§ 2.4 a.m.
§ Mr. B. T. Parkin (Paddington, North)
I have given notice to the Minister of Health, to whom I am much obliged for his courtesy in staying in person at this stage of our discussions, that I wish to raise the question of the professional ethics of revealing the cost and content of medical prescriptions. I use that phrase because I want to narrow my intervention to one particular problem arising from the recent increase in the Health Service charges.
During the course of many debates on the subject, the Minister was very anxious to persuade us—he had quite clearly convinced himself—that the hardship which many hon. Members thought would fall upon people as a result of their having to pay an increased prescription charge for an article which did not, in fact, cost as much as 2s., had been exaggerated. The Minister gave an unqualified assurance that in the case of appliances on prescription, the normal retail price would be charged and the item crossed off the prescription list and noted as not prescribed. He went on to give, I thought, confident assurances that the same thing would apply in the case of medical preparations and formularies which found a place on the prescription form and which could be recognised by the dispenser as something which could be sold at a retail cost of less than 2s.
800 The Minister will be aware that there has been a good deal of dismay and grumbling at these increased charges and uncertainty by the public and among pharmacists. Many of us have had representations made to us about the hardship of the new charges on these grounds. The Minister will be aware that in theory there are a large number of common formularies—I am told, between 200 and 250 of the prescriptions in commonest use—which cost less than 2s. retail. Therefore, their elimination from the prescription and getting a cash payment for them over the counter should be an important part of the pharmacist's work.
When representations have been made to me about the matter in recent weeks, I have replied that the Minister has given assurances that there is a way out, that the chemist can indicate the cost of the prescription and, if it is less than 2s., he can charge it over the counter. I have said that although that does not, in my view, justify the Minister's policy, at least it is something which adminstratively would work out when chemists and the public became accustomed to using that machinery.
It seems, however, that there is no immediate prospect of that working out, because the pharmacists are disquieted by the intrusion into their system of professional ethics in this matter. This came to my notice, in particular, when one of the people who had been protesting to me about this, following representations from a dispenser who was disturbed about it, had herself occasion to call in a doctor to look at a 3½-year-old child who had a tummy pain.
The Minister would wish, as the medical profession wishes, that in the case of young children there should be no question about notifying the doctor quickly. He would rather be told and come and look at the child, prescribe, perhaps, a soothing teaspoonful or so and see whether he was all right next morning and that it was not appendicitis or something serious. That involved, in this case, taking a prescription to the chemist to get a tiny bottle from which a couple of teaspoonful would be drunk. The mother tried it out on the chemist and asked him, "What is this? What will it cost?" The chemist was indignant and replied, "I cannot tell 801 you either of those things. It is against the professional ethics of pharmacists. It does not matter what the Minister has said. It cannot be done."
I then sought the advice of the chairman of one of the regions of the union representing the pharmacists to ascertain the weight of their objection. What the pharmacist says is that he must respect the secrecy of the doctor's prescription and that the doctor is entitled to protection by the pharmacist of the confidential nature of his prescription if he chooses to prescribe, appropriately to the nature of the complaint, something which the patient might consider trivial, not sufficiently costly and not sufficiently effective to change his or her condition.
The situation therefore, as I understand, is that if the doctor chooses to write on a prescription form "25 aspirin tablets" the patient can read it and knows what it means, and the chemist can say, "You see what this is. You can have 25 tablets for 6d. over the counter or you can pay 2s. for having the prescription dispensed." But if the doctor writes "Tabs, Acetylsalicylic Acid, 5 grains" and the formula for taking one three times a day, as a professional secret the pharmacist is not entitled to say, "This is only aspirin. Give me 6d. and you can have 25 tablets".
This is of some professional importance. I do not know whether the Minister has thought of it in these terms. I am sure that he will now. If he gives an assurance that he will do so then, though this happens to be the shortest of the debates on the Consolidated Fund Bill, it will at least have proved worth while. It will not be easy for the Minister to get over this problem. I suggest that he should consult the professional organisations and try to get back on to the doctor the responsibility of deciding whether or not the nature of the prescription can be revealed. I do not know how it can be done, but it ought to be the doctor's decision rather than the pharmacist's whether these things can be sold at less than 2s. Perhaps the Minister will have these consultations and seek an administrative way out and then cause a statement to be printed by his Department and distributed for hanging up in places where prescriptions are dispensed.
802 This leaves a further point which will be a little more difficult from the Minister's point of view. It is that the outpatients' departments of hospitals are not empowered to sell drugs and take cash. They do not have a little cash chemist's shop in the clinic. Therefore, there is the special difficulty that those in charge cannot say to a patient, "You had better have 6d. worth of aspirins to take home." It seems that with them it is a prescription charge or nothing. I do not know the answer to that problem either, but the Minister can think it out. I should have thought that it was not impossible for an out-patients' department to give small quantities of cheap preparations which may be necessary at the early stage to see what will develop in an ailment about which the patient has sought a consultation, and enough to last until the next visit.
I suppose that the Minister would not think that was a good arrangement. I must say that on this last point we are pressed inevitably to the conclusion that a free service at the point of need is the only logical answer, and if it applies to the out-patients' department it ought to apply to pharmacists in general. There is no need for us to re-debate that subject now. All I ask is that the Minister should accept that this problem is a little more intractable than he appeared to think when he gave us an assurance in the course of previous debates, but that that should not prevent his tackling it within the framework of his own policy effectively and rapidly.
§ 2.15 a.m.
§ Mr. Kenneth Robinson (St. Pancras, North)
The House should congratulate my hon. Friend the Member for Paddington, North (Mr. Parkin) on his persistence in remaining here until two o'clock in the morning to raise a narrow, but, I think, very important, matter. I am sure that the House would also like to thank the Minister of Health for coming here in person to deal with it.
Before I deal with the matter which my hon. Friend has raised, I should like the Minister to clear up what seems to me to be something of a mystery arising out of a speech which he is supposed to have made this afternoon. The only report I have is from the tape, and it is very short, and it may, indeed, be a misreporting. The Minister was addressing the 803 annual meeting of the Central Council of the Conservative Party, and the report on the tape said:Mr. Enoch Powell promised this afternoon that the Government would reconsider its refusal to let private patients get drugs on 2s. National Health Service prescriptions.The report went on to say:Immediately after he gave this promise, the delegates narrowly defeated a resolution expressing grave concern and demanding serious reconsideration of this matter.I do not know whether the delegates, assuming that the Minister said what he was reported to have said, were dissatisfied about the nature of the reconsideration, that he was not perhaps serious enough, but the fact is that a very large number of them voted for the resolution expressing concern.
The Minister does not need me to remind him that we on this side of the House regard this campaign as a squalid one from a pressure group which is wholly unrepresentative and which is merely trying to get increased privileges for a group which is already favourably placed. We think that to give in to this demand would really begin the destruction of the National Health Service so far as general practice is concerned.
I do not want to go over the arguments at this stage, but there is no need for me to warn the Minister that if he were to give in, this would really result in a major explosion not only on these benches, but in the country as a whole. On the other hand, if the Minister will continue his resistance to this pressure group, he can have all the support that he wants from this side of the House, short of our actually embarrassing him. I invite the right hon. Gentleman to clear up this little matter, because this is probably the last opportunity that we shall have this side of Easter.
I now turn to the matter which my hon. Friend raised about the prescriptions which cost less than the charge of 2s. The Minister has told us that he estimates that these will be a very small number. He has said that his estimate of the revenue from these increased charges is based on the assumption that the number of prescriptions will fall by 2 per cent. He added that the principal factor in the 2 per cent. was the elimination of the prescriptions costing under 2s.
There is accumulating evidence that the Minister has made an under-estimate 804 in the figure of 2 per cent. I see from The Times today that the secretary of the National Pharmaceutical Union says that he thinks that there will be a reduction in the number of prescriptions of 10 to 15 per cent. Some of my hon. Friends tabled some Questions on Monday listing a very large number of proprietary products in which the average normal weekly prescription would be substantially less than 2s. Does the Minister still think that 2 per cent. is the right estimate for these small prescriptions?
If the Minister's forecast is wrong, what does this add up to? First, it means that if the number of prescriptions falls below the estimate he has made, he will not get the £12½ million which he estimated he would get from the increase in charges. Perhaps he will get nothing like that figure. Secondly, it means, as we have prophesied, that patients will go without medicines in quite substantial numbers. I do not want to deal with the question of the hardship arrangements, but the more we learn about the National Assistance Board arrangements the less satisfactory they appear to us.
I now turn to prescriptions costing under 2s. My hon. Friend has outlined a number of serious objections to the course which the Minister has advocated to the pharmaceutical profession. As I said at Question Time the other day, if a chemist is to have to look at every item on the prescription form, as he gets it across the counter, from the point of view of cost, to see whether any item will cost less than 2s., it will undoubtedly put a considerable additional burden on him. It will be a time consuming process if he does it conscientously and honestly, as the majority of chemists will do it. But those who are less conscientious have a built-in disincentive to do anything of the kind.
The Minister could say that if the item is sold retail over the counter, the chemist will get his retail profit margin on it, but he gets an on-cost on the ingredients when he dispenses a prescription which, I would guess, is roughly the same. He gets a dispensing fee in addition, and, therefore, if he is honest with the customer and tells him that he can get an item across the counter, have the prescription marked "Not dispensed", and thereby save money, he will lose his dispensing fee. The chemist will thus 805 have a disincentive to do what the Minister invites him to do.
These are comparatively trivial objections compared with those mentioned by my hon. Friend concerning the relationship between the chemist and the doctor. I believe that the Minister has been far too casual about this. I do not believe that doctors are in any way happy about the proposal that chemists should be allowed merely to strike off items from their prescriptions and mark them "Not dispensed". Doctors I have spoken to say that they expect their prescriptions to be dispensed as they are sent to the chemist. Then there is the other matter mentioned by my hon. Friend—the question of the hospital pharmaceutical department, where there is no provision for retail sales, as far as I am aware.
There is another aspect which has just come to my notice. I do not think that the Minister foresaw it, and I think that it is an unintentional consequence, and an unfortunate one, of his new provisions. The effect of increasing the prescription charge to 2s. seems to have set up a sort of conditioning process. The manufacturers of proprietary drugs will feel that the public is conditioned to regarding 2s. as a sort of minimum figure for a drug supplied over the chemist's counter. Indeed, the effect of this can already be seen.
I am told by a correspondent that his wife has for a long time been in the habit of buying across the counter a laxative, widely advertised and widely used—how effective it is I do not know—called Bile Beans. For some time they have been 1s. 8½d. per tube. By an extraordinary coincidence, on 1st March, the day that prescription charges were increased to 2s., the 1s. 8½d. tube went up to 2s. I am quite sure that these is some connection, direct or indirect, between the new prescription charges and the increased charge for the preparation, and we ought carefully to watch whether that happens with other similar preparations.
I reinforce my hon. Friend's plea to the Minister to study this matter very carefully and, if necessary, to reconsider his proposals. He will find that the matter of these prescriptions of less than 2s. is not quite as simple as he implied in the first place, and, if he comes to 806 that conclusion, I am sure that he will not be afraid to come to the House with amended proposals.
§ 2.26 a.m
§ The Minister of Health (Mr. Enoch Powell)
First, to deal with what I may call the extraneous point raised by the hon Member for St. Pancras, North (Mr. K. Robinson), it would be inadvisable to comment at second-hand on a report seen on the tape. I suggest to the hon. Member that both he and I should look in the morning at what has been reported, when I will consider it and see whether it represents at all correctly what transpired.
§ Mr. Powell
I do not know what I am said to have said. I think that we shall get into great difficulties if we engage in argument at second-hand on what has been reported on the tape. Perhaps we can leave it at that and study the reports at our leisure, to see what they actually say.
To come to the point of substance in this short debate, of which the hon. Member for Paddington, North (Mr. Parkin) was kind enough to give me notice, I say clearly and emphatically that nothing I have said alters, or can alter, the ethical and other obligations of the chemists. The duty of the chemist, and what he can do within the ethical rules of his profession, is in no way altered, and cannot in any way be altered, by anything I have said.
Moreover, nothing I have said about the sale of items costing less than 2s. retail differs from what has hitherto obtained with regard to the sale of items costing less than 1s., so that no new principle or new procedure is introduced, and no statement of mine in reply to Questions, has been intended to imply that there is any innovation.
The situation is this. Where, within his duties and within the proper procedure, a chemist would be able to sell an item retail over the counter for less than 2s., I expect that he will do so, and there is a recognised procedure which he then follows for marking the prescription form. That does not mean that there is any alteration or modification in the way in which he is entitled to 807 treat a prescription form from a doctor, whether it is an E.C.10, or a prescription form made out privately by a doctor for a private patient.
Misunderstanding may have arisen, at any rate in part, by a confusion between ingredient cost and retail sale price.
§ Mr. Powell
I mention this even though that confusion may not have been present in the hon. Member's mind. I am advised that where the actual dispensing of a prescription is in question, it would be rare to the point of impossibility for an item sold retail over the counter to be charged for at less than 2s. In practice, we are here dealing only with cases where, within the rules of his profession and within what he is entitled properly to do, the chemist would be selling an item over the counter—and it would be only a very simple item—for a sum less than 2s.
§ Mr. K. Robinson
Would the right hon. Gentleman clear up that point? Does he mean that when a dispensed item is sold over the counter the dispensing fee is such a large part of the 2s. that the total would probably be above that?
§ Mr. Powell
That is exactly the case; and that is really a large part of the answer in regard to hospital out-patients' departments. I have looked into this with considerable care, and have made inquiries about the sort of items which are dispensed in hospital dispensaries to out-patients. I find that in the overwhelming majority of cases those items if bought on private prescription from a chemist would cost, when dispensed over the counter to the customer, more than 2s. It would be extremely exceptional for there to be such an item which could be obtained on prescription over the counter at the chemist's for less than 2s.
Nevertheless, where a simple item such as bandages or kaolin is prescribed I do not doubt that the dispenser at the hospital dispensary would say to the patient, "This is an item which you can get at the shop down the road." I think that common sense in that extremely small minority of instances would be 808 applied in the circumstances of the case by the hospital dispensary; but I repeat that in the overwhelming majority of cases, where there is actual dispensing involved and not some appliance or item of ordinary use, then the patient is not getting an item which would be obtainable on prescription at less than 2s. across the counter.
The hon. Member urged me to have further consultations with the profession on this matter. As I think he knows, I am considering with their representatives whether, although this is only further application of arrangements which are in existence and are understood, any further guidance or clarification is required. I must await the results of that. Indeed, more generally, I would say that I shall of course watch closely how this works out.
The hon. Member for St. Pancras, North referred to the best estimate I could make, upon which I had founded the figures in my Estimate laid before this House. I think it must be far too early to form any impression yet how far they will be fulfilled. It takes, after all, two months for the first prescriptions since 1st March to come through for costing and analysis, so I think that it would be very premature for us, on partial reports, to come to any conclusion on how this is working out in terms of numbers of prescriptions or yield of the charge.
I would very much recommend the same attitude of suspension of judgment to the hon. Member in regard to the cost of a tube of Bile Beans. I do not even know whether it is within my competence to make inquiries as to what may have been the causes behind this "extraordinary coincidence" to which the hon. Member drew attention. So I think that we must suspend judgment there till we have a lot more experience of the facts as they unroll.
One final thing I should like to say. I began by emphasising that nothing which I do or intend, or, indeed, can do, can affect the ethical duties of the chemists. I want to end by saying that, although it may perfectly well be true that in the individual case it might pay the chemist to dispense on an EC 10 an item he would be entitled to sell for much a smaller figure across the counter to the customer, I have not the slightest doubt that the chemists in this matter 809 as in others will deal ethically, that they will play fair by the customers. This is really a theoretical difficulty. I do not believe that chemists, in practice, will be in any hesitation about fair treatment of their customers.
This brief debate may have served to remove some misconceptions, and I have been glad of the opportunity to re-emphasise, in reply to the hon. Member for Paddington, North, that there is no question of any interference with the accepted standards and procedures of the pharmaceutical profession.
§ Question put and agreed to.
§ Bill accordingly read the Third time and passed.