he will see that that is what I said. I spoke of the medical administration, the matron and the lay administration, but I said that in my opinion it was necessary for someone in medical matters to have the final word.
§ Sir H. Linstead
I am grateful for that explanation. I do not think the right hon. Lady will find much support among medical practitioners in hospitals for her suggestion that the medical administrator in medical matters should be in a position to take decisions over the head of the medical advisory committee. It was precisely on that point that the medical members of the Bradbeer Committee were insistent that medical administration of that kind, replacing the 1506 advisory committee by the will of the individual, could not be justified.
§ Dr. Summerskill
The hon. Member is apparently hingeing his speech on to what I said. What I said about the medical advisory committee was that I did not think that individuals on a committee would be prepared to make a decision, because on a future occasion their department might be questioned.
§ Sir H. Linstead
I think that I was right in saying that the right hon. Lady said that it was necessary to have a medical administrator to make decisions because committees cannot make decisions. That is simplifying the argument. It was precisely that attitude of mind which was so strongly opposed by the medical members of the Bradbeer Committee.
Two points to which I wish to devote special attention arise on the Supplementary Estimate in relation to the salaries of hospital staffs. First, I want to refer to the position of hospital pharmacists, and then, in particular, to medical auxiliaries employed in hospitals covered by the Cope Report of 1951. These are both specialised subjects, but I believe that both of them require the attention of my right hon. and learned Friend.
My right hon. and learned Friend will agree with me that at the moment the hospital service is short on its establishment of pharmacists by 20 to 25 per cent. That shortage is resulting in extremely rapid promotion of young and rather inexperienced pharmacists. It is resulting in an unbalanced pharmaceutical service with a majority of people at the higher levels and very few coming along behind to replace them. In some hospitals the pharmaceutical staff is becoming dangerously low.
Side by side with that, not enough thought is being given to the employment in the pharmaceutical service of technicians and skilled assistants of one kind and another. The career structure of the service is unsatisfactory, largely because the salary structure is unsatisfactory. At present well over 80 per cent. are on a scale the maximum of which is £1,070 a year. That will be the maximum which they can reach during their professional life. Compared with salaries outside the hospital service, there is no attraction for 1507 competent men to offer themselves for the hospital service.
A solution to the problem has been proposed to my right hon. and learned Friend by the Central Health Services Council. That solution is connected with the conception of the group system in hospital organisation. All of us connected with hospitals are inclined to forget that the new conception of the group was brought into the 1946 Act and ought to be a directive for any development of the hospital service. As and when opportunities occur within a group for consolidating a service, because someone has retired or staff changes have taken place, the existence of the group in the Act should be recognised and an attempt made to build up a group service rather than an individual service.
In pharmacy, that is usually possible. Pharmacy is a service which lends itself to grouping, in relation to purchase of materials, manufacturing and employment of staff. My right hon. and learned Friend will find a solution to the problem with which he is faced by the creation of a group pharmaceutical service. This will meet the basic need for grouping the pharmaceutical service within a hospital group and also help to overcome the weakness of the present career structure. It need not necessarily mean an increase in cost, because I believe that the need is possibly for fewer and better-paid pharmacists, and a better and more organised use of technicians, rather than a substantial increase in the number of pharmacists.
These proposals have been before my right hon. and learned Friend for nearly a year. So far, he has not found it possible to make a public pronouncement about his intentions with regard to group pharmacists and their salary scale. I hope that the pronouncement will not be delayed much longer, because if it drags on the serious drain from the service will continue. I hope that my hon. Friend the Parliamentary Secretary will have something to say about it this afternoon.
My second point is about the number of hospital employees who come within the grade of medical auxiliaries. They are such people as occupational therapists, almoners, dieticians and laboratory technicians. Their future was considered 1508 by a committee under the chairmanship of Sir Zachary Cope, which reported as long ago as 1951. The main regret which I express to my right hon. and learned Friend is that all this time has elapsed and he has not yet found it possible to come forward with proposals for legislation along the lines which the Committee recommended.
The general picture which the Cope Committee proposed was a medical auxiliary council as an overall umbrella to cover all these professions and some other professions, on which there was to be a medical majority. Under the council there were to be professional committees. This recommendation was opposed by most of the professions, particularly because of the medical majority of the council. They were afraid that the individuality of their professions might be overwhelmed by the medical members of the council.
One should have a great deal of sympathy with the desire of well organised professions to retain their entity and not be subordinated to the views of doctors, although my right hon. and learned Friend will have to balance against that consideration the fact that the majority of these professions, if not all of them, work under medical supervision.
The Report was published in 1951. A working party was set up in 1954 and reported in the same year. Not until 1958, after a delay of four years, was anything further heard of the recommendations of the working party. In 1958, a conference was called and a decision is now awaited from my right hon. and learned Friend. These professions are entitled to say to the Minister that they ought to know where they stand. It is not satisfactory that they should be left with their professional future dependent upon regulations made under the National Health Service, which take no account of their work outside the National Health Service. It is unsatisfactory that the qualifications that are recognised are not statutory qualifications, but are prescribed by the Minister for the time being. That is a very unsatisfactory way in which to deal with a group or profession.
We are experiencing difficulty at present over chiropodists, because my right hon. and learned Friend is now trying to make some use of chiropodists 1509 within the National Health Service, but has no statutory register of chiropodists upon which to work. That illustrates the problem with which these professions are faced.
There was a Private Member's Bill dealing with opticians. If a decision can be taken by the Minister now, it might not be beyond the hope of Parliament that, if not in a Government Bill, in a Private Member's Bill, during next Session, we shall be able to do something for these people.
I hope that my right hon. and learned Friend will not delay any longer his decision on what he wishes to do with hospital pharmacists and what he will do with the professions dealt with in the Cope Report.
§ 6.10 p.m.
§ Mr. Denis Howell (Birmingham, All Saints)
I am very concerned about several trends in the National Health Service—particularly on the hospital side—which do not augur very well for its future as a social service for the community as a whole. Nothing has so far been said about the talks that we know are going on about free drugs for private patients. I know that it would be out of order to pursue that matter at length, but it is pertinent to ask for an assurance that none of this Supplementary Estimate is intended for that purpose.
Some of us read with a little alarm an inspired leading article in The Times recently which made it clear—whether or not it was true I do not know, but I presume that it was—that the Minister was ready to implement his party's policy that private patients should have free drugs. There would be very grave objection to that, as it would undoubtedly create within the Health Service the old set-up of first-class and second-class patients. All of us on this side would be very strongly opposed to that. If fee-paying patients could have free drugs, their numbers would increase, and they would demand preferential treatment. If they did not get the priority treatment that they were accustomed to in the pre-National Health Service days they could put a financial sanction on medical practitioners—
§ Mr. Howell
And priority of admission, which is something to which I shall refer later. I leave the matter there for the moment, but I think that we are entitled to an assurance on that score.
I am particularly concerned about a trend in the consultant service. It has been apparent for some time that there is a definite move everywhere by these people to change from being full-time consultants to what is called maximum part-time consultant work, and the figures I have quite clearly show that that trend is on the increase. The other day, the Minister told us that between 1955 and 1957 there was an increase of only twenty-six consultants in the Service. I do not think that one can accept that.
It is obvious that whole-time consultants are going on to the maximum part-time basis. This means that nine-elevenths of their time is available for the hospital, and they use the other two-elevenths for their own private purposes. In part, it is an Income Tax dodge. It affords them an opportunity to charge against Income Tax all sorts of expenses that they have not been able to charge before.
I am worried about the control of consultants. As a member of a hospital management committee I feel—without making any personal imputations—that there is no control at all over what they do, how many sessions they work, and the amount of time devoted to each session. Nobody wishes to treat eminent professional men as many working-class men are treated and ask them to clock in and out, but I am sure that the system could be so arranged as to avoid large-scale abuse.
The consultants in the whole-time Service require an increase in salary, and there is justification for giving it to them, but I do not think that the increase should be given, as it were, through the back door. This transfer of consultants is happening everywhere. The Birmingham Regional Hospital Board refused to sanction the move from full-time to maximum part-time work. It wanted to keep its consultants on whole-time service. It wanted the consultants, to whom it pays considerable sums of money, to give all their time to the Service.
The Board went so far as to get the opinion of Mr. Gerald Gardiner, an 1511 eminent Queen's Counsel. His opinion was that, when a whole-time consultant went over to part-time service, that involved new terms and conditions of service. He pointed out that a man who might not have applied for a post because it was whole-time, might apply for it when it was on a maximum part-time basis; that there were then new terms and conditions of service, and that the post should be re-advertised.
I understand that there was considerable correspondence between the Board and the Minister, at the end of which the Board had no alternative but to disregard Mr. Gardiner's opinion. It could no longer hold back the tide of consultants who wanted to cash in on this new maximum part-time consultant work.
This is all very regrettable, and it is a trend that I am very sorry to see. It marks a definite turn in the conditions of the hospital services available to the public. It is, of course, linked up with the whole question of pay beds. One cannot deny that there has been a terrific increase in the number of pay beds, by means of which these doctors can bring in their private fee-paying patients with priority over ordinary members of the public.
In reply to a Parliamentary Question that I asked on 23rd February, the Minister made a remarkable statement. He said:… I have no evidence that patients urgently needing admission are having to pay to obtain it."—[OFFICIAL REPORT, 23rd February, 1959; Vol. 600, c. 106.]I do not know what he means by "urgently". If, in the middle of the night, a man has a sudden attack of appendicitis or haemorrhage, I think that he does get urgent attention, and is admitted to hospital. But there are other sorts of medical urgency, and there can be no doubt whatever that in many of those cases a premium is put on ability to pay. It is common knowledge in Birmingham that at the Queen Elizabeth Hospital—a teaching hospital—if one sees one of the consultants attached to it, he will probably say, "I am very sorry that you are a National Health patient. You need this done to you, but you must wait several months. However, if you are prepared to pay £20 a week, you can come in tomorrow".
1512 That is happening all over. It is disgraceful that money should determine admission—
§ Mr. Howell
Yes, especially children. A week or two ago the West Bromwich Executive Council passed a public resolution—for the first time, I think, since the Health Service began—drawing attention to the disgraceful position in West Bromwich in regard to tonsils operations on children. If under the Health Service children go to the hospital to have their tonsils removed they have to wait several months, but if the parents are prepared to pay a fee, the operation can be performed in the very same week.
As I say, it is all linked with the pay-bed system. We had a controversy in the group of which I am a member, when I and others of like mind lost in the debate by one vote. The Marston Green Maternity Hospital had never had a single pay bed, but there was a sudden recommendation that there should be four. Why were they wanted? The reason is that the consultant gynaecologist—a very eminent man, who does a very good job of work—suddenly decided to transfer from whole-time to maximum part-time service, and said, "If I have not any pay beds for patients there is not much point in my transferring." So, for the first time, the Committee has decided that in Marston Green Hospital there shall be four pay beds.
As I said at the meetings of my committee, if there is one branch of the hospital service where private facilities are readily available, it is in the privately run maternity and nursing homes. There are more of these facilities available in this branch than in any other branch of the Service. But then, I am told by the doctors, it is no good their sending their patients to these private establishments, because they are badly equipped; they have not the facilities and equipment which, so the doctors say, they need if one of their ladies who is prepared to pay should need such equipment. That is proof of the argument. As I said at the meeting we had, it is not for the services of a particular specialist that people are really paying. They are paying to have priority in hospital treatment.
1513 The same thing applies when private doctors send patients to see consultants, at a small consultation fee. The doctor, physician or surgeon, decides that some further check is needed with special equipment; perhaps the patient needs a barium meal X-ray or something like that. The patient is sent to the local hospital. Of course, he cannot have priority of treatment as a result of paying for the barium meal X-ray, or whatever it may be, but, armed as he is, after paying his two guineas to the consultant, with a letter introducing him to the hospital, invariably he goes to the top of the queue. Indeed, it is more than that. At a teaching hospital, a patient armed with such a letter has staff and facilities made available at once for him; he immediately has his barium meal X-ray, cardiograph, or whatever it may be that the consultant wants. Here again, people who are prepared to pay receive priority of treatment. In my view, this is quite wrong.
I have asked questions about the consultant services committee in Birmingham. I am told that there is no obligation on a region to have one, but I notice that there is one in Birmingham. It has an absolutely overwhelming majority of medical men, which I regard as quite wrong. In all these things, it is wrong that people should determine their own terms and conditions of service. It does not happen anywhere else.
Another matter which calls for close examination by this Committee is the determination of merit awards. There are 275 consultants receiving an extra £2,500 a year. There are 698 receiving an extra £1,500 a year. There are just under 1,400 receiving an extra £500 a year. These merit awards are determined by a small body in an atmosphere of secrecy. Nothing is made public. Nobody knows anything about it. No member of a hospital committee is ever told how much extra his consultant is receiving over and above his salary. No report is ever made to the public.
Who are the people who determine these awards? What appeal is there against any decision? Consultants whom I know who receive nothing at all are very concerned at the fact that they have no merit award payment. They feel that the situation is quite wrong, that they can do nothing about it and they know 1514 nothing about it. This is a rather serious matter. This is the only branch involving the expenditure of public money for which the House of Commons is responsible—which includes a very wide range indeed—in which money is paid out in an atmosphere of secrecy without anybody knowing anything about it and without any aggrieved person having a right of appeal. It is quite wrong. The whole matter should be carefully examined by the House of Commons.
I do not wish to detain the Committee, so I will make my comments about the teaching service very brief. According to my experience in Birmingham in trying to enlist co-operation from the teaching hospital, it has been almost impossible to get it to take its fair share of the burden of cases, and I am driven to the conclusion that it is ridiculous administratively to have two separate administrations, one run by the regional hospital board and the other run by the teaching hospitals.
This is one of the things that I hope my right hon. and hon. Friends will consider closely when they come back to office. The hospital with which I am connected in Birmingham takes about 50 per cent. of the emergency cases. This can be a fantastic number, especially in the bad weather we have had. We had a little more help from the teaching hospital, this year, but for some years it has been almost impossible to feel satisfied that the teaching hospital, with the high quality of nursing and medical staff it has, is prepared to take its fair share of the ordinary public work.
I am concerned also about the appointment of members of hospital management committees. This is something else which I hope my right hon. and hon. Friends will look at. Indeed, I ask the present Minister to look at it now. Most of the hospital management committees are becoming self-perpetuating bodies. The chairman recommends people, and the people he recommends often find their way to the committee. This system is not a good one. In Shropshire, where we had a lot of difficulty and the Minister set up an inquiry into a very small part of a large number of allegations which we had been making, we found that the composition of the hospital management committee was very bad. Only this year, for the first time, has there been a trade 1515 union nominee on the committee, and this was achieved only after a bitter struggle.
There is a great need for good people in the Health Service on these committees and there is a great need for good leadership. A great deal can be done in this way. The Rubery and Hollymoor hospitals are an outstanding example of what I mean. New wards were provided there for fifty patients at a cost of £15,000, which is £300 per place, far less than the cost of providing new places anywhere else in the Health Service.
Some wonderful modernisation has gone on which is a credit to the leadership there. The re-equipping of the laundry, for example, which was, I understand, opposed by one or two interests, has resulted in much improved efficiency. It now has at least double its previous capacity and the articles are laundered at a cost of about 2¼d. each as compared with a national cost of almost double that. In addition, the people are working in modern conditions. In passing, I should like to tell the Minister that some of the hospital laundries I have seen in the Birmingham region are an absolute disgrace and would not be tolerated for five minutes by a factories inspector if they were in a factory. They have not been cleaned. Their conditions are bad. At times, they drive me to distraction.
I return to the point I made when I began. In the consultant service, it is quite wrong, under any guise at all, that back-door methods of payment should be introduced. If salary increases are needed, they should be negotiated in the open. We should understand the trends in the Health Service. Some of us have very considerable reason to be alarmed at what we see and we hope that the Minister will give more adequate answers tonight than we have had hitherto. If he does not, I hope that my right hon. and hon. Friends will deal with these matters very speedily in the near future when they have the opportunity.
§ 6.28 p.m.
§ Mr. Julian Snow (Lichfield and Tamworth)
During the past few weeks, I have been fascinated by some of the Questions which have been put to the Minister about the cost of drugs to the National Health Service. I have been even more fascinated by some of the replies.
1516 Because I have an interest to declare, as several hon. Members from both sides have had to declare this afternoon, I do not propose to be drawn into the particular matters which have been raised by some of my hon. Friends, except perhaps, to pass on to the Minister two suggestions, which I hope he will not take amiss. In parenthesis, I will say that I have a great admiration for his advisory staff and for his supplies department. I know, as everyone knows, that they are not likely to be unwittingly misled, unless they receive erroneous information from suppliers which they have no opportunity to check.
My first suggestion is that his advisers should take with a little more salt some of the claims made by suppliers of foreign patented drugs who claim that the cheaper equivalents of some of the drugs are, perhaps, not entirely trustworthy or are sub-standard. These claims should be treated as part of a deliberate, commercial campaign aimed at maintaining high prices to the Health Service.
I take issue with the hon. Member for Putney (Sir H. Linstead), who is no longer in his place, because to accuse the Minister and his advisers of buying badly because of the cost of finished drugs, finished in the sense of their forms of application, topical or systemic, is going the wrong way about it. The Minister gave an Answer to one of his hon. Friends recently about the cost of a certain drug. He said that he was not concerned with the cost of raw materials. I do not know who drafted the Answer for him, but I think that he was slightly in error in giving that reply.
If one takes an ordinary tablet which is 99 per cent. a basic drug, one must not consider that basic drug to be a raw material in the general sense of components of other tablets which have large quantities of separate therapeutic agents in them. In other words, a tablet which has a minimum of excipients in it is fundamentally made up of a basic non-variable drug.
I therefore suggest to the Minister that he should have a look at the methods by which costing is done in his Department. There should be an intense examination of basic material costs compared with those obtaining in other countries. But I do not want to go into discussion of this matter too far. I wish rather to deal 1517 with something which I trust is less controversial and which fundamentally affects the cost of drugs to the Ministry, namely, the cost of research. The Minister should accept that in the normal course of events the element of research payable to a patent holder of a drug is about 5 or 6 per cent. on the sale price.
therefore draw the Minister's attention to the prices charged for drugs where the main argument for high prices concerns the cost of research. Over and above that element where research is paid for, terrific profiteering goes on in connection with certain categories and groups of drugs. I must here draw the Minister's attention to the regrettable lack of basic research in this country. I distinguish here between basic or pure research and development research, which is a very different thing.
The Minister will possibly have read an interesting, though in certain ways superficial, article in the News Chronicle of 6th August by Mr. Paul Bareau, in which he mentioned the expenditure on pharmaceutical research in the United States compared with this country. He sail that the annual current return of expenditure in the United States was £43 million compared with approximately £4 million in this country. The Minister probably has a source of information which is better than mine, but I have found it difficult to ascertain how much money is spent on pharmaceutical research in this country. Although the Minister may say that research is not the province of his Department, I suggest that it is inevitably his responsibility now, bearing in mind the fact that the National Health Service is by far the greatest single customer of pharmaceuticals in the world.
In America, the contact between commercial companies' research departments and hospitals, and between commercial companies' research departments and universities is much more intense than in this country; but whereas one sees from time to time, with great, reputable companies like Glaxo, reference to the provision of reserves for pharmaceutical research, it is difficult to discover how much is spent on pure research. I have examined ten main groups of drugs which, without being dogmatic or too precise, are those which I think we should 1518 consider conveniently in the context of this debate.
I refer to antitubercular drugs, poliomyelitis vaccines, diuretics, antihistamines, antidiabetics, sulphonamides, antibiotics, Vitamin B12 which is of increasing importance, psychoactive drugs and prednisteroids. I think that the original pure research, as opposed to development research on seven of those drugs was carried out and patented in the United States. Part of the original research on two of these groups of drugs was carried out in this country. One group, sulphonamides, is almost exclusively of British basic research origin.
I think that this is a relevant point in the debate, because in the long run we are paying for patent rights held outside this country. If only we had spent more money in the past in pure research there would not be this leakage of hard currency and we would not be dependent to the extent that we are at present on having to buy other people's ideas.
§ Mr. Edelman
Would my hon. Friend explain in what circumstances the recent research carried out on new penicillins has now been transported, as it were, to America, where it is now being developed? Although I accept that research in this country is unduly limited, is it not undesirable that, though limited, it should be, as it were, taken over by the Americans and then developed purely for commercial profit?
§ Mr. Snow
My hon. Friend has mentioned the new penicillins, and the significance of these is quite extraordinary, as the Minister will know, in the sense that, theoretically, it should now be possible to develop penicillins which will attack specific bacteria which up to now has been resistant. There is also the drug meprobamate. In both cases, the basic research was done in this country, but it appears that we shall lose the development work, as well as the marketing and patent rights in the United States.
What is the reason for this? On an examination of the history of pure research in the United Kingdom, it looks as though it is because companies in this country do not, in the main, appreciate the possibilities. In the case of meprobamate the work was done by a very great English drug house. The man who did the work went to America and before 1519 we knew where we were the drug was patented in the United States and throughout the world by American interests.
It is difficult to discover why the great English drug house of Beecham, having carried out the basic research work on penicillin this new discovery, has allowed the development of it to go to the United States. As far as one can gather, it is because there is spare fermentation capacity in the United States, coupled with the fact that there is a ready-made team of technicians available to American companies. It looks as though the original sorry history of Fleming's great discovery will be repeated and that we shall lose our control of these new penicillin discoveries to the United States. The Minister should consider how his Department can stimulate research so that in the long run, as the pattern of drug invention changes, we do not have to pay vast bills to overseas companies.
The other point to which I want to draw the Minister's attention is this Under Sections 335 to 340 of the Income Tax Act, 1952, an allowance was granted for research purposes. He ought to find out what advantage has been taken of that allowance in respect of pharmaceuticals. I think that he would find that it was surprisingly small. If it is a fact that the National Research Development Council initiates pure research, and has on its staff people who are ex-employees of certain big drug houses, the Minister should be very careful and use his influence, as Minister, to ensure that the possibilities of development are farmed out fairly and not concentrated in the hands of one or two big companies.
I refer to Hecogenin. It is claimed as the invention of a big English drug house, but it is nothing of the sort. The drug house did the development, but the invention was on the initiative of the National Research Development Council. If the Council continues its present policy, the Minister will continue to concentrate in the hands of one or two big companies the power of development which, if it was more widespread, could result in the long run in very great economies to the National Health Service.
I have, possibly, made the Minister a little impatient. I am sorry if I have. I merely ask him to see whether his own Department is capable of looking into basic cost and ensuring that research is 1520 stimulated sufficiently to secure economies for his Department and to treat carefully the claims of certain foreign companies that they are the only producers of pure drugs.
§ 6.42 p.m.
§ Mr. Arthur Moyle (Oldbury and Halesowen)
The first of my few observations is that the problem with which any Minister is faced in connection with the conditions under which consultants, specialists, dentists and the rest are employed by the Health Service depends largely on the measure of agreement which can be established through negotiation with these professional services in relation to the needs of the Service.
We have to carry the good will of all these professional experts who are so essential to the Health Service, whether the Administration is in the hands of a Labour or of a Tory Government, because they are perfectly free to sell their labours in any market of their choice. Having said that, however, I would add that the conditions by which these professional people use the hospital and health services are not a matter for them to decide. The decision should be that of the hospital administration. In that regard, there is much that needs to be dealt with by the Minister in the interests of good administration.
For example, it should not rest with a consultant, however important he may be from the point of view of efficiency of the Service, to decide as a condition of employment that he should have a certain number of pay-beds for his patients. That is a matter entirely for the hospital authority to decide in accordance with the limits and the circumstances of the hospital. It should not in any way rest with either the consultant, the specialist or any other professional employee of the Health Service.
My next point concerns drugs, and from a different aspect to that which has already been raised. I refer to the Health Service patient and not to the private patient. It is out of tune with the Health Service for a person suffering, say, from asthma and for whose recovery or proper treatment a particular kind of drug is essential to be told that the drug which the general practitioner regards as essential for his treatment is not available under the Health Service and is, therefore, a matter of 1521 private arrangement as between the patient and the general practitioner. The fees which are charged for providing the drug and for the treatment is then a private matter as between the general practitioner and the patient concerned. That is entirely wrong.
I consider it an essential ingredient of a common Health Service such as we have that any drug, no matter how expensive, which is considered essential to the proper treatment or recovery of a patient should be available in the Health Service it precisely the same way as a surgical operation.
When I raised the matter with the Minister, I was advised that this was a private matter as between the doctor and the British Medical Association. I say at once that it ought not to be a private arrangement, because in relation to the people who use the Health Service the Minister should have direct control over the terms upon which the treatment or the provision of drugs is made available to the patient. If the Health Service is to do the maximum amount of good to those who use it, no patient should be denied because of cost the right to the treatment that his or her medical adviser considers to be essential.
I come now to the point so well made by my hon. Friend the Member for Birmingham, All Saints (Mr. D. Howell). There is one regard in which we must do something to improve public relations. If we write to the Minister and say that we have reason to believe that prior 'treatment is given to a paying patient, whether a child seeking an operation for defective tonsils or a patient requiring some other treatment, and we say that the paying patient is known to have had prior admission over the non-paying patient, the Minister at once adopts—I do not blame him—a very cautious and self-satisfied attitude by telling us that in cases of urgency no such priority exists which militates against the proper interests of the non-paying patient.
The Minister can send us letters containing that well-known phrase as often as he likes, but immediately we deal with these matters in our constituencies we have case after case brought to our notice by which we are convinced that prior consideration is conceded to paying patients. Can he not do something about this administratively? While 1522 admitting the privilege of the paying bed or the paying patient, is it not possible for the Minister, in present circumstances, to be able to issue a directive to the hospital authorities with a view to placing it beyond any doubt that no paying patient has priority of consideration over the rest of those who seek to use the Health Service?
The Minister will recall the vexed controversy which arose last year concerning rates of pay and the alleged intervention of the Minister which prevented the operation of a decision of the Joint Whitley Council in regard to clerks in the Health Service. I do not want to refer to that unduly, but I do want to say to the Minister that, having regard to the need for good industrial relations, I think it is essential that, however great the liability of the Minister is in regard to Health Service expenditure, neither he nor his representatives must give an impression through the Joint Whitley Councils in the Health Service that he alone decides these issues of rates of pay and conditions of service.
It is not good from the point of view of good relations that it should be assumed that no matter what the representatives—his own representatives and those of the local authorities and the hospitals—may do in the field of negotiations as to the right rates of pay and conditions of service, the Minister can intervene and say that the decisions reached are not acceptable. In other words, we do not want to make a sham of the negotiating machinery in the hospital service but to give it a sense of reality by conveying to those who are engaged in this very delicate work of adjusting rates of pay and conditions of service a feeling that not only have they responsibility but also power of decision, in the issues that come before them.
I ask the Minister to look at this aspect of the matter. Collective bargaining is important, but good will in the expression of it is much more important. Finally, I ask him whether the time has not come when he should review the existing machinery of collective bargaining in the Service with a view to simplifying it and making it much less cumbersome and much more efficient in discharging the task of determining rates of pay and conditions of service of those engaged in the Health Service.
§ 6.52 p.m.
§ The Parliamentary Secretary to the Ministry of Health (Mr. Richard Thompson)
We have had our usual fairly discursive, and I think useful, debate on this Supplementary Estimate, and, very largely, the theme running through it has been the question of drugs. It might be for the convenience of the Committee if, first, I deal briefly with some of the lesser but not unimportant points made by hon. Members during the debate, and dealt rather more fully with that question, to which several hon. Members have made contributions, later in my remarks.
First, may I say how greatly I appreciate the welcome given by the right hon. Lady the Member for Warrington (Dr. Summerskill), in her turn, for the improved system of hospital costing which we now have in the Health Service? Nobody pretends that a better capacity to arrange figures is a substitute for all the other things we should like to see, but there is no doubt that the introduction of this system has been enormously beneficial. I think that we shall get a great deal of benefit out of it in future, because unless we know with some precision what different activities are costing in different hospitals, we lack the means of a proper comparison of one activity with another. Now that we have that system available—and it is a tool of management, no more—I shall look forward to very much improved administration as a result of it.
The right hon. Lady asked me one or two specific questions which perhaps I might deal with now. She wanted to know how we were getting on with implementing or otherwise the 10 recommendations of the interim Report of the Hinchliffe, Committee. I am very pleased to be able to tell her that we are making good progress there. We have either completely or substantially accepted seven of the 10 recommendations. There was one which has been referred to the Royal Commission on Doctors' and Dentists' Remuneration, which is now sitting, and that can hardly be settled until we have its report before us.
There were two which were discussed further by the Hinchliffe Committee and the Pharmacopoeia Commission. So we can honestly say that we have moved swiftly in that matter, though, of course, 1524 the final report of the Hinchliffe Committee is still to come. I think that we have done what was possible on the information available to us now.
The right hon Lady's next point was on the Bradbeer Report, and on that matter she had an exchange of view with my hon. Friend the Member for Putney (Sir H. Linstead). As the right hon. Lady knows, the Report was published and has been widely studied in the hospital service. All this was some time ago. Much of its contents was generally acceptable and is normally practised now, but some of the suggestions were of questionable value, and none of this advice appeared to the Minister of the day, or to my right hon. and learned Friend, as sufficiently novel or weighty as to warrant special action to draw the attention of hospital authorities to it.
On the specific point which the right hon. Lady raised on medical administration in general hospitals, the Committee opposed the appointment of medical superintendents, but supported the establishment of medical staff committees, at any rate, for medical staffs themselves, but declined to lay down any general pattern. It suggested an alternative, applicable, we believe, in most of the large general hospitals—which is going fairly close to what the right hon. Lady herself said—in the appointment of one consultant to be selected generally by the medical staff committee, the hospital management committee and the regional hospital board from the medical staff, and to spend some part of his time in administrative work.
My right hon. and learned Friend has thought it wise to leave hospital authorities to reach their own decisions and to experiment in this way, and some, in fact, have done so. I am not currently aware that hospital costs are necessarily lower in those hospitals where such an appointment has been made, but, probably, with the better costing machinery which we now have, we may be able to say more about that a little later.
My hon. Friend the Member for Devizes (Mr. Pott) spoke of the problem of the small maternity units which were having great difficulty in carrying on because of the shortage of hospital midwives. It is true that over the past few years the number of practising midwives in hospitals and domiciliary work has actually changed very little, and the shortage which exists 1525 is caused by the rising birth-rate, and the lack of sufficient new midwives remaining in the profession in the hospital service.
The number of new recruits coming forward and taking the training is, on the whole, satisfactory to maintain the numbers, but there is a very considerable wastage because not a sufficient number of them practise. The matter has received the urgent attention of the sub-committee of the National Council for the Recruitment of Nurses and Midwives. A number of suggestions for making the profession of hospital midwifery more attractive were made, and these have recently been commended by a circular to the hospital authorities.
In addition, arrangements are now in hand for the problem to be studied in greater detail on the spot by medical and nursing teams from my Department, which will visit the areas where the shortage is most acute to advise on remedial action and obtain more information on local difficulties, as a guide to future policy.
My hon. Friend also mentioned the question of remuneration, and asked whether some special differentiation could be introduced to attract these people into the worst staffed areas. I can only say that a scheme is at present tinder consideration by the appropriate Whitley Council, and that, while I accept that this has a bearing on the problem, though not a strong one, it is not the only incentive that could be applied. I hope that what I have said will show that we regard the matter very seriously. The steps that we have taken to apply expert knowledge and experience to the subject and our intention to benefit by and apply the result of these inquiries will be evidence of that.
The hon. Member for Manchester, Exchange (Mr. W. Griffiths) does not seem to be in his place. Therefore, I cannot tell him the particular piece of information which I think he might have found helpful or valuable to him. My hon. Friend the Member for Bromsgrove (Mr. Dance) raised the question of the closing down of a hospital house committee in his division. He referred to the indignation which this has seemingly caused locally. I can well understand his feelings on this matter but, of course, it is one on which 1526 there is no immediate ministerial responsibility. It is a matter which must be ironed out by the hospital management committee which took this step in the first place, and that committee will probably wish to see the regional board about it if the dissatisfaction to which my hon. Friend refers is as great as he says it is.
§ Mr. Thompson
It might be said that everything in the Health Service stems from the Minister in the end, but we have no immediate responsibility for the appointment of people to a house committee or, indeed, to hospital management committees.
The hon. Lady the Member for Wood Green (Mrs. Butler) asked one or two specific questions about protection against ionisation. My right hon. and learned Friend has urged hospital authorities to give effect as soon as possible to the code of protection against the effects of radiation. The cost of doing so must necessarily come, out of their own resources, that is, the sums for hospital revenue and capital voted by the House of Commons. I am sure that the importance of giving this development high priority is widely appreciated.
The hon. Lady also asked whether the increased sums provided in the Supplementary Estimates which we are now discussing include increased remuneration for radiographers and physicists. I am advised that an agreement on the remuneration of physicists has just been reached on the Whitley Council and is about to be submitted to my right hon. and learned Friend. No provision was included in the Supplementary Estimates, but, of course, effect will be given to the increase if it is approved. Negotiations are proceeding on the remuneration of radiographers and are to be continued at a Whitley Council meeting as early as tomorrow.
The hon. Member for Birmingham, All Saints (Mr. D. Howell), the whole of whose speech, unhappily, I had the misfortune to miss, raised mainly the 1527 question of part-time and whole-time consultants. The Guillebaud Committee considered that under existing conditions, that is, in 1956, there was a valid case for the retention of part-time consultant appointments in addition to whole-time appointments, but that the financial arrangements should not be such as to induce a consultant to seek a part-time rather than a whole-time appointment. Evidence has been given on the matter to the Royal Commission on Doctors' and Dentists' Remuneration and any observations that the Commission makes in its Report we shall await and study with a good deal of interest.
In the present circumstances, my right hon. and learned Friend was advised that if a consultant with the agreement of his board, changes from whole-time to part-time work and there is no substantial change in duties, there is no need to advertise the post when the contract is varied by the parties. I am sure that the hon. Member appreciates that in this matter we have an agreement with the medical profession and it is inadvisable to seek any modification or adjustment of that while the Commission is still sitting. When we have the Commission's views on it we shall be able to look at the matter again.
I think that it would be now appropriate for me to say something about drugs in the National Health Service, a subject which has formed a considerable part of the debate. It might be appropriate if I started off by refreshing the Committee's recollection of some of the steps which we take or are contemplating taking to make doctors and hospitals cost-conscious, in particular with regard to the cost of drugs and medicines. I realise that that is not the whole of it and that we have to deal with the cost of the drugs themselves. There are two questions here—whether prescribing is extravagant and whether we are paying too much for the drugs. Some of these matters, of course, are familiar to hon. Members who follow these things closely.
The principal means that we have used for this purpose has been our old friend the "Prescriber's Notes". These notes, which go out roughly every quarter were originally prepared for general practitioners, but since January, 1953, we have issued them to regional hospital boards, boards of governors and teaching hos- 1528 pitals for distribution to their medical staff. The Report of the Joint Committee on Prescribing has been sent to hospital authorities, who have been asked to distribute copies to all hospital doctors and pharmacists.
From time to time, the Chief Medical Officer of the Ministry has sent personal letters to all doctors in the hospital service asking for their co-operation in reducing prescribing costs. Besides asking doctors to have full regard to the Report of the Joint Committee on Prescribing, these letters have dealt with many points including the danger of extravagant use of antibiotics and vitamins and the need for care in prescribing proprietary drugs. In addition, clinical teachers, since 1953, have been asked for their help in instructing young doctors in the cost of prescribing.
The Sub-Committee on Hospital Pharmaceutical Services, under the chairmanship of my hon. Friend the Member for Putney, spoke in its Report of substantial economies secured without prejudice to treatment through the investigation by the medical committee of the current prescribing practice. The Sub-Committee said that where this had not been done it might now be put in hand with periodical reviews on subsequent occasions. The Sub-Committee's Report was brought to the notice of regional boards and boards of governors by circular, dated 3rd March, 1955, which recommended regional boards to set up pharmaceutical advisory committees to advise them of any steps necessary to make the service efficient and economical.
In March, 1955, also, a circular letter, signed by an Administrative Officer, was sent to hospital boards and management committees suggesting methods by which economies might be achieved, among other things, in the preparation of 30 or so of the most expensive items. The medical committees of the hospital concerned would then be asked to examine the prescribing of these items to see whether economies could be made without prejudice to the treatment of patients. The second measure advocated was special attention to the possibilities of economies in the use of surgical dressings and the prescription of vitamins, and the third was the setting up of a committee on which medical and nursing staff were represented to make sure 1529 that medical advice was readily available on the best use of and the storage and handling of drugs.
Then again, in 1957, the Chief Medical Officer of the Ministry sent a letter to the chairmen of the group medical advisory committees asking for their cooperation in connection with the introduction of improved hospital costing arrangements, about which I said something earlier. This letter stated:If the figures are produced with care and sensibly interpreted, hospital costing can help those responsible for running the hospital service to secure the most effective use of the limited resources available.In accordance with those recommendations of the interim Report of the Hinchliffe Committee which concerned the hospital service, and to which I have referred, we have arranged for the issue of the alternative edition of the British National Formulary to all clinical students and hospital doctors. The right hon. Lady made a point of that; she wanted to be sure that people coming into medicine were seized of the importance of due economy in prescribing. Those are steps, some quite well known, which show what we do to try to keep economy of prescribing constantly before those in the hospital service.
Now I will turn to the other side of the picture, what we pay for the drugs we use, and, in particular, the very costly antibiotics, corticosteroids, and drugs of that kind.
§ Mr. Moyle
Would the hon. Gentleman deal with my point about the Health Service patient who is charged for the provision of a drug which a general practitioner considers is essential to her proper treatment? I asked what is the basis on which the Ministry acts which precludes certain drugs from being made chargeable to the Health Service and what is the procedure in this connection? That question concerns a case I took up with the Minister, with which the Parliamentary Secretary dealt, and he said that it was quite in order and was a matter between the practitioner and the B.M.A.
§ Mr. Thompson
It is competent for a doctor to prescribe any drug considered appropriate for the treatment of his patient. We do not tell the doctor that he must prescribe this or the other drug.
1530 That is something we should never do, and we do not seek to do it. However, I shall be able to give the hon. Gentleman a fuller answer to his question if he will allow me to refresh my memory of that case.
Turning to the speech of the hon. Gentleman the Member for Coventry, North (Mr. Edelman), he was concerned, among other things, about the cost of the polio vaccine which we have been using in such quantities in connection with our original and expanded programme. The original plus the Supplementary Estimate provided for an expenditure in England and Wales of £2.7 million, which was divided roughly as follows. About £900,000 for the British vaccine, which the hon. Gentleman will remember was relatively scarce—and there was, consequently, less of it—and £1.8 million for American and Canadian vaccine. The price we are paying for British vaccine per litre at present is actually substantially higher than the prices we have recently been paying for American or Canadian vaccine.
We should bear in mind, in this connection, the fact that the British vaccine is not identical with the American or the Canadian, and, also, that the American firms have been in production for several years. During this time their prices have been reduced as production increased. British firms are only now coming into substantial production after considerable difficulties, and this may account for the difference. We have not purchased poliomyelitis vaccine from all the American manufacturers, of whom the hon. Gentleman gave us a list at one point. But I can tell him that we did not receive identical quotations from those from whom we bought supplies. There were three firms involved. I hope that this purely factual point will help the hon. Gentleman on the question of what we pay for the vaccine and the position as between the English and the American firms.
§ Mr. Edelman
I am obliged to the hon. Gentleman for his analysis of the various suppliers, but he has not really answered my point. It was whether the contracts were put out to tender to British manufacturers and whether the British manufacturers quoted a uniform price for the poliomyelitis vaccine.
§ Mr. Thompson
I can assure the hon. Gentleman that they are not uniform. In the case of the British manufacturers we were in the situation that last year we could not get anything like as much from them as we would have wished to purchase, so we were purchasing relatively small quantities, but I can tell him that the prices were not uniform.
§ Mr. Thompson
I would say, "No." I put it that way because the two firms from whom we have received our supplies up to now are British firms. There is another firm which is an American subsidiary, I understand, coming into production, but we have not taken anything from it yet.
Now perhaps I can deal with the point which the hon. Member for Coventry, North made at some length about mecamylamine. Up to February, 1957, this drug was imported in its finished state, but in fairly small quantities, from the U.S.A. and it is now made here by a British-based subsidiary of the United States firm. A patent has been applied for it. If it is granted, it will run for sixteen years and the drug will be available in proprietary form only from the manufacturers or from anybody who may have a licence to manufacture it.
The Controller of Patents, under Section 41 of the Patents Act, 1949, can order a licence to be granted on terms which seek to secure that the medicine shall be available to the public at the lowest prices consistent with the patentee's deriving a reasonable advantage from his patent rights. If an application is granted in this case, any British or other firm may apply for a compulsory licence to make mecamylamine hydrochloride. So far no one has come forward.
I have no figures of the cost to the Health Service of this drug supplied to hospitals. The manufacturers say that hospitals are the principal users here. Its importance lies in the fact that it is much the most powerful of three or four valuable drugs used in the treatment of hypertension and, as I understand, it is the strength factor which commands its 1532 use in certain cases. It is classified by the Cohen Committee in category I as a "new drug of proved value not yet standard."
With certain exceptions, the voluntary price regulation scheme agreed between the Health Departments and the Associated British Pharmaceutical Industry applies to all proprietaries in categories 2, 3 and 4 of the Cohen Committee's classification, and these comprise 90 per cent. by value of all proprietaries available on National Health Service prescription. The scheme does not apply to products so available for less than three years, and, therefore, in practice, it applies to roughly 60 per cent. by value of all proprietaries.
This scheme, I think, has a considerable bearing on what the hon. Member for Coventry, North would like us to do. Its duration is from June, 1957, to June, 1960, and before the latter date its working will be reviewed in all its aspects. We shall not wait until June, 1960, before considering the lessons to be drawn from it. We shall study in good time the information to hand, to see whether the scheme should be renewed, whether it needs to be improved, or what should be done.
Mecamylamine, to which the hon. Gentleman referred, is a category I product and has also not yet been available for three years on National Health Service prescription, so it is not price regulated. On reclassification by the Cohen Committee in categories 2, 3 or 4, its price will become subject to regulation under the scheme. Of course, if it is replaced by a new product and goes out of favour that is a risk which the manufacturers have to take. It seems to me that it was a little unrealistic of the hon. Gentleman to take the raw material cost, which he did, compare it with the price of the finished product and call the difference gross profit.
§ Mr. Edelman
The hon. Gentleman has gone into this matter in great detail and I am much obliged to him for doing so; but he will recall that I submitted to him a detailed analysis of the cost of this drug and of alternatives which could be supplied. I think that the comparison showed that, on the basic figures as presented to him, the manufacturers at present were making the profit to which I referred—1,990 per cent. I should like 1533 to establish, first, that the hon. Gentleman has seen and does accept those figures as presented to him.
§ Mr. Thompson
That was the point I was making. I have seen the calculation of the hon. Gentleman—indeed, I replied to his letter—but I do not necessarily accept the arithmetic.
As I was saying just before his intervention, I think that it is unrealistic to compare raw material costs. After all, we ought to know whether the raw material has the same potency and the same efficacy as whatever may be used in the finished product over here. It is unrealistic simply to deduct a figure for raw material cost from the price of the finished product over here and call the difference gross profit. It leaves out of account processing, packaging, cost of research and marketing, and also the possibly short life of a drug.
I would not accept the hon. Member's view that all these drugs have a life of only two or three years. I think that many have a life longer than that. But it is a factor, when putting a price on these drugs, that if they are likely to be superseded in a very short few years it follows that the development expenditure which went into them, plus all the development expenditure which went into other drugs which did not find acceptance, has to be recouped in a much shorter time. Therefore, it is unfair to single out one product and make an oversimplified calculation based on the cost if its raw material alone. It is with the factors I have mentioned in mind that a free period is allowed under our voluntary price regulation scheme.
Nevertheless, all this is public money, and my right hon. and learned Friend is closely concerned to ensure that reasonable prices for new drugs in category 1 or categories 2, 3 or 4 after the three-year period should be secured. I think that the best thing that we can do is to review this scheme very thoroughly, as I have said we shall, before it comes to its end to see whether it is fulfilling its function and whether there are grounds for the kind of allegation that the hon. Gentleman made—which, while not accepting, I certainly take seriously—and also to see whether there is a case for replacing or improving it.
1534 On the question of American subsidiaries as a whole, I would say that if new drugs are not manufactured in Britain the alternative is to import the finished product; and that is always more expensive. It is not right to think of these firms as plunderers. Foreign firms have sunk considerable sums in setting up appliances here and we derive a valuable export trade and thriving industry from it apart from the benefit to the National Health Service of having these drugs which would otherwise be unobtainable from home production. I would hope that nothing that is said in this Committee would have the effect of frightening away foreign firms who are prepared to export their brains and sink their capital in the drug industry, supplying employment to people in this country.
We must not allow the rise in the drug bill to obscure the fact that the increasing use of these drugs has led to much quicker recovery of patients and that more patients have been treated more cheaply at home rather than in hospital, and that the more rapid turnover of hospital beds has been possible. Unless there were to be some restriction on the freedom of doctors to prescribe as they think best, we cannot limit the use of new drugs, although we can and do, in the way I have described, keep the need for economic prescribing constantly before them.
I should like to say a word on research, because the hon. Gentleman the Member for Lichfield and Tamworth (Mr. Snow) had a word to say on that. The drug industry is spending about £4 million annually on pharmaceutical research. It is of two types, long-term fundamental, which can only be undertaken by the largest firms, and short-term progress and development research. A measure of the work undertaken is shown by the fact that, on average, about 1,000 new substances are synthesized to produce one for the market.
Each firm which does research on any scale has a research team or teams working as a closely integrated unit. For instance, a large firm may employ over 100 graduates. Research in the industry is not into a single product or allied group of products, as in some other industries, but into a wide range of substances designed to have quite different effects on the human body.
1535 Central research which, I think, was implicit in something that the hon. Gentleman said—
§ Mr. Thompson
I am happy to have that correction. The hon. Gentleman may remember that I came in during the middle of his speech. If he agrees with me that research should not be over-centralised I should have thought that one of our protections in seeing that we pay an acceptable and reasonable price for these new drugs, which we so badly need, was the existence of a number of firms capable of carrying out this kind of work independently, although that inevitably means a certain amount of overlapping.
May I conclude by saying one or two things which I think the Committee would like to hear about certain developments which are pending. My right hon. and learned Friend attaches the maximum importance to getting the best possible value for money in the National Health Service. Hon. Members may remember that he referred in the debate on 30th July to his intention to set up a body to assist in the development of efficient techniques in the Service.
I am very happy to tell the Committee that Sir Ewart Smith has agreed to serve as chairman of the council which the Minister is setting up. We are very fortunate indeed to have a man of his calibre and experience and holding an almost unique position in this field of work study to help us in this way. My right hon. and learned Friend hopes to be able to announce shortly the names of the other members. One of the first problems which, no doubt, the council will wish to consider is the best method of extending efficient studies in the Health Service.
My right hon. and learned Friend told the House a few months ago, on this same theme, that he had accepted an offer from the Management Consultants' Association to demonstrate, by studies in four hospitals, what economies could be secured in the Service. He has just received the first report from the four hospitals and is studying it. Further more detailed study will, however, be 1536 necessary to complete this particular exercise.
We shall shortly be issuing guidance to hospital authorities designed to improve the methods of selecting candidates for administrative appointments in the Health Service. These include the establishment of registers of officers suitable for promotion and the inclusion in appointments committees of assessors drawn from outside the employing authorities. It is hoped, in this way, to reduce the disadvantages attached to the multiplicity of employing authorities and work towards the evolution of common service standards.
The present manpower control in respect of non-medical staff of hospitals is to be removed and hospital authorities are to be given wider delegated powers. We are proposing to establish a small team in the Ministry whose job will be to visit hospital authorities and report on their staffing situation in order to facilitate the spread of good management practices and promote the economical use of staff.
I hope that what I have said will show that we are not in the least complacent about the enormous sum of money which we are asking the Committee to sanction. We have very good plans here. Plans and advice are now being supplied from the various bodies which have been studying important problems and we intend to apply those plans and advice with the utmost enthusiasm and speed. I hope that in all the circumstances the Committee will feel that this money is being worthily spent and that it should be voted.
§ Question put and agreed to.
That a Supplementary sum, not exceeding £16,589,706, be granted to Her Majesty, to defray the charge which will come in course of payment during the year ending on the 31st day of March, 1959, for the provision of a comprehensive health service for England and Wales and other services connected therewith, including payments to Northern Ireland and the Isle of Man, medical services for pensioners, etc., disabled as a result of war, or of service in the Armed Forces after the 2nd day of September, 1939, certain training arrangements including certain grants in aid, the purchase of appliances, equipment, stores, etc., necessary for the services, and certain expenses in connection with civil defence.