HC Deb 07 February 1984 vol 53 cc856-62

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

10.25 pm
Mr. David Heathcoat-Amory (Wells)

I am grateful for the opportunity to raise this issue on the Floor of the House.

We spend a huge quantity of money on drugs in this country—about 9 per cent. of the cost of the National Health Service. It is a vital part of health care, but there is considerable evidence that many medicines are wasted. Most people's bathroom cabinets are stocked with unwanted drugs. That is demonstrated by the quantity of medicine handed in during dump campaigns. For instance, a recent campaign in Glasgow produced 2.25 tonnes of medicines, all of which had to be destroyed. When an old person dies, it is not uncommon for hundreds of pounds worth of drugs to be found, unused and unwanted.

The Government have estimated that 10 per cent. of all drugs may be wasted. That would be an annual cost of about £103 million. I believe that it is considerably higher. It is not just the cost—it is dangerous to have excess drugs in the house. Children take them, neighbours try them and old people get the bottles muddled up. Such misuse of drugs is a serious health problem.

A study in 1976 showed that about one in 10 of all admissions to geriatric units was solely or partly because of adverse drug reactions. Two weeks ago the Royal College of Physicians published a report on the problem. Under the chairmanship of Sir Douglas Black, the working party highlighted excessive prescribing by doctors as a major cause.

Of course, general practitioners are under pressure to prescribe. When we visit the doctor, we feel almost cheated if we do not come away with a prescription. We believe, wrongly, that there is a pill for every ill. However, it also seems that doctors too readily prescribe large quantities of drugs. It is my experience that the bottle of pills that I get almost always contains more than is needed. My impression was confirmed after discussion with the Somerset Pharmaceutical Society.

Pharmacists are in the front line of health care. They can prevent many unnecessary visits to the doctor. In a county such as Somerset, they are an important asset to the rural and town communities that they serve. I should be very sorry to see any reduction in the number of local pharmacies. Pharmacists are also in a good position to study the quantity of drugs issued to the public. I am grateful for the help that they have given to me.

Doctors are encouraged to prescribe a maximum of 28 days' supply, but it appears that about 16 per cent. of prescriptions are for larger amounts — sometimes for three or four months' supply at a time. Such quantities are often for the long-term treatment of patients, but if the patient recovers, or changes treatment, a stock of medicine is wasted or deteriorates through age.

A scheme has been designed to reduce the quantity of such drugs in circulation. Doctors could be provided with triplicate prescription forms. After examination, a patient could be given a prescription for two or three months' supply, but each page would be for one month only, and would be presented to the pharmacist on the appropriate date. Only one prescription charge would be payable for the series. I believe that the scheme would limit the quantity of medicine prescribed at one time, which is not only safer but cheaper, because the cost to the NHS would be spread over three months instead of being incurred all at once. It would also enable pharmacists to keep lower stocks and to plan ahead. Again, that would save money.

Such a scheme was agreed by the British Medical Association and the Pharmaceutical Society of Great Britain, but it was turned down by the Department of Health and Social Security. Even a pilot scheme was rejected. I ask my hon. Friend the Minister to re-examine the idea. When two important professional bodies agree about something, the Government should not dismiss it without giving very good reasons.

Even without such a scheme, I ask my hon. Friend to use his influence to limit prescription quantities. The 28-day limit has been urged by successive committees and reports. As I said earlier, it is not being observed by some doctors. There is a box on each prescription form for general practitioners to write in the number of days' supply that is required, so that the pharmacist can adjust the amount accordingly. More often that not, it is ignored by the doctor. Could it not be made a condition of a valid prescription that the box is filled in? I hope that my hon. Friend will not say that it is purely a matter for doctors themselves. Of course, we respect and understand their professional responsibilities, but we pay the bills.

The problem of wasted medicines must be tackled, particularly at a time when spending on health is under pressure.

Dr. Brian Mawhinney (Peterborough)

Does my hon. Friend accept that as long as general practitioners are independent contractors and not responsible to a family practitioner committee—which the Government hope to set up under the auspices of the Health and Social Security Bill now before the House—no pressure can be brought to bear on them? I happen to share my hon. Friend's views on the matter, but does not the logic of the situation demand a relationship with general practitioners that would allow his very sensible suggestion a chance of succeeding?

Mr. Heathcoat-Amory

My hon. Friend the Member for Peterborough (Dr. Mawhinney) raises an interesting point, because my suggestions require an alteration in the contractual relationship between general practitioners and the NHS. I hope that my hon. Friend the Minister will say whether such an alteration is being considered by his Department. My suggestions and those of my hon. Friend the Member for Peterborough are designed to save money without affecting the care of patients. Indeed, by cutting the quantity of drugs in circulation, my ideas should benefit patients and the public. I ask the Government to take a lead in the co-operative effort that is necessary.

10.35 pm
The Under-Secretary of State for Health and Social Security (Mr. John Patten)

I am very pleased that my hon. Friend the Member for Wells (Mr. HeathcoatAmory) has raised this important topic. I am sure that he, like me, is very glad that my hon. Friend the Member for Peterborough (Dr. Mawhinney) is also in the Chamber. My hon. Friend the Member for Peterborough also has a considerable interest in this issue, and by his intervention he has turned this occasion into a proper debate.

The topic of drug costs is of very great interest to patients and doctors, and should—because of the size of the drugs bill—be of compelling and consuming interest to the taxpayer. Drugs account for about 40 per cent. of the total cost of the family practitioner service. If the Health and Social Security Bill, which is at present in Committee, becomes an Act, the present form of that service may be amended and there may be opportunities for interesting developments.

More critically, drugs consume about 10 per cent. of the cost of the National Health Service as a whole. That is a prodigious sum of money. In 1982–83, prescription medicines in England cost over £1.2 billion.

My right hon. and learned Friend the Minister for Health and I are certainly concerned to try to control NHS expenditure on drugs at a national level. We can claim to have begun by adjusting the amount of return on capital employed which can be paid through the pharmaceutical price regulation scheme, as announced by my right hon. and learned Friend in his statement to the House on 8 December. My hon. Friend the Member for Peterborough made his voice heard on that occasion. Those revised arrangements will effect overall savings to the NHS of £65 million in 1984–85 and of well over £100 million in later years. The Government are making great efforts to reduce the overall cost to the Exchequer of the drugs bill.

Those major savings are on a macro-scale — a national scale. An enormous variety of savings can be made at grass roots level, and particularly in the doctor's surgery. My hon. Friend the Member for Wells referred to his knowledge of the scene in Somerset and the doctors and pharmacists there. The decisions that lead to the presentation of a prodigious but necessary bill to the Exchequer each year are made in the doctor's surgery.

The Government are concerned, above all, that there should be effective prescribing. We want effective prescribing in the interests not of doctors, politicians or the pharmaceutical industry but of the patients. Medicines should be prescribed only when they are essential and in adequate, but not excessive, quantities. My hon. Friend the Member for Wells was right to draw our attention to the problems of over-prescribing. Lastly, full advantage should be taken of generic equivalents to proprietary drugs where they exist and can meet patients' needs.

Effective prescribing is much more effective than any of the suggestions that have been heard from the Opposition Benches in recent months and years. The Liberal party, in particular, has made generic substitution a plea of its own. The Liberals almost claim that generic substitution will of itself solve the problems of the NHS. At future Liberal party conferences the question of generic substitution will be as important as loft insulation, site value rating and all the other issues which are of such importance to Liberal Members. By itself, generic substitution will not solve any of the problems of the NHS. Equally, if the Labour party were represented here tonight, we would hear that the solution is to cane the drugs industry. That is a disgracefully one-sided view of the industry, which has done an enormous amount to help people in this country and around the world by the advances in medicine and the preparations that it manufactures. I am pleased to put that on the record and will be pleased to do so again and again.

It is incumbent upon the Government to do what we can to curb some of the worst excesses of overprescribing and over-expensive prescribing, and it is to that that we are turning our attention. We are considering what the campaign should contain, and some of the matters suggested by my hon. Friend the Member for Wells are food for thought. As part of the campaign, we are exploring ways of educating doctors to become cost-effective prescribers while at the same time exercising their critically important freedom to prescribe in the clinical interests of their patients. There is no reason why clinical freedom and cost-effectiveness cannot be linked. The medical profession must make major efforts not just to ensure that that happens but to demonstrate publicly that it does.

Such movements cannot be dictated by the Government because, as my hon. Friend the Member for Peterborough said, doctors are independent contractors and as such they have considerable control over their affairs. The size of the drugs bill is of prime public interest. I can assure my hon. Friend the Member for Wells that all prescribing by doctors in England is monitored closely. Prescriptions are examined and costed monthly by the prescription pricing authority. the average cost per patient is calculated for each doctor, and a summary of the figures is sent to him for information through the family practitioner committee with the average cost for all doctors' prescribing in the area.

In addition, the figures for all the doctors in the area are examined by the Department and, where a doctor's costs are substantially above the average for the area, a detailed analysis is made of the doctor's prescribing habits. They are doctors whose names and addresses are known. They are not some statistical figment.

On the basis of that analysis, a visit may be made by the Department's regional medical service which is sometimes looked upon by general practitioners as a re-educational corps of sinister men who descend upon general practioners at the dead of night. That is not the case. The work that they do in drawing general practitioners' attention to ways of prescribing more efficiently and cost-effectively is excellent. During such visits the doctor's prescribing pattern is discussed in detail and advice is given. For example, a doctor might be asked to try to prescribe generically on suitable occasions. That is something upon which I place great stress as does, I know, my hon. Friend the Member for Peterborough.

Dr. Mawhinney

What my hon. Friend has said is encouraging. Some of us might want to ask whether he is satisfied that the service is applied as rigorously and extensively as possible, bearing in mind that there is evidence that when GP's overprescribing habits are brought to their attention, they change. I wonder whether my hon. Friend feels that enough is being done in that area. One accepts that the facility is there and that it is used. Is there not a cost-effective case for producing more of those investigative gentlemen for them to have a greater effect than most of us currently see?

Mr. Patten

That is something that my Department and my right hon. and learned Friend the Minister for Health are considering. Doubtless there will be future developments that will interest my hon. Friend.

Visits are also made — this is important — where exceptionally large quantities of drugs are prescribed. That takes me to the subject of triple prescribing which my hon. Friend the Member for Wells mentioned. I will mention here the support that we have received from the British Medical Association — we warmly welcome its co- operation—in encouraging doctors to restrict the amount they prescribe on any one occasion to no more than is strictly necessary in the patient's interests on clinical grounds. That is not easy, particularly with patients receiving long-term therapy. We have considered measures to help doctors limit their prescriptions to a 28-day supply of drugs. That is a point raised by my hon. Friend the Member for Wells. For instance, the pharmaceutical and medical professions suggested that a formal prescription scheme might be the answer. The idea was to let doctors have specially prepared stationery in their surgeries which would enable them to write three prescriptions, each for one month, to be dispensed when needed.

I note that my hon. Friend suggested that, should such a scheme be adopted, only one prescription charge should be made. The proposal was interesting. We considered it closely, but, in the end, we decided reluctantly that we could not introduce it, as it was always possible that under such a scheme, the needs of a patient—even a patient on apparently long-term therapy and in a stable condition—could change. If that patient were not seen regularly by a doctor over a period of months, adequate treatment might not be given.

Mr. Heathcoat-Amory

The point I was trying to make was that, under the existing system, the doctor does not see the patient regularly, because a three-month prescription means that there is almost no way that the doctor keeps touch with the patient during that time. At least, if a patient were to visit the pharmacist every month, the pharmacist could keep an eye on the patient's drug-taking habits and, if there was concern, could alert the doctor accordingly.

Mr. Patten

That is an interesting point. Writing three separate prescriptions, which could, under variants of the scheme, be used over a number of months, would mean that the time-span within which a patient could, theoretically, not receive a medical examination would be extended. We have not closed our minds to the scheme but are prepared to look carefully at it again. For the moment, we have decided not to accept its introduction. That does not mean that we are not continuing our efforts to educate.

Doctors receive high quality and independent information about drugs and therapeutics, and that is important. We in the DHSS provide all doctors with the "British National Formulary" and the "Prescriber's Journal" free of charge. As an example of the guidance offered to doctors to draw their attention to problem areas in prescribing, the "British National Formulary", which my Department sends to all prescribing doctors, contains advice about prescribing for children, during pregnancy and in particular for the elderly.

Another important point raised by my hon. Friend the Member for Wells was prescribing for the elderly. Medication for the elderly has been the subject of a fascinating and interesting study by the Royal College of Physicians, which came out in the past week or 10 days. I read the report with great interest. I am happy to say that we welcome the report's recommendations. Its conclusions are in close conformity with existing guidance in the "British National Formulary". The report was critical of aspects of prescribing for the elderly under certain conditions. It was especially critical of arrangements for the bulk prescribing of drugs for residents in homes for the elderly.

It would be helpful, following the points raised by my hon. Friend the Member for Wells, to set out our thinking on this matter. Bulk prescribing for residents of homes can be a useful means of ensuring that a stock of commonly used remedies is available, but that is really all it does. My Department's memorandum of guidance on arrangements for health care in residential homes for the elderly makes it unequivocally clear that the administration of medicines by staff must be in accordance with medical advice. If medicines are not administered to patients in accordance with medical advice, that is a serious matter. Doses must not be varied in such circumstances without a doctor's authority, nor must medicines be administered to residents for whom they have not been prescribed. Those all are all important points, which the Royal College has picked up.

Local authorities must designate a member of staff in each home to take responsibility for medicines and to ensure that records are kept in respect of each resident. We would take a serious view of any home in which those conditions did not obtain.

Mr. Heathcoat-Amory

What pressure does the Department intend to apply to ensure that those very good recommendations are carried through into action? Far too often, similar recommendations have been made by other reports and ignored or only partially implemented by the medical profession.

Mr. Patten

We have only just received the report and are considering it in detail. We shall doubtless bring forward recommendations on how to achieve the closing of any loopholes. Malpractices seem to occur here and there rather than generally, but I assure my hon. Friend that with the characteristic zip, vim and vigour of the Department, under my right hon. Friend the Secretary of State, everything that we do will be done with maximum speed. That is the hallmark of the Department now, whether on the Griffiths proposals or on care for the disabled. Incidentally, I am pleased to see that my hon. Friend the Minister with responsibility for the disabled has entered the Chamber to support us in this most interesting debate.

The positive campaign that we intend to introduce to widen the perceptions of doctors about positive prescribing will, I believe, create a great deal of interest. The Greenfield report recommended generic substitution by pharmacists on occasions when prescribers did not indicate otherwise. That is an interesting idea, but we do not feel that it is the right way forward at present, for the reasons given by my right hon. and learned Friend the Minister for Health in his statement on 8 December. Time does not permit me to go into those reasons today.

In our new campaign we shall try to reinforce the measures that I have mentioned — this relates to the point raised by my hon. Friend the Member for Peterborough—with much more emphasis by regional medical officers on the need for doctors to try to prescribe generically wherever possible and to limit the quantity prescribed at any one time. Those will be the two most important themes of the campaign.

In conclusion, we must keep prescribing costs in perspective. My hon. Friend the Member for Wells certainly kept them firmly in perspective. If only we could have such common sense from the Opposition when these matters are discussed. Most doctors in this country prescribe wisely, and it would be wrong and foolish to suggest otherwise. We compare very favourably with other west European countries, both in the number of items prescribed and in the total overall cost of medicines, but we cannot in any circumstances be complacent about the drugs bill when so many other items of patient care are competing for NHS funds within the total pool of money available.

There is certainly room for an improvement in attitude by us all, the public as well as the professions. I was interested to hear what my hon. Friend the Member for Wells had to say about public attitudes. Overprescribing, for whatever reason, is bad for the National Health Service, bad for the taxpayer and, above all, bad for the patient, because it diverts much-needed public funds from areas of need. It is therefore right to ask doctors to consider economy when making prescribing decisions. Certainly during 1984 we shall be bringing forward measures to encourage them to do that. I hope that those measures will meet with the approval of my hon. Friend the Member for Wells.

Question put and agreed to.

Adjourned accordingly at seven minutes to Eleven o'clock.