§ Mr. Laurie Pavitt (Brent, South)I welcome the Under-Secretary to the Dispatch Box. It is not the first time that he has held a position there, but his is the first time that we have met on this subject. I have had the privilege of crossing swords with every Tory Minister responsible for health over many years, and I hope to continue the process over the next five years. As Lord Shinwell once said, "Although I do it with as much force as I can command, I always do it in a very civilised manner."
This debate is about injustice and unfair discrimination against women. It is about a basic injustice which the Government impose on 30 per cent. of all patients under medication. I remind the House that 70 per cent. of patients who take prescriptions through the NHS are exempt from charges because of age or for some other reason. The prescriptions are given by a qualified medical practitioner and are vital for the patient's health. Therefore, it is an injustice that there should be a further payment.
However, this debate concerns the second injustice that is piled upon the chronic sick who, if they are to remain alive, will take medicines for the rest of their lives. I also draw attention to a third injustice that falls on that group. For obvious reasons, the second tax applies only to women who are receiving treatment for breast cancer in the form of chemotherapy. I invite the Minister to imagine the trauma suffered by a woman who has had a breast cut off. With the utmost good will in the world, neither he nor I can really plumb the emotional depths or stand in the same shoes as that woman in our search to understand her problems. That grand canyon is the raison d'etre for maintaining the South London hospital for women and the Elizabeth Garrett Anderson hospital. Such hospitals start from a different viewpoint.
To the malignancy of the cancer, and the fears created by it, is added the feeling of being mutilated and of losing basic femininity and attractiveness. The House will know that more people recover from cancer than die from it. However, it is unfortunate that cancer should, like a disease that occurred during my younger days, which carried with it a stigma—tuberculosis —stir up such a depth of shame and fear within emotional feeling. One reason for the lack of early diagnosis is that people fear a disease that is, after all, only another major illness that is quite capable of being dealt with these days.
To that emotional background we must add the cost of paying £1.40 every three weeks, or an annual prepayment, for which the certificate will cost £21.50 a year. The issue is particularly relevant today, because of advances in pharmacology. We all rejoice that in recent years doctors have often been able to treat the proliferation of cancer cells by chemical means instead of by radiology. Radiology is far more hazardous than chemotherapy, and so that advance is to be welcomed. Chemotherapy can also do a far better job and give a much longer life expectancy. However, with radiology, the patient pays nothing, while with chemotherapy she pays for the rest of her life.
I should like to deal with the injustice of the prescription charge itself. In 1982–83 the average taxpayer paid £1.35 per week for medicines, regardless of whether they were used, and regardless of the fact that he may not have taken medicines for 20 years. It is a form of insurance 1438 payment. The citizen pays it while he is working, but he does not see why he should pay a second time. In 1982–83, the cost of providing National Health Service pharmaceutical services amounted to £1,497 million. The source of that figure is the "Health and Personal Social Services Total Costs of Services" and the "Sources of Finance" FBI June report. With an estimated 21.4 million income tax paying units, that represents £1.35 per unit per week. Therefore, we have all paid for our medicines.
The only people to pay twice are those in need, and those who are sick. That is a grave injustice. I would not take out an insurance policy on something if I was told that there would be an additional payment to make when I wanted to claim against it.
Perhaps I could remind the House of the history of such charges. Those who are students of the Labour party's political history—and in recent weeks everyone seems anxious to look into its political history—will recall the great split of the Bevanites in 1951. Although prescription charges were first put on the statute book by a Labour Government, it was not a Labour Government who imposed them. We lost the election as a result of that split. It was one of the great Conservative statesmen, the late Iain Macleod who had the task of imposing prescription charges on patients.
When we won the general election in 1964, the first thing that we did was to remove all prescription charges, in accordance with our election pledge. That job was undertaken by the Minister at that time, the right hon. Kenneth Robinson. Alas, it proved to be short-lived happiness for me. On 1 February 1965 we took them off, but on 1 February 1966 we reimposed them, although the Minister pledged to the House that the chronic sick would be exempted.
In the event, that did not happen and he apologised to the House for that. The reason was that the British Medical Association refused to designate which illnesses were chronic and which were not. However, over the years there was some negotiation, and a slight change was brought about. The BMA agreed to designate eight chronic sick conditions, which are now exempt from the payment of prescription charges. The conditions that are exempt are permanent fistula, Addison's disease, diabetes insipidus, diabetes mellitus, hypoparathydroidism, myasthenia gravis, mixoedema, and epilepsy.
Every hon. Member must know someone who has suffered a coronary thrombosis and who will be on medication for the rest of his life. However, such people are not exempt. Another permanent condition, Parkinson's disease, is not exempt. To some extent, that is understandable because the severity of the illness can alter and therefore it may prove difficult to argue for an exemption. However, I submit that there is no difficulty about being able to know whether a woman has had a breast cut off. She is easy to diagnose, and thus to designate. The crux of my argument is that the Minister should enter into immediate discussions with the BMA with a view to adding breast cancer to the list of diseases that are considered chronic and that are exempt from prescription charges. Why should a woman who has paid her taxes, and who often continues to pay them, suffer that additional outgoing from her purse for the rest of her life?
Recently, I asked a question in the House on this issue. However, the Minister for Health dodged it by using a trick that is not peculiar to the DHSS, but is common to all Ministries. Departments hate precedents. Therefore, 1439 they argue that if they do one thing, it will enlarge to something else. They then explain how much it will cost to enlarge the scheme, instead of responding to the specific request. This is precisely the sort of answer that I got from the Minister for Health, who told me that it would cost a great deal of money.
Let me give the Minister some figures. The latest statistics of cancer that I can get are for 1980. The provisional figures show that in England and Wales there were 21,700 newly diagnosed cases of female breast cancer. If my arithmetic is correct, to carry out my suggestion would cost less than £500,000 out of a budget that is running at £2 billion a year.
There are possible savings on the drug itself, and we must use our resources to the best of our ability in a hard-pressed service that is dying the death of a thousand cuts. The drug is called Tamoxifen or, to give it its group name, Nolvadex and is made by Imperial Chemical Industries. I believe, although I cannot verify this, that there is no competition as there is a monopoly. Because of the way that the compound is made there is no way, even if the House accepts my private Member's Bill on generic substitutions of cheaper commodities, of doing that in this case. Therefore, will the Minister get his Department to study the high cost of this important drug, check its cost under his price regulation scheme and consider, if he finds that there is no way in which the cost of the drug can be brought down, whether he will use the Secretary of State's powers to bypass the patent laws and purchase it on behalf of the taxpayer, doing so more economically by purchase as a "service for the Crown"?
I am only a layman in this matter and I have to seek advice where I can get it from the professional. Therefore, I take this opportunity of thanking the BMA for the help that it has given me in trying to get this case into shape, and particularly Dr. Bramwell who, in a very busy day, took the time to come down to the House yesterday to give me further information. Dr. Bramwell made a suggestion that is worthy of future consideration—the possibility that, in view of the difficulty of exemption on grounds of chronic illness, the Department should look at exempting a life-saving drug itself rather than the patient and the case. In this case, Tamoxifen could be listed as a drug for which prescriptions would be free.
I regard it as the height of meanness that the Government have raised the pre-payment certificate, which affects only those on permanent medication, from £3.50 in 1979 to £21.50 now. This stands on its head the basic principle on which the NHS was built. Instead of the healthy paying for the sick, the sick contribute to the Exchequer on behalf of the healthy. What is more, the more sick one is the more one contributes.
The administrative costs make nonsense of much of the 30 per cent. of charges that are falling on sick people. It was only after the second increase, in 1981, that there was breakeven between the running cost of the scheme and the level of income. The Government want fewer administrative staff and more resources for patient care, and this is an aspect of the service that could be examined. I forget how many millions of pounds are involved in checking the prescription forms, but in each regional health authority, and in the Minister's part of the Department, officers are paid large salaries to do the administrative work.
1440 Although I am an optimist, I am afraid that I do not expect this Government to do anything much for the poorer section of the community or for the sick or the disabled. I talk as one who is facing huge cuts in my inner city constituency. I make a special plea for a special case, for women who have had the misfortune to contract cancer of the breast, who, as a result, have had a mastectomy and, as a consequence, will be paying into the Exchequer for the rest of their lives.
§ The Under-Secretary of State for Health and Social Security (Mr. John Patten)I thank the hon. Member for Brent, South (Mr. Pavitt) for his courteous remarks on my translation from Stormont castle to the Elephant and Castle. In both cases I have been concerned with matters of health care and I welcome the hon. Gentleman's persistence and consistency in these matters and his robust line of questioning, which is important in the conduct of proper debate about the right levels of health care.
The hon. Gentleman raised a number of points of wider interest than that encompassed by the title of the debate. He talked about the history of prescription charges, about the general issue of prescription charges, about the problems of the Elizabeth Garrett Anderson hospital, which is being rebuilt, and about the possible closure of the South London hospital for women. I hope that the hon. Gentleman will forgive me if I do not follow the subjects that he has opened up for me, but—to follow the cricketing metaphor of my hon. Friend the Under-Secretary of State for Education and Science, who answered the previous debate—prefer to keep my eye on the ball and address my remarks entirely to the issue of breast cancer and chemotherapy.
I welcome this debate, as we all do in the Department, and I appreciate the hon. Gentleman's concern about breast cancer, a disease which, as he said, kills large numbers of women every year. I should perhaps correct him on one point. The disease is not restricted entirely to women, but can also affect men—there were 84 deaths from breast cancer among men during 1981. If the hon. Gentleman thinks that there are injustices, they are not restricted entirely to women.
On this occasion, the hon. Gentleman's concern is wrongly directed. The diagnosis and treatment of breast cancer present patients and those treating them with many problems. However, I have no clear evidence that the payment of prescription charges is a particular burden for women suffering from breast cancer, or that it is a barrier to their receiving the most appropriate treatment.
I shall first dispense with what I feel is the largely irrelevant issue of exemption from prescription charges. The hon. Gentleman is right in one respect — breast cancer is not one of the specified medical conditions that confer exemption from charges, and I can confirm that his list of those that do so is correct. The list was drawn up on 1968 by my Department in collaboration with the General Medical Services Committee. The criteria for inclusion in the list then were that the conditions should be readily identifiable and call automatically, in virtually all cases, for prolonged continuous medication. To include other conditions where the need for medication varied from patient to patient according to the severity and stage of the illness would have meant doctors deciding which patients should be exempt. This is obviously unacceptable 1441 to the medical profession because of risk of damage to the doctor-patient relationship, about which the BMA is particularly concerned.
The hon. Gentleman criticised my hon. and learned Friend the Minister for Health in that connection, and I shall reply to his charge. My hon. and learned Friend gave the hon. Gentleman an exact and precise answer. He did not attempt to dodge the issue. The hon. Gentleman may not like the answer, but it was based on the fact that, clinically, the situation has changed since 1968. We accept that, in isolation, a good case can be made for the inclusion in the list of many other conditions—not just those treatable by chemotherapy, for example. Hon. Members on both sides have argued for inclusion in the list of a range of conditions—for example, cystic fibrosis, multiple sclerosis and glaucoma. Taken in isolation, a good case can be made for all those conditions. However, as a Government we cannot consider them in isolation. In fairness, we have to consider together all the claims for inclusion. They would cost a great deal of money, and we have to look at the cost of extending the list in relation to the needs of the NHS as a whole.
It is not true that the specified medical conditions are the only way to gain exemption from charges, as the hon. Gentleman was good enough to recognise. Exemption is available automatically to people under 16, to women over 60 and to men over 65. There are also low-income exemption arrangements. Overall, as the hon. Gentleman fairly said, more than 70 per cent. of prescription items are dispensed without any charge. In addition, a further 6 per cent. or so are dispensed to holders of prepayment certificates—the "season tickets" to which the hon. Gentleman referred. Taking those together, there is no reason for anyone to be deprived of medicine on financial grounds. Moreover, when drugs are administered in hospital, as they generally are with breast cancer, under the care of a consultant, to patients who are either day patients or outpatients, no prescription charge is properly payable.
§ Mr. PavittThat is at the beginning of the treatment. Once the treatment is over, the woman returns to the general practitioner. She still has to have an FB10, and it means that for the rest of her life she goes back to hospital only for a check-up, first of all every six months and later yearly, but her medication comes through the family practitioner.
§ Mr. PattenMost of the expensive medication comes when the patient is treated in hospital, in the charge of a consultant, when the patient is either an inpatient or an outpatient. At that stage, there is no prescription charge. So the question of exemption for those people should not normally arise during the acute stage of the treatment for breast cancer, whether by chemotherapy or by any other means.
Of course, 70 per cent. of the patients, who are predominantly female, are exempt from charges if they continue under the care of the general practitioner. With the great advances that are being made in chemotherapy, the question of prescription charges is largely irrelevant. It should not be thought that prescription charges are likely to deter women, or the occasional man, from being treated in hospital. The hon. Gentleman's approach to this issue represents perhaps a misunderstanding of the nature of the disease and the developments that have taken place in the 1442 treatment. He and I are both laymen, but we are both interested in the subject because we are Members of Parliament. I am interested because of my ministerial duties. To a certain extent, we both are affected by the medical advice that we receive from experts.
I do not say that the hon. Gentleman's concern about breast cancer is misplaced. It accounts for the largest number of deaths from cancer among women—more than 12,500, tragically, in 1981—and it is the leading cause of all deaths for middle-aged women. It is estimated that any woman has a 1 in 14 lifetime chance of developing breast cancer. More than 20,000 new cases were registered in 1979, and that is over one fifth of the total female cancer registration. It is difficult to interpret trends in the incidence of the disease. The number of breast cancer registrations rose steadily up to 1974. Since then, the figures have varied, but they have stayed below the 1974 level. It is difficult to explain why. The concern that surrounds breast cancer, as with most other forms of cancer, is because we do not know what causes it. Despite much research, many basic questions about the origins and nature of breast cancer still remain to be answered.
Research is continuing into the cause of breast cancer and its treatment in laboratory experiments in medical schools and universities throughout the country, and through clinical trials. In 1981–82, the Medical Research Council, the main Government-sponsored research body, spent just over £17 million on research related to cancer. Research into cancer is extremely expensive. The cost of the drugs used in the treatment can also be extremely expensive, particularly when the drugs are new. I heard what the hon. Gentleman said about the drug that he named, but I hope that he will forgive me if I cannot answer his question about it today. However, I undertake to write to him on the matter.
§ Mr. PavittWhen I was a member of the Medical Research Council, there was never any problem of shortage of funds for cancer. There was shortage of funds for rheumatology and elsewhere, but the public subscribe generously to cancer research. It is a question not of shortage of funds, but of new areas to research.
§ Mr. PattenThe hon. Gentleman is right. He bases his remarks on his distinguished service as a member of the MRC. More and more money is spent, but we sometimes seem despairingly far from a solution to finding the causes of cancer.
I come now to the different treatments for breast cancer, so as to set chemotherapy in a wider context. There are three main methods of treatment—surgery, radiotherapy and drug treatment. Each different type of cancer— there are 200 or more different pathological entities—has its own treatments. Many cancer patients receive not just one form of treatment, but sometimes two or all three at different stages of treatment.
Until now, the main surgical treatment of breast cancer has been radical surgery—the mastectomy—with all the surgical and emotional problems that the hon. Gentleman mentioned. That treatment often goes alongside radiotherapy. However, in recent years there has been an important movement away from such radical surgery. The hon. Gentleman was right to draw attention to the emotional side effects of radical surgery and the total removal of a breast, but recently there has been a more conservative approach in surgery. This trend exists and 1443 there is now a major school of thought which prefers more localised surgery, followed by an extended course of radiotherapy, for the treatment of early breast cancer.
Clearly, such treatment has major advantages for the patient, not least in the emotional advantages after the condition has been stabilised. However, the long-term effects of this more conservative surgery on the survival of patients, compared with mastectomy and other treatments, are not yet known. A number of trials have been organised by clinicians in the United Kingdom to compare mastectomy with the removal of the tumour by local excision combined with radiotherapy.
Clinical trials are continuing and it will take some years to know what effect that has on the long-term prognosis of breast cancer patients. If it can be shown—I stress the word "if"—that the conservative approach is at least no worse than radical surgery, the former is likely to become the preferred treatment. I am sure that women sufferers would say that that was a jolly good thing too. However, as with all such clinical trials in the cancer field, it will be some time before we know of the impact of new forms of surgical treatment, related as they are to radiotherapy.
Chemotherapy is one of the more recent innovative developments in the treatment of cancer. Again, I stress how recent such research is. It involves the use of systemic drugs to kill cancer cells which have spread throughout the body. Many drugs are highly toxic and it is important to say that that can have painful and distressing side effects. Sometimes those can be just as distressing emotionally as radical surgery on the breast of a woman can be. Nonetheless, chemotherapy has greatly improved the survival rates for some cancer patients, particularly those suffering from, for example, the leukaemias in their different forms.
The impact of chemotherapy on the course of commoner forms of cancer such as breast cancer has so far been disappointing. I must report that. However, the feasibility of eradicating widely disseminated cancer has been demonstrated and it is likely—no more than that—that more cancers will prove susceptible to this form of treatment in future. We shall await those developments with considerable interest.
There are in progress throughout the world a large number of clinical trials of the use of particular chemotherapeutic agents in the treatment of breast cancer. While there is evidence that chemotherapy may improve the outlook for some patients, none of those trials has yet shown a major role for chemotherapy in treating breast cancer. Some treatments would be lengthy but it unlikely that many patients would require such treatment for the rest of their lives.
In chemotherapy the superiority of one form of treatment over another may be small but the marginal improvement may be beneficial to many. Therefore, it is essential in the next few years that the evaluation of chemotherapy should continue with the greatest possible care. As the hon. Gentleman knows from his service on the MRC, that can only be conducted through properly conducted and controlled clinical trials. Trials are of considerable importance in the evaluation of treatment in 1444 many fields of medicine. They are of particular importance in relation to cancer chemotherapy because, as I mentioned earlier, of the high toxicity of the drugs and the need to be able to identify clearly any improvements that are made as being related to the drugs themselves. Therefore, ideally all chemotherapy for cancer should be given within the framework of clinical trials and proven protocols—all the sort of things with which the hon. Gentleman is familiar from his time on the MRC.
For all those reasons—the aggressive nature of the treatment and its side effects, the need for close control and observation of the outcome—I expect that normally chemotherapy would be administered while a patient was still under the direct care of a hospital consultant.
As I said, there is still considerable ignorance of the cause of breast cancer. That being so, there is little that we can do in the way of prevention. In the little time that is left to me I shall not be able to deal with screening, although that was not a point raised by the hon. Gentleman.
§ Mr. PavittI urge the hon. Gentleman to recognise that we have both made a strong case on the importance of this subject. Will he agree and reiterate that, as more people are cured of breast cancer than lose their lives, there should not be any undue pessimism? I do not want it to go out from the House that the concern was such as to add to the fears of people who, instead of going for early diagnosis, defer doing so because they fear the fatal nature of the disease that they have contracted.
§ Mr. PattenI could not agree more. Early diagnosis and early treatment, whether by chemotherapy or other forms, is a life-saving development in the treatment of breast cancer, and I urge women, and the occasional man, who fear that they may suffer from this condition, to seek at the earliest possible time clinical and consultant help.
It is understandable that interest has turned to the early detection of breast cancer in the hope that an improvement in that direction will lead to more successful treatment. Although we know that cancer is best treated early, we, do not know with sufficient certainty that a breast screening programme would always discover those early cancers in sufficient numbers. None the less, where screening is available, I urge women in particular to make use of it.
Looking to the future, major problems confront those suffering from breast cancer and they cannot be underestimated. There are also major problems for those involved in its treatment. The problems are not only those raised by the hon. Gentleman. We cannot predict the impact of preventive and early detection measures. Similarly, we do not know at this stage how treatment for breast cancer will develop. I stress that surgery, radiotherapy and chemotherapy are complementary in the management of cancer. It seems likely that that pattern will continue in the foreseeable future.
What I can say at this stage is that in the light of present medical and surgical knowledge it is unlikely that any single successful treatment will appear in the near future. Experience suggests that there will be advances in cancer treatment, but that they will be slow and dependent on continuing and painstaking research. That research will continue to receive the support that it already gets from the Government.