§ Mr. Speaker
Before I call the hon. and learned Member for Leicester, West (Mr. Janner) for the next debate, I remind the House of the ruling that I gave earlier this afternoon, when some hon. Members now present may not have been here. That ruling applies to the three remaining debates that are likely to take place.
The Supplementary Estimates under discussion merely, in the terms set out in "Erskine May",provide additional funds of a relatively moderate amount required in the normal course of working of the services for which the original vote was demanded".Therefore,only the reasons for the increase can be discussed and not the policy implied in the service which must he taken to have been settled by the original vote".
§ 11 pm
§ Mr. Greville Janner (Leicester, West)
I am pleased to have the opportunity to raise the matter in the Vote in Class XI, 2:General Medical ServicesPayments under arrangements made with medical practitioners, &c.Increased payments with effect from 1 April 1979 following the recommendation of the Review Body on Doctors' and Dentists' Renumerationand the reasons therefor, andPharmaceutical ServicesPayments under arrangements made for the supply of drugs, &c.and the reasons therefor.
Apart from reasons of inflation, which afflict all, these increases are due to the burden placed on the general practitioner in the exercise of his skill in his profession on behalf of those who need his help; the difficulties that arise because of the increased complications imposed upon the general practitioner by the increase in the weight of work that comes upon him; the difficulties that he encounters in assisting and working together with other bodies in the field and other agencies; and his difficulties in running his practice 1478 properly, having regard to the number of patients with whom he must cope.
I submit that those reasons are entirely valid but that general practitioners who will benefit from the increase should he assisted to make the best use of the additional funds and of the facilities available to them and should be enabled to co-ordinate their work properly with other agencies in the field. If that is done, the reasons for the additional payment will have been met, the review body will no doubt be satisfied, and the public will have an improved service as a result of the revised provision and the increase thereto.
If, however, the doctors do not rise to the challenge, if they are not now enabled to do their work better, the result will be not only added difficulty and public dissatisfaction but a series of tragedies of the nature of that of Carly Taylor in the city of Leicester. That is a case with which many hon. Members have been deeply concerned. It was brought to my attention some time ago by Carly's grandmother, who lives in my constituency, by the child minder and by people who had tried theoretically with the general practitioner's help to avoid the tragedy that occurred.
That case is purely an illustration of the need for the increase that is being voted. It is the clearest illustration, being a clarion call of warning of the tragedy that lies in store if general practitioners do not use the services available and if they are not helped.
The general practitioner concerned no doubt had a heavy case load. It is he, among others, who will benefit from the increase, one of the reasons for which is to enable such people to do their job properly.
The report of an independent inquiry about the tragic case of the twin who was battered to death by his mother was published last month. It contains an indictment of the system used by a general practitioner, of which I hope the House will take careful note. I hope that the Minister will assure us that it will be dealt with when considering the increased provision.
The practitioner saw fit to prescribe a drug called Tenuate Dospan, which is deliberately designed to take away the appetite and to help patients to reduce 1479 their weight. That drug was prescribed for the mother of the twins at weekly intervals for about a year. At the same time, the doctor saw fit to prescribe the same drug for the father, along with a barbiturate called Tuinal.
I know the problems that doctors face with the weight of the burdens which lie upon them in their surgeries. Even so, to prescribe a slimming drug to a woman described in the report as slight, slender and weighing about seven stone is about as vigorous a denunciation of the system that requires more funds for better operation as anything that could happen.
Somebody describing the continuous prescription of the drug to the inquiry gave—
§ Mr. Speaker
Order. I have been generous to the hon. and learned Gentleman. However, his illustration should be brought to a conclusion soon, and he must turn his attention to the excess claim made for payment.
§ Mr. Janner
I am much obliged to you, Mr. Speaker. The illustration will come to a close shortly. I am sure you will appreciate that it is a matter of the very greatest concern to the medical profession, to all who benefit from it and to all who are concerned with the revised and additional amounts to be paid to it.
The problem is how a doctor, with a heavy case load, will be helped by the additional provision to make better arrangements for his patients. It is whether the revised provision is to be given in accordance with the recommendation of the review body, so that doctors will cease to churn out prescriptions for patients because they have no time to consider the consequences. It is whether those who provide the prescriptions for drugs, for which payments will be made in the next Vote, should continue to prescribe without care and without regard to the tragedy that could result, as it did in the case of a woman who weighed only seven stone and was addicted to drugs prescribed by a doctor who was, no doubt, overworked.
The reason for the Vote is to improve the professional work of doctors and is based upon there being co-operation between the doctor and the health visitor, who is not covered by the Vote. One of the objects of the review body was to 1480 ensure that the work of doctors would be more satisfactorily integrated into the overall picture.
Another reason for the increased payment is to enable doctors to employ appropriate staff. It is to enable them to co-operate—in a way that that doctor did not—with the health visitor, who also did not take note of the state of either the patient or the child. The contact was insufficient. This sort of additional fund must be made available so that it can be fed into a system that is working properly. We also need a full review of the effect that the spending of this public money will have on the service that the public receive in return. The Minister may feel it appropriate, for example, to consider whether some form of computerisation might not be appropriate. In that way, might not the money paid to the practitioner be better spent through the facts of cases such as that of Carly Taylor being properly available to all the agencies concerned?
One cannot deal with the family practitioner in total isolation. The Review Body on Doctors' and Dentists' Remumeration did not. It recognised that the work of doctors in this area was a cooperative effort for the benefit of the public. In the Taylor case, the cooperation was with the probation officer, with the health visitor, with the housing department and with the Department of Health and Social Security. One possible cause of disaster in a case like this is that people move from one area to another and their doctors are under constant pressure, with which a £16.6 million increase cannot cope.
The increased amount is aimed at ensuring that doctors are more efficient in their work, to ensure that family practitioners, represented as they were on the review body, will be able to work better in better circumstances. However, they cannot operate on their own. There must be a total review of the way in which the money is spent and the way in which practitioners deal with circumstances such as the persistent prescription of addictive drugs to patients, week after week, month after month and year after year. At the end of the day, those patients, if they do not harm themselves, are liable to cause death and destruction to others, as this unfortunate woman did to her child.
§ Mr. Jim Marshall (Leicester, South)
I am sure that my hon. and learned Friend realises that my intervention arises because we share a common interest in the case he is discussing. I hope that my hon. and learned Friend will not go on to suggest that the addiction to the drug led to the death of the child to whom he has referred. As he knows, a great deal of attention has been drawn to the drug addiction of this individual. I fully accept the need to look into the prescription of the drug to the woman and the over-expenditure which might arise therefrom, but I do not believe that any individual has yet suggested that the death of this infant arose because of the mother's addiction to the drug.
§ Mr. Speaker
Order. Before the hon. and learned Gentleman replies, may I say that I have no doubt that he and his hon. Friend are dealing with a very sad case which they both want to bring before the House. However, this is not the occasion for us to go into that case in depth. We must keep to the rules of order and discuss the excessive claims for payment of general practitioners' medical and pharmaceutical services. I know that the hon. and learned Gentleman will co-operate with that appeal.
§ Mr. Janner
I am sure that you would not wish me to ignore totally what my hon. Friend has said, Mr. Speaker. I shall deal with it in one sentence, if I may.
§ Mr. Janner
Before doing so, may I say how much I appreciate the way in which we colleague MPs in the city of Leicester work together on these matters.
No tragedy occurs from one cause alone. It arises from a combination of circumstances. If one circumstance were withdrawn, the rest might not exist. The inquiry certainly gives clear indications that this unfortunate lady had not received from a general practitioner the sort of treatment she should have received. She was in a very bad state at the time she committed this awful crime. I do not think that we can separate the effect of drug addiction in an addict who commits an offence from the prescription of the drug at the time. I am grateful to you, Mr. Speaker, for allowing me to say that.
1482 The reasons for these increased payments are such that the Government should now institute a full inquiry not only into the sort of case of which the Carly Taylor disaster was merely an illustration but into the whole operation of the family practitioner system.
I hope that, when explaining the reasons for the grant, the Minister will give the House the assurance that full inquiries will be carried out into the various matters that I have brought before the House and hope to bring before it again on a more suitable occasion—perhaps in an Adjournment debate. It will then be possible to go in more detail into this tragic case, which has worried people not only in my constituency but throughout the country who are concerned with the treatment by family practitioners of drug abuse, child abuse, baby battering and with the disasters that the family practitioner could and should help to avoid.
§ The Under-Secretary of State for Health and Social Security (Sir George Young)
The hon. and learned Member for Leicester, West (Mr. Janner) has most ingeniously raised in the debate on the Consolidated Fund (No. 2) Bill a particularly tragic case in his constituency where drugs were a factor. I listened very carefully to what you said at the beginning, Mr. Speaker, and I realise that this is not the time for an extensive debate on the tragic case of Carly Taylor.
I should like to concentrate on the specific aspects raised by the hon. and learned Gentleman which concern drugs. He explained at the beginning of his speech why, in his view, it was in order to deal with the drug aspects of this particular case. I can confirm that any Minister who reads a report about the death of a child is bound to treat it as a matter of the utmost concern and to wish to ensure that any lessons that can be learnt are learnt and that any necessary action should be taken.
Putting it briefly in context, during Carly's life her family were visited frequently by health visitors, social workers and a probation officer. Her father and 1483 mother appeared to have been misusing drugs during most of the material time, and the home conditions varied from poor to squalid.
As the hon. and learned Gentleman knows, there was an inquiry, and the report made six recommendations, one of which deals specifically with drugs. The fourth recommendation was that general practitioners should be encouraged to undergo training for professionals in the detection and handling of suspected child abuse and drug abuse.
The hon. and learned Gentleman raised the question of liaison between the GP and the health visitor. The inquiry report reveals very poor communication between the health visitor and the GP. I can only regret this. Experience has shown that, where health visiting and district nursing staff have been attached to general practice, this has generally encouraged the development of co-operative patterns of working and making the best use of the special skills of the different disciplines. This has improved the quality of service to individual patients. No doubt this is a matter at which the Leicestershire area health authority is now looking.
The hon. and learned Gentleman specifically mentioned the monitoring of general practitioners' prescribing, which falls under this broad heading. Family doctors in the National Health Service are required to prescribe whatever drugs or medicines they deem to be necessary for their patients, but they may be called upon to justify their prescribing decisions. I think that that is what the hon. and learned Gentleman is looking for in this case.
The general practitioner services are administered by 90 family practitioner committees in England, each of which is concerned with the arrangements for providing general medical, dental and pharmaceutical and ophthalmic services to the population in its own area. Doctors, dentists, pharmacists and opticians in that area enter into a contract with the committee to provide their services and receive payments. It is the payments which are from the Consolidated Fund.
In each family practitioner committee area there is a local medical committee, elected by the family doctors in the area and recognised by the Secretary of State under section 44 of the National Health 1484 Service Act 1977, which acts as adviser to the FPC about all matters affecting the provision of general medical services in the area and, specifically in this context, as a body to which the Secretary of State may refer any cases in which it appears that a doctor's prescribing costs are excessive.
Prescriptions issued by every general practitioner in each FPC area during one particular month in each year are examined and costed. The prescription forms are sent by chemists to the prescription pricing authority and the prescribing data are collected from the prescription forms after the pricing function has been completed.
The average cost per patient is calculated for each doctor and the figures are sent to him in simple summary form through his FPC together with the average cost per patient for the area as a whole. The figures for all the doctors in the area are examined in the Department and, where a doctor's costs are substantially above the average for the area, his prescribing for the month in question is analysed in detail.
If appropriate, a copy of the analysis is provided to the doctor, who is then visited by a doctor of the Department's regional medical service. The GP's prescribing pattern is discussed in detail and advice is offered. Often a GP's prescribing costs then fall to an acceptable level. Formal procedures provide, where this does not happen, for the matter to be reported by the LMC, which may, if it finds that excess cost has been incurred, recommend, subject to the doctor's right of appeal, that part of his remuneration be withheld. Formal control of prescribing costs rests on these statutory powers.
Apart from the monitoring of overall costs, as I have just described, the prescribing of individual drugs is also monitored and the prescribers concerned are visited by the regional medical service. The main contact between the Department and the GP is the regional medical service, and it is the attitude of the officers of that service to their tasks which is paramount in determining the nature of the response. The present approach is to eschew reference to the formal procedures and to concentrate rather on impressing the GP with the idea that the Department wishes to give as much support and 1485 encouragement as it can to doctors to improve the effectiveness and economy of their prescribing by extending to them the facilities for retrospective study of their prescribing habits and any other information on drugs and therapeutics which the Department is able to provide centrally. This has been done with the agreement of the representatives of the profession.
I turn briefly to the case raised by the hon. and learned Gentleman to give him some assurance that appropriate action is being taken. It is worth reminding the House that the inquiry team which I mentioned earlier referred the prescribing of the family GP to the FPC.
The FPC meets on 27 March to decide what more can be done in this case. I understand that the GP has been visited by the regional medical officer to check his prescribing, which was found to be above average but not remarkably so. A subsequent visit showed that prescribing had improved. No complaint has been made by a patient. The FPC has administrative powers to investigate, but it would need the Secretary of State's consent to proceed as this matter is outside the time limit of eight weeks.
I must tell the hon. and learned Gentleman that it might be difficult now to establish some of the facts to which he referred—for example, the weight of the patient when the drug was first prescribed and whether the GP had broken his terms of service. We shall have to await the report of the FPC.
The hon. and learned Gentleman raised one or two points about the drug itself. There are fairly strict procedures within the Department for ensuring that only appropriate drugs reach the market and adequate controls are imposed to ensure that those who receive the drugs are safeguarded.
Under their terms of service, family doctors in the National Health Service have a duty to prescribe whatever drugs or medicines are needed for the treatment of their patients; but only the doctor concerned—who is not an NHS employee but an independent contractor— 1486 can decide what is necessary in the individual case. My right hon. Friend the Secretary of State has no authority to prohibit the use of any particular substance or drug.
Apart from preparations which contain only cellulose or stercula as their active ingredient, all slimming pills are available on prescription only. In addition, most drugs for the treatment of obesity are controlled under the Misuse of Drugs Act 1971 and regulations made under that Act.
Detailed questions about the application of that legislation fall to the Home Office, but briefly the effect of the Act is to limit authority to possess or supply controlled drugs to doctors and certain others acting in their professional capacity and to patients for whom they have been prescribed and to impose requirements as to record-keeping, prescription and destruction which are designed to prevent their illicit use. I understand that this drug is now under review and is to be controlled when the next Order in Council is made amending the scope of the Misuse of Drugs Act.
§ Mr. Greville Janner
I am much obliged to the Minister for all that he has said and the way in which he said it. While we are awaiting the decision regarding this drug, will he take the opportunity to warn both practitioners and their patients of the grave danger of side effects from this slimming drug and from most others that do not consist, as he has said, mainly of cellulose?
§ Sir G. Young
My right hon. Friend the Secretary of State has established specific professional committees which are to advise him on this matter. I should like to refer that remark to one of those committees so that we get the right response. Perhaps I may write to the hon. and learned Gentleman on that specific point.
I hope that there will be another more appropriate occasion when we can have a full debate on the tragic case that the hon. and learned Gentleman has raised, because it deserves the attention of the House.