HC Deb 14 March 1960 vol 619 cc1030-56

Motion made, and Question proposed. That a Supplementary sum. not exceeding £23,586,640, 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, 1960. for the provision of national health services 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.

8.30 p.m.

Dr. Barnett Stross (Stoke-on-Trent, Central)

On a point of order. I understand that it is customary for all the Votes to be taken at thirty minutes past nine o'clock. It is now thirty minutes past eight o'clock. Could you advise me, Mr. Arbuthnot, whether there will be any way in which a grievance can be raised after 9.30? Are we to be limited in this important debate to sixty minutes?

The Temporary Chairman (Mr. John Arbuthnot)

All outstanding Votes will be taken at 9.30, as the hon. Member says, when he may record his vote.

8.33 p.m.

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

I think that I would discharge my duty of exposition to the Committee if I first gave a brief broad outline of the Supplementary Estimate and then considered in a little more detail the main items which comprise it.

The original estimate of the gross cost of the National Health Service in England and Wales was £617,900,000. Deducting Appropriations in Aid, there was an estimated Exchequer liability of £477,600,000. Now we expect the outturn to be £501,200,000. This leaves a gap of £23,600,000, or, to be more precise, the figure of £23,586,640, and that is the sum to be bridged by the Supplementary Estimate as a whole.

There are three main items, each over £1 million and two of them substantially more, which comprise the greater part of the Supplementary Estimate. These three items in order of magnitude are, first, a hospital revenue item of £13,800,000; secondly, an item for pharmaceutical services of £5,700,000; and, thirdly, an item in respect of the purchase of poliomyelitis vaccine of £1,600,000.

Before commenting on these three items, perhaps I should repeat the cautionary comment which I made last year, that is to say, that many of these items relate to expenditure whose course is particularly difficult to predict. This Supplementary Estimate was prepared in January and represents the best estimate that could then be made. Because of the difficulty of prediction we cannot be certain even now that it prognosticates within narrow limits the expenditure which, in due course, will be found to have been incurred.

Now I will come to the first of my three main items, hospital revenue, that is to say, advances made to hospital boards on revenue account. This constitutes much the greatest item of expenditure in the National Health Service, in fact well over half of the gross total. Of this expenditure the greater proportion, well over 60 per cent., goes in wages and salaries for those who run our hospital service, and very glad we are of their devoted labours when sickness or the need for surgery takes us to hospital.

The relevant figures in respect of hospital revenue expenditure are these. Our basic Estimate was £381,138,000. Our revised Estimate is £394,913,000, an increase of £13,775,000. Now, £381 million of our original Estimate was comprised mainly as follows: salaries and wages £244 million; provisions £41½ million; drugs, dressings, appliances, and so on, £26 million, fuel, light and power £30 million. Obviously, the original Estimates were based on the cost current at the time when they were settled, but it was well understood that additional amounts would be made available to hospital authorities to meet increases in pay following from Whitley awards, and that adjustments would be made, if necessary, to meet changes in the prices of goods and services taking effect during the year.

I am happy to say that, so far as prices are concerned, there is a small reduction of £200,000, and, therefore, what, in effect, we are asking Parliament to do is to vote the additional money required to meet pay increases. Of those pay increases £200,000 represents minor awards to various grades of staff. The rest is made up as follows: nurses and midwives account for £10,900,000; administrative and clerical £1,700,000; professional and technical £600,000; domestic and ancillary £500,000. So the Committee will see that by far the largest proportion of this item, which itself is the largest item in our Supplementary Estimate, is due to the increase in pay for nurses and midwives.

This results from bringing their pay into line with the relative rewards enjoyed in the community as a whole for broadly comparable work. It was, therefore, at once an act of justice and an act of policy, and I certainly make no apology for it, costly as it is; on the contrary, I am proud that this action has been taken during my term as Minister of Health.

I now come to the second main item, the pharmaceutical services. Here the basic Estimate was £60,173,000 and our revised Estimate is £65,857,000, leaving a gap of £5,684,000. This is a field in which precision in estimating is notoriously difficult to achieve due to the effects of epidemics, changes in prescribing practice and the introduction of new drugs. This part of the Supplementary Estimate is due both to an increase in the number of prescriptions and an increase in their average cost.

Taking first the number of prescriptions, the original Estimate for 1959–60 was framed in the autumn of 1958. At that time the Estimate was based on an expectation of 205 million prescriptions for the financial year. In the event, about 10½ million more prescriptions than had been expected had to be paid for in the first nine months of the financial year, largely due to the influenza epidemic of February and March last year. This seems to point to a total of 217 million prescriptions to be expected for the year, and my Supplementary Estimate is based on this figure.

It is always difficult to assess the number of prescriptions in advance, as we can see from the fluctuations which have taken place over the years in the number of prescriptions actually issued. In ten years they have, in fact, ranged between 202 million and 229 million a year, and the Committee will see that my expected figure of 217 million is about half way in this range; though there is always the hope that it may not, in the event, be as high as 217 million, particularly if we can survive this spring without a major epidemic.

Coming to the average cost of prescriptions, the original estimate was 6s. 8d., but now we think 6s. l0⅕d. will be nearer the mark. There has, of course, been a notable increase in the average cost of prescriptions over the years since the inception of the Service due to three main causes: first, the inflationary tendency over the decade; secondly, the increased quantities prescribed; and, thirdly, the introduction of new drugs. I am happy to say that the first of these has not, I think, contributed to this year's increase in cost. Nor probably has the second.

There is no doubt that the introduction of increasingly complex, and consequently costly, new drugs has been the predominant feature in this year's increase. But, of course, there are roundabouts as well as swings. There are the obvious social and humanitarian advantages derived from these new drugs. But, in addition to that, new remedies—the antibiotics, the corticosteroids, and the new cardiac remedies and so on—benefit the national economy as well as the individual well-being because they make it possible for people to be treated at home instead of having to go to hospital, and they shorten the duration of illness and promote the economic efficiency of the community thereby.

I have analysed and explained this item of the Supplementary Estimate, but I should perhaps make a short reference —because it is a matter in which hon. Members always take a keen interest—to the measures that we are taking to control the drug bill. These fall into three main categories: first, the avoidance of extravagance in prescription; secondly, the containment of the price of drugs; and, thirdly, the containment of dispensing costs.

Perhaps the most important recent development in the context of prescription has been the final Report of the Hinch-liffe Committee and the action we have taken on it. Obviously, I cannot deal in detail with this, but I can tell the Committee that action has been taken on practically all the recommendations, including the circularising of more information to doctors about the economic aspects of prescription of the drugs available.

I should like just to mention, in particular, the suggestion for a scheme of voluntary limitation by doctors of the quantities prescribed. On 29th January last I sent out a special notice, previously agreed with the General Medical Services Committee of the B.M.A., in which the importance of limitation of quantities was prominently featured.

We continue to be much concerned with the price of drugs, and we are very anxious to keep them to a reasonable minimum for the benefit of the taxpayer. Cost investigation in 1955 established that profits for unbranded standard drugs were not unreasonable, and there is no reason to suppose that the position has changed since then. I think that in the field of standard drugs competition keeps prices reasonable, though, of course, I keep the position under review.

For proprietary preparations, we have, as the Committee knows, an agreement for price regulation. It applies to most proprietary preparations. It is now in the third year of its trial period, which ends in June, and we are in consequence reviewing it. It is a complex problem especially as the pharmaceutical industry is of considerable importance going beyond the provision of drugs for the Health Service. It has, for example, an excellent export record of more than £40 million last year.

There have over the past few years been some major advances in drugs, to which I have just referred, which have had tremendously important results. These advances have flowed from a substantial research programme conducted by the industry at its own expense, estimated at about £5 million last year.

Therefore, in view of all these factors, I think that our policy must have regard to two basic points: first, the desirability of obtaining drugs for the National Health Service at reasonable prices; and, secondly, providing conditions favourable to further research and development in the industry.

It is in this dual context that we are reviewing the voluntary price regulation scheme. So far as the containment of chemists costs are concerned, we had a pilot inquiry into the payment of chemists and, following that, are now carrying out a large-scale inquiry covering a range of nearly 1,000 standard drugs. The results of the first six months of the inquiry became available on 1st December and, after consultation with chemists, certain price adjustments have now been introduced.

So, on the drug bill, I would say that we are in these various ways seeking to contain these costs and we shall certainly continue to do so, but we must not be so mesmerised by increases in costs that we overlook the great benefits conferred not only for the cure of disease, but in the promotion of health.

The third main item is the purchase of polio vaccine. Here we have required an additional £1,600,000, and, once again, this is money well spent. Last year, I told the Committee that we had made considerable strides with the vaccination of children, but I went on to say this: 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."—[OFFICIAL REPORT, House of Commons, 12th March. 1959; Vol. 601, c. 1468.] What effect this exhortation would have had it is difficult to say. Probably it would not have been anything very dramatic. It was, however, beneficially reinforced in the following month by an unwelcome circumstance which made an impact on the minds of younger people far more vivid than any Ministerial or medical exhortation could hope to do.

An international footballer was struck down by this dread disease and cut off in the full flower of his splendid young manhood. The consequence was an immediate and emphatic increase in the rate of acceptance for young people. In February, 1959, before this tragic event, it was 500,000. By April, 1959, it had trebled to 1½ million. By the end of the year it was just under 2½ million. At the same time, 8½ million children have accepted vaccination and more than 6½ million people—children and adults— have had a third injection. That is, therefore, at the basis of our increased request to the Committee in respect of the purchase of polio vaccine.

I have endeavoured to give the Committee a full, fair and faithful account of the three main heads which comprise the great part of this Supplementary Estimate. The Committee is right to give detailed consideration to these matters, a consideration which reflects the primary and traditional function of the House of Commons, rooted in the beginnings of Parliamentary history. I do not shrink from such examination. I welcome it and wish that we could have had longer for this examination, because I think that such examination will clearly show that this Supplementary Estimate, so far from being due to extravagance, reflects valuable results in terms of the health of the nation and the well-being of those who work for it.

8.49 p.m.

Dr. Edith Summerskill (Warrington)

I am prepared to accept the Minister's explanation on every head of the Supplementary Estimates he has mentioned except the one dealing with pharma-ceuticals, and I propose to raise certain questions concerned with the Supplementary Estimate of £5,312,000, the additional sum required for the pharmaceutical services. I listened very carefully and was astonished that he did not deal with a number of matters which are closely concerned with this service. I was astonished that he forgot to mention the Report of the Comptroller and Auditor-General, which is a most important Report in this connection. This is not the first time I have questioned the increasing cost of drugs under the National Health Service and asked what action is being taken to halt it, and when. No reply has been given by the Minister this evening.

I would remind the Committee that on 7th May, 1956,I asked the then Minister of Health: Has the right hon. Gentleman's attention been drawn to the statement of the Public Accounts Committee on this question of high prices of drugs, and, in view of the statement last week "— that was the week before 7th May, 1956— that the price of prescriptions had risen to 4s. 4d.. will he tell the House what he proposes to do about the matter? Tonight the Minister told us that the original Estimate took into account an average cost of 6s. 8d. per prescription, but that the position has again changed, and he has to consider the sum of 6s. l0d. as the average cost of prescriptions in the future. On 7th May, 1956, the right hon. Gentleman's predecessor said that he had submitted to the pharmaceutical industry certain criticisms of its proposals and the industry is now reviewing the proposals in the light of those criticisms. That is what is happening at the moment."— [OFFICIAL REPORT, 7th May, 1956; Vol. 552, c. 802.] I shall show later that this Supplementary Estimate arises largely from the fact that the proposals mentioned in 1956 have proved ineffective, a submission which the Comptroller and Auditor General endorses.

The right hon. Gentleman will recall that on 29th November, 1956, we prayed against the Regulations imposing a 1s. charge on each item in a prescription. We warned him that no savings would be effected and that the drug bill would increase because it would cause over-prescribing. I could hardly believe it when the Minister told us tonight that he had been instructing doctors to limit their prescribing. In 1956 his predecessor told us that the doctors were going to be given permission to over-prescribe. He even proposed that a quantity of drugs to cover a period of three months should be prescribed.

I do not like to say, "I told you so," but HANSARD will show that hon. Members on this side of the House uttered warnings again and again that if doctors were told to over-prescribe all our medicine cupboards would be filled with tablets, powders and ointments. We said that the instruction to over-prescribe would worsen the position. Furthermore, we warned the Minister that the high drug bill could, in part, be attributed to the cost of new and expensive drugs, but the most important cause would be the increased proportion of proprietary drugs. Tonight the Minister has told us that he is asking for this Supplementary Estimate precisely for that reason. In 1956, the proportion of proprietary drugs accounted for 36 per cent. of the drug bill. The Minister has not mentioned the present proportion, but I believe that it now stands at 70 per cent. of the drug bill. Since 1956, the same abuses have continued, the drug bill mounts and the cost of prescriptions increases. That is why we are faced with this Supplementary Estimate. The Minister has not told us what he intends to do to prevent the situation from worsening.

In 1958 the total number of prescriptions dispensed fell from 228 million to 224 million, but the total cost rose from £68 million to £73 million. The average cost of prescriptions rose by about 10 per cent. from 4s. 4d. in May, 1956. Then it went up to 5s. 11½d

The Temporary Chairman (Mr. John Arbuthnot)

I must ask the right hon. Lady to confine her remarks to the Supplementary Estimate.

Dr. Summerskill

I am coming to that. The Minister gave the prices of drugs and I was about to mention the one he gave. But in order to relate the matter and to show the Committee how the Minister arrived at the new figure, I think it is in order to mention the other figures. You will find, Mr. Arbuthnot, that I shall stay in order, but so as to relate my remarks to a matter of this kind it is important that I show how the figures have increased.

From 5s. 11½d. it went to 6s. 6½d., and then the original estimate of 6s. 8d. Now, tonight, the Minister says the figure is 6s. l0d. We ask ourselves what it will be next year.

The Comptroller and Auditor General drew attention to the figure in his Report on the Civil Appropriation Accounts, 1959 and, of course, we must relate this Supplementary Estimate to that Report. In 1958 there was a continuing rise in the amount of proprietary preparations prescribed, the Report tells us. These accounted for over 70 per cent. of the cost of ingredients of all prescriptions dispensed by chemists under the National Health Service. The majority fell into categories classified by the Cohen Committee as not therapeutically superior to standard preparations.

In other words, according to this Report cheaper standard drugs would be equally effective. Indeed, I would go so far as to say that they would be better, because many of us know that they would not have the unfortunate side effects which results from some proprietary drugs which have never had adequate clinical trials in this country. That is why time after time during Question Time in the House I have asked the Minister when he was going to insist upon adequate clinical trials for these proprietary drugs which are flooding the market and being consumed by the innocent and ignorant people.

Dr. Barnett Stross (Stoke-on-Trent, Central)

Has my right hon. Friend read the editorial in the British Medical Journal this week, which states that injections of a proprietary drug of iron and dextran intramuscularly injected has been shown conclusively to be carcinogenic in effect in animals, but it is still being used for human beings and is sold for such use?

Dr. Summerskill

Yes—

The Temporary Chairman

That is a matter which goes wide of the Supplementary Estimate.

Dr. Summerskill

I am sorry to have to disagree with you, Mr. Arbuthnot, but I propose to quote from that leading article. We are paying in this Estimate for the drug which was referred to by my hon. Friend. I have carefully read the leading article in the British Medical Journal. This drug is carcinogenic and it is still being prescribed to people although it is not being advertised. Surely we cannot ask the country to pay an extra £5 million for a carcinogenic? Surely that should be brought to the attention of the country?

Mr. Kenneth Lewis (Rutland and Stamford)

Surely the right hon. Lady must accept that this drug is prescribed by medical people. The Minister does not prescribe the drug, although he may pay for it. This is a matter of medical prescription and the right hon. Lady should direct her criticism to the medical people and not to the Minister.

Dr. Summerskill

The hon. Gentleman must realise that the Minister—I am quite sure that he would not deny it— has a responsibility to the people of the country. If it is brought to his attention that a carcinogenic is being prescribed under the National Health Service to pregnant women and for those suffering from anaemia and osteoarthritis, and if the British Medical Journal draws attention to the fact in its leading article, surely that should be brought to the attention of the Committee whose duty it is to protect the public. I still cannot understand why the Minister has failed to report this to the Committee.

The Auditor-General refers to a report by Departmental accountants who made calculations from published accounts of forty-three pharmaceutical firms. The accountants concluded that these companies' profits had been higher than those of general industry and had tended recently to increase when the rates for the latter had fallen. In particular, the profit rates of British subsidiaries of American concerns had consistently been much higher than those of general industry". The Auditor-General considers the results of the voluntary price regulation scheme which the Minister has mentioned and upon which he still appears to rely, to my astonishment, ineffective.

Mr. Walker-Smith

Until June.

Dr. Summerskill

The right hon. Gentleman keeps saying until June. The Minister has said that at Question Time month after month. He recognises that it has failed completely, but he tells us to wait until June. I have tried to be patient, but I find it very difficult.

The Auditor-General, in considering the results of the voluntary price regulation scheme, states that the large proportion of drugs excluded from control because they are new— What the Committee must recognise is that one of these drug firms can put a new drug on the market and charge anything he likes for it for three years. and the high profits achieved cast doubts on the effectiveness of the scheme. That I think is a masterly understatement of the Auditor-General. It is this scheme to which the Minister referred in answer to the Question which I read out to the House and which he uses now to counter probing questions from this side of the Committee on the cost of the drug bill, while year after year the National Health Service drug bill increases and the cost of prescriptions has risen at the expense of the British taxpayer. The revelations at the hearings of the United States Senate Anti-Trust and Monopoly Sub-Committee on the price of drugs have shocked public opinion in America.

Anticipating your interrupting me, Mr. Arbuthnot, and saying that it is out of order, I should like to tell the Committee precisely why I think that this is in order. The investigation in the United State of America is of special interest to the right hon. Gentleman's Department and to the Treasury because while the Senate sub-committee is investigating the activities of American firms, these firms for the most part have established themselves in Britain and are adopting the same business methods here. In fact, a great part of this £5 million Supplementary Estimate, which the Committee is being asked to vote tonight, will go into the pockets of the American subsidiaries in this country.

In the United States, this business has become a sordid race after profits with the result that many drugs are now beyond the reach of those who need them most—the aged, the sick and the disabled. The Federal Trade Commission gives the industry's rate of profit as the highest in any major manufacturing industry, and twice the general average. The big manufacturers are also accused of charging identical prices and refusing to license new drugs to smaller firms which might undersell them. For instance, investigators said Schering, Merck & Co., Upjohn Co. and Charles Pfizer & Co.—

Mr. John Peyton (Yeovil)

On a point of order. There is only a short time left for debate. Surely it cannot be in order for the right hon. Lady to go into details of the American pharmaceutical industry.

The Chairman

I think the right hon. Lady is trying to give the reasons for the increasing cost of drugs.

Dr. Summerskill

This is a very serious matter. The hon. Member for Yeovil (Mr. Peyton) will probably need some of these drugs. It is very important for it concerns the taxpayers' money. I am very sorry if hon. Members who spoke before me insisted on taking rather a long time. The point I am making is that these American companies which I am now mentioning all operate in this country and will share some of this Supplementary Estimate. Charles Pfizer & Co. for the last several years have charged identical prices for drugs used in treating arthritis. The Americans are not mealy-mouthed in this matter. The Arthritis and Rheumatism Foundation told the Sub-Committee: Greedy quacks in the patent medicine business bilk arthritis sufferers of 250 million dollars a year …". Again I emphasise that these three firms produce drugs in this country. The Chairman of the Sub-Committee, a man we in this Committee always respect, Senator Estes Kefauver, said that the hearing had already shown the need for Congressional action. He accused Mr. John Connor, president of Mercks—and Mercks is established in this country— of veering away from the firm's long-proclaimed motto that: Medicine is for the people and not profits. The Senator investigators said that Upjohn and Company bought female sex hormones for 14 cents, a gram and sold to the druggists for 15 dollars a gram. One tranquilliser sold at 3950 dollars a thousand is sold by a small company for 2.65 dollars.

A third of the turnover, a very high proportion by the standards of most industries, is devoted to the promoters. The industry maintains a small army of "detail" men who march from doctor to doctor extolling the virtues of the 400 new drugs marketed annually. I have described to the House how doctors in this country are subjected to high-pressure salesmanship day after day in their consulting rooms. During the hearing the Justice Department said that two companies, Carter Products and American Home Products, were conspiring to rig the prices of tranquillisers and to monopolise the trade. Forty million dollars of mild tranquillisers were sold in 1958. The name of one is Carter's Miltown.

Does the Minister recall that on 29th November, 1956, I drew his attention to the fact that Carters were selling Miltown in this country at the expense of the British taxpayer at £6, later reduced to £4, for 250 tablets. Research workers of St. Thomas's Hospital examined Miltown and discovered that phenobarbitone, which sold at 2s. 8d. for 100 tablets, was equally effective. The reason the Minister has mentioned time after time is that this vast sum goes into research. The scientist who works in the laboratory does not enjoy these great profits. They are shared out among the parasites who infest this industry today. Has my language been too strong?

May I draw the attention of the Committee to the leader in the British Medical Journal of 16th January? That article was on "New Drugs for Depression." I am sure that hon. Members here are slightly depressed at times—[HON. MEMBERS: "Hear, hear."] I knew that would draw one hon. Member. I wonder whether there might be some drug which might lift that depression. In the British Medical Journal, referring to new drugs which are being widely used, the writer said: So far comparatively little work has been published in Great Britain on these two groups of remedies. But this has not stopped manufacturers from indulging in intensive advertising here to try to persuade general practitioners, physicians and psychiatrists to use these drugs. P. G. Dally and W. Sargent recently drew attention in this Journal to their dangers if used too frequently by doctors who have only a manufacturer's over-enthusiastic leaflets as their guide to therapy. They predicted, for instance, that avoidable suicides would occur if the statements of some manufacturers that their preparations were as good as and could replace electro-convulsion therapy were taken too literally, and severely depressed patients were treated with them too long before being referred for convulsion therapy. This is a shocking indictment of the profit-making methods of the drug houses. For the Minister again to come tonight and not to reveal their methods to this Committee, and not relate them to this Supplementary Estimate and the fact that the prescription cost keeps on soaring, is difficult to understand.

The Minister is subject to the greatest pressure from hon. Members behind him to allow private patients to receive free drugs. I can only say—I have no interest in this matter—that if another Supplementary Estimate of this size or larger were presented next year, I would not be surprised if the Minister were so stupid as to give way. I ask him to examine the pressure methods of the drug lobby in the United States and to relate them to the pressure to which he is now subjected.

The Chairman

Order. The right hon. Lady cannot pursue this argument.

Dr. Summerskill

I agree, Sir Gordon. I was going just a little wide. This is an important matter. The hon. and gallant Member for Ripon (Sir M. Stoddart-Scott) knows that this is factual—

Colonel Sir Malcolm Stoddart-Scott (Ripon)

When the right hon. Lady refers to these American drugs and others, would she tell us how much of the £5 million refers to drugs of which she is speaking? Is it £100 or £1,000? The right hon. Lady should give some idea of whether she is building castles on the tops of moleheaps.

Dr. Summerskill

I am surprised that the hon. and gallant Member is not being honest in this matter and is trying to raise a debating point. I should have thought that his scientific education would have led him to be honest. He knows perfectly well that nobody can say precisely which drugs people in this country have consumed. He can only analyse the situation broadly on the figures which are before the Committee tonight, as I am doing.

I ask the Minister to get a copy of M.I.M.S., the Monthly Index of Medical Specialties. This will inform him of the extent of what he has described tonight as the sale of proprietary drugs. This Monthly Index of Medical Specialties has been compiled by a shrewd American and embraces hundreds of proprietary drugs. The hon. and gallant Member for Ripon has asked me which of these drugs are being consumed. Perhaps he would like to read this document and inform himself. The first few pages give lists of new drugs produced this month; it is a monthly publication. Some of them read like a witch's brew.

I am sorry to tell the Committee that in these first pages is the name of Upjohn of England, Sussex—the firm of Upjohn in the United States which was called to give evidence before the Senate Committee. Here is its name with its new drugs for this month. Then, Merck, Sharp and Dohme, of Hertfordshire, the same people who were called to give evidence before the Senate Committee. There are many familiar names here. The Minister now justifies the prescribing of these proprietary drugs and the colossal expense in the name of freedom for the doctor. I am sure that there are other hon. Members who will support him in that.

I at this stage—I have never said this before—challenge the validity of that argument. The patient's welfare should be the first consideration. I have already quoted the B.M.J. and the manner in which drugs are prescribed for depressed people. These expensive drugs are put on the market without clinical trials, and very few doctors know their real therapeutic value. Is it in the interests of the miserable, unhappy patient that this kind of freedom should be exercised.

Lord Balniel (Hertford)

On a point of order. Sir Gordon, I am sure it is your wish, as always, to protect the interests of back benchers in a debate. It is clear that in this debate, after the charges which are being made, my right hon. Friend the Minister will wish to wind up. If that is the case, no back bencher will have any chance of intervening on Estimates of over £23 million. May I ask if you can help us?

The Chairman

That is not a point of order for me.

Dr. Summerskill

The hon. Gentleman should have entered the Chamber before and spoken to his hon. Friends who have taken all the time. He himself said that this is a very important debate. That is why I am devoting myself to this point.

The defence for this is that the doctor should have freedom. I challenge the Minister on that. In the British Medical Journal of 12th March there is this article: Carcinogenic risks of Iron-Dextran. It has been observed that sarcomas "— that is a form of cancer— developed in the rat at the site of intramuscular injection of the iron dextran in 'Imferon' manufactured by Bengers. This preparation has been used for some years in cases of iron deficiency, including those of pregnancy and rheumatoid arthritis. We understand that the product is no longer being advertised in Great Britain, though it continues to be sold and prescribed. Surely this solution is not only unsatisfactory and illogical, but also dangerous from the point of view of the producers themselves? We cannot affirm the hazard to man, let alone measure it … But the existing evidence is certainly sufficient to warrant, and indeed to demand, its speedy withdrawal from any kind of general use by man. This preparation, believed to be a carcinogenic, continues to be sold and prescribed in the name of freedom. Again I say that the doctors should be controlled and this should not be allowed to continue.

The Minister mentioned to the House that doctors are given some instruction on how to prescribe. Has he seen the document I now hold in my hand? This is what he bases his argument on tonight —this flimsy little thing called "Pre-scriber's Notes", which gets absolutely lost in the vast amount of advertisements and leaflets which reach doctors. I do not know how many busy doctors relate the information in here to the vast number of drugs. Obviously it makes no contribution to the problem.

Lastly, has not the time come to examine the prescribing of the specialists? Some of them are asked by the drug houses, in return for a suitable remuneration, to test various preparations. It is remarkable how a consultant then becomes prejudiced in favour of one firm. The drug bill of the hospitals has become so high that it was decided to prescribe only for one month for outpatients and then let the general practitioner continue on E.C.10. This of course was ingenious and the drug industry did not suffer.

Will the Minister listen to these figures, because I think they are absolutely correct. In hospitals the antibiotic bill accounts for 25 per cent. of the drug bill. I believe that 50 per cent. of the antibiotics belong to the Tetracycline group. I have here the cost from one hospital of antibiotics for the last six months for 500 acute general cases. The cost was £3,474 16s. 7d. Tetracycline accounted for £1,593 1s. 4d. of this. Could we know whether Tetracycline prices are coming down?

The next expensive group is corti-costeroids. The six months' total for these at the same hospital was £4,375. The price of this was held until material was brought in from Italy a year ago, when the American manufacturers were compelled to cut the price by 50 per cent. As might have been expected, a number of new modifications are being introduced, but clinicians claim that their advantages are not very great. I should like to know, if the price is doubled or trebled, what is being done about it.

Finally—[HON. MEMBERS: "Hear, hear."] Good; one never succeeds in this House unless one is able to provoke someone on the benches opposite. I have learnt that in this House. What does the Minister propose to do in view of the failure of the voluntary price regulation scheme and the widespread sale of a large number of high-priced drugs which have not been subject to adequate clinical trial? What does he propose to do in order to protect the patient and the taxpayer?

You have been very patient, Sir Gordon, and so have the Committee, ex- cept for one or two hon. Members, but this is a serious matter which concerns not only the sick and the disabled, but healthy people, depressed people and people who are inclined to take a drug feeling that it might help them in their work. This matter must be ventilated, and I consider that it is scandalous that it has been hushed up over the years. The Minister has it in his power to take action to relieve the minds of many hon. Members and doctors who have been concerned with this problem.

9.22 p.m.

The Parliamentary Secretary to the Ministry of Health (Miss Edith Pitt)

I feel that I must apologise to all those hon. Members who, I know, would have liked to have taken part in this debate. We have a limited amount of time, and the right hon. Lady he Member for Warrington (Dr. Summerskill) has taken thirty-five minutes out of it, so that if I am to answer any of the numerous points she made I must deal with them now.

Mr. John Rankin (Glasgow, Govan)

On a point of order. Was it in order, Sir Gordon, for the other two debates to take up practically the whole of the evening, with the result that the Scottish Vote is not even going to get a nod in its passage?

The Chairman

That is not a point of order.

Miss Pitt

The right hon. Lady made a complaint about a drug manufactured by Benger's and used in the treatment of anaemia. I must say at once that this particular drug was subjected to extensive animal tests and that when it appeared safe, it was released for clinical use. Over the past five years, an enormous number of patients have been treated in this way, and apart from a local staining reaction at the site of injection, no side effects or toxic reactions have been reported.

There have been a number of investigations subsequently on animals by other doctors, and, as my hon. Friend the Member for Rutland and Stamford (Mr. K. Lewis) rightly pointed out, these have used most massive doses, and proportionately far higher than those ever likely to be used clinically on humans. In any event, this carcinogenicity seen in animals will not necessarily be followed in human subjects, and it remains simply as a warning.

The doctors have been given this warning in the medical Press, so that few can be unaware of it. It must be left to the practitioners in each case to assess the benefits and conceivable risks, and to decide for themselves whether to embark on such treatment.

Dr. J. Dickson Mabon (Greenock)rose—

Miss Pitt

I am sorry; I am not prepared to give way.

The right hon. Lady went on to make a number of points, and, in particular, she said that my right hon. and learned Friend has at times advised the doctors that they may prescribe generously for their patients, and is now asking for a limitation.

As to limitation of quantities, the Hinchliffe Report recommended that there should be provision for exceptions in chronic and particular cases. The previous encouragement to doctors to prescribe reasonable quantities related to suitable cases in long-term or chronic illness, where the need for drugs for a long period could be foreseen.

Turning to prices and U.S.A. manufacturers, our information suggests that for many of the most important drugs, prices in the United States are about twice as much as those charged in Britain by the American subsidiaries. My right hon. Friend is, of course, interested in the reports of the investigations which, as the right hon. Lady says, are now being made by the American Senate Sub-Committee, the Senate Judicial Committee and the Federal Trade Commission. We will take them into consideration, but it is clearly necessary to have full information not only of the charges made against the drug firms, but also of their replies to those charges.

I want to stress that the American firms of which the right hon. Lady was so critical help considerably both in the production of our drugs and in our exports. The industry comprises a substantial number of firms of varying size, and includes the British-based subsidiaries of United States and Swiss firms. Through the activities of these firms our industry has benefited from the very considerable research efforts in the United States of America and Switzerland. As I say, the United States firms have made a major contribution to our exports.

The right hon. Lady said that Pre-scriber's Notes really gave no information to doctors, and suggested that they were of little value. In fact, the form of Prescriber's Notes has been agreed with the British Medical Association as being the most likely to be effective, or read by the doctors. The right hon. Lady also mentioned the cost of a drug called tetracycline. I am informed that last May there was a reduction of 10 per cent. in the price.

I had prepared a long reply to the debate, and in the course of it I would certainly have been able to answer the right hon. Lady's criticism that no action had been taken in the matter of the drug bill and, in particular, the proprietary medicines. My right hon. and learned Friend has explained the reasons for the increased expenditure on the pharmaceutical service, and the active steps being taken to control the drug bill.

Following the Hinchliffe Committee's Report, there was a suggestion to doctors for voluntary limitation on quantities prescribed together with circulation of more information to doctors about the cost of the various drugs. Other measures designed to make doctors more cost conscious include the regular supply of statements about their own prescribing costs compared with those of other doctors, and visits by the Minister's regional medical officers, of which there were between 900 and 1,000 in 1959. Action has also been taken on other recommendations designed to secure economy in the drug bill. Had there been time, I would have given a long list of the actions being taken.

The drug bill is not solely a matter of avoiding extravagance in prescribing. There is also the question of the price to be paid for the drugs, and we are very much concerned with this aspect. For proprietary preparations there is a scheme of voluntary price regulation, agreed with the manufacturers, which will shortly reach the end of its three-year trial period. This voluntary price regulation has produced a considerable number of price reductions—about 300. It has, we believe, helped to produce a climate of price restraint. It is a voluntary scheme, and has not inhibited price competition or prevented price reductions by individual manufacturers who feel able to make them as individual research and development costs are recovered.

For example, during the last two years prices of corticosteroids have been reduced by 30 per cent. without any prompting—

It being half-past Nine o'clock, The CHAIRMAN proceeded, pursuant to Standing Order No. 16 (Business of Supply), to put the Question necessary to dispose of the Vote under consideration.

Question put and agreed to.

Resolved,

That a Supplementary sum, not exceeding £23,586,640, 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, 1960, for the provision of national health services 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,

ARMY SUPPLEMENTARY ESTIMATE, 1959–60
That a Supplementary sum, not exceeding £4,000,000, 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 1960, for expenditure beyond the sum already provided in the grants for Army Services for the year.
Schedule
Sums not exceeding
Supply Grants Appropriations in Aid
£ £
Vote
1. Pay, etc., of the Army 4,640,000 *—700,000
2. Reserve Forces, Territorial Army, Home Guard and Cadet Forces 1,160,000 *—80,000
3. Salaries, wages etc. 330,000 —
4. Civilians 760,000 *—140,000
5. Movements 70,000 700,000
6. Supplies, etc. 240,000 *—270,000
7. Stores Cr. 3,500,000 —
8. Works, Buildings and Lands Cr. 1,570,000 —
9. Miscellaneous Effective Service 300,000 —
10. Non-Effective Services 1,570,000 30,000
11. Additional Married Quarters — *—460,000
Total, Army (Supplementary) 1959–60 £4,000,000 *—£920,000
* Deficit.

Question put and agreed to.

the purchase of appliances, equipment, stores, etc., necessary for the services, and certain expenses in connection with civil defence.

The CHAIRMAN then proceeded forthwith to put severally the Questions, That the total amounts outstanding in such Estimates for the Army for the coming financial year as have been put down on at least one previous day for consideration on an allotted day, and the total amounts of the outstanding Estimates supplementary to those of the current financial year as have been presented seven clear days, be granted for the Services defined in those Estimates and Supplementary Estimates.

ARMY ESTIMATES. 1960–61

That a sum. not exceeding £39,990,100, be granted to Her Majesty, to defray the charge which will come in course of payment during th year ending on the 31st day of March, 1961, for expenditure in respect of Army Services, viz.:

Vote £
10. Non-Effective Services 39,990,000
11. Additional Married Quarters 100
£39,990,100

Question put and agreed to

ARMY

ROYAL ORDNANCE FACTORIES ESTIMATE, 1960–61

That a sum, not exceeding £7,400,000, be granted to Her Majesty, for the expenses of operating the Royal Ordnance Factories which will come in course of payment during the year ending on the 31st day of March, 1961.

Question put and agreed to.

ROYAL ORDNANCE FACTORIES SUPPLEMENTARY ESTIMATE, 1959–60

That a further Supplementary sum, not exceeding £10, 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, 1960, for expenditure beyond the sum already provided for the expenses of operating the Royal Ordnance Factories.

Question put and agreed to.

WAR OFFICE PURCHASING (REPAYMENT) SERVICES ESTIMATE, 1960–61

That a sum. not exceeding £100, be granted to Her Majesty, for expenditure incurred by the War Office on the supply of munitions, common-user and other articles for the Government service, and on miscellaneous supply, which will come in course of payment during the year ending on the 31st day of March, 1961.

Question put and agreed to.

CIVIL ESTIMATES AND ESTIMATES FOR REVENUE DEPARTMENTS, SUPPLEMENTARY ESTIMATES, 1959–60

That a Supplementary sum, not exceeding £44,633,732, 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, 1960, for expenditure in respect of the following Supplementary Estimates, viz.: —

CIVIL ESTIMATES

CLASS I
£
1. House of Lords 15,182
4. Treasury and Subordinate Departments 192,500
6. Charity Commission 8,482
7. Civil Service Commission 47,092
8. Crown Estate Office 8,049
10. Friendly Societies Registry 10,615
11. Government Actuary 10
15. National Debt Office 10
17. Public Record Office 10
21. Tithe Redemption Commission 10
22B. Civil Service Remuneration 1,558,600
24. Scottish Record Office 10
CLASS II
1. Foreign Service 525,285
2. Foreign Office Grants and Services 788,900
4. Commonwealth Relations Office 10
6. Oversea Settlement 10
7. Colonial Office 73,000

Question put and agreed to.

MINISTRY OF DEFENCE SUPPLEMENTARY ESTIMATE, 1959–60

That a Supplementary sum, not exceeding £10, be granted to Her Majesty, to complete the sum necessary to defray the charge which will come in course of payment during the year ending on the 31st day of March 1960, for the salaries and expenses of the Ministry of Defence; expenses in connection with International Defence Organisations, including international subscriptions; and certain grants in aid.

Question put and agreed to.

Resolutions to be reported.

Report to be received Tomorrow; Committee to sit again Tomorrow.