§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. G. Campbell.]
§ 4.8 p.m.
§ Mr. Laurence Pavitt (Willesden, West)
I am sorry that the Minister of Health is not in his place today. However, I know that he is absent in a good cause. He is in my own constituency. I hope that the hon. Lady the Parliamentary Secretary will forgive me if I direct most of my fire at the Minister, since I consider him to be the chief architect of most of our troubles concerning prescription charges.
The more I examine the effects of prescription charges, the more astounded I am that so intelligent a person as the Minister can be so utterly wrong in his policy. The more he comes to the Dispatch Box, the more obvious it becomes that in this matter he is obstinate to the point of arrogance. There has been overwhelming evidence and opinion against them from doctors, chemists and patients, and one in three of the local executive councils, which can hardly be called political bodies, has protested against them. All this has been swept aside contemptuously. The Minister seems to pursue his belief that taxation of the sick is a just and fair thing to impose with an almost evangelical fervour to the last 2s. from the last chronic bronchitic.
During previous debates we accused the Government of taxing the sick to pay for the healthy. How much worse it has proved—not just for the healthy but now for the wealthy. The sum of £12½ million has come from suffering people, but £19 million is to be paid to people already rich, not on account of their productivity, but on their unearned income alone.
1936 I contend that the Minister is entirely wrong in his policy. He estimated a 2 per cent. drop as a result of these charges, but in the event, in the period between February and March, as is shown from the Answer to a Question I put in the House on 5th June, the drop was more than 20 per cent.—from 22,200,000 items to 17,500,000 items. In the course of exchanges, the Minister pointed to other evidence and said that we could not ascribe the fall only to the prescription charges policy. But when we compare the charges for the previous year, we see that there is a drop of 13 per cent. if we compare March this year with the figures for March, 1960.
The whole conclusion which the Hinchliffe Committee has drawn about previous impositions of prescription charges has been entirely ignored by the Minister. The Committee sat from June, 1957, to June, 1959. From page 90 of their Report, it is quite clear that these learned gentlemen decided that the previous impositions of prescription charges were so much resented by both patients and doctors that they stimulated action to avoid them.
It stimulated the wrong incentives and it was a financial failure. It further proved, at least to my satisfaction, that the whole operation led to extreme waste in the National Health Service. But worst of all is the fact that the Minister has entirely flouted and ignored the Hinchliffe Committee's specific recommendation when it said:We recommend, nevertheless, that if any change in the basis of the prescription charge is contemplated in the future, it should not be put into effect without an attempt to assess in advance its probable effects by means of an inquiry…There was no inquiry and there was not even an attempt at an inquiry. The whole operation was pursued with unseemly haste.
The Minister was entirely wrong also to ignore the report of Drs. Martin and Williams which was published in the Lancet on 3rd January, 1959. The whole basis of their argument proved fairly conclusively that the charges on prescriptions had led to a loss of cash and not a saving by the Ministry and, ultimately, by the Treasury. For example, they showed that the estimated charge imposed in December, 1956, which, according to the 1937 Minister, should have yielded £4½ million, in actual fact had cost an additional £1,374,000.
Comparing the impact of these charges with the charges imposed three years previously, we see that the change between November and December, 1954, was that the cost per prescription went down by 0.22 pence and that in 1955, during the same period, it went down by 0.16 pence, but in 1956, when the fresh charge was imposed, it went up by 7.54 pence. We are now seeing the same kind of proceeding all over again and the Minister has learned nothing from experience.
The increase arises in two ways. First, a good doctor is on the side of his patient. Only this week a doctor told me that he feels so guilty about this charge that inevitably, when he finds that a patient is being charged in excess of what the cost would be—is being charged 2s. for something costing less than 2s.—he tends to give something "a little fancy", as he put it, or larger quantities, in order that the patient might not be at a disadvantage. The Minister's whole policy is against the policy which his own Ministry has been pursuing for years, that of persuading general practitioners to switch from proprietary brands to drugs in the British National Formulary. "The Handbook of Prescribing" issued by the Ministry of Health about eighteen months ago showed that if general practitioners accepted the recommended quantities, out of 423 non-proprietary articles listed in the British National Formulary 244 cost less than 2s. Of course, a general practitioner is aware that it appears to give more value to the patient to go away from the Formulary and prescribe expensive proprietaries.
The second thing is that the large fall in prescriptions which occurred in March led immediately to reactions on the part of the dispensing chemists. Three days after my original Question was unsatisfactorily answered in the House, the Central National Health Service Chemist Contractors' Committee launched a claim with the Ministry for an increased dispensing fee of 2s. per prescription, an increase of 2½d., container allowance, an increase of 10s. 6d. on urgent fees, 3s. 6d. for prescriptions before 11 p.m., an 1938 increased payment for rota, 15s. an hour or 30s. for overtime periods. This claim was slapped in three days after it was so obvious that prescriptions had fallen so drastically from 22 million to 17 million. Significantly, the claim is asked to be post-dated to 1st March, and that is the date when the charges became operative.
The charges are both unfair and unjust. These points have been made before. The greater the illness the more one pays. If one is under 5 or over 65, the incidence is twice as heavy. This charge even differentiates between areas. The rate of morbidity among people who live in South Wales is three times as high as it is among those who live in Surrey. There is three times as much morbidity in that part of the country. So, therefore, the people of South Wales are taxed three times as much as those in Surrey. It destroys the doctor-patient relationship, especially for the 2,500 dispensing doctors who act as tax collectors to the extent of £1 million per annum.
So incensed are these people—and perhaps the hon. Lady saw this in the Manchester Guardian—that one of them asked to be supplied with a bus conductor's ticket apparatus to issue his 2s. receipts. They resent this not so much because they are tax collectors but because it makes it appear that their services are valued at 2s. a time. The 2,500 doctors consider that this is an appalling burden, and that it lowers the dignity of their profession.
It destroys the doctor-chemist relationship. I sent a letter which I received from a dispensing chemist in my area to the Minister. This letter showed that the chemist had increasingly been receiving requests from people who came to see him when they had three items on a prescription, to ask which was the most important because they said they would take that one and leave the other two until Friday. This means that if a chemist is conscientious he must ring the doctor, otherwise he is taking over the doctor's functions. As to the Answer given on a previous occasion that the chemist can write "Not dispensed" for these items, what kind of support can the chemist give the doctor if he has some little hyroglyphic which means Brompton lozenges costing 1939 ninepence, and he tells the patient that his doctor's cure is only Brompton lozenges? It takes some of the magic away from the doctor's advice, and can do physical harm to a sensitive highly-strung patient who feels that she is getting something extremely relevant and important to her complaint.
It is socially unjust, because it hits the hard-working poorer section of the community who are not on National Assistance. Professor Titmus recently pointed out that one-fifth of the population was on the poverty line. That is not National Assistance. These are people who have no right to receive National Assistance but who are nevertheless hard up and unable to afford luxuries. It is on this section of the community that the charges fall particularly heavily. I do not know whether any of the hon. Lady's friends suffer from varicose ulcers, but this is a complaint common in my constituency. These sufferers pay for three items of prescription once every two weeks.
Last week I was speaking to a rally of old-age pensioners. An old lady of 70 asked what advice I could give her because instead of getting needles on prescription for her diabetic husband she was told to pay 1s. 9d. over the chemist's counter. I advised her to go to the National Assistance Board. That is the advice one always has to give.
Why, with all these things in mind, have the Government acted in this way? A factual and non-political article in The Times of 3rd February, 1961, made it clear that their action is based on an illusion and that there is no correlation at all between total drug costs and the method of financing them. The United Nations study of twelve countries shows that in 1959 the expenditure in this country was lower than all but two of them on the public drug bill and that the proportion of the national income spent on drugs in 1959 was much the same as it was in 1930, thirty years earlier.
The Minister's preoccupation with his ideological illusions has certainly damaged the Health Service but, perhaps worst of all, it has diverted his attention from the many real problems that wait to be solved. It has alienated doctors and dentists and a host of others, active 1940 in the Service, who could help in a constructive way. Let the right hon. Gentleman reverse his policy on prescription charges forthwith, or make way for someone who will.
§ 4.20 p.m.
§ Mr. Kenneth Robinson (St. Pancras, North)
I am sure that the House is waiting with interest to hear the Parliamentary Secretary's reply to the devastating case presented by my hon. Friend the Member for Willesden, West (Mr. Pavitt). As he has said, everything that has happened since 1st February bears out what we on this side said when the charges were introduced.
It is just no good the Minister saying that he has not sufficient evidence to draw any firm conclusion. My hon. Friend quoted figures for March. Yesterday, a Written Answer in HANSARD gave the figures of the prescriptions issued for April. We now have two months' experience, and the result is very similar. There was a further fall of 2.3 million between March and April of this year. Looking at it another way, it is a fall of more than 2½ million compared with April of last year. There is, therefore, already abundant evidence that people are not taking up prescriptions or are not getting prescriptions, or are not going to the doctor—one or all of these things—in the same numbers as they were before the charges were increased.
My hon. Friend mentioned items costing less than 2s. When we raised this point at the time these steps were being introduced, the Minister said, with what was, for him, some blandness, that it was perfectly all right; that the chemists had received instructions that they were to dispense these items over the counter. I believe that it has turned out to be not as simple as that.
I understand that the professional pharmaceutical bodies have warned chemists against doing this very thing. There is a definite conflict of view between the Department and the pharmaceutical profession about this and, as far as I know, chemists are continuing to dispense, as prescription items, items which cost less than 2s.; and that the procedure advocated by the Minister is not being carried out in many parts of the country. I hope that the hon. Lady will deal with that aspect.
§ 4.22 p.m.
§ The Parliamentary Secretary to the Ministry of Health (Miss Edith Pitt)
The hon. Member for Willesden, West (Mr. Pavitt) sought to show that the reduction in numbers of prescriptions for the month of March—and his hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) quoted the figures for the month of April—means that patients are not obtaining the medicine they need. I think that the period is much too short to draw conclusions. Indeed, the figures for May show quite a marked increase on the two previous months, so the hon. Member for St. Pancras, North is not right in saying that everything that has happened proves he case of his hon. Friend.
When we consider the May figures—
§ Sir Barnett Janner (Leicester, North-West)
Would the hon. Lady compare the figures in the last two months with the figures for the same two months of last year? That is really the method one should use.
§ Miss Pitt
I have done so, and had the hon. Gentleman been present earlier in the debate he would have heard his hon. Friends put those figures on the record.
I want to make it clear that I am not suggesting that the May figures by themselves serve to disprove the hon. Gentleman's argument. All they serve to show is that in seeking to find evidence of changes a much longer period needs to be taken into account. As my right hon. Friend said in reply to the hon. Member for St. Pancras, North in answer to a supplementary question on 5th June, nothing less than the experience round the whole year can disclose any trends that are capable of being interpreted as evidence that people are not getting the prescriptions they need. He pointed out that his previous estimate of the fall in the number of prescriptions of about 2 per cent. related to a whole year.
My right hon. Friend is satisfied that the revised basis of charge in December, 1956, resulted in a substantial reduction in the net cost to the Exchequer, below what it would otherwise have been. He certainly expects that the doubling of the charges will mean that the cost of the pharmaceutical services for 1961–62 will be substantially less than it would 1942 have been if the 1s. charge had remained in operation.
The estimates for the current year allow for the expected yield of the extra 1s., some reduction in the number of prescriptions and some increase in the average cost per prescription. It is still too early to say just how these expectations will work out, but there is certainly nothing to suggest that the charges are likely to defeat their own object.
The hon. Member for Willesden, West referred to the Hinchliffe Committee. The Government have never committed themselves to accepting the Hinchliffe recommendation that no change in the basis of charging should be introduced without a preliminary survey of likely public reaction. The most that was said, by the previous Minister of Health, was that obviously it would be given careful consideration. As for the suggested scheme for voluntary limitation of prescribing, the Committee's recommendations were, with the agreement of the British Medical Association, commended to all doctors in January, 1960. There is no evidence, however, that prescribing habits have altered significantly as a result.
To return to the figures, as I promised to do, in the previous four years there had been a fall in prescription numbers between February and March only in 1959, when there was a 'flu epidemic in February, as there was in January and February this year. The numbers for January, 1961, 23.7 million, and for February, 22.2 million, were higher than they have been for those two months in any of the previous four years, except for February, 1959.
The numbers for March, 1961, 17.5 million, and for April, 15.2 million, both provisional as I should make clear, are certainly appreciably below those for the same months in the previous four years. No doubt the increase in charges has played a part in the reduction, but there is also no doubt that the end of the influenza epidemic in February would have led to a substantial fall in March in any case.
The provisional figure of items declared by chemists when submitting May prescriptions for pricing is 16.9 million, well in the same range as numbers in May have been for the previous four years. Other factors that may have affected 1943 the number of prescriptions dispensed under the National Health Service are, firstly, that some items prescribed will have been obtained outside the Service at a retail price of less than 2s., the item not being subsequently submitted for pricing. Secondly, in some instances doctors will have decided that they would be justified in extending the period for which they have been previously prescribing in long-term cases. As my right hon. Friend has several times made clear, they have discretion to do this but there is no evidence of the extent to which any of these reasons may have operated.
The hon. Member referred to many drugs costing less than 2s. I am advised that no item dispensed on a prescription, that is involving a dispensing fee, would be dispensed privately for less than about 2s. The majority of items, of course, cost much more, but there would be items which the chemist within his rules would be entitled to supply in the form of a retail transaction which would cost less than 2s. Where this was the case as my right hon. Friend said, and I hope that I recollect his exact words, he would expect the chemist to do just that. That was the practice when the prescription charge was 1s. an item, and I think that it was fully recognised by the profession. Nothing in this can affect the ethical or professional practices of the chemist of the duties and relationship with the doctor which remain the same, or the relationship with the patient, which remains the same.
The hon. Gentleman went on to say that the charges are a barrier between the patient and the medicine he needs. The House is well aware that my right hon. Friend has several times offered to look into cases where it is alleged that the charges are producing hardship and he has offered to inquire into the matters raised in the letter from the Willesden chemist which the hon. Gentleman sent to my right hon. Friend, and to which he has referred in his speech today. As the hon. Gentleman will know, from the answer which he must have received a few days ago, my right hon. Friend has offered to arrange for one of our regional medical officers to visit his chemist constituent to discuss this matter. I hope that the hon. Gentleman will take this as a confirmation of our sincere desire 1944 to investigate any cases where it is asserted that people are not obtaining the medicine which they need.
We have no specific evidence that standards of treatment have been affected through inability to pay the charges where arrangements for relief have been unable to operate. I should expect doctors and pharmacists immediately to bring such evidence to the notice of my right hon. Friend. Indeed, my right hon. Friend has already said that he thinks that there is no ground for initiating any special inquiry into this aspect at present. But he will continue to keep a watch on any evidence there may be as to the effect of the higher charge.
A further point made by the hon. Gentleman—I thank him for having notified me in advance of the points he had in mind—was that the charges could have unfair strain on the doctor-dispensing chemist and the doctor-patient relationships. Regarding the doctor-patient relationship, I can see nothing wrong in a discussion between a doctor and his patient about the number of items, or about the quantities on a prescription, and hence the frequency with which the patient will have to pay a prescription charge.
Regarding the doctor-chemist relationship, one of the professional principles of pharmacists is that they must not discuss prescriptions with patients in such a way as to impair the patient's confidence in his doctor—or, to use the expression of the hon. Gentleman, which I like, to "destroy the magic". In the view of my right hon. Friend there is no reason why the charges should lead a chemist to fail to observe this principle. It has long been agreed that if a patient asks whether he can do without a particular item, or about its value in treatment, the chemist should ask him to discuss that with his own doctor. There is no reason why information about the price of a drug or dressing should undermine confidence in the doctor. The value of a medicament for treatment should not be judged by its price. Some low-priced drugs are among the most valuable.
Government policy is to give help where it is needed. The hon. Member referred to people not necessarily already in receipt of National Assistance but who might be a little above the 1945 borderline. Government policy is that followed when charges were first introduced—that relief on grounds of hardship should be given by the National Assistance Board broadly on the same lines as apply to ordinary National Assistance.
The details of the refund service have been given so often in this House that I do not need to cover the same ground again, but I would add that the Board's arrangements are explained in its new leaflet, A.L.19, which is being made available to doctors and chemists. A note about the refund of prescription charges has been included in the current reprint of the National Health Service prescription forms which will gradually come into use in the course of the rest of the year. As far those people not already in receipt of National Assistance, there may be, as we have often explained, other considerations which will be taken into account.
I join with the hon. Member in urging that in all cases, if they think they are eligible, they should apply. The leaflet to which I have referred sets out the particular circumstances to be taken into account in such cases. Then there is the other way of helping people by the period to be covered by the doctor's prescription which, of course, is a matter for his discretion, but in suitable cases where there is a continuing need 1946 for medicaments it is open to him to prescribe for reasonably long periods. Where this can be done the cost to a patient over a long period need not be unreasonable.
The great majority of people have only a few prescriptions a year. I appreciate that those are not the ones the hon. Member is primarily concerned with today. He is concerned about hardship cases. I should assure him that my right hon. Friend and I are equally concerned to ensure that there should be no hardship or to investigate hardship cases suggested to us. I think that the question of hardship could arise only in the minority of cases where there is a regular need and the patient's means are limited. Any such person should be advised to ask the National Assistance Board to consider whether he has any entitlement to relief, and should consult his doctor about the possibility of prescribing for reasonably long periods.
I repeat the assurance my right hon. Friend has so often given to this House. If there is any hardship which cannot be relieved in any of these ways, we shall he prepared to look into the circumstances of any case if details are sent to us.
§ Question put and agreed to.
§ Adjourned accordingly at twenty-three minutes to Five o'clock.