DOCTORS (DISPENSING) (Hansard, 25 March 1969)

§ Mr. Tim Fortescue (Liverpool, Garston)

I am grateful for this opportunity to raise the question of the direct dispensing by doctors to patients of pharmaceutical drugs in rural areas.

This problem has been a festering sore within the National Health Service for some years. It is beginning to poison the relationships between the two professions involved—the doctors and the pharmacists—and it can be cured only by prompt Ministerial action.

The background of the problem is not difficult, and I will attempt to explain it very briefly.

The principle behind the National Health Service, as the Minister will know much better than me, is that each profession carries out the duties for which it is specially trained.

For pharmacy, this is enshrined in the original National Health Service Act, 1946, Section 39(1) of which states: Except as may be provided by regulations"— which is the crux of the matter— no arrangement shall be made by the Executive Council with a medical practitioner…under which he is required or agrees to provide pharmaceutical services to any person to whom he is rendering general medical services.… (2) Except as may be provided by regulations, no arrangements for the dispensing of medicines shall be made with persons other than persons who are registered pharmacists… This is the background. This is the whole spirit of the National Health Service. But for a very long time—since the National Insurance Act, 1911—there has always been a proviso, by regulation, whereby in rural areas, where chemists' shops are few and far between, doctors shall be permitted to do their own dispensing. This has been perpetuated in all the regulations under the National Health Service Acts, the most recent being the National Health Service (General Medical and Pharmaceutical Services) Regulations, 1966, which, in turn, consolidated the 1962 Regulations, and so it goes right back to the 1946 Act. The 1966 Regulations are in force 1445 now. Regulation 27(1), which is the key part of the Regulation, reads: A person who— (a) satisfies the Council"— that is the Executive Council— that he would have serious difficulty in obtaining any necessary drugs or appliances from a chemist by reason of distance or inadequacy of means of communication, or (b) is resident in an area which in the Council's opinion is rural in character, at a distance of more than one mile from the premises of any chemist, may at any time request the practitioner in whose list he is included to supply him with drugs and appliances. The Regulation goes on to say that if the practitioner is willing to supply these drugs the Council may authorise him to do so, if he is not willing the Council may instruct him to do so, and so on. Clearly the whole Regulation is framed so that a patient who is finding difficulty in getting his drugs through a chemist can arrange to have them supplied to him by a doctor.

It is unusual, I think it is generally agreed, to find a patient taking direct and obvious advantage of this Regulation as it is framed. It is far more normal for the doctor to say to the patient that he would be willing to supply him with the drugs which he, the patient, needs, if he, the patient, agrees. The patient normally does agree because people do not like to say "No" to their doctors, and it often seems to the patient to be a convenient arrangement.

In practice Executive Councils give doctors in rural areas a blanket permission whereby they can provide drugs in certain circumstances to any patients whom they see fit, to supply.

Pharmacists say that this whole arrangement is anachronistic. They say that it goes back to 1911, when there were about 88,000 motor cars in this country, and that now there are more than 9 million cars here. They say that there are more cars to families in rural areas than there are in uban areas, and that there is hardly anywhere need for a patient to say that he cannot get his drugs from a chemist.

The pharmacists further say that the dispensing of drugs by doctors is not directly supervised as theirs has to be, by a qualified pharmacist as laid down by the National Health Service Act and 1446 under the new Health Services and Public Health Act. They also say that a doctor's dispensing is not subject to the testing which is required under Regulation 25(1) of the 1966 Regulations.

The doctors, on the other hand, say that dispensing has always been traditional for them in rural areas, that they have done it since time immemorial. They further say that income from this dispensing is essential to make a rural doctor's practice economic, and that unless they are allowed to do it doctors will begin to disappear from some rural areas because they will not be able to afford to stay there.

The doctors further say that it is often more convenient for a patient to make only one stop for his medical treatment and for his drugs. The pharmacists on the other hand say that a doctor cannot possibly keep such a comprehensive stock of drugs as a pharmacist can, that he cannot keep his knowledge of pharmacy and drugs on the market up-to-date in the way that a pharmacist has to, and that in fact he provides an inferior service.

There are great differences of opinion on the one-mile rule. The rule says that a doctor may dispense drugs to a patient if that patient lives in a rural area, and if he is more than one mile from a chemist. But if he may be one mile from a chemist, he may be 10 miles from a doctor, and it is not a sensible rule to say that in these days of the motorcar a mile is necessarily inconvenient for a patient to go and get his drugs. The chemist may be on the way to the doctor. He may be two miles away from the patient, on the way to the doctor who is five miles away, and it thus may be more convenient for the patient to get his drugs from the chemist rather than go all the way to the doctor for a second supply.

This disagreement between the two professions on which we depend for our health simmered for quite a long time. It came to the surface in 1965 when the so-called Doctors' Charter, which was published in that year, said provocatively that every rural family doctor should be free to dispense for his patients if he so wishes and remain free to do so. 1447 The pharmacists were at once up in arms, and there were joint consultations between the pharmaceutical profession, the Government, and the doctors' representatives.

A report was then issued, known as the Third Report, which said: The vast majority of patients who have drugs prescribed for them by their doctors will have these dispensed by a pharmacist. There are, however, some areas in which it has been traditional for dispensing to be done by doctors and in which an adequate service can still only be provided by the doctors because it would be seriously inconvenient for the patient to have his drugs dispensed by a pharmacist. This seems to be the beginning of an agreement between the two professions. On the one mile rule, the same report said: It is contemplated that Regulation 27"— which I quoted— … should be amended to remove the present ' one mile ' rule. This was three years ago. The sole criterion in future in deciding whether a doctor should dispense would be whether patients would otherwise have serious difficulty in obtaining any necessary drugs from the chemist by reason of distance or inadequacy of communication. It was also agreed in that Report that the Dispensing Committee referred to in Regulation 27 should be established in these rural areas and, some time later, that it should have three lay members as well as the three pharmacists and three doctors. This removed many worries. Here again, we seem to be taking a step towards agreement.

In January, 1966, the right hon. Member for St. Pancras, North (Mr. K. Robinson), then Minister of Health, wrote to the pharmaceutical profession about his proposals to amend Regulation 27. He said that he was prepared to amend it in the sense that I have described. Nothing has happened.

In August, 1967, the next instalment in the saga, the right hon. Member wrote to my hon. Friend the Member for Tiverton (Mr. Maxwell-Hyslop), who had become involved in this controversy: It is quite wrong to suggest that I have never considered the views and interests of patients and that I am deliberately abolishing the ' one mile rule' to make it more inconvenient for patients. I made it quite clear in the House of Commons on 23rd January, 1967 that I did not believe that the proposed new arrangements will in general make it more 1448 difficult for patients in rural areas to get their medicines". What he had said in the House on that date, in answer to a Question, was: Discussions with representatives of the medical and pharmaceutical professions on the introduction of the changes are currently in progress."—[OFFICIAL REPORT, 23rd January, 1967; Vol. 739, c. 962.] That was two years ago, and still nothing has happened.

He went on to say in that letter to my hon. Friend: 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 overworked doctor. He made it clear in his conclusion that his only concern was to be fair to all parties—patients, doctors and chemists—and that he believed that the proposed arrangements would achieve this aim. That was two years ago.

The next meeting which I can discover in my investigations was the one which the Minister of State, Department of Health and Social Security—whom I am glad to see present—had on 27th January this year with representatives of pharmacists, who pressed him to make a decision. After all, the matter had been going on for three years. He said that, before doing so, he wished to have clear in his mind all the factors involved and that he wanted to hear the arguments of both professions at first hand. This was reasonable and proper for a newly-appointed Minister, but by this time the controversy had been going on for three years and the arguments must have been easily to hand in the files of his civil servants. It had been thrashed out backwards, forwards and sideways in all the journals of the two professions.

After that length of time, to say that he must have another look smacked of procrastination. I would gently suggest that this was not the most urgent way in which to tackle the problem. Still nothing has happened and there is no sign of anything happening, unless, as I hope, the Minister will tell us tonight that something will happen.

There is a rather alarming report from a large new housing estate in Ebbw Vale. I am glad that the formidable Member for that constituency (Mr. Michael Foot) is not here, as he would probably put a fearsome light on this problem.

1449 Apparently in this new housing estate in Ebbw Vale the question of establishing a pharmacy was considered. The Health and Housing Committee of the Ebbw Vale Urban District Council was told that if a pharmacy were established there, the dispensing doctors would withdraw their dispensing facilities not only for patients living one mile from a pharmacy but for all patients.

The council promptly decided against the establishment of a pharmacy, but that decision was reversed at the next meeting of the council. Meanwhile, doctors organised a petition against the establishment of a pharmacy—I gather that the petition was organised by what is known as the Beaufort Doctors' Dispensing Rights Campaign Committee—and tomorrow the whole matter will again be considered by the Council.

This may seem a trivial affair, but is it not entirely opposed to the spirit of Regulation 27? Is it proper that the Regulation should be used in this way to prevent a pharmacy from being opened on a newly established housing estate? After all, this one-mile limit does not exist in Scotland. Apparently there is no need for it there. In Scotland there is no quarrel between the pharmacists and medical professions. Doctors dispense only for patients who live in very remote areas and the whole problem has been solved.

That the quarrel in England is hotting up can best be illustrated by a quotation from some remarks made by the President of the Pharmaceutical Society at Chester on 16th March last. He said: We shall never be prepared to acquiesce in a situation which is depriving the pharmacist of his livelihood and thereby depriving whole communities of the comprehensive service in medicines which is available in the pharmacy—and nowhere else. Certainly it is not to be found in the ante-room to a doctor's surgery. After referring to the history of this matter, which I have described, he concluded: But I regret to say that since that Ministerial judgment was given, we have witnessed a lack of positive Government, with the result that our profession continues to suffer what I can only call an intolerable encroachment by members of the medical profession. Those are words which one does not like to hear uttered by the head of one profession 1450 about a sister profession. I do not criticise either.

On the face of it, it would seem that pharmacists are losing business because the remuneration of doctors in some areas is inadequate. I criticise the Government, because they first raised the issue officially in January, 1966, because they stated their policy in August, 1967, and because they have still done nothing to change Regulations which stem from 1912.

§ The Minister of State, Department of Health and Social Security (Mr. David Ennals)

The hon. Member for Liverpool, Garston (Mr. Fortescue) has shown that he has detailed knowledge of this subject, and hon. Members are grateful for that. He has also shown that this is not a simple matter, that both the medical and pharmaceutical professions are closely involved in the question of how far doctors should be authorised to dispense for their patients and that both professions are taking positions that are somewhat in conflict with each other.

It has been a basic principle of the National Health Service since its inception that normally doctors should diagnose and prescribe, while pharmacists should dispense. Consequently, the original 1946 Act laid it down that, except as provided in regulations, patients should take prescriptions from their family doctors to chemists for dispensing.

The present rule, which is contained in the General Medical and Pharmaceutical Services Regulations, is that patients can get their medicines dispensed by a doctor when they live in a rural area more than one mile away from a chemist's shop. In addition, any individual who can show that he would have serious difficulty in obtaining medicines from a chemist, because of distance or inadequate communications, can be dispensed for by his doctor.

One difficulty which may arise under these arrangements is that a doctor must give up dispensing as soon as a chemist opens a shop nearby. The annoyance is greater if the chemist fails and leaves the area, so that the doctor soon afterwards has to be asked to resume dispensing. On the other hand, chemists have pointed out anomalies which may follow adherence to the rigid "one-mile 1451 rule" where, for example, patients may have to pass the pharmacy on their way to the doctor's surgery.

Discussions on these and other difficulties and possible ways in which these might be overcome have taken place between the Department and the professions over some years. The hon. Member detailed some of the circumstances in this long exchange. The possibility of amending the relevant regulations has been investigated in some detail. The present arrangements in substance are indeed of long standing, and one would not change them lightly. On the other hand, it must be agreed that since they were first introduced general conditions in the countryside have changed considerably. The hon. Member referred to the great increase in the number of motor vehicles, but this has also led in some cases to a decrease in the number of public service vehicles, and it has not always meant that it is easier for some sections of the public to travel. Again, the so-called "one-mile rule" does provide an objective criterion, but an arbitrary one.

For reasons which I hope will emerge later I do not think that it would be useful or proper for me to consider these proposals in detail tonight; but because the purpose of reconsidering the arrangements has been misunderstood in some quarters I should perhaps say something about the Department's general attitude on the question as a whole. It has been feared by some that discussions were taking place secretly with a view to bringing dispensing by doctors to an end altogether, and by others that the Department would permit a widespread extension of such dispensing arrangements.

In fact, the consistent view of the Department has been in accordance with the general principle to which I referred earlier, namely, that except in emergency dispensing by doctors should be the exception rather than the rule; but that those patients who would have serious difficulty in reaching a chemist's shop—and these would normally be found in rural areas—should be covered by such an exception, and the Department has been concerned to pay regard to the interests of patients in general and of rural patients in particular. Consequently, 1452 whatever decision is reached on this subject it is clear that where there would otherwise be serious hardship to the patient existing arrangements for dispensing doctors would not be disturbed.

On the other hand, just as a chemist's shop will not be viable unless it is supported by a population of a certain size so, too—particularly in these days of more expensive drugs—it is becoming increasingly difficult for doctors to provide a dispensing service for fewer than a certain minimum number of patients.

Although both doctors and pharmacists are thus anxious to provide a service for, and safeguard the interests of, patients, it is entirely understandable that in some areas the interests of the two professions should conflict. The hon. Member has pointed out that this has taken place, and that the profesions have made their positions clear. It is right that the Department should consider sympathetically the problems and opinions of each profession in the light of the interests of the patients for whom the service exists.

As I have already indicated, these discussions have proceeded for some time, and they had reached an advanced stage when, late last year, the former Ministry of Health was merged into the new Department of Health and Social Security, and new Ministers were appointed who had not been concerned in the negotiations leading up to this stage and to whom necessarily the detailed considerations were unfamiliar, as the hon. Member, in his detective work, discovered. On 27th January I met the representatives of the pharmaceutical profession in order to acquaint myself at first hand not just with briefs but with the views of those mainly concerned in the issue before coming to a decision on any amendment to the present regulations. The pharmacists were therefore invited to state their general position, which they then did with great clarity.

Clearly the next step was to invite the representatives of the medical profession to state their case also and as it happens they met my right hon. Friend the Secretary of State for Social Services yesterday. In the light of what has now been said my right hon. Friend will consider the matter. The professions have, I believe, clarified their views through the discussions which have already taken place and 1453 my right hon. Friend hopes that his decision will not now be long deferred. He will wish to take into account the points raised tonight. As the House will see, the professions concerned have put their views to the Ministers, and it is for the Ministers to decide.

The hon. Member mentioned the case of Ebbw Vale. This is something that I had not heard about, but I shall certainly look into it to see whether I can discover any more information. I thank the hon. Gentleman for raising the subject. I recognise and agree that the negotiations have been protracted ones, and I hope that we are very near the point at which a decision can be taken and announced in the House by my right hon. Friend.