HC Deb 07 July 1969 vol 786 cc1120-30

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Harper.]

11.36 p.m.

Mr. Tim Fortescue (Liverpool, Garston)

In the short time that I have been privileged to be a Member of the House, nothing has made a stronger impression on me than the ordinary back-bencher's right and opportunity to demand the presence of a Minister at the Despatch Box to tell him of an apparent injustice to the humblest constituent and to be quite certain that the matter will be investigated promptly, closely and objectively.

To me, it is this right and opportunity which is at the heart of our democracy when quietly, in an almost empty Chamber, late at night, the elected representative of the people brings a grievance from the people to the Executive and is certain not only of a hearing but of investigation and justice. In most countries this would be unimaginable. In ours it is, perhaps, more valuable than all our noisy set-piece debates so passionately engaged under the eyes of the world.

Tonight I bring before the House a sense of injustice burnt deep into the minds not of one constituent but of 20,000 pharmacists, who are constituents of every hon. Member in England and Wales, although not in Scotland, where the Regulations of which I complain do not apply and, therefore, there is no sense of injustice.

The facts are familiar and are not in dispute. Briefly, the National Health Service Act, 1946, provides that except as provided by Regulations, medicines shall be dispensed only by registered pharmacists or authorised sellers of poisons or under their direct supervision. The exception to this is set out in Regulation 27 of the National Health Service (General Medical and Pharmaceutical) Regulations, 1966, the essence of which has appeared in all corresponding Regulations since those made under the original National Insurance Act, 1911.

The Regulations provide that doctors may dispense medicines for patients living more than one mile from a pharmacy and were designed for an age when rural transport was difficult and primitive. This one-mile rule has long been recognised as obsolete. This recognition led in 1966 to negotiations being opened between the Ministry of Health, as it then was, the British Medical Association, the Pharmaceutical Society of Great Britain and the Central National Health Service (Chemist Contractors) Committee. After nearly three years, those negotiations led to a draft unanimous agreement that the Regulations should be amended.

Under the amended Regulations the rural doctor, instead of dispensing for patients living more than one mile from a pharmacy, was in future to dispense only for those who otherwise, because of distance or inadequate communications, would have difficulty in obtaining their medicines. In each executive council area there was to be a committee, chaired by a layman and consisting of three doctors, three pharmacists and two other lay people to watch over the public interest and to decide which patients should have their medicines dispensed by their doctors.

This agreement was described by the then Minister of Health, the present Minister for Planning and Land, as fair to all parties—patients, doctors and pharmacists". He added, In principle, patients' interests generally would be better served if their dispensing was done by a competent and well-stocked pharmacist rather than by an over-worked doctor; few doctors could provide as wide a range of drugs as the average pharmacy, or have the turnover to ensure freshness and quality; and it could hardly be in the patient's best interests if the doctor's judgment about treatment might be coloured by the drugs he happens to have in stock. It seemed that at last the Regulations were to be brought into line with the needs of the seventh rather than the second decade of this century.

But two things then happened: first, responsibility for health was taken over by the present Secretary of State for Social Services, and, secondly, the rural dispensing doctors—that is, those doctors who were dispensing their own medicines in rural areas—refused to ratify the agreement so painstakingly argued and reached by their own negotiators from the British Medical Association.

The present Secretary of State examined the position anew, and on 23rd April this year he told a deputation of pharmacists that, faced with a difficult choice between imposing a change without the agreement of one of the professions or maintaining the status quo, with some reluctance have concluded that I should do the latter. The substance of the present Regulations will stand. He added that he regarded as a regrettable development the fact that the medical profession as a whole were not prepared to ratify the agreement, and that he would be ready to reopen negotiations on any alternative proposals on which there was a prospect of reaching agreement between the two professions. He repeated that assurance to me at Question time on 30th June.

But the Secretary of State must appreciate that that assurance is entirely futile. His predecessor was party to a draft agreement which he described as being in the best interests of patients, for whom he was at that time trustee in these matters. A small minority group of one of the professions concerned then deliberately obstructed the ratification of that agreement, putting their own interests before those of their patients. The present Secretary of State then, in his own words, "with reluctance" surrendered to that minority, in spite of the "regrettable" nature of their action, and left them undisputed masters of the field. How can he possibly suppose that they would be prepared to accept freely alternative proposals which might give them less than the complete victory which they had already gained.

It is as if a High Court judge, hearing counsel for two litigants, had agreed with them both that a given solution was fair and just; and then one of the counsel went back to him and said that his client did not agree; and the judge, instead of handing down the judgment which he had already agreed as being the proper judgment, said that he could take no further action until the litigants had agreed among themselves. That is an apparently judicious attitude, but in fact it is an abdication of responsibility and an admission of impotence.

From where does the Secretary of State obtain this doctrine that the Government cannot or must not amend regulations, however equitable the amendments, unless all parties concerned agree? Would it be fair to suggest that this doctrine came from the same book as that which the Prime Minister had before him when he abandoned his promised industrial relations legislation in order to please the T.U.C.? Where now is the proud precept that the task of the Government is to govern?

Why is the Secretary of State content to allow prescriptions to be dispensed by rural doctors whose pharmacological knowledge is rudimentary and who often, apparently legally under present regulations, delegate this work to their completely unqualified and unsupervised wives, secretaries, receptionists, or, in cases which I have documented, even gardeners and handymen, rather than by pharmacists qualified after three years' training whose work is constantly and precisely supervised by the Pharmaceutical Society's visiting inspectors?

I have with me letters showing many examples of the malpractices of doctors in this respect, and I will gladly let the Secretary of State have them if he desires. I remind him that under the one-mile rule a doctor may dispense only if a patient asks him to do so. I suggest, however, that in nearly all instances this regulation is broken by the doctor giving the patient no choice. Of the many letters I have received, I will quote from only two. A pharmacist in Yorkshire writes: This week a patient complained that she had to go each week to get her insulin from the doctors surgery, and on one occasion she had been told that she would have to wait until Monday before she could have any more tablets. She asked if she could in future obtain her insulin from the chemist, as she had done in the past, and was told that she could not. A Bodmin, Cornwall, pharmacist writes: One of my girl assistants attended two months ago with a sore throat. The doctor gave her a prescription for Prodosol, but the girl receptionist refused to let her bring it back for dispensing and insisted on supplying it. But the surgery was out of stock and the girl receptionist, without consultation with the prescriber, substituted a completely different product. These instances are entirely in breach of the regulations and are firm proof that the regulations need to be changed.

In the extreme case—I would not say that this has happened, but it could, in theory, happen—if a patient were to die because of a drug wrongly dispensed or inadequately labelled by a doctor, that doctor would sign the death certificate. That doctors make mistakes is evidenced by the sizeable number of occasions—two or three a day in one large hospital—on which pharmacists check with prescribing doctors about apparent errors in prescriptions, and the errors are admitted.

I will give only one example of this. In the journal G.P. for 27th June, 1969—a journal for general practitioners—a pharmacist writes—and supports with a photograph of the bottle involved—of a doctor who dispensed three entirely different kinds of tablet, with different dosages, in the same bottle, for a patient suffering from mental disturbance. The House will be aware of enough cases of deaths from an overdose of drugs in a state of mental confusion without wishing an additional hazard to be introduced. Such behaviour would be unthinkable in a professional pharmacist, and, if discovered, would mean his disqualification.

There are two arguments in favour of rural doctors continuing to do their own dispensing. The first is that in some cases it will be in the interest of the patient, and these cases are fully covered by the agreement reached by the negotiators—and rejected by the rural doctors—which stipulated that the latter should dispense for those …who otherwise, because of distance or inadequate communications, would have difficulty in obtaining their medicines. The second is that the incomes and pensions—half a doctor's income from dispensing counts towards his superannuation—of rural doctors would otherwise be reduced. But where is the justice of increasing the incomes of rural doctors by reducing the incomes of rural pharmacists?

Against these arguments I place not only those I have adduced tonight, but also the fact that the one-mile rule is being cynically and deliberately abused by many rural doctors. It was intended for the convenience of the patient in certain circumstances. It was never intended to enable the doctor to dispense for a patient living more than one mile from the pharmacist when that patient lives at some distance from the doctor.

I can quote numerous instances of a doctor's surgery being within a few yards of a pharmacist, but the doctor insisting on doing his own dispensing under cover of the one-mile rule. Losses of income to the pharmacists concerned are calculated variously at between £800 and £1,500 a year, and I have here a pathetic letter from a pharmacist's wife who tells me how overnight, when the doctor opposite started dispensing his own prescriptions, her husband saw his whole business disappearing out of the window.

Inevitably, villages and small towns are losing their pharmacists. In 1967 and 1968, 22 localities lost their only pharmacy—nearly three times as many as the average for the preceding 13 years. And a village pharmacist is just as important a man as a village doctor.

Nearly a hundred hon. Members from all parts of the House have put their signatures to my Motion urging the right hon. Gentleman to look at this matter again, and to ensure that, whenever possible, prescriptions are dispensed by qualified pharmacists. I plead with him not to leave things as they are, wringing his hands and talking of his reluctance, and of regrettable developments. It is not the slightest use his waiting for alternative proposals acceptable to both professions—the rural doctors will see to that, though the pharmacists are most anxious to open negotiations.

If he cannot introduce amended Regulations on the lines of the agreement reached by his predecessor, let him at least explain to the House why he cannot. He never has. And let him, above all, rather than sitting back and hoping that if he ignores this crisis within the National Health Service it will go away, take the initiative by calling the two sides to the negotiating table once more, and informing them of the lines on which he considers the Regulations should be amended. Only thus will he convince the pharmacists that he has at heart the interest of the patient and, even more, a true sense of justice.

11.52 p.m.

The Under-Secretary of State for the Department of Health and Social Security (Mr. Julian Snow)

This matter involves the interests of two professions which have a vital part to play in the National Health Service, together with those of the patients for whom the Service exists. As my right hon. Friend the Secretary of State for Social Services has said in this House, the decision he was asked to reconsider was not an easy one to take.

It has been a basic principle of the National Health Service from the beginning that, normally, each profession should carry out the duties for which it was specially trained—doctors to diagnose and prescribe and pharmacists to dispense—and this was recognised in Section 39 of the original Act of 1946. But this Act allowed for exceptions; and I do not think that very many people would dispute the need for exceptions to be made.

Under paragraph 7(9)(a) of the Doctors' Terms of Service (Part I of Schedule 1 to the General Medical and Pharmaceutical Services Regulation 1966), for example, all doctors are required to supply to a patient such drugs and appliances as are required for immediate administration or application or for use before a supply can be obtained otherwise—that is, through a chemist.

Besides this emergency provision, there is a clear need to protect the interests of patients who could not reasonably be expected to obtain their medicines from chemists because there is no pharmacy reasonably accessible. As so often happens, the difficulty arises in drawing the line; a flexible criterion may lead to subjective judgments, an objective criterion to arbitrary ones.

The present rule is contained in the General Medical and Pharmaceutical Services Regulations of 1966, Regulation 27, but it is in substance of much longer standing and dates back to 1911. I think that it is common ground that anomalies can arise under the present arrangements although, by and large, patients have found them satisfactory.

Under these arrangements, any patient who lives in a rural area and over a mile from a chemist's shop may ask—and, I repeat, may ask—his doctor to supply him with medicines. So, too, may any individual patient who does not satisfy these criteria but can, under Regulation 27(1)(a), show his National Health Service Executive Council that he would have serious difficulty in obtaining medicines from a chemist because of distance or inadequate communication. In certain circumstances, a doctor may be required to dispense for such patients, but even if the criteria are satisfied the ultimate decision rests with the patient himself. If he finds it more convenient to obtain his medicines from a chemist and prefers to do so, the option is entirely his.

This is the second time the hon. Member for Liverpool, Garston (Mr. Fortescue) has raised this matter. I read his speech on 25th March on the Consolidated Fund Bill and I admire his persistence. On that occasion my hon. Friend the Minister of State gave examples of some of the anomalies which could arise. In general they tend to arise directly or indirectly from the rigidity of the one-mile rule. For example, a dispensing doctor with whom the National Health Service Executive Council arranged that he shall supply his patients with medicines, even one who has been required to dispense for certain of his patients, loses the right to do so when a newly opened chemist's shop brings these patients within one mile of it. Again, a dispensing doctor's patient may actually pass the pharmacy on his way home from surgery.

As I have indicated, these difficulties represent the price which one has to pay for a line drawn objectively. But even the examples I have quoted are not also necessarily anomalous; a doctor is rarely required to supply his patients with medicines unless he is already a dispensing doctor; and if the patient who passes the pharmacy would have to get off the 'bus and wait hours for the next one, the fact that there is a chemist's shop between his home and the surgery loses some of its relevance.

Both doctors and pharmacists are affected by the difficulties which can arise, however, and for that reason they both have an interest in considering how far it would be desirable and practicable to amend the present arrangements. Separate consultations with the two professions were initiated following the discussions over the Doctors' Charter in 1965 and as a result it was possible to draw up proposals as a basis for an agreement with the two professions and these were set out in the Third Report of the Joint Discussions of the Family Doctor Service.

The proposals were slightly amended during subsequent negotiations but the basic principles throughout were the replacement of the "one-mile" rule by the criterion of serious difficulty and the protection of a doctor's right—once it had been granted under the new arrangements—to continue dispensing for his patients as long as he remained in the same practice and unless there were a major change of circumstances arising from a significant increase in population. The task of deciding whether "serious difficulty" would arise for the patient was to be given to a dispensing committee on which were represented both professions together with laymen to represent the interest of patients.

The pharmaceutical profession have substantially endorsed what their negotiators agreed; and at one time there seemed to be every hope that the medical profession also would agree. In the event, however, the medical profession as a whole felt unable to ratify the proposals to which their negotiators had agreed. Such is democracy.

As I have explained the two professions were not negotiating together; the proposals were agreed during parallel discussion with the Department. The pharmaceutical profession endorsed what their negotiators had agreed; and I can readily understand their disappointment that the medical profession did not do likewise. The rejection of the proposals by the medical profession as a whole was not foreseen by anyone engaged in the discussions in 1966. My right hon. Friend the Secretary of State concluded that it created new circumstances; and for this reason he decided reluctantly, as he has already explained to the House, that the proposals I have described should not at present be introduced; this decision applies to both a change in the one-mile rule and the proposals which had been designed to resolve difficulties which can arise for doctors under the present arrangements.

At the same time my right hon. Friend has expressed to both professions, for example in the letters he wrote to inform them of his decision on 25th April, the hope that it would in due course be possible, as a result of changes in the view currently held by the profession, to put the proposals into effect, and he has on more than one occasion stated his willingness to reopen negotiations on any alternative proposals which offer the prospect of being agreed by both professions. In coming to his decision that there was no case for imposing the proposals on the medical profession against their wishes, my right hon. Friend bore in mind the lack of any real evidence that this change was desired by the patients concerned. It is also the case that the work of implementing the unratified proposals properly would have demanded the willing co-operation of both professions.

There have been suggestions that the existing arrangements are not being properly carried out. Could the hon. Gentleman give some examples of what sounded to me rather like abuses of the arrangements? If the hon. Gentleman will give me evidence in writing, I shall have the matters investigated. Naturally, we should be prepared to examine any such evidence.

It has been claimed that doctors have been taking more patients away from the rural pharmacist. Naturally, there are movements one way or the other all the time, and one tends to notice those which affect one's own position most; but, over the last few years, there has been no increase in the number of dispensing doctors. I think that the contrary impression has arisen from information about the numbers of prescriptions dispensed by doctors, but these can relate only to medicines supplied by doctors who have elected to be paid on the basis of the Drug Tariff, that is to say, who are paid according to the medicines actually supplied, on a similar basis to that applying to chemists, as distinct from those who receive set capitation fees for their dispensing according to the numbers of patients on their lists. Doctors paid by capitation fee have in recent years tended to elect to change the basis of their remuneration. In 1964, for example, there were 1,656 such doctors as compared with 918 paid under the Drug Tariff. In 1968, the respective figures were 1,267 and 1,222. Since there was a substantial increase in the numbers of dispensing doctors paid on a Drug Tariff basis, and in any case the total numbers of prescriptions issued by all doctors have tended to increase, the figures are not comparable.

The Department remains prepared to consider sympathetically any alternative proposals offering the chance of a genuine agreement, and any suggestions to improve the arrangements under the existing regulations would be considered sympathetically. I very much hope that these two great professions, which to a large extent have common interests, might be able to formulate, or re-formulate, some proposals which have a prospect of general acceptance.

The hon. Gentleman cited what sounded to me like cases of abuse. He is a fair man. I am sure that he will agree that he was speaking on behalf of the chemists affected—I do not complain about that—and the discussion would be incomplete unless we had a comparable speech from the doctors' point of view.

Dr. M. P. Winstanley (Cheadle)

Before leaving the question of the advisability or otherwise of the general practitioner dispensing in any circumstances, will the hon. Gentleman bear in mind that in private general practice, which has the enthusiastic support of the Conservative Party, it is normal practice for the general practitioner to dispense?

Mr. Snow

I am not certain that that is an entirely accurate formulation of Conservative Party policy, which is not always easy to understand, but I take the point which the hon. Gentleman makes.

Mr. Fortescue

I made two further points to which the Under-Secretary of State has not fully replied. First, he said that there was no evidence that what I proposed is desired by patients. The previous Minister of Health said that the proposal which I am supporting was in the best interest of patients. What has happened to make the new Minister change his mind? Second, what proposals does the Secretary of State expect to find acceptable to both the professions when it is obvious that a militant minority of one of the professions has deliberately and successfully obstructed agreement on proposals which were acceptable to the representatives of the entire medical profession?

Mr. Snow

The test which my right hon. Friend has used has been that, so far as we can trace, there have been no serious representations by patients against a change such as the hon. Gentleman is formulating. But there is still time for there to be a modification of view on both sides. I leave the matter at that for the moment, because I hope that, sooner or later, we shall have an agreement on this matter.

Question put and agreed to.

Adjourned accordingly at four minutes past twelve o'clock.