HC Deb 12 June 1973 vol 857 cc1321-34

'(1) With a view to securing that the number of persons undertaking to provide pharmaceutical services in the areas of different Area Health Authorities or in different parts of those areas is adequate, the Secretary of State may establish a committee to be called the Pharmaceutical Practices Committee for the purposes of considering and determining such applications as are referred to in subsection (2) of this section.

(2) The Secretary of State may at the request of an Area Health Authority declare to be applications to which this section applies any applications made on or after the appointed day, for inclusion in the list kept by that Authority of persons undertaking to provide pharmaceutical services, by persons proposing to provide such services at premises any part of which is situated one quarter of a mile or less from any part of any premises or set of premises which are specified in the request and at which four or more medical practitioners undertaking to provide general medical services provide or propose to provide such services:

Provided that the Secretary of State may make such declaration before any application has been made to the Authority.

(3) Every application to which this section applies made in the prescribed manner to an Area Health Authority shall be referred by that Authority to the Pharmaceutical Practices Committee and any person whose application is granted by the said Committee shall, subject to the provisions of Part IV of the principal Act relating to the disqualification of practitioners, be entitled to be included in the list.

(4) Notwithstanding subsection (2)(b) of section 38 of the principal Act the Pharmaceutical Practices Committee may refuse any such application on the ground that there is already an adequate number of persons undertaking to provide pharmaceutical services in the vicinity of the premises at which the applicant proposes to provide such services.

(5) The Pharmaceutical Practices Committee shall be established in accordance with section 5(6) of this Act and the provisions of that section shall, so far as applicable, apply to the Committee.

(6) Any person who has made an application to which this section applies which has been refused may appeal to the Secretary of State, and the Secretary of State may, on such appeal, direct the Pharmaceutical Practices Committee to grant the application.

The Secretary of State may make regulations:—

  1. (a) prescribing the procedure to be followed and the information to be supplied by an Area Health Authority on making a request to the Secretary of State under subsection (2) of this section;
  2. (b) requiring an Area Health Authority to supply to the Pharmaceutical Practices Committee such information as may be pre- 1322 scribed for the purposes of considering and determining any application to which this section applies;
  3. (c) prescribing the procedure for the determination of applications by the Pharmaceutical Practices Committee and for the making and determination of appeals to the Secretary of State under this section;
  4. (d) requiring Area Health Authorities and applicants to be informed of the decisions of the said Committee and of the Secretary of State'.—[Mr. Ogden.]

Brought up, and read the First time.

Mr. Eric Ogden (Liverpool, West Derby)

I beg to move, That the clause be read a Second time.

I should first declare my interest in the clause, as I have done in previous debates on the National Health Service. I am a parliamentary adviser to the Council of the Pharmaceutical Society, though I am not a pharmacist, as one Government back bencher thought a week ago. I took that to be a compliment from him. So my interest is declared, as it ought to be.

The intention of the new clause is to try to help the Secretary of State to ensure that the number of persons engaged in providing pharmaceutical services in any given area is adequate for the needs of the people in that area. The clause may seem rather long and complicated. To be fair, clauses sometimes have to be written in a long and complicated manner. The new clause takes up a whole page on the Notice Paper because it provides a system of appeals against decisions, and references through to the Secretary of State. Therefore, of necessity, the clause must be rather long.

The new clause is a "revised version"—that might appeal to the UnderSecretary—of new Clauses 2 and 3 which I moved in Committee. There is a full report of that debate in the report of the proceedings of the 16th Sitting of the Committee on Tuesday 22nd May, at columns 938–956. I do not intend to repeat in detail all the arguments that I put forward on that occasion, or, indeed, to answer the arguments that were put against the new clauses, though they were not many. In Committee, on 22nd May, five back-bench Members from both sides spoke on the new clauses. Three backbenchers were in favour of the principle behind the new clauses and two were not persuaded in favour of it.

In concluding the debate the Minister made it clear that whilst he recognised the difficulties and problems he was not persuaded at that date that the clause was the way to solve all or any of those problems. He asked me to withdraw those new clauses so that he and his right hon. Friend could have the opportunity of weighing what had been said, of considering the proposals, and of deciding what, if anything, should be done at later stages. I hoped at that time that, having read what he said and having read in detail what had been said in Committee, he would have brought forward some proposals on Report.

A week ago the Under-Secretary of State met Mt. John Ferguson, the Assistant Secretary of the Pharmaceutical Society of Great Britain and myself in his office at the Elephant and Castle—an appropriate description for some of the team across there. I am grateful to the Minister and his officers for the time that they gave, for their understanding, for the way that we were received, and for their concern. It was—I do not want to use the hackneyed phrase "a full and frank discussion"—useful. We cleared up some points, and I have no doubt about the Minister's concern. However, I regret that that concern was not sufficient for him to bring forward his own proposals on Report.

Since then the hon. Gentleman and his Department have sent me a long, complicated and detailed answer to the points that were made in the discussion, but it is a matter of fact that, so far, none of the proposals that we put forward has persuaded him that this is the way to act. So this is the latest, but not, I assure him, the last attempt to persuade him of the need for this type of action through the new clause.

The need for action outlined by hon. Members on both sides in Committee was referred to in debate after debate. It is agreed by Ministers, Members of Parliament, pharmacists—both members of the Pharmaceutical Society and those who belong to the "company chemists", as they are sometimes called—the Executive Councils, the British Medical Association and the public, that there is cause for concern. That concern arises from the changes in the practice of medicine over the past 20 or 25 years. Probably no other profession has seen so many changes in such a short time. The relationship or interdependence between doctor and pharmacist is still very close. Each has his own sphere, but the relationship, particularly between the family doctor and the local pharmacist, is extremely close. Their physical proximity has always been very close; the doctor's surgery, the local chemist; the prescriber and the pharmacist—the one to prescribe, the other to dispense.

9.15 p.m.

One of the many changes that have taken place is the establishment of group centres. It is only one of the many changes that have been bringing all sorts of organisations and services nearer to the centre of towns and communities. This has inevitably meant a reduction in the services in the rest of the areas concerned—some people call them peripheral areas, but I prefer to call them community areas.

Where three, four or five doctors have gathered together in a group health centre, which is the overall term for either a health centre or a group practice, surgeries in the other areas, which used to be as much as a mile apart, have closed down, and in almost every town groups of doctors are gathering together in smaller or larger numbers—with, in the Department's own regulations, up to 21 general practitioners in a family centre.

Inevitably, pharmacies have concentrated near the group centres, and the number of pharmacies in the other areas has declined. On occasion, groups of pharmacists have gathered together to provide a joint service and the income from the pharmacy near the group centre has helped to maintain the service in the other areas.

But in this respect, the National Health Service and the Secretary of State have no power to refuse an application for a contract to provide group pharmaceutical services if the applicant is properly qualified and has the right place in which to carry out this service. This contrasts with the restrictions that can be imposed upon the medical profession itself. There are "open" areas where doctors may freely establish their own practices and there are other areas in which there are restrictions. But there are no restrictions on pharmacists. Local authorities can control carpenters' shops, betting offices, and even chip shops, but they cannot control the number of pharmacies in any area.

In my own area, three years ago, a group centre was established and a shop became a pharmacy. Then another, close to it, and even a garage, became pharmacies. This was happening at the same time as pharmacies in other community areas were closing down. The town of Bury, in the North-West recently had 23 pharmacies, well distributed throughout the area. There are now only 11, concentrated more or less in the centre of the town, close to two or three group practices.

For those who think that a group centre involves only four or five doctors, I would point out that the growing practice is for much larger numbers. In many parts of the country it is not unusual for there to be 14, 16, 17, or even 20 doctors working from one set of premises. When that number of doctors are employed, it means service for an average population of 50,000—a town of no mean size. This is one of the effects. In every other way the Minister can control the provision of adequate services, but not in this respect.

The proposals in the clause are intended to do something about this situation. It has been argued that this is a negative, restrictive attempt. But Ministers and Governments of both complexions have often thought it necessary to have both the carrot and the stick, and the proposals in the new clause would enable the Minister to designate a very small area, which the main area health authority would decide, within a quarter-mile radius of a group centre practice, as one in which there were already adequate services and where further applications to provide additional services at the expense of the other peripheral or community areas could be refused.

The new clause is complicated partly because this will be a two-way traffic. The area health authority, on its own initiative, could decide that an area already had enough pharmacists, that no more were needed, at the expense of other areas, and that the Minister should be asked to designate the area within a Quarter-mile radius of a group centre practice. The Minister could do this in the reverse order and designate an area on his own information. If there were any further applications for new contracts to provide pharmaceutical services, they would be referred to the Pharmaceutical Practices Committee mentioned in subsection (1).

The purpose of placing the Pharmaceutical Practices Committee on a national basis is so that people in one part of the country shall not be treated differently from those in another. The Pharmaceutical Practices Committee would be able to obtain information and draw experience from all over the country. There would be a fair ratio and equal consideration over the whole country. An applicant whose application was refused would have the right of appeal to the Minister. Equally, the area health authority would have the right of appeal to the Minister. Through the new clause, implemented by regulations at the right time and in places where the Minister considered it necessary and desirable, there would be this limited degree of control over a growing problem.

It was suggested in Committee that the problem was caused by a shortage of pharmacists—the professional men and women. That is not so. It is a strange contrast that in 1954 there were 15,000 pharmacies but in 1973 there are only 12,000. At the same time, the number of professional pharmacists has risen from 26,000 to 29,000. The shortage is not of professionally qualified people but of places where they are operating. This is due to economic and social forces. Pharmacists are going into industry and into other services. However, the proposal in the new clause would have some effect if used where thought necessary and desirable by the Minister.

If so designated the area would be a limited and restricted area, but for every other area in the country the present arrangements would remain and applications for services would be subject to no control except in the small number of areas so designated.

The clause will not solve all the problems of pharmacy or public need. It is only one side of the coin. It does not prevent the Minister bringing forward his own proposals, soon or some time later, to help the community pharmacist. That would have to be done in another way. We have discussed this matter. All hon. Members who served on the Committee were concerned about the problem. We have put forward a number of proposals and discussed them with the Minister. This is the third set of proposals, which is a revised version streamlined. In effect, this would give the Secretary of State reserve powers, to be implemented at such time and in such areas as he considered this limited degree of control to be necessary.

The proposals have been discussed by the Pharmaceutical Society with their opposite numbers, the chemists' contractors. The British Medical Association has considered the problem and has said in its committee reports that there is a need for this kind of provision and that something ought to be done about this need. The executive councils say that something ought to be done about this need. The Minister has said that he is aware of the problem, and that something ought to be done about this need.

We do not get National Health Service Reorganisation Bills every five minutes. If something is not done in this Bill the opportunity will pass and we shall have years of an ever-growing problem. This is a way in which some of the problems can be met. The clause meets many of the points made in Committee. I hope that it will find acceptance by the Minister.

Mr. John Golding (Newcastle-under-Lyme)

I support the clause. One of the difficulties that have beset some of my constituents for many years has been that of getting prescriptions made up. Before I discuss the problem in the localities, I think the House should be aware that many people face such difficulties, which will exist whether or not we re-site pharmacies.

The Minister should bear in mind the difficulties of those who are housebound in getting prescriptions made up. This was brought home to me when I recently canvassed for the district elections. I met a very old lady who had had occasion to call in a doctor recently. On being given a prescription she told the doctor that she could not get it made up. He said that she would have to get a neighbour to take it to the chemist. All the neighbours were very old. This lady had been placed in a ground floor flat in a row occupied by other old people. She explained this to the doctor. The doctor's attitude was "Hard luck". The lady told me that she could not get the prescription made up until she recovered. We must turn our attention to the problem of providing medicines for people, who cannot get prescriptions made up.

In two areas of my constituency—Knutton and The Bradwell—this has been a problem for a long time and people are acutely conscious of it. On several occasions I have raised the question with the Minister, but he has told me that he is powerless.

I am not sure whether the problem of the absence of pharmacists can be dealt with by restricting the mobility of pharmacists elsewhere. My recent experience has been that it is much more likely to come from the siting of health centres because it appears that pharmacists follow general practitioners. This is obvious. People come from the doctor's surgery with a prescription and take it to the nearest pharmacy. Thus, pharmacists tend to be located close to doctors.

To some extent this situation is satisfactory for those who are visiting doctors. It is not satisfactory for those who are being visited by doctors, where the doctor travels some miles to see them, gives them a prescription, and tells them "Take this to the chemists and get it made up", the doctor often being oblivious to the fact that whereas his visit to the patient has been made easily by car the journey for the patient may be very difficult. If a patient is given a prescription at half-past five or six o'clock at night there is often no way of his getting to the chemist to have it made up on that day.

Doctors often do not want to practise in working class areas. Knutton is a substantial village of several thousand people. Because the doctors have preferred to live in another village and because there is now a health centre in that village, there is no doctor in Knutton. Because there is no doctor in Knutton there is no pharmacist there. The same is true of The Bradwell. This is primarily because The Bradwell is a very large council estate of several thousand people. Doctors prefer to live in and have their surgeries in what they regard as the posher parts and when they make calls on houses in The Bradwell they travel by car. People living on The Bradwell must always travel to the chemists to get prescriptions made up.

When the county council asked the doctors if they would like a health centre on The Bradwell, the creation of which would automatically be followed by an inflow of chemists, the doctors said "No, we would prefer to stay where we are". That is because they prefer the people to have to come to them rather than that they should have to go and live and work amongst the people.

This is a disturbing situation. It is one that we have to tackle at some time or other. We have to create health centres including perhaps pharmaceutical services, and we must say to the doctors that those are the centres in which they must work. There is no reason why we should accept the present intolerable situation in which our people, because they live in working-class areas, are denied medical and pharmaceutical services on their doorstep.

I hope not only that the Government are sympathetic to our pleas but that in the very near future they will take action to ensure that all who are in need get the services they deserve.

9.30 p.m.

Mr. Alison

The hon. Member for Liverpool, West Derby (Mr. Ogden) has referred to the debate we had in Committee on this important subject, and he was discreet and helpful enough in his speech to refer to what he said earlier and not to go in extenso into the full range of arguments he deployed there. With the permission of the House I shall follow his pattern.

The problem which confronts us here was fairly described to us by the hon. Member for Newcastle-under-Lyme (Mr. Golding). He referred to the tendency for all sorts of services and facilities, not only pharmacies and doctors but even social security offices, sub-post offices, village shops, grocers and other services and amenities to tend to concentrate, for example, in shopping centres. They do so for very good and proper reasons of economy and better provision of services and so forth. However, there is an unfortunate by-product where people in suburban and rural environments are hard hit by the loss of the corner shop. This produces a problem of which we are well aware. We are deeply concerned with the tendency for peripheral pharmacies to be snuffed out by modern developments and we want to do everything we can to sustain these peripheral pharmacies, not to mention the local village doctor or the doctor living in a house close to his patients.

Often in the general development of services, particularly medical services, there are great advantages in getting people together in groups, and this includes social workers, attached health visitors, local authority health services, and so on. There is great advantage here in centralisation and concentration but it produces these peripheral difficulties.

Dr. Tom Stuttaford (Norwich, South)

Will my hon. Friend ensure that when a vacancy occurs through death in a general practice that vacancy is always advertised so that the local medical authority can find out whether there is any demand among doctors to go to the area? All too often the vacancies are never advertised and it is assumed by the deceased doctor's erstwhile colleagues that no one wants to go to that village or area. If the advertisement were placed in the professional Press it might be found that a great many doctors would be prepared to look after a small area with greater personal contact with the people.

Mr. Alison

I have noted my hon. Friend's remarks. They go wider than the terms of the clause, which relates specifically to the question of pharmacies, but I will think about his suggestion and drop him a line to let him know my conclusion.

I come now to the measures which the hon. Member for West Derby is proposing to try to sustain the peripheral pharmacies. As I contemplate this massive complex clause which it has been necessary to table—excellent and clear as the drafting of it is—I am overwhelmed by the complexity of the steps necessary to achieve what is essentially a negative result. The effect of the clause would essentially be to stop developments—that is, the location of pharmacies close to where doctors practise.

As the hon. Member for Newcastle-under-Lyme rightly pointed out, pharmacists tend to go where the doctors prescribe. There would be power to stop that happening, though there is the self-evident interest of the great mass of patients and consumers in having a pharmacy pretty close to a health centre. That is very convenient. It may produce problems at the periphery, but in positive terms there is an interest for the consumer in having a pharmacy close to a health centre. The power sought in the complex clause is the negative one of simply stopping such developments.

Mr. Ogden

We have argued the matter many times. The Minister knows that it does no such thing. It does not stop development of pharmacies in any area; it allows the Minister to decide that in a given area of a quarter of a mile radius there is already an adequate service. It does not prevent an adequate service for the needs of the people in that area but stops an over-provision, which is exactly what the Minister does with regard to doctors through the provision of medical services.

Mr. Alison

The clause is negative in so far as it seeks to arm my right hon. Friend with powers to keep pharmacies at least a quarter a mile away from a health centre. From the point of view of many consumers, that is not an attractive proposition.

Mr. Ogden

The Minister has said that the clause will keep pharmacists a quarter of a mile away from a group centre. It would not, and the hon. Gentleman knows that it would not. We have argued the matter many times. It would give him the power to say that within a quarter of a mile radius there should be only so many pharmacies. There could be 20 if the area needed 20 and 50 if it needed 50. But if the area required only five to provide suitable services, and the provision of more would be at the cost of services elsewhere, there would be the power to control the number. The clause would limit but not prevent.

Mr. Alison

I return to the general point. The hon. Gentleman may say "limit" if he likes, but it is a negative measure.

The trouble the Government face is that there is no convincing argument that I have been able to understand to suggest that the clause would have a measureable effect upon the fate of the peripheral pharmacy. There is no positive indication that it would do anything to help a peripheral pharmacist faced with a range of problems and not simply a possible decline in the prescribing business, as 50 per cent. of his business is probably concerned with goods and services outside the direct pharmaceutical provisions. Because of supermarkets and other developments, such pharmacists may still be in great difficulty and still be tending to disappear.

I do not believe that the rather complicated measures proposed would be effective in sustaining peripheral pharmacies. We must try to have a more positive way to encourage their existence. We are considering the whole time what should or could be done in that direction.

After weighing up what was said in Committee, and thinking of all the pros and cons of what was a very mixed reception for the proposals in Committee, I cannot see that the clause, which is lengthy, complicated and involved—I say that without in any way denying its precision—would do anything to solve our problem of a declining service at the periphery of small pharmacies affected by a whole range of pressures, not simply by the tendency for the prescriptions to be dispensed near to group practices or health centres.

We want to encourage pharmacists voluntarily to make sensible agreements where practical and possible to come together to share the profit of group or health centre practices. There is nothing in the present arrangements to stop them doing that. Nothing that might arise as a result of a decision by the House against the clause would in any way inhibit pharmacists from voluntarily taking steps on their own account to share out the business where it takes place in the centre, to sustain their own mutual interests in keeping out-of-town pharmacies going. We shall encourage them. We shall specifically ask the new health authorities, when they come into operation after 1974, to give particular attention to the encouragement of sensible voluntary arrangements between pharmacists in a town to share out the business that might arise in the centre or close to the health centres.

The hon. Member for West Derby will know of the sort of ways in which family practitioner committees in particular will be able to give some fairly positive and active encouragement to existing pharmacists in this context. They will be responsible for setting up health centres. The House will be able to imagine how they might approach and encourage existing pharmacists to make sensible voluntary arrangements to share out the business which may arise without any of the rather complicated provisions which are taken up in the clause.

Against the background of the many pressures to which peripheral pharmacists are subject at present, there is the tendency for a lot of their business outside the purely pharmaceutical range to go to the centre. In that context this rather negative provision provides no guarantee that it will save the peripheral pharmacy. We cannot advise the House to adopt the clause. We shall do everything possible in the reorganised set-up to encourage sensible voluntary arrangements to achieve the same result as the hon. Gentleman is seeking by statutory means. I ask the House to reject the clause.

Mr. Ogden

I thank my hon. Friend the Member for Newcastle-under-Lyme (Mr. Golding) for his words of support. I also thank my hon. Friends who supported me in Committee. We are all agreed that the best way of meeting the need which we are discussing would be to have pharmacies in an area close to the group centre and pharmacies in the local community area for those who need such a service—for example, the very young, the very old and the very ill.

The present situation is undesirable for a whole range of reasons. The Minister will agree that those reasons have been put to him clearly, carefully and cogently with all the information which we could possibly give. It must be accepted that the hon. Gentleman has responded by making time available for meetings to take place. In his reply the Minister complimented my discretion and brevity. I well remember the occasions when I have sat with my hon. Friend the Member for Huddersfield, West (Mr. Lomas) waiting for Ministers to wind up before 12 o'clock, so we could catch our trains home. I shall be brief tonight.

Brevity is all right and argument is all right if the Minister is open to persuasion. The back benches are often the worst and the last place from which to persuade Ministers. To a degree hon. Members waste their time in trying to do so. If we cannot persuade them in their own offices we have little chance of doing so in the Chamber. I am afraid that tonight the Minister was no longer open to persuasion. It is my view—I do not know whether this is or is not the view of the Pharmaceutical Society—that the Minister's decision to reject the opportunity of having these powers is a purely political decision. He said that the proposal had a mixed reception in Committee. In fact, there were three hon. Members in support from both sides and two in opposition from his side. That is another argument. I consider that the Minister has made a political decision for political purposes rather than a practical decision for pharmaceutical purposes. I regret that I cannot withdraw the clause. It is up to the House to make its own decision.

Question put and negatived.

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