§ 7 pm
§ Mr. Donald Dewar (Glasgow, Garscadden)
On a point of order, Mr. Deputy Speaker. Can you help me on a matter of some difficulty? I wonder whether you have seen the 15th report of the Joint Committee on Statutory Instruments for the Session 1984–85, which deals with the regulations that we shall be discussing tonight. Paragraph 3 states:In oral evidence, the Departments pointed out that while the England and Wales Regulations carry one alphabetically arranged list, the Scotland Regulations carried three separate alphabetical lists. There were still, however, differences between the two Regulations which were not intended and which had arisen through printing and compilation errors.It went on to say that the lists were not accurate and would have to be amended by subsequent instruments.
I recognise the difficulties of the Committee as regards what was or was not in the list. It was a morass of different lists which were difficult to cross-reference. It was thought that there were substantial differences between the English and Scottish appendices. It has now become clear that, thanks to a great deal of effort at the last minute, most of the discrepancies have been ironed out. However, some still remain, and I think that that is common ground between the Government and the Opposition.
I understand that the Scottish list leaves out Vicks coldcare capsules, and that a cough syrup called Guaiphenesin will still be available for prescription in Scotland under the NHS. On the English list, Vicks inhalor has been missed out, but I presume that it can be prescribed under the NHS in Scotland.
It is clear that those are errors and that the Government's intention was that the appendices to the two sets of regulations should be identical. However, they are not identical. That is a mark of the chaos and confusion, the muddle and haste, with which the whole scheme has been thrown together by the Scottish Office and, I suspect, its colleagues south of the border. I ask you, Mr. Deputy Speaker, where that leaves the House. We are being invited tonight to accept regulations which, by the Government's public declaration, do not have the effect that was intended. That is bound to lead to a great deal of confusion and difficulty in Scotland and in England.
I also wish to ask you about the Scottish schedule, Mr. Deputy Speaker. It is a remarkable document to lay before Parliament. Pages 31 and 32, for example, are spattered with pen emendations. It looks as though a Victorian clerk with an inefficient quill pen has been trying to improve the draftsmanship before the fair copy was ultimately made. I wonder about the standing of the pen additions interpolated between the lines and added at the bottom of the page. Do they carry full authority and are we to take them seriously?
The main point is: what is the standing of the regulations and how can we amend them? We are in the ludicrous position that, because of the incompetence and inefficiency of the Scottish Office and the DHSS, Ministers are asking us to accept regulations that, quite clearly, are not the ones that they intended to lay before Parliament. That is a thoroughly unsatisfactory position. I ask your guidance, Mr. Deputy Speaker, on how we can protect ourselves from the results of such maladministration.
§ Dr. M. S. Miller (East Kilbride)
Further to that point of order, Mr. Deputy Speaker. In view of the serious anomalies that have been disclosed by my hon. Friend the Member for Glasgow, Garscadden (Mr. Dewar), can you guide us on whether there should be a separate debate for Scotland so that we are not forced to debate something that applies to England and Wales and into which, by cross-reference and the sort of notations made in the statutory instrument alluded to by my hon. Friend, Scotland will be brought without a debate of its own?
§ Mr. Charles Kennedy (Ross, Cromarty and Skye)
Further to that point of order, Mr. Deputy Speaker. When I raised this matter last week during business questions, I thought that the Leader of the House was extremely helpful and constructive when he said that the anomalies and discrepancies that the DHSS and the Scottish Office had admitted in evidence to the Joint Committee would be dealt with by relevant Ministers. Obviously, that would clear up many of the difficulties faced by hon. Members on both sides of the House.
I appreciate that the choice of Ministers in any debate is not a matter for you, Mr. Deputy Speaker, but Scottish Members face the difficulty that departmental Ministers, the Minister of State and the Secretary of State for Social Services, will be delivering the opening and concluding speeches. While I do not doubt that they will refer to the difficulties facing Scotland, it is predominantly a matter for the Scottish Office. Therefore, it is incomprehensible that Scottish Members should be asked to accept the regulations.
An official, in reply to a question relating to the difficulties, said:I think, Sir, that there may be difficulties, but we cannot, at the moment, gauge the extent of that. This has only just been drawn to our attention and we have not had an opportunity to collate the lists in any detail.If the Departments have not had an opportunity to collate the two lists, surely it is utterly unreasonable, without a speech from the Scottish Office Minister responsible for the Health Service in Scotland, for the House to make a decision on the lists.
§ Mr. Christopher Murphy (Welwyn Hatfield)
Further to that point of order, Mr. Deputy Speaker. As the acting Chairman of the Joint Committee, it may be for the assistance of the House to know that the report is available in the Vote Office as is the evidence that was taken and the written memorandum. If hon. Members avail themselves of the opportunity to consult the report, they will be in a better position to assess the merits or otherwise of the regulations.
§ Mr. Deputy Speaker (Mr. Harold Walker)
The House is grateful to the hon. Member for Welwyn Hatfield (Mr. Murphy). The hon. Member for Ross, Cromarty and Skye (Mr. Kennedy) referred to the Ministers who would speak in the debate. That is not a matter for me, but I do not doubt that what he said will have been heard by Ministers.
I must tell the hon. Member for East Kilbride (Dr. Miller) that the decision to debate the two prayers together was agreed by the House on 12 March.
I am grateful to the hon. Member for Glasgow, Garscadden (Mr. Dewar) for giving me advance notice of his point of order. I have looked at the 15th report, and I must tell him that there is nothing that invalidates the regulations before the House. I do not doubt that what he 683 has said will be taken into account in the debate and in any subsequent Divisions when the Questions are put to the House. There is nothing that I can do this evening. The Ministers will have heard the hon. Gentleman's remarks and will, no doubt, take them into account.
§ Mr. Dewar
I do not wish to delay the House, Mr. Deputy Speaker. However, is it not unsatisfactory that the House should be presented with regulations which, on the Government's admission, are not the ones that they intended to lay? The result is that a minor number of drugs — although significant in themselves — will be available in either England or Scotland but not in both? Is there no way in which a manuscript amendment could be tabled, given the fact that the Scottish regulations are already spattered with manuscript amendments?
I hope that you will not think that I am in any way seeking to take advantage of you, Mr. Deputy Speaker, but, as an ordinary Member, I have the greatest difficulty in deciphering the last item added in ink at the bottom of page 31. Perhaps you could help by telling me which drug is referred to there. If so, you are certainly a better man than I am.
§ The Secretary of State for Social Services (Mr. Norman Fowler)
Perhaps I can help the House. The hon. Member for Glasgow, Garscadden (Mr. Dewar) is correct in saying that there are one or two differences. I think he will concede that they are very minor differences. There are three drugs at issue out of a list of about 1,760. The main complaint was of spelling mistakes. For instance, "Scott's husky biscuits" came out as "Scott's husky buscits". I think, however, that the hon. Gentleman's acumen is such that his comprehension of the regulations will not be affected. In direct reply to him, I should state that we shall be putting amending regulations before the House to amend the mistakes.
§ Mr. Deputy Speaker
No doubt the House will take into account what has been said by Members on both Front Benches.
§ Mr. Michael Meacher (Oldham, West)
I beg to move,That an humble Address be presented to Her Majesty, praying that the National Health Service (General Medical and Pharmaceutical Services) Amendment Regulations 1985 (S.I., 1985, No. 290), dated 1st March 1985, a copy of which was laid before this House on 1st March, be annulled.In explaining why the Labour party strongly opposes the regulations I shall begin with three quotations. The first is:It is almost impossible to establish whether the introduction of a limited list of drugs will in itself produce any financial saving for the NHS. What does seem apparent is that any attempt so to do is likely to arouse hostility, result in higher administrative costs, affect the pricing of drugs and the industry, generate unwelcome pressures for GPs and pharmacists, and possibly cast some doubt on the Government's intentions towards the standard of provision of general medical services in the NHS.That quotation comes not from the British Medical Association, the Royal College of General Practitioners, the Association of the British Pharmaceutical Industry or the Labour party but from the DHSS itself in evidence to the Greenfield committee in 1981. Perhaps the Secretary of State should read that.
The DHSS document summarising the consequences of introducing a limited list states:Export sales of pharmaceutical products would be likely to suffer (countries with central control of the supply of medicines 684 would tender to purchase only those products on the list); research would suffer (the uncertainties of whether a product might eventually gain acceptance on the list might inhibit research); competition would suffer (although competition in pharmaceuticals is imperfect, it does arise because companies seek to produce alternatives to existing successful medicines and a limited list would discourage this); investment would suffer (one of the attractions of the UK as a base for research and production of active ingredients is the existence of a local market open to all licensed products)".Perhaps the Secretary of State should read that, too.
The third quotation reads:we have resisted any system of limiting the freedom of a doctor to prescribe whatever he thinks his patient needs. Not for us are such devices as limited lists, black lists, the compulsory substitution of generics, or the financial pressures involved in reimbursement regimes or the like. We talk about the doctor's freedom to prescribe. But what we should really talk about is the patient's freedom to be treated as his doctor recommends.Those are not the words of the last Labour Minister for Health. They are the words of the Tory Secretary of State for Social Services on 2 April 1981 and they reveal beyond any doubt the complete somersault on thinking that the Government are trying to palm off as a common-sense development.
That is a devastating indictment. The present Secretary of State has answered none of the objections of his Department or of his predecessor. In previous exchanges on this we have been treated to one of the most unconvincing exercises in justification of an over-hasty, half-baked scheme that I have ever heard in the House. I can think of no starker example in recent years of a Secretary of State being so entirely contradicted by the evidence of his own officials. By any standards, this is a rushed, ill-thought-through and damaging measure. It has been condemned by almost every organisation associated with the National Health Service and it is being forced through precipitately before essential parts of the scheme are in place.
From the Department which gave us the housing benefit scheme which the Tories described — that was a Freudian slip—which The Times described asthe biggest administrative fiasco in modern timeswe now have the limited list, which has all the same hallmarks in terms of sensitivity and sophistication.
§ Mr. Anthony Beaumont-Dark (Birmingham, Selly Oak)
This may sound strange coming from the Conservative side, but many of us think that the Opposition are playing the drug companies' game. Is the hon. Gentleman aware that many of those companies are trying to force through changes in their favour to safeguard their profits? This is the only country to allow an entirely unlimited list. Why is what is good for other countries—including Scandinavia, where there are some Socialist Governments — so bad for this country? Will the hon. Gentleman address himself to those points?
§ Mr. Meacher
I assure the hon. Gentleman that we are not playing the ABPI game. We are playing the patient's game, as the previous Secretary of State did until the Treasury proved too strong for him. In fact, important countries such as Sweden do not have a limited list.
§ Mr. Thomas Torney (Bradford, South)
Is my hon. Friend aware that the proposals will cause considerable unemployment in the drugs and chemical industry? Evidence to that effect has been submitted to me by my trade union, the Union of Shop, Distributive and Allied Workers, which organises people in that industry.
§ Mr. Meacher
I repeat that none of us is playing the drug companies' game and I shall certainly not be using the arguments and techniques of the ABPI, of which I disapprove as much as anyone else.
The measure will certainly lead to significant unemployment. The Secretary of State has yet to answer that point or to give his estimate of the likely job losses.
§ Mr. Meacher
No, I should like to make some progress. Many hon. Members wish to speak. The hon. Gentleman may have a chance to contribute later.
This measure was introduced without a shred of consultation with the medical profession. At 3.15 pm on 8 November, during a routine negotiating meeting, DHSS officials pushed towards the chairman of the general medical services committee of the British Medical Association a brown envelope containing a letter from Dr. Acheson, chief medical officer at the DHSS, setting out the proposals which the BMA then saw for the first time at the same time as the Secretary of State was making his announcement to the House.
Because there was no consultation, the earlier proposed list was so ill concocted and so abbreviated that it looked like the thin end of a very thick wedge. It resembled an ill-disguised attempt to begin the shift to the privatisation of clinical medicine. Even with the longer final list, that suspicion has by no means been fully removed. There is a report in The Guardian today that the Government are considering requiring patients to pay for treatment by their doctors through a voucher system. The Secretary of State should immediately disown that report if it is not true. I will gladly give way to him if he will do so. If he does not do so, our suspicions will be substantially increased.
Perhaps the clearest sign that these proposals are being rammed through in far too precipitate and ill-digested a form is that there is still, with only two weeks to go, no appeals machinery in place, no agreement with the BMA to allow general practitioners to prescribe black-listed drugs in special circumstances, and no settlement of the appalling shambles of the arrangements in Scotland.
A week ago, officials of the DHSS and the Scottish Office admitted to the Joint Committee on Statutory Instruments that Parliament was being asked to approve a Scottish black list that was inaccurate in several items. When asked why the English and Scottish lists did not tally as they were supposed to do, the DHSS official said:It was because they were laid in something of a hurry that there were some errors of compilation".It is monstrous that Parliament should be asked to pass regulations that are known to be significantly inaccurate. The Government should withdraw them until correct regulations can be put before the House.
There have been so many zigzags and voltes-face in the Government's handling of the matter that it is beginning to resemble the terminal voyage of the Belgrano, with exactly the same smokescreen of innuendoes and misinformation.
In 1980, the then Minister for Health said that he was not yet persuaded that a limited list would of itself produce lasting economies in the cost of the NHS or necessarily be in the best interests of patients.
That is not all. As late as 22 November 1983, the present Minister for Health said — [Interruption.] It is 686 not funny. To people outside this place this is an extremely serious matter. What the Government are doing offends millions of people. The Minister for Health said:We are not convinced that such a list confining the judgment of doctors"—hon. Member should note that phrase—would be in the best interests of patients."—[Official Report, 22 November 1983; Vol. 49, c. 112.]Now we are told, in a complete reversal of policy, that the interests of patients will not be jeopardised. I wonder who is persuaded of that.
On the comprehensiveness of the limited list, the original DHSS letter of 8 November of last year stated, referring to the original list of 31 items:An adequate range of cheap and effective generic drugs will remain available for those cases where doctors feel that the clinical needs of individual patients genuinely require such medication.If the Government originally claimed that 31 items were adequate, why has the Secretary of State now increased the list three and a half times to about 113 items, and why should his assertion that it is now comprehensive be any more credible?
On the question of flexibility, the DHSS was at first totally uncompromising. In a letter of 4 February this year to the BMA, Mr. Pilling, a DHSS official, said:From 1st April GPs will not be able to issue NHS scripts for any listed drug under any circumstances. To do so will be a breach of their terms of service.A month later, the Government are having second thoughts yet again on that point. BMA leaders met the Minister for Health at 6.15 pm last Thursday to discuss a Government concession on that issue, and I understand that there is to be another meeting later this week.
On the question of generic drugs, the Minister for Health stated on 28 January this year in a parliamentary answer:There is no, and never was any, element of generic substitution in the limited list proposals".— [Official Report, 28 January 1985; Vol. 72, c. 59.]A month later, in his statement of 21 February, the Secretary of State told us that generic substitution is to be enforced by the Government wherever possible.
The whole story is a sorry one of constant backtracking and indecision. However, wriggle though they have in U-turn after U-turn, the fundamental fact remains that—
§ Dr. M. S. Miller
Will my hon. Friend make it clear that generic prescribing and generic substitution are two very different matters? It is one thing to persuade doctors to prescribe generically—which is not necessarily a bad thing — and another to leave it to the whim of the chemist to substitute generic equivalents for the substance prescribed by the doctor.
§ Mr. Meacher
That is another question that the Secretary of State must address. In the past two months the DHSS has given contradictory answers. We need to know exactly what the Secretary of State's policy is well before the scheme comes into operation.
The objections to a limited list raised by the DHSS's own evidence to the Greenfield committee in 1981 are as valid today as they were then, and the Secretary of State must know it. Those objections have in no way been answered. In its evidence, the DHSS referred tothe concern of individual doctors at having to take account of a patient's financial circumstances when deciding whether to continue treatment with drugs not on the limited list".That still remains true. It referred to 687the confusion and worry—and possibly hostility—of patients who found themselves with a changed regime of treatment as a consequence of the limited list".That still remains true. It referred to the fears ofthose who saw in the very act of delineating which drugs the NHS could afford to provide the introduction of an explicit system of second-class medicine.That still remains true. Lastly, it stated thatin the new dispensation there would be little distinction between a private patient of a family doctor (who would, as now, pay the full economic rate for any drugs prescribed) and the NHS patient of that doctor who was prescribed drugs not on the limited list (and would also have to pay the full economic rate for the drugs prescribed)".That was the view of the DHSS in 1981, and the Secretary of State has failed to answer any of those central points. How could he do so when not even his own officials believe him?
In trying to defend the indefensible, Ministers have given three main reasons for standing on their heads, each of which is specious. First, they say that a fuller study of the health system in other countries has convinced them that financial savings of the order indicated by the Secretary of State can be made. [HON. MEMBERS: "Hear, hear."] That comforting illusion is clearly shared by some Government Back Benchers. It must also please the Treasury, but it will not convince me. The DHSS's own document of 1981 once again reveals what a two-faced confidence trick the Ministers are trying to pull off. I quote again from that invaluable document:Examination of the schemes"—abroad—suggests that no simple comparison of them is possible and that evaluation of them to determine their suitability for adoption by the NHS is extremely difficult … representatives in the UK of the countries concerned have suggested their schemes do not serve to effect the economies expected of them.Secondly, the Government have tried to justify their somersault over the limited list by complaining that the number of prescriptions dispensed each year by doctors has been rising too quickly, thus implying some profligacy. The opposite is the case. Britain is at the bottom of the spending league of prescriptions per head of population in developed countries. In the United States, 16.6 prescriptions are issued per head of population each year. The equivalent figures are 11.2 for Germany, 10 for France and only 6.9 for the United Kingdom. There is therefore no justification for introducing this scheme from that quarter.
Thirdly, Ministers fall back on the £75 million savings to explain the exercise. I must tell them that analysts in the industry think that it could turn out — [HON. MEMBERS: "Ah."] I am not saying that they are right, but they are worth quoting. If the Secretary of State thinks that they are wrong, he can tell us why. Analysts in the industry say that savings are much more likely to be about £20 million to £35 million—so low that presumably even the Secretary of State would not claim that it warranted blacklisting 1,800 drugs.
I hope that the Secretary of State will read the DHSS document. I shall be glad to make a copy of his own document available to him. It suggests that the industry is probably right. This is my last quotation. [HON. MEMBERS: "Hear, hear."] I shall be glad to send every Conservative Member who votes in support of the regulations a copy. It says:The Department would be forced to ensure that only a fair share of costs and a fair profit were accepted, and this would lead to the control of the price of each item separately — a difficult and costly administrative exercise.688 It does not suggest much of a saving.
§ Mr. John Butterfill (Bournemouth, West)
Does the hon. Gentleman agree that some savings might be made in the £140 million a year that drug manufacturers spend on promoting their products to general practitioners?
§ Mr. Meacher
That is an excellent proposal. I entirely agree with it. I hope that the Secretary of State will stop these regulations and listen to his hon. Friend, who is making a much more sensible suggestion. I shall be glad to give way to more hon. Members such as the hon. Gentleman.
Ministers have tried to save face by suggesting that limited lists have long been used by hospitals locally and that this is merely an extension. Presumably they know that hospital formularies are a completely different mechanism. They are arranged and agreed by the doctors who do the prescribing—that will not be the case here. They are adaptable and subject to change in the light of the effectiveness of new drugs — that will not be the case here. In hospitals, drugs are given under close supervision — that will not be the case here as patients will be at home. There will be confusion, especially among elderly people, with changing colours and shapes of drugs as different generics are prescribed. It is clear, therefore, that what we are debating is quite different from hospital formularies.
§ Mr. Henry Bellingham (Norfolk, North-West)
Has the hon. Gentleman read his speech of 8 December 1983 in which he asked:Is the Minister aware that … £25 million could he saved by substituting unbranded versions of the branded drugs that cost the NHS £60 million a year? Does he agree that an enormous saving could be made in this area? Does not his rejection of generic substitution owe much more to the arm-twisting of the drug companies"?—[Official Report, 8 December 1983; Vol. 50, c. 476.]What does the hon. Gentleman have to say about that?
§ Mr. Meacher
I am delighted to hear my words repeated — they are extremely sensible. I hope that they will be taken on board. However, that is not what we are discussing today. This is a completely different matter. What I said was sensible and I should like to repeat what the Minister for Health said on 28 January:There is no, and never was any, element of generic substitution in the limited list proposals we announced on 8 November 1984."— [Official Report, 28 January 1985; Vol. 72, c. 59.]Perhaps the hon. Member for Norfolk, North-West (Mr. Bellingham) would have a word behind the Chair with his right hon. and learned Friend the Minister for Health. I think that he could learn a lot from him.
For the reasons that I have given, none of the Government's arguments about the regulations wash. The motives for its introduction are wrong and we oppose the entire framework of the scheme. It is not, as the Secretary of State claims, comprehensive. I have been briefed by doctors that, for example, the white list includes Sudafed, a decongestant, while three alternatives are blacklisted. Sudafed leads to hyperactivity and cannot be given to children late at night because it would prevent them from sleeping. Orovite is omitted from the white list, but it is needed to control alcohol withdrawal symptoms. Cologel, which is designed to counter chronic soiling problems, is on the black list, but Celevac, which contains the same substance, is on the white list. Celevac is in the form of 689 granules and I understand that its consistency is frogspawn-like. It is clearly unacceptable to children and is therefore not suitable. I am simply quoting information that I have been given by doctors.
Another example concerns a drug which controls temporal lobe epilepsy. A GP who has contacted me finds that Tranxene controls it well, but Tranxene and its generic equivalent are on the banned list. The alternative, called Clobazam, is on the white list. The GP believes that changing the drug to Clobazam could well result in the patient having a fit. That also clearly is unacceptable.
I quote those merely as examples. I have no doubt that doctors could — and will — provide many others. Once the Secretary of State's claim that the list meets all of the clinical needs of patients is significantly breached, the rationale of the list falls to the ground. And so it has.
§ Mr. Patrick Nicholls (Teignbridge)
If, by any chance, there are still any omissions from the list, does the hon. Gentleman agree that they could have been avoided if the BMA had co-operated with the Government in the interests of patients and tried to get the list right? Does not the hon. Gentleman feel slightly embarrassed to use information supplied by BMA-inspired doctors when it is saying now what is would never say in the consultation process?
§ Mr. Meacher
It is typical of the Conservative party, in its defensive mood, to lay the blame elsewhere. The BMA was never consulted. The Secretary of State made his statement in the House on 8 November without a shred of consultation with the BMA.
§ Mr. Meacher
No, I shall not give way.
There have been further meetings with the BMA, including that of 10 January. At none of them has the Secretary of State taken the BMA into his confidence or shown any desire to take account of its opposition to the scheme, or the reasons for it.
§ Mr. Meacher
I shall not give way. I understand that many Conservative Members wish to speak and I do not wish to prevent them from making valid arguments.
There is serious doubt about whether the list is legal under EEC law. I understand that the Duphar case in the Netherlands, which was decided on 7 February — I am sure that Ministers know what I am talking about — showed that if a limited list was not to infringe EEC law it must not be discriminatory concerning the origin of products, be carried out on the basis of objective and verifiable criteria and be capable of amendment whenever compliance with the specified criteria so required. It is arguable that none of those conditions applies here, and that is yet another reason why we believe this over-hasty, pig's ear of a scheme should not be rushed through.
There is also the question of job losses resulting from the package. Despite the small savings that we believe will result from the likely switch in prescribing patterns, there may be a disproportionate loss of jobs because of the huge length of the black list. For those reasons, too, we reject the regulations.
690 The central point for us is that, because the list is not comprehensive in meeting the clinical needs of all patients, it runs directly contrary to the fundamental principle of the National Health Service — that the individual's ability to pay determines his tax, but not his medical treatment. Once that principle is breached, a two-tier system of care within NHS general practice is established. The regulations could turn out to be the thin end of a very thick wedge.
Our policy is that prescribing should be exclusively on the basis of clinical need. The regulations would inevitably mean that the treatment that patients require may be influenced by their ability to pay. That is why we reject them.
There was a word that gained currency on the Western Front, SNAFU — situation normal, all fouled up. Perhaps we are seeing a variant of it—situation normal, all Fowlered up.
We all know that the scheme is being introduced as a simple, straightforward, squalid little cost-cutting measure. It is being introduced because the Secretary of State caved in to the Chancellor of the Exchequer in Cabinet, and we all know that the present Chancellor is the most heartless, arrogant, and dogmatic holder of that office in modern times. A little less kow-towing to the Chancellor and a little more standing up for patients would not come amiss from the Secretary of State. If he will not do that, we will. We shall not only vote against the regulations, but we shall be taking the issue into the country, along with the Secretary of State's obnoxious £2 prescription charge.
§ The Secretary of State for Social Services (Mr. Norman Fowler)
In the long debate on the selected list, nothing has been more remarkable than the policy that has finally emerged from the official Opposition.
Given the terms that the hon. Member for Oldham, West (Mr. Meacher) has been using today — "half-baked", "two-faced", "confidence trick", "squalid" and so on—one would think that when I announced the policy it met with his instant and outraged opposition. No one would ever accuse the hon. Gentleman of understating his case. "The destruction of the Health Service" is a phrase that falls as easily from his lips as does "Have a nice day" from an American waitress, but the extraordinary fact is that at the time of the announcement in November the hon. Gentleman said absolutely nothing — not a thing. It was not until four weeks later that the Opposition came out against the policy.
The House may take the view that the indignation welling up in the hon. Member for Oldham, West was of such a quality that it took a four-week gestation period to find expression. Alternatively, it might take the view that he was labouring long and late to find a way to reconcile his opposition to the Government's proposals with his previous calls for a reduction in the drugs bill.
Only last July, the hon. Member for Oldham, West said:while the drug companies are permitted to rip off the NHS, with excessive profits this year probably in excess of £250 million, Government talk of 'Can't afford any more for the NHS' is simply stinking hypocrisy."— [Official Report, 5 July 1984; Vol. 63, c. 481.]After years of campaigning for cuts in the drugs bill, the hon. Gentleman is now inviting his hon. Friends to oppose 691 a reduction and to oppose the resources thereby released being made available for health care. The House can judge whether that is "stinking hypocrisy" or just a typical taste of Meacher humbug.
On the subject of humbug, the hon. Member for Oldham, West mentioned an article in The Guardian. I say frankly that that article is a load of nonsense. The Government have no plans to introduce a voucher system and never have had. Indeed, the article did not suggest that was the case.
The essential issue of the debate is that in the next financial year the Government will be spending over £17 billion on the National Health Service. That is the biggest budget that the Health Service has ever had, in both cash and real terms. However, to say that is not remotely the end of the responsibility of the Government.
The Government must ensure that the money is being spent to the best effect. That is why we have followed a series of measures to achieve value for money in the Health Service. It would be indefensible if the drugs bill were to be exempt from that examination.
Clearly, there are a number of factors to be balanced. The drugs bill is now £1,500 million a year. That is 10 times as much as it was 15 years ago and represents an increase of about 5 per cent. a year more than price rises over the past 10 years. The aim has been to find a way in which that bill could be reduced, while, at the same time, giving the medical profession a choice of drugs to meet all clinical needs and not harming the essential interests of our research-based pharmaceutical industry.
§ Mr. Allen McKay (Barnsley, West and Penistone)
Can the right hon. Gentleman tell us the cost of drugs as a percentage of total NHS spending? Has that percentage altered over the past few years?
§ Mr. Fowler
The proportion has kept more or less the same, but it is £1,500 million out of a total budget of £17 billion. The hon. Gentleman seems to be arguing that we should not seek any economies in the drugs bill. Even the hon. Member for Oldham, West is not proposing that view.
A number of options have been put forward to contain the drugs bill. The BMA apparently now favours what I can best describe as a modified Greenfield approach—an entirely voluntary form of generic substitution. That approach might make it easier for doctors who wanted to prescribe generically to do so, but the trouble is that no one thinks that it would much reduce the drugs bill.
Others would favour compulsory generic substitution across the whole range of drugs, including what are undoubtedly life-saving drugs. That would be totally opposed by the pharmaceutical industry. It would mean that a company could lose the market for any drug the day after its patent expired. There is no doubt that the industry's research efforts would be seriously undermined by that sort of action.
The Labour party would go one step further. It would add to all this by taking major pharmaceutical companies into public ownership. That would cost money, not save it; it would destroy the British pharmaceutical industry; and, if the record of eastern Europe is anything to go by, it would put an end to innovation and research.
The Government adopted a different approach. We began by asking whether all the drugs being prescribed needed to be prescribed. Having examined the evidence 692 carefully and having looked at what happened in other countries, we concluded that there was room for improvement and that the Health Service was not getting the best value from the money that it spent, particularly in the groups of drugs we identified and which are covered by the selected list. These are basically tonics, antacids, laxatives, cough and cold remedies, vitamins, analgesics and tranquillisers.
It was clear to us that in those groups the Health Service could achieve a more economical pattern of prescribing without harming the interests of patients, without infringing the clinical freedom of doctors and without discouraging research into medicines for the more serious conditions.
§ Mr. Bowen Wells (Hertford and Stortford)
Before my right hon. Friend proceeds further, can he tell us, regarding the clinical freedom of doctors, whether he has been able to work out some method by which there could be an appeal, if a doctor considered it essential for a drug not on the list to be prescribed in a particular case?
§ Mr. Fowler
I shall come to that point shortly. I realise that many of my right hon. and hon. Friends and, perhaps, some Opposition Members are worried about it. I promise to deal with it in my own time.
§ Mr. Colin Shepherd (Hereford)
Is my right hon. Friend aware that many general practitioners are worried that this may be the thin end of the wedge and that it could be taken on a broader basis later? I should not like to think that this is the thin edge of the wedge. Will my right hon. Friend assure the House that the list will be restricted to those categories only?
§ Mr. Fowler
I can and shall come to precisely that point shortly.
The mechanism that we chose was the selected list. That is a list of drugs selected from all those available in the seven categories which will cover patients' clinical needs as effectively as the full range.
Schedule 3A to the regulations lists all the drugs which we have not selected for NHS use. Copies of the much shorter selected list have been sent to every doctor and pharmacist to help them to operate the new system when it is introduced.
The selected list has been the result of a thorough process of consultation and consideration. Not only did we seek views from all the interested organisations but the chief medical officer also wrote to every doctor m the country asking for comments. We received comments from about 2,000 doctors. Those comments have been taken fully into account. What is more, the chief medical officer brought together a group of eminent doctors to help him in a detailed examination of all the medicines covered by the list. That group contained experts practising in all the relevant specialties. It included a clinical pharmacologist, a physician, a geriatrician, a paediatrician and a psychiatrist. It also included three practising general practitioners and a practising community pharmacist. It is ludicrous to suggest that the group was anything other than highly qualified for its task. It is absurd to seek to belittle its experience and expertise or to deny the authority of its recommendations. That group prepared the selected list which we are now introducing. It recommended it unanimously as providing a sufficient range of drugs to 693 meet all clinical needs. I accepted the group's recommendations in their entirety, and I hope and believe that most doctors will do so.
§ Mrs. Anna McCurley (Renfrew, West and Inverclyde)
Does my right hon. Friend agree, despite the fact that he has attempted to get a broad spectrum of opinion, that one swallow does not make a summer, one doctor does not represent the whole specialism in his profession and that there are many conflicting views in the specialisms that were represented on the panel?
§ Mr. Fowler
I entirely accept what my hon. Friend said. We tried to produce and provide as wide a range of specialities to deal with the problem as we conceivably could. From the beginning, I made that clear to the House and indeed, I announced the proposals to the House first. I make no apology for that because it is vital to announce proposals to the House before announcing them elsewhere. At the same time, I invited the British Medical Association to consult me. It is a matter of deep regret that it did not accept that invitation.
§ Mr. Meacher
Before the right hon. Gentleman reads Department of Health and Social Security briefs, he should ensure that he reads from the correct one. What he said had nothing to do with the question asked by his hon. Friend the Member for Hereford (Mr. Shepherd). Will he now answer the question? Does he or does he not propose to extend the principle of the limited list to other clinical areas?
§ Mr. Fowler
My hon. Friend asked whether this was the thin end of the wedge, and I said unequivocally that it was not. I shall come precisely to that point in a moment.
§ Mr. Meacher
The Secretary of State must answer what is perhaps the single most significant question in the debate: does he propose to extend the principle of the limited list to other clinical areas? Will he answer yes or no?
§ Mr. Fowler
I made it absolutely clear that I did not intend to extend the list. I gave my hon. Friend the Member for Hereford (Mr. Shepherd) that assurance. The hon. Gentleman had better calm down and listen to what is being said. Then he might get a glimmer of understanding about the debate. He made a most pathetic speech, even by his standards. Now he must relax, sit back and educate himself.
The final selected list contains about 100 drugs, compared with the 30 on the provisional list, demonstrates that we meant what we said about consultation, and that we have listened to the comments made to us. Indeed, the final list contains almost all the drugs on which substantial representations were made by doctors. Many of the changes were made for convenience—to enable patients to take more than one drug in a single medicine—or for greater palatability. But the result is that the list contains not only what is essential, but sufficient choice to ensure that it can meet the clinical needs of all patients.
The House will be aware that the selected list contains not only generic drugs, but some branded ones. That is because the chief medical officer's group advised that in some cases there was no suitable generic drug available and that we should retain a branded drug, or a number of similar branded drugs, for the time being. Wherever 694 possible, it is the generic name which will be used on prescriptions, not the brand name. That is to allow other manufacturers to bring their own generic versions of the branded drugs on to the market. That will introduce an element of price competition into the supply of medicines, for which the promotion of brand names has, until now, been the main determinant.
The regulations provide that from 1 April general medical practitioners may not prescribe at NHS expense the products listed in schedule 3A. Nor may community pharmacists and dispensing doctors dispense them. General practioners will, however, be able to issue a non-NHS prescription for schedule 3A drugs, if their patients wish it. They will not be able to charge a fee for such a prescription. Doctors will not be able to sell or dispense schedule 3A drugs, except that dispensing doctors will be able to supply and charge for those drugs to patients on their dispensing lists when they are prescribed as part of the patients' NHS treatment. For dispensing doctors the regulations will, therefore, effectively maintain the status quo and their dispensing patients will look to them for the supply of all prescribed medicines.
§ Mr. James Wallace (Orkney and Shetland)
I acknowledge that that maintains the status quo and that patients in remote rural areas will be able to get drugs which are on the so-called black list from dispensing doctors, but what message would the Minister give to dispensing doctors who find it repulsive to be brought into such a commercial relationship with their patients?
§ Mr. Fowler
With respect, I should say that we are trying to take the point that has been put to us by dispensing doctors. The Liberal party had better make up its mind before the end of the debate what it wishes to achieve for dispensing doctors in rural areas.
When I announced the final selected list last month, I explained that there were several issues about the operation of the list on which I would be ready to hold discussions with the professional interests concerned. There were two major points. First, there should be a committee of professional and independent advisers to review the contents of the list on a continuing basis. The committee will be asked to consider whether new drugs coming on to the market fall within the scope of the selected list and, if so, whether they should be added to it. It will also be asked to review the existing list on a regular basis to help to ensure that it still gives the best possible value for money. I wish to consult on the arrangements for the new committee as soon as possible, so that there is no delay in the important task of maintaining the list.
Secondly — I come to the point that was raised a moment ago—as I have already made clear, I am also ready to consider with the profession whether in exceptional circumstances doctors should be allowed to prescribe drugs not on the list when they believe their patients need them. My expert advice is that the list is comprehensive as it stands, and obviously I have accepted that advice. None the less, I have said persistently that if the profession believes that there are real problems here, I shall be ready to consider with it any proposals that it might make to overcome such difficulties. Clearly, I could not agree to exceptional arrangements that would enable a doctor simply to ignore the selected list. There must be adequate safeguards. But, given that, it should be possible to reach an agreement.
695 Perhaps I can tell the House about the latest developments here. In my statement on 21 February, and again at Question Time last Tuesday, I made it clear that I was ready to discuss this matter with the representative medical organisations. The result was that on Thursday I received a request from the general medical services committee of the British Medical Association to discuss with me an appeals mechanism. A meeting was immediately arranged, and it took place the same evening. We were agreed on several points. We agreed that any mechanism should be non-bureaucratic and should be applied locally. The crucial issue is the exact nature of the mechanism: whether it should operate on the basis of prior approval or monitoring; in what circumstances appeals should be allowed; and whether the proposed committee should be based on the local medical committees, on family practitioner committees, or on the sort of system that is common in hospitals. Clearly, we shall need some time to work out the details, but I have asked my right hon. and learned Friend the Minister for Health to convene a meeting on Wednesday this week with the general medical services committee and representatives of the Royal College of General Practitioners. That means that the matter will now be pursued with urgency. As the discussions have started at such a late stage, it will be impossible to bring any mechanism into effect from 1 April. But it will be my aim, provided that a satisfactory agreement can be reached, to introduce a system as soon as possible after 1 April.
§ Mr. Michael Meadowcroft (Leeds, West)
Since the Secretary of State has accepted the principle that, in certain circumstances, appeals might be necessary and that an override mechanism would be valuable, would it not be better to delay the implementation of the regulations until after 1 April? If it is right in principle to have an override mechanism, is it not right to delay the implementation of the regulations?
§ Mr. Fowler
I cannot accept that, and I made that entirely clear to the general medical services committee when it came to see me. I shall tell the hon. Gentleman why. I made it clear at the beginning of November, when I announced the proposals, that I was willing to talk to the general medical services committee of the BMA. I repeated that invitation frequently. The fact is that the GMSC came to see me last Thursday. I cannot take the responsibility for the delay, which was entirely the fault of the GMSC, not of the Government.
§ Mr. Beaumont-Dark
Will my right hon. Friend deal with the unscrupulous campaign carried out by some pharmaceutical companies? Will he accept from me that, of 47 letters from people who were scared that their sick relatives would be unable to receive specific drugs, having checked with the DHSS, only two proved to be justified? Is that not a case of sick advertisements being made at the expense of sick people?
§ Mr. Fowler
I shall come to that point.
I recognise the anxiety of some pharmaceutical companies about the implications of the list for their activities. As sponsor of the industry, I appreciate the enormous benefits for patients and for the country as a whole that have resulted from the existence of a strong and independent research-based pharmaceutical industry. But 696 it is unreasonable for the companies to expect the NHS to accept responsibility for providing a continuing market for all the products of all manufacturers.
We have a responsibility to be selective in order to achieve the best value for the money spent by the NHS, where that can be done without harm to patients. I should make it clear that we were selective in the groups to which we decided to apply the selected list. This is not, as some have described it, the thin end of the wedge. It is a sensible, limited measure that has enabled more Health Service resources to be applied to the development of new services.
It is important to retain a sense of proportion about the impact of the selected list on the industry as a whole. For example, the groups of drugs covered by the selected list account for little more than 10 per cent. of the United Kingdom drugs market. In any case, more than 95 per cent. of the drugs affected can be bought over the counter from a pharmacist without a prescription.
That sense of proportion—this deals with the point raised by my hon. Friend the Member for Birmingham, Selly Oak (Mr. Beaumont-Dark)—has been absent from some of the campaigning against this measure. Some of the tactics used to frighten patients have been disgraceful, and I much regret that any general practitioner should have had any part in suggesting to patients that a drug would not be available before the consultation was completed. It is easy now to see that the vast majority of those scare stories were simply untrue. To use the phrase of the hon. Member for Oldham, West, they were humbug. It is less easy to allay the unnecessary fears and anxieties that have been caused to patients during the campaigns.
One campaign especially that helped to cause those fears and anxieties was run by the Association of British Pharmaceutical Industries. The ABPI has spent about £1 million on a highly misleading series of advertisements. Its latest tactic has been to pose publicly as the defender of old people, while behind the scenes suggesting that to save money reductions could be made in the range of exemptions from prescription charges—exemptions that benefit old people more than any others. The time has come to ask the ABPI where it believes that it is leading the industry—and I speak as a supporter of the industry. It now appears to be lining up with the Labour party, whose policy it is to nationalise the drug companies. I leave it to the ABPI's members to decide whether they should have allowed themselves to be dragged into such an alliance.
The question over the campaigns goes further. We have seen a crude exercise of political pressure, advertising, poster campaigns and the rest. One company sent to all general practitioners a completely distorted standard letter on to which general practitioners were asked to put their surgery stamps before sending it to their Members of Parliament. The same stock letter warned Members of Parliament in these terms:Your reply will undoubtedly be of interest to my patients and I shall consider the best way of informing them. It may be appropriate to post a copy on my surgery notice board.That was a deeply insulting campaign, and I say to the company and to those involved that it would be a sad day for this House if such crude threats were ever to work here.
The selected list has achieved one thing—far wider recognition than ever before of the need for action on the scale and quality of prescribing. The debate that has taken 697 place over the past few months has probably been the most extensive on prescribing in the history of the National Health Service.
I should like now to build on that base — not in extending the list but in promoting other wider action on prescribing. All the professionals involved in the debate have acknowledged that there is room for more effective and economical prescribing. Therefore, I propose to convene a conference involving the relevant professional interests which will set the agenda for detailed discussions of further ways in which we can voluntarily raise prescribing standards and reduce costs. I hope to announce details of this new proposal shortly.
One of the benefits of such a conference would be to set in its proper perspective the selected list proposal. The selected list is about putting resources to better use in the Health Service while protecting the clinical needs of patients, preserving the freedom of doctors to prescribe and recognising the legitimate needs of the pharmaceutical industry.
On those grounds, I commend the regulations to the House.
§ Mr. Willie W. Hamilton (Fife, Central)
On a point of order, Mr. Deputy Speaker. You will know that there are a considerable number of Conservative Members of Parliament in the pay of the drug companies. In view of the very disparaging remarks made by the Secretary of State for Social Services about the despicable behaviour of these private enterprise companies, will you make sure that every single one of those Conservative hacks is called in this debate?
§ Mr. Deputy Speaker (Sir Paul Dean)
Because of the large number of hon. Members who wish to speak, the hon. Gentleman knows that that is bound to be beyond my power.
§ Mr. Gordon Oakes (Halton)
I agree with the Minister's remarks about the drug companies. They have waged not only a disgraceful campaign but a most inept and counter-productive campaign. We were bombarded not with a letter a day but with several letters a day from the association as well as from individual drug companies. As the Minister stated, we received letters from doctors who did not even sign those letters but merely put upon them their practice stamp. Neither I nor my hon. Friends will be influenced in any way in the view that we take tonight by that inept and counter-productive campaign.
I was more impressed by the letters I received from doctors who are genuinely concerned about their right to prescribe being undermined and about the effect that this will have upon their patients. Care and thought had obviously been put into the typed and handwritten letters that were sent to me by those doctors. However, what impressed me most were the scores of handwritten letters that I received from ordinary people in my constituency, many of them old and most of them chronically sick. Nearly all of them said that they had never before written to a Member of Parliament. They are seriously worried about their own medication being affected.
It is all very well for the hon. Member for Birmingham, Selly Oak (Mr. Beaumont-Dark) to quote figures to the House and say that many of the drugs to which he referred 698 are not blacklisted. They were originally blacklisted. Only about 30 drugs were at one time able to be prescribed. The Minister has trebled the number of drugs which can be prescribed. Therefore, one cannot blame the patients for being afraid. The patient does not read Hansard or see the list. All he knows is that the drug which his doctor correctly prescribed for him at the time will have to be paid for in future, although he cannot afford to pay for it because he is old and chronically sick. That is the kind of thing that has influenced the Opposition, not the counterproductive efforts of the drug companies.
I am a little surprised that no hon. Member has mentioned the Pharmaceutical Society of Great Britain. That society has got nothing whatever to do with the industry. It sets the examinations for pharmacists, registers pharmacists and disciplines both retail and hospital pharmacists in a way similar to that by which the Law Society disciplines the legal profession in England and Wales. Neither my hon. Friend the Member for Oldham, West (Mr. Meacher) nor the Minister saw fit to mention its views. The society is opposed in principle to the Government's proposals. In its letter to me it says:It is our view that appropriate treatment should be available without restrictions, at the time of need. It is the prescriber's responsibility to make the clinical judgment. These proposals are a further attack on the very basis of the health service.That is the view of this statutory body, the Pharmaceutical Society of Great Britain. The society is also completely opposed to the disgraceful increase in prescription charges to £2. Almost every week the National Health Service is under attack in one way or another from the Government.
The Pharmaceutical Society of Great Britain discussed with the Minister ways in which to reduce the drugs bill. The society believes that much could be achieved by the elimination of excessive prescribing. It wants prescriptions to be made available to long-term patients. However, it wonders whether the 28-day period, even as a maximum, is sensible, provided that we look after the chronically sick. Even in the case of the chronically sick the society has proposed a triple prescription scheme. This was agreed with the doctors and the medical profession generally but the Minister steadfastly sets his face against it.
The society also suggests that money could be saved if doctors used the box on the prescription form to indicate the number of days for which treatment is needed. Although the inclusion of this box on prescription forms was agreed by the professions and the Department, doctors seldom use it. Money could be saved in that way rather than by means of the bull-in-a-china-shop scheme that the Minister has put before the House today.
Generic substitution is a subject upon which people hold many different views. The society has written to me and said that it is not opposed to generic substitution. However, before giving its blessing to it, it says that pharmacists would need to be reassured by an independent sourse of the quality of the generic substitutes that would be made available. That is a perfectly fair point of view for a responsible profession to hold.
May I put one question to the Minister, which is causing great concern to the Pharmaceutical Society of Great Britain. If a doctor writes out a prescription for a blacklisted medicine it is the pharmacist who, under the regulations, will bear the financial responsibility. That is the complete opposite of the present method. The society believes that the best way to ensure that doctors write 699 correct prescriptions is to place the financial responsibility not on the pharmacist but on the doctor. That is a technical point affecting the regulations, but my main point is that the statutory body which is responsible for the registration, examination and policing of the pharmaceutical profession in this country is opposed to the Government's proposals.
§ Mr. Deputy Speaker
Order. I hope that hon. Members will follow the good example set by the right hon. Member for Halton (Mr. Oakes) because many hon. Members wish to speak.
§ Mrs. Sally Oppenheim (Gloucester)
I shall detain the House only briefly. I declare an interest in that I am on the main board of Boots plc which is affected both as a drug company and as a retailer of drugs. I shall not, however, be playing what has been referred to as the drug company game. I shall not be speaking with a forked tongue and I make it clear from the beginning that I support the regulations.
Many points have been raised by the Opposition which cloud the issues and important principles which have arisen. The principle which concerns the pharmaceutical industry is, first and foremost, whether this is the thin end of the wedge. If the Labour party came to power and nationalised the pharmaceutical industry, would widespread and wholesale generic alternatives be imposed which would not be in the patient's interests?
§ Mrs. Oppenheim
Many generic substitutes are imported. They are not made under the same quality control as drugs with proprietary names made by British companies. That is why one has to approach generic substitution with the greatest caution. That is why I urge my right hon. Friend the Secretary of State, when listening to the review committee, to pay attention to the quality control of the generic substitute drugs that are being prescribed. That is a valid and important point.
A point of principle has been raised by the doctors and, in particular, the BMA. They have got on their high horse about their clinical judgment in prescribing. Yes, fair enough, they are entitled to that because if they make a mistake they must carry the blame for it. But we must ask those same general practitioners and doctors about their clinical judgment in prescribing such things as are on the black list at the moment—raspberry tablets, buttercup syrup, rhubarb mixture, male gland double strength supplement, skin-glow capsules and rock salmon cough mixture, to name but a few.
That brings me to the main point of my right hon. Friend's objective, which to is to make available resources in the Health Service where they will be most useful. Those placebos may have some sort of psychological value —I am not saying that they have not—but it is not for the medical profession to conduct a scare campaign among patients on the basis of drugs which are being prescribed for which there are alternatives or which their patients can go into any chemist and buy without a prescription at a reasonable price.
However, it must be said that many people, not just the elderly, will be confused during the transition period by different names, different coloured tablets, and, in some 700 cases, different drugs. It is up to the medical profession not to frighten them but to reassure them that in most cases there will be no difference in the treatment. I can tell those who say that my right hon. Friend is trying to fob people off with cheap drugs that there is still an antacid on the white list which costs £96 for about 50 tablets and that is still prescribable because it is considered the best remedy. Anybody who thinks that my right hon. Friend has been partial in the way that he is trying to save money and thinks that he is trying to fob NHS patients off with cheap drugs is wrong.
I hope that my right hon. Friend will tread carefully during the transition period. I hope that he will listen quickly to any complaints from the review committee about standards and quality control and make available to the public, if possible, a list such as I believe exists in America, published by the Food and Drugs Administration, of drugs of no proven efficacy, a number of which I believe appear on the black list. That would be a constructive step which would complement the measure, which I support.
§ Mr. Donald Stewart (Western Isles)
If the Government had followed more closely the recommendations of the Greenfield report instead of going down the wrong road, we might already have arrived at a more sensible conclusion. A number of alternatives were proposed, particularly the introduction and encouragement of generic prescribing. It suggested that a box should be provided on the prescription form to enable general practitioners to show whether a branded or generic drug was desired.
It should be noted that the report also categorically rejected the idea of a limited list. But the Government, with their usual obstinacy, decided to ignore that good advice. The Greenfield committee rejected a limited list on the ground thatWe have not seen any convincing evidence that suggested financial benefits would outweigh the administrative problems in drawing up and maintaining the list.That committee is not the only body to oppose a limited list. The BMA has stated its concern that the proposal will undermine a fundamental principle of the parent NHS Act that a patient's ability to pay should not dictate the treatment that he or she receives. It has also pointed out that on 22 November 1983, after consideration of the Greenfield report, the then Minister for Health told the House:We are not convinced that such a list confining the judgment of doctors would be in the best interests of patients." —[Official Report, 22 November 1983; Vol. 49, c. 112.]In the course of a year that sound judgment has been overturned.
The Royal College of General Practitioners has also stressed its opposition to a list. Although the Minister for Health assured the House in a written answer of 21 December 1984 that the drugs still available after the first limited list had been published would "meet all clinical needs", the college rightly described the provisional list as "clinically inept".
Scottish Members have been informed by the hon. Member for Argyll and Bute (Mr. McKay), the Minister with responsibility for health matters in Scotland, in a letter of 22 February 1985, that the new revised list will 701 "meet every clinical need". I accept that the revised list is far less damaging than the original one, but I can only say that we have heard that promise somewhere before.
I share the doubts of bodies such as the BMA and the Royal College of General Practitioners that the introduction of a list will save much money. Doctors, who will obviously still regard as their first and greatest priority the effect of the drug that they will have to prescribe for their patients, will always try to prescribe the best and most effective treatment available. It may not necessarily be the cheapest alternative to a drug on the banned list.
It may be that we shall not save much money, but I am sure that it is the patients who will suffer because of the introduction of a list and those who will suffer most will be the poor and the disadvantaged.
§ Mr. Richard Tracey (Surbiton)
The right hon. Gentleman has quoted rather selectively the BMA and the Royal College of General Practitioners. Will he deal with the fact that the Royal College of Physicians, the Royal College of Surgeons and many general practitioners and pharmacists have written to hon. Members and the Government supporting the measure?
§ Mr. Stewart
Like every other hon. Member, I have received submissions and representations. It is rather odd to describe the views of the BMA and the Royal College of General Practitioners as being rather selective in a debate of this kind.
Most doctors and the bodies who represent them have nothing against the idea of generic prescribing where generic drugs of a reasonable and consistent quality are available. But the BMA in Scotland said:It should not be necessary for doctors to be required to enquire into their patient's financial status as part of the consultation before deciding what to prescribe".That brings me to a particular problem that will be faced by doctors in rural areas such as my constituency where doctors are also the dispensers of drugs. Some patients in my constituency live 60 miles from a chemist's shop. They may now have to be advised by the doctor to have a particular drug. That will put the doctor in an unfair position. It represents a fundamental and potentially damaging change in the doctor-patient relationship.
When the limited list becomes law, some of the dispensing doctors in the rural areas will be left with large stocks of expensive drugs that cannot be disposed of by sale. Small practices cannot bear the financial cost. There is no way of getting rid of the drugs, and some of the doctors will be in severe financial difficulties as a result.
What arrangements will the Government make to compensate dispensing doctors for stocks of drugs that they are unable to sell but which they have been required to stock heretofore under their obligations in the terms of service of the NHS?
I underline the total opposition of my colleague and myself in the Scottish National party to any attempt to introduce a two-tier National Health Service. The introduction of any kind of limited list is bound to lead towards that. I realise that the banned category of drugs has been curtailed since the original list was published last November. Nevertheless, I believe that, as has already been said in the debate, it is the thin end of the wedge. It 702 will mean second-class treatment for the less-well-off people. It is shameful and unacceptable, and should be strongly opposed.
§ Mrs. Jill Knight (Birmingham, Edgbaston)
I was brought up in a fairly hard and thrifty school in which waste was regarded as wicked. I believe that waste is not only wicked but very wrong, and it is never so wrong as when what is being wasted is desperately needed elsewhere.
It makes me feel sick when I hear members of the Labour party screaming for more and more money to be spent on the National Health Service, for when we seek to make savings they fight us all the way along the line.
The waste of expenditure on drugs in the NHS is a national disgrace. There are hundreds of thousands of medicine cupboards in ordinary homes throughout the country that are jammed with NHS medicines that have not been used. [Interruption.] I am sorry that Labour Members are so incredibly ignorant, because many details have been published about it.
Anyone who claims that general practitioners prescribe only what is necessary should ponder on the fact that some general practitioners give repeat prescriptions for years without ever seeing the patient. The regulations being discussed this evening may not alleviate that practice, but over the years many efforts have been made to get doctors to do something about waste in drug prescribing. Unfortunately, they have repeatedly failed to listen or to take note of the fact that the money they are wasting could be used to great benefit in another part of the NHS.
Many doctors prescribe merely to get the patient out of the consulting room. Some doctors will admit that they do that. My right hon. Friend referred to the placebo syndrome.
Some elderly patients are already receiving seven, eight or nine different drugs. Some of them have pink pills, blue pills, purple pills, heart-shaped pills, square pills and all sorts of other pills, and no one monitors them.
§ Mrs. Knight
I know that many hon. Members wish to speak and I am anxious to finish my speech, so I shall not give way.
No one monitors whether elderly people take their pills. It is very confusing for many of them to be told that they must take four pills after breakfast, seven at 11 am, seven more at lunch time, and so on. I am told by pharmacists that many elderly people, having run out of one of the seven or eight types of pill that they have to take, always return to the pharmacist and ask for the whole lot to be prescribed, whether they need them all or not. That is something that will always happen. It is largely due to the confusion that people feel when they are taking so many different drugs.
My mother had to take about seven different kinds of pills, and then she developed a duodenal ulcer. [Interruption.] I am sorry that hon. Members will not allow me to recount a personal experience that is relevant in the context of the debate. My mother had to be rushed into hospital for an operation and very nearly lost her life. The surgeon asked my father to take to the hospital any drugs that my mother had been taking. When he did so, the surgeon pointed to one of the drugs and said, "That is 703 the one that has caused the duodenal ulcer." Therefore, I question whether all the drugs prescribed in the great torrent which go down British throats are really needed.
Recently, at a meeting in this House, two working pharmacists told us of their experiences with drug prescribing. They said that it was a common practice in any pharmacy covering an average number of persons to have people coming in two or three times every week with suitcases, with bags, and sometimes with prams, full of medicines. Perhaps auntie Mary or uncle Bill had died and it was felt that the best thing to do with the drugs was to take them back to the pharmacy to see whether they could be used.
There is a campaign, which I strongly back, for the disposal of unwanted medicines and pharmaceuticals. The campaign, known as DUMP, is active in various parts of the country. There was a recent campaign in the Bradford area, and 1,950 lb of unused medicines were handed in. Those medicines were costed, and in that one region alone the cost was £170,000. We cannot go on wasting money at that rate. It is ridiculous.
My right hon. Friend and the Government have had six charges levelled against them in relation to the proposed regulations. The first is that the money saved may not be used on the NHS. My right hon. Friend exploded that allegation at once. The money that is saved will indeed be used on the NHS. [Interruption.] I know that it is painful for Labour Members to try to understand that money does not grow on trees, and that even needed medicines have to be paid for somehow. They should recognise that this is an important saving and that the money is needed elsewhere in the NHS.
The second charge is that the Government are seeking a two-tier system so that only the wealthy will be able to get the drugs they need to make them better. My right hon. Friend and others have made it clear on many occasions that the limited list will meet all medical needs, and that there is no question of a two-tier system coming into operation. Many of the fears instilled into elderly and sick people by doctors are totally unfounded.
§ Mrs. Knight
No, because I want to finish my speech.
The third charge is that the Government have refused and still refuse to consult. No one can accuse my right hon. Friend of that. There have been offers of consultation and there have been consultations. His door has been open, and time and again—[Interruption.] His door has been open—
§ Mrs. Knight
No. The hon. Gentleman has already heard what I said.
Every doctor in the country was consulted. Every one had the opportunity to make representations about the list and about what would be in the list. If the medical profession wished to consult on the—
§ Mrs. Knight
I am anxious to assist you, Mr. Deputy Speaker, in the task of calling all hon. Members who wish to speak.
My right hon. Friend the Secretary of State has also said that if the medical profession wishes to consult on the mechanism for dealing with exceptional individual problem cases, it can do so. There could be no Minister more ready to listen to what others outside have to say than my right hon. Friend, so that charge goes as well.
The charge was made that this scheme will ruin the drug companies. Indiscriminate generic prescribing would do so, and that is why those of us who are interested in this matter are aware that the Greenfield suggestions could not be introduced. We recognize — although we think that they have been wrong in the way that they have handled this campaign — that the pharmaceutical companies make a substantial contribution to our economy through exports and in medical research. The list will help, not harm, pharmaceutical companies.
The fifth charge is that this is a new, revolutionary and unique attack on the freedom to prescribe. I am sorry that Labour Members are so ignorant about this matter. They should know that nowhere in the world can doctors prescribe anything that they wish for their patients at taxpayers' expense. Hospital doctors have had similar restrictions — [HON. MEMBERS: "Reading."] If Labour Members go on like that, I shall read on for a great deal longer, and they will be sorry.
The restrictions that have always obtained —[Interruption]. Mr. Deputy Speaker, if I cannot read, I shall repeat, because Labour Members are making such a racket that I shall not be heard and what I am saying is very important.
Hospital doctors have had similar restrictions to those now being imposed on GPs. Hospital doctors have approached my right hon. Friends and myself asking why the Government do not bring in for GPs the regulations to which they have to submit in hospital. We must also bear in mind that of 17,000 drugs being prescribed reasonably regularly, only 1,000 will be affected by the list.
Finally, it is said that nobody else agrees with what is being done, in particular, none of the professional organisations. However, apart from the bodies mentioned by my right hon. Friend — the Royal College of Physicians and the Royal College of Surgeons — as agreeing with what the Government are doing, the pharmaceutical services negotiating committee, which knows a great deal about drugs, and the dispensing pharmacists agree with it because they have to work at the sharp end.
I congratulate my right hon. Friend on his patience and determination in getting together a new regulation, which will benefit the Health Service and improve prescribing.
§ Dr. Roger Thomas (Carmarthen)
We had a ray of light at the end of the Secretary of State's speech, when he said that he would set up a conference to look into various aspects of prescribing. Having listened to most of his speech, I was in a doleful mood, and I was taken a little unawares by what he was proposing. For my sake, and perhaps for others who were taken aback by what the Secretary of State said, I hope that the Minister, when he winds up, will enlarge upon that point.
705 As a general practitioner, I feel that this matter is worth investigating. Over the past 15 or 25 years, prescribing in general practice has become chaotic. It has become a quagmire. The main reason for this is that every year hundreds of preparations for family medical practitioners to use are added to the list. Every month, a book called Mims is published. It has nearly 300 pages and contains a list of between 17,000 and 20,000 preparations.
As general practitioners, we also have at our disposal a book that is published by the much maligned Association of British Pharmaceutical Industries, which is a huge tome of 16,000 pages. I would never say that therapeutics was one of my strong subjects at medical school, but at least in those days therapeutics was simple. We appreciated that there were certain confines to it, but now it has flooded over the plain. It is no longer confined to the river bed. It has flooded the whole area, which means that doctors are falling down on their job and their work. They are not able to get adequate knowledge of even 3 per cent. of the drugs that are available to them out of a list of 17,000. It is an impossible task.
We often say that Members of Parliament need research assistants. I assure the House that general practitioners as well as Members of Parliament need research assistants if they are to be able to understand the complexities of prescribing. The fault lies also in our medical education. Young doctors are not taught enough about the economics of the medical profession. It is essential that they realise the immense amount of money that they will have to spend on their patients when they qualify. It is said that on average a GP will spend about £40,000 a year on his patients. That is a tremendous amount of money, but the pressures on GPs through the activities of the pharmaceutical industries — they have magnificent techniques — are immense. Saatchi and Saatchi are duplicated many times within the pharmaceutical industry. Doctors become victims of calculated advertising techniques used to put across the highlights of the properties of certain drugs to the detriment of other drugs.
At the front of the vast book published by the pharmaceutical industry is a little warning that medical representatives should not knock the products of rival firms. However, some medical representatives do not stick to the Queensberry rules in this matter.
I am one of those who feel that, for the sake of bringing a degree of rationality back into prescribing, we must have limited lists, but not limits that are pushed through at the behest of Ministers in the Elephant and Castle, who feel that it is high time that they delivered a sharp left and gave the medical profession a bloody nose. They tried to do that about the introduction of substitute doctors, but they had to retreat. They tried to do it with a limited list of drugs which could be prescribed, when they listed 30 and had to expand it fourfold.
What has gone wrong here is that this method should have been rehearsed. There should have been consultations with all branches of the pharmaceutical, medical and paramedical professions. At the end of the day, I am sure that we could all have agreed a method to bring some rationality to prescribing and, by so doing, increasing the safety of our patients.
I have great sympathy with what the hon. Member for Birmingham, Edgbaston (Mrs. Knight) said about elderly people who are on eight or nine different drugs. This form 706 of polypharmacy is one of the curses of the medical profession. What we do not appreciate is that often these drugs have adverse effects one upon the other. Until we research them, we are on very unsafe ground.
In advocating a limited list I suggest to the Minister that most certainly he should extend it if there are savings to be made and if those savings can be translated into extra cardiac surgery, extra renal dialysis, and so on. But we must make sure that if these savings are to be made, they are not made at the expense of the poor patient. They must be made at the expense of the drug companies, because they are still the people who will benefit.
By all means have limited lists. However, I cannot help feeling that the proposals before the House are little more than window dressing. I ask Ministers to go to the heart of the matter. In that way, they will have far more support in the House and throughout the country.
§ Sir Dudley Smith (Warwick and Leamington)
My right hon. Friend the Secretary of State did not disguise the fact that there had been real problems in getting this list together and before the House. I suggest that that is very much of his Department's own making. In fact, we heard a great deal from my right hon. Friend about the refusal to co-operate and to discuss the subject. I am indebted to the British Medical Association, which wrote to me only yesterday saying:Neither Ministers nor officials have communicated, consulted or discussed prescribing … with us since 4 February 1983, despite our sending detailed comments on Greenfield to the Department on 25 February 1983.That is the answer. Perhaps the BMA was wrong to sulk in its tent, but it was understandable. It is a complete disgrace that neither Ministers nor officials took into their confidence a great organisation such as the BMA.
I declare an interest. It is well known in the House that I have been associated with the British pharmaceutical industry for nearly 20 years. At one stage in my life, I worked in it full time. I also advise a number of companies involved in pharmaceuticals. However, that does not debar me from speaking what I believe to be the absolute truth in these circumstances.
I am against the regulations for two basic reasons. The first is that they erode the prescribing independence of members of the medical profession. The position has improved since the initial shock of that rather absurd list introduced the first time round, which bore no relation to reality. Thank goodness, it has been improved upon. However, I fear that future health Ministers of whatever political persuasion will undoubtedly wish to undermine that freedom further as time goes by, ostensibly in the name of economy but probably in reality for more bureaucratic reasons.
§ Mr. Greenway
Does my hon. Friend agree that, above all, there must be no inclusion on any list which results in tampering with the right to prescribe drugs, such as life-saving antibiotics, preparations for the treatment of arthritis, and so on? It could happen.
§ Sir Dudley Smith
My hon. Friend is right, and that is my point. It may be that some of what we are dealing with today is trivial. We all know of so-called drugs which have not been prescribed for years. They have been on lists, but they are, to all intents and purposes, dead. They present no problem. I have asked a number of 707 parliamentary questions about them. There is no information available on them. However, when we come to the life-savers, who is to say that a future Health Minster will not lay down his diktat to members of the medical profession and tell them exactly what they can and cannot do?
My second objection is that the regulations do great harm to one of our really successful industries which we can ill afford to damage. We have not got so many industries which are successful. Here is one which has been a winner. I do not suggest for a moment that it should not be kept in control and that there should not be proper supervision because of its unique relationship with the Department of Health and Social Security, but I believe that this is not the way to do it.
My right hon. Friend said that his Department was the sponsoring Department of the pharmaceutical industry. Listening to some of the remarks in this debate, one would have thought that my right hon. Friend was its main enemy.
§ Mr. Douglas Hogg (Grantham)
My hon. Friend says that this proposal is very damaging to the drug industry. I have some difficulty in understanding that.
§ Mr. Hogg
I was putting a specific question to my hon. Friend the Member for Warwick and Leamington (Sir D. Smith), which I am sure he will treat more seriously than my hon. Friend the Member for Macclesfield (Mr. Winterton). My hon. Friend the Member for Warwick and Leamington said that the proposal was very damagingߞ
§ Mr. Hogg
We know that these seven classes apply only to 10 per cent. of the drugs prescribed. Bearing in mind the exemptions, which cover about 70 per cent. of the drugs prescribed, and the fact that pharmaceuticals enjoy an international market, I do not see why the proposals should damage the industry.
§ Sir Dudley Smith
It is true that the industry is not being swept aside. No one could pretend that. However, a number of companies will be affected quite seriously. Their production is being eroded. If I am not interrupted too many times, I shall give my hon. Friend a few figures which may help bring him on to my side. I shall not give way again, because that was a rather long intervention, from various sources.
708 There must be effects on the profitability of the various companies which operate in the United Kingdom. The move will depress the industry and undoubtedly it will curb its expansion and hamper its sales. The pharmaceutical industry has a very good export record. But, worst of all, the regulations will make those responsible for the industry, particularly the multinational companies, think very hard about the wisdom of further investment in the United Kingdom, especially where original research is concerned. We should not lightly dismiss that point.
My ministerial colleagues at the DHSS may feel that the regulations will be carried, and no doubt they are right. My only regret is that too many of my right hon. and hon. Friends do not fully understand this very complex matter. I make no criticism of that, as the subject is very complex. However, I can assure my colleagues that, although they may well demonstrate their ministerial virility, the whole sorry episode will be long remembered. If the pharmaceutical industry in this country eventually declines, they will have to carry that unhappy tag of responsibility with them for many years. They will have been the architects of its decline—
§ Sir Dudley Smith
I shall not give way, as I do not wish to speak for too long. In such a debate, giving way to interventions can encourage others to make further interventions, and the hon. Member speaking is left up in the air.
The United Kingdom's pharmaceutical industry is one of the most highly developed and rapidly growing sectors of British manufacturing industry. That perhaps is the answer to my hon. Friend the Member for Grantham (Mr. Hogg). The majority of companies that operate in the United Kingdom operate worldwide. Until now, they have regarded the United Kingdom as pretty enlightened. The industry employs about 75,000 people, and no other industry in the United Kingdom has a higher proportion of qualified scientific staff.
The price of medicines has always been an easy target in this country compared with the cuts that could be made in more sensitive areas, and particularly in NHS staffing. That is where the major costs are, as can be seen from looking at the figures that my right hon. Friend the Secretary of State gave. Although I was not particularly enchanted with the speech of the hon. Member for Oldham, West (Mr. Meacher), it was true when he said that general practitioners in this country are at the bottom of the spending league per head of the population. The United States is at the top with 16.6 prescription items per capita, and then the league goes right down to Italy, West Germany, and France. Australia is just above the United Kingdom with 7.7 items, and the United Kingdom has 6.9 items per capita. Therefore, we have nothing to be ashamed about in terms of the amount of money involved in the pharmaceutical products dispensed by doctors operating within the NHS.
I say to my hon. Friend the Member for Grantham that a recent survey showed that the Government's limited list proposals have been responsible for investment projects to the value of £143 million in pharmaceutical production or research being either cancelled or postponed since last November. It may be a "limited" list, but it is the thin end of the wedge. If £143 million have been lost, what will be lost next year and the year after that? We need to pay 709 attention to that point. We have had great economic trouble in this country. I support the Government, and believe that they are doing the right thing in that respect, but I shall vote against them tonight because this is a crass move on their part.
We very much need to take account of the experience of other countries. I think of the sorry story of the Australian pharmaceutical industry. It was clobbered very hard and there was excessive state intervention in Australia. As a result, many companies were driven away, and the Australian pharmaceutical industry is now nothing compared with what it used to be, to the detriment of Australian residents. We must be very careful that that does not happen here. We have taken the first step. Let it be the only step, and let us ensure that in future we attend to things rather more circumspectly than in this case.
§ 9.3 pm
§ Mr. Michael Meadowcroft (Leeds, West)
The Government seem to have an infinite capacity to botch good ideas. In their passionate haste to implement the limited list they have introduced a statutory instrument that is defective on one major and two minor grounds. Without the assurance that my right hon. and hon. Friends and I have asked for on the vital question of an appeal or of some override, we shall be unable to support the regulations.
I turn first to the whole principle of prescribing by a limited list. If any assessment were made of the political line-up on this issue, one would have expected to find a Labour Secretary of State introducing the measure on the ground of curbing the excesses of the drug industry, and one would have expected it to be opposed vehemently by a Conservative Secretary of State, defending the commercial interests involved. Indeed, I cannot see why Conservative Members are so concerned about the advertising campaign that has been launched by the ABPI if they believe that the object of private enterprise is to maximise profits and the amount of cash that comes in from profit-making enterprises.
The concept of a limited list for good prescribing challenges two well worn and deeply held beliefs about the nation's health. The Government deserve some commendation for their courage in standing up to the twin spectres of clinical freedom for GPs and the limitless expectations of health resources. They might appear to be self-evident truths, but they inhibit new attitudes to healthy living and the power of any health service to assist.
In the health sphere, more than any other, expectations grossly outrun resources. There is a case for higher NHS spending, particularly to buy time until new attitudes can be implemented, but at any level the treatment of the sick is intrinsically constrained by infinite resources. Whatever limit one sets for NHS spending, and however far one wishes to extend spending, it is impossible to deal with what everybody expects or to cope with the demands made upon it.
The trouble is that the limits are currently imposed in random and illogical ways. For instance, GPs can prescribe and order treatment regardless of cost, but if the district health authority has to reduce its staff or equipment the patients' freedom is eclipsed by the waiting list. It is odd and illogical to try to inhibit clinical freedom by the blunt instrument of the waiting list. In practice, inevitably, 710 the glamorous side of the NHS gains a disproportionate amount of resources and the preventive side — the geriatric and mental handicap work—suffers.
Those involved in other services that we have to support from public resources such as housing, education and social services do not believe that whatever invention comes on to the market should be available to all. Alas, that is the general expectation within the Health Service. It is intellectual and political cowardice to continue as we have over 10 years of declining national resources. No Government of any political colour will be able to continue in that way.
The key is in allocating finite resources to achieve the greatest benefit for the greatest number. The limited list is a conscious decision to change from prescribing expensively for the few to improving the health of the many.
I cannot understand why the Government should have decided to put up prescription charges by such a draconian amount at the same time as trying to save money through the limited list. The Government say that they might save £75 million by the limited list. I doubt that sum, but to pretend that they then should raise £19 million by increasing prescription charges is a ham-fisted way to argue about the public's health.
The family practitioner committees' drugs bill is open-ended and demand-led. There is little incentive to prescribe generically or economically. Alas, GPs are excessively influenced by drug companies' advertising. Surveys show that drugs that are currently advertised in the press are those that are most often prescribed out of order with the general run of prescribing.
§ Mrs. McCurley
The popular drugs that are often heavily subsidised and advertised are quite effective. When a drug is not effective general practitioners and other practitioners of the medical arts cease to use it and it is withdrawn from circulation by the drug companies.
§ Mr. Meadowcroft
I wish that that were true generally. The suggestion is that advertising by the drug companies leads doctors to prescribe drugs simply because of their novelty value. We are pressed to accept that doctors prescribe because of careful scrutiny of the thousands of drugs available. Alas, the evidence does not bear that out.
The overspend on the notional budget for GPs is taken off the hospital budget which causes more spending to be thrown back on the family practitioner committees. The hospitals have automatically and voluntarily adopted generic substitution and their own limited lists. The financial benefits may be limited, and possibly not anything like that predicted by the Secretary of State. However, at least it is something that challenges the belief that we can simply continue to pour more and more money into the NHS and thereby gain continuing advantage.
It is important to challenge the attitude towards the use of drugs. The current edition of World Health Forum, the magazine of the World Health Organisation, states bluntly that:Throughout the world, unnecessary drugs are prescribed for self-limiting conditions. Sometimes the physician uses the prescription as a substitute for counselling or to satisfy the expectations of the patient. Usually it is a mixture of the two, where both doctor and patient have come to see a prescription as an essential outcome of the visit. The most common examples are antibiotics for the common cold, sedatives for mild insomnia and vitamins for nearly everything.711 Faced with that, something needs to be done about some form of limitation on prescribing.
The view that a prescription is a substitute for doctors' advice, sympathy and expertise is not only illusory but harmful. One of the problems of our modern age is the tremendous dependence on professionalism and expertise as a belief that they can actually do more than they can. Ivan Illich's polemic about the overestimation of the powers of the health services deals with the failure to come to terms with genuine health care. He says:The pharmaceutical invasion leads industrialised man to medication by himself or by others that reduces his ability to cope with a body for which he himself can still care.A MORI poll last month showed that 3.5 million adults — 8 per cent. of the population — have taken tranquillisers for more than four months at some time in their lives.
§ Dr. M. S. Miller
The hon. Gentleman is not doing justice to the experts. He is not in the medical profession, so he does not accept that medical students, in their training, are taught from the beginning that sometimes the best form of treatment is masterly inactivity. I assure the hon. Gentleman that doctors keep that uppermost in their minds. Nearly every doctor I know clearly tells the patient that it is his own defences that will cure him. All that the doctor can do is to give a little assistance.
§ Mr. Meadowcroft
Doctors who take that attitude are precisely those who do not need the encouragement of the proposals—it is the other doctors for whom the list is important.
Pharmacists have told me that on one prescription for one patient there has been prescribed an anti-diarrhoeal and a laxative, or an antussin and an expectorant. That is ludicrous. We are aiming to deal not with the good doctors but those who overprescribe or who see a prescription as a means of getting a patient out of the surgery. The NHS, regardless of the resources made available to it, can be expected only to supply what patients need and not what patients want.
The matter of dispensing doctors has already been mentioned. If those who live in urban areas can obtain what they want because they have access to a pharmacy, it would be illogical to say that those who do not live in urban areas cannot receive what they want because they have to obtain it from a dispensing doctor. I appreciate the Secretary of State's point in putting the commercial problem before doctors, but I see no way around that unless he intends to do something about all two-tier medicine. There cannot be a differentiation between rural and urban areas.
The ability of drugs to improve health is constantly being challenged by efforts to improve preventive medicine— healthier eating, nutritional food labelling, well woman clinics, and so on. The Consumers Association publication, "The Wrong Kind of Medicine?" is crucial to understanding those efforts. The author, Charles Medawar, writes:The benefits of our huge drug list are essentially to do with trade, not health. The advantages of a restricted drug list include having fewer bad drugs and a reduction in drug-induced disease; and better information about drug use and less confusion about which drugs to use.If this were a Bill, I should have no problem in voting for its Second Reading and seeking to amend it in Committee, but it is not a Bill and the regulations as they stand are defective. First, they do not deal with the 712 problem of patent life, which will have to be faced if this principle is extended to other categories. If the Government believe that it is right in principle to limit prescribing in some categories, I cannot see why they say that they do not wish to extend it to other categories. If it proves effective in this regard, it seems inevitable that it will be extended to other categories. To deal with the drug companies' research problem at the same time as extending the categories it would be necessary to extend the patent life of drugs so as not to inhibit research.
Secondly, the regulations do not deal with pharmacists' remuneration, which will be significantly affected if the proposals are effective. A GP who tries to prescribe as little as possible and to prescribe generically has told me that the pharmacist across the road from his surgery told him that, although he agrees with the doctors' approach, it is putting him out of business because the method of remuneration for pharmacists is not adequate to cope with the proposed changes.
The most significant defect, however, is that no appeal mechanism is likely to be in operation when the regulations come into operation. My hon. Friend the Member for Berwick-upon-Tweed (Mr. Beith) raised this at DHSS Question Time last Tuesday and said that it would help alliance Members to support the regulations if the Secretary of State would give an undertaking that an override mechanism would be in place when the regulations came into force. No such undertaking has been given and I do not see why the Secretary of State should shelter behind his desire to force the BMA to negotiate with him on this. Once he accepts the possibility that the list may not be complete he ought to delay its implementation until an appeal procedure is in place.
A list may be 95 per cent. or even 99 per cent. comprehensive and satisfactory, but if one cannot claim that it is 100 per cent. correct an override mechanism is essential. I believe that every other national limited list has such a machanism as part and parcel of its operation. The key principle of the NHS, providing for need, means that such a mechanism is crucial. If the Secretary of State would delay implementation until such a mechanism is in place, we could support the proposals, but we cannot support the way in which the Government have introduced the measure although the principle behind it is to be commended.
§ Mr. Jonathan Aitken (Thanet, South)
I am pleased to follow the hon. Member for Leeds, West (Mr. Meadowcroft), not least because it was a relief to return to the real issues and to thoughtful debate after the somewhat hysterical and at times unintentionally hilarious opening comments from the Labour Front Bench.
I agreed with much of what the hon. Gentleman said, but I part company with him in his failure to understand why some Conservative Members were concerned about the ABPI campaign. Only a few weeks after the initial announcement by my right hon. Friend the Secretary of State, Members in all parts of the House were caught in the crossfire of what was nothing less than a propaganda war. As the saying goes, in all wars truth is the first casualty, and I believe that it has been the need to sort out truth from fiction which has led to parts of today's debate being somewhat overheated.
The parliamentary lobbying campaign set new and dangerous precedents. The first shots in the propaganda 713 war were fired by the ABPI. However, I believe that the pharmaceutical industry—for which the ABPI purports to speak—has a somewhat better case than the one so far made on its behalf in an entirely counter-productive advertising campaign. The leaders of the ABPI seem to have been infected throughout that campaign by Scargillitis. In matters of exaggeration, hyperbole, and, at times, misrepresentation, the only difference between the ABPI and the NUM is one of degree, not of principle.
Against that background of propaganda, I am glad that my right hon. Friend stood firm against the tidal wave of pressure unleashed against his proposals. I am glad that megaphone lobbying is to be defeated in tonight's vote. I am glad that our Ministers have the common sense to hold the ring between competing interest groups. They have done their job well. They have struck just about the right balance between the interests of the pharmaceutical industry, the concerns of the medical profession, the need to make efficient use of the resources of the NHS, which the hon. Member for Leeds, West rightly identified as the kernel of the matter, and, above all, the worries of patients — the least vocal but most important group to be affected by the regulations.
I have a constituency interest in the pharmaceutical industry.
§ Mr. Aitken
At his age, the hon. Gentleman should be able to see the difference between a constituency interest and a financial interest.
My constituency contains the great pharmaceutical company of Pfizers — a well-managed and successful company that employs 1,500 people in an area where jobs are precious.
§ Mr. Aitken
Pfizers is not one of the worst. To all intents and purposes, Pfizers is unaffected by these regulations. Its total sales of some £70 million a year could be affected to the tune of about £250,000 a year. The impact will be infinitesimal.
Pfizers is a good company. It invests regularly every year and its sales and exports increase every year. Last year it invested more than £10 million in its plant at Sandwich, a large part of which was spent on the new research department which my right hon. Friend very kindly came to open.
§ Dr. M. S. Miller
Does not the hon. Gentleman take seriously the possibility of Pfizers not going ahead with a £20 million development, to which the representatives of Pfizers have referred?
§ Mr. Aitken
I take that possibility extremely seriously. I am glad that the hon. Gentleman, like myself, appears to take some cognisance of the good case for the pharmaceutical industry.
As Pfizers is largely unaffected by the regulations, one might expect the company to be somewhat laid back about them, but it is deeply concerned about what it describes as the wider picture of the growing climate of hostility towards drug companies. Even making allowances for a degree of multinational paranoia, it should be noted that there is a degree of hostility towards the drug companies 714 in this country, although not, I believe, within the Government. It certainly exists on the Opposition Benches. For example, the hon. Member for Oldham, West (Mr. Meacher) was quoted in The Observer yesterday as making some remarks that reek of ignorant prejudice, accusing the drug companies of "ripping off' the NHS because they are allowed a return of 16 per cent. on their investment. In fact the drug companies, which are operating in what is undoubtedly a high-risk business, have suffered four compulsory price reductions via the pharmaceutical price reduction scheme in the past three years and are now only allowed to make profits — on those of their products that are successful — at a level smaller than those that the Government allow to companies in the defence industries. No great bonanza is taking place.
Pfizers regards the regulations as part of a wider picture that causes concern. The company sees business becoming more difficult; the Government becoming more interventionist; and confidence declining. One local sign of the state of confidence is that, as the hon. Member for East Kilbride (Dr. Miller) has pointed out, Pfizers' current plan to build a £15 million pharmaceutical finishing plant at Sandwich is in jeopardy and has a large question mark hanging over it.
When drawing my right hon. Friend's attention to these anxieties, I am not for a moment suggesting that he is wrong or was wrong about the limited list, but that business confidence — and the investment and employment that go with it — is a fragile plant in today's pharmaceutical industry. We need a strong manufacturing base and do not want it eroded. When the dust of this battle has settled, my right hon. Friend the Secretary of State and my right hon. and learned Friend the Minister should consider some confidence-building measures for this great industry. It needs some reassurance beyond the time-honoured parliamentary phrase, "I have no plans to do so at present." We need some assurance that the limited list is not the thin end of the wedge and that large extensions of it are not envisaged.
I hope that my right hon. Friend will examine other means of increasing confidence in the industry. For example, he might consider some recent United States legislation on patent term restoration and extension to see whether we might benefit from similar measures. Just because the ABPI has made an enormous hash of its propaganda, we should not lose sight of the fact that it is strongly in our national interest to have a strong, vigorous and healthy pharmaceutical industry.
§ Mr. Nicholas Winterton
My hon. Friend has rightly mentioned Pfizer. Does he agree that one of the most successful pharmaceutical companies — Imperial Chemical Industries — which is also unaffected by the proposed limited list, is also in principle totally opposed to what the Government are doing, as it believes that it will be damaging to its future investment and the additional employment that it could create?
§ Mr. Aitken
When I hear phrases such as "totally opposed", I can hardly believe that the rather modest nature of the limited list is enough to trigger such enormous opposition.
§ Mr. Aitken
My hon. Friend has made his point. We must try to see the issue in the proportion that it deserves.
715 I am sad that leaders of the British Medical Association have had their moments of going over the top at their end of the propaganda war. When I recently heard Dr. John Marks, the chairman of the BMA, solemnly telling BBC television viewers that it is only a matter of time before amputation patients would be compelled to wear Fowler artificial limbs, I realised that the clock at Tavistock square had struck 13 and that the BMA too had got a touch of Scargillitis.
Members of the BMA are much more sensible than their leadership. Of course there are anxieties but, with few exceptions, doctors in Thanet tp whom I have spoken are not in outright opposition to the plans. That is logical, for in medical terms there is no great issue of principle here. All the slogans about the end of clinical freedom and the beginnings of a two-tier NHS do not stand up to serious examination when one studies the limited list. It is a modest proposal. However, there are lingering doubts among doctors on, for example, how to discharge responsibilities to special case patients such as the terminally ill patient who may be dependent on one sedative or analgesic. I am glad that the appeals procedure is likely to take care of that.
Above all, there is a vague general worry that the regulations are a first step on the road to more centrally directed prescribing restrictions. My right hon. Friend's assurance should put an end to some of those worries.
The key issue is the efficient deployment of resources in the NHS. We should all recognise that £75 million worth of savings on the drugs bill is money badly needed in other areas of health priority. If the Beecham's powders and the male sex hormones on the list have now to be bought over the counter so that patients can have more kidney machines—
§ Mr. Aitken
—more ventilators for premature babies and more and better arrangements for cervical screening, most patients will recognise and accept the trade off, whatever the pressure groups and lobbyists may say. My right hon. Friend has a duty to be a good housekeeper for the patients of the NHS. That is a great deal better than being a parrot for the ABPI, which is what the hon. Member for Oldham, West was today. In a world of finite resources, good housekeeping means difficult choices about areas of priority. Nearly every other country has some form of limited prescribing to keep its drugs bills in check and to get health priorities right. My right hon. Friend has got it just about right.
§ Dr. M. S. Miller (East Kilbride)
The Secretary of State and the.hon. Member for Thanet, South (Mr. Aitken) complained about the ABPI campaign, but surely they are both seasoned enough Members to be able to relegate such propaganda activity to its proper position. I must have received as much information from the industry as anyone else, but I did not read it, and I relegated most of it to the place where it belonged. However, the industry had every right to lobby hon. Members, and I did not notice the Secretary of State or the hon. Member for Thanet, South complaining when the National Coal Board went overboard with its advertisements during the miners' strike or when other organisations, such as British Telecommunications, went overboard.
716 I have no pecuniary interest in the drugs industry, but I jump to the defence of the underdog. Conservative Members may not regard the ABPI as an underdog, but the Government are prepared to emasculate the trade unions and they did not blink a collective eyelid at spending £4 billion to bring down the miners. Any organisation that wishes to withstand the Government's might needs a bit of help.
The Secretary of State made great play of the fact that my hon. Friend the Member for Oldham, West (Mr. Meacher) did not leap to the attack when the Government announced their intentions. Perhaps, like me, my hon. Friend did not believe that the Secretary of State would go ahead with his ridiculous scheme. The hon. Members for Thanet, South and for Leeds, West (Mr. Meadowcroft) described the scheme as a mouse of a proposal. I am not opposed to a clean-up of the methods of prescribing, but this is not the way to do it.
The Secretary of State said that the drugs bill amounted to £1,500 million out of a total NHS budget of £17 billion. In percentage terms, that is a reduction. When I was in practice, the drugs bill was 50 per cent. more than what was paid to doctors. Drugs accounted for 12 per cent of total costs and doctors for 8 per cent.
Conservative Members have said that no country can afford to produce for its citizens an unlimited list of drugs. But there has not been such a list in this country for at least 25 years. When the NHS started, it was said that there would be an unlimited list, and doctors used to prescribe Ribena and many other commodities that were not drugs. However, that soon stopped and we have settled into a pattern. It may not have been entirely satisfactory, but we do not live in a perfect world. Expecting a cohesive system in the NHS, without any waste, is expecting the impossible. One has only to compare the British Health Service with health provisions in other countries—they are not services—to find that in every way ours is less expensive than that of any other country in the western world.
§ Mr. Tracey
I recognise the hon. Gentleman's knowledge of this matter, but the 1983 Labour party manifesto stated that the Labour party would seek to make drugs more economic. Will the hon. Gentleman explain what that means in the light of what he has just said?
§ Dr. Miller
I shall come to some aspects of that shortly. If the hon. Gentleman is not then satisfied, I invite him to question me again.
I do not understand why the Government embarked on this matter, creating such antipathy to it from the medical profession and causing patients a great deal of anxiety. I accept that drug firms may have gone overboard in fostering that anxiety, but it was started by the Government's stated intentions.
There are other ways of reducing the drugs bill. I am not opposed to reducing the cost of drugs to the country. Other ways include careful monitoring of prices, checking research and development costs, allowing for the reasonable recouping of the costs of research and development, watching carefully, and having consultations with drug firms and the medical profession. Sometimes it would be a good idea also to consult patients.
As the hon. Member for Thanet, South pointed out, profits have been cut four times already. Why not use that system? Why embark on this sort of activity which, 717 whether Conservative Members like it or not, creates a two-tier system? It is all very well to say that many drugs can be bought for less than the prescription charge, especially when the prescription charge is raised to £2, but people on supplementary benefit do not pay prescription charges and they will have to pay for these drugs, if they want them.
I am in favour of a campaign to persuade the medical profession to prescribe generic drugs as far as possible, but we should persuade, not force, it to do so. It should certainly not be done by substitution. The practitioner, not the pharmacist, must write the prescription and state what medicines he wants for his patients.
We must be careful where drugs are manufactured. Generic drugs can be manufactured in parts of the world which cause headlines, such as that which appeared in the The Observer yesterday. It stated:Wave of killer capsules sweeps the Third world.We know that can happen. The article states:Growing quantities of faked antibiotics—potentially lethal to those who take them—are being smuggled into Africa and other parts of the third world.These "killer capsules" are being manufactured in places as far apart as Taiwan and South Korea. We must be extremely careful about that when we buy generic drugs. It is possible to embark on a policy of generic drugs, but we have a highly responsible and large drugs industry, and the Government may be putting it at risk.
The issue of polypharmacy — of people taking medicines which they may not need or the effects of which are not well established—has been referred to obliquely. Doctors prescribe for some patients who take drugs because of the psychological factor in treatment. I must emphasise that this is an extremely important element in the treatment of patients. As I said in an intervention in the speech of the hon. Member for Leeds, West, doctors try not to prescribe potent or potentially dangerous medicines.
I should draw to the attention of the House an interesting article on this subject which appeared in last week's General Practitioner. It talks about placebos, which are often prescribed. The doctor who wrote the article describes his patient as a pleasant middle-aged woman who, five and a half years ago, was diagnosed as a hypertensive. He said:She had been registered in another practice and her raised blood pressure had been picked up at their `NIRC hypertension trial' screening clinic.It was a Medical Research Council trial screening clinic. After she was discovered to have significantly raised readings, she was started on treatment in a double-blind trial. That meant that neither the doctor nor the patient knew what drug the patient was receiving. It was either a placebo or an anti-hypertensive drug.
The doctor continued:When she left the practice area and registered with me, her previous GP dropped me a line to say that as the five years on the trial was up, they had broken the double-blind code and had discovered that she had been taking a placebo, and that this could obviously be discontinued at an appropriate time. An appropriate time presented itself a few days later when she turned up to see me to get a repeat supply of her tablets. I took her blood pressure"—which was normal at 125/80—told her I had been in touch with her previous doctor, and that we both felt her blood pressure had settled so well that she could 718 probably try without her treatment. She seemed quite happy with this, stopped taking the tablets, and arranged to see me after a month for a check up.Then the doctor said:You've guessed it. Her blood pressure after a month off the placebo was 195/110. I waited a week and checked again. 190/110. There was no doubt about it, she needed treatment again. When I told her this she wasn't in the least surprised, told me her tablets had suited her so well and had made her feel so much better that she would like to go back on the same ones now.He gave her the same tablets, and her blood pressure went down again.
Another case is even more intriguing, but I shall not labour the point. This is something that doctors see time and again. Incidentally, that doctor had a good recommendation to make to the Secretary of State. He believes that a proportion of patients should be given placebos and that some of them will get well. I do not say that I agree with him.
The list has some ludicrous aspects. For example, one drug on the list is called Capramin; another drug, which is exactly the same and cheaper, is not on the list. One wonders why there should be such discrimination.
The doctor-patient relationship is precious, and Conservative Members will accept that it must be fostered. The British medical profession in not a business as it is in the United States. There is no incentive in Britain to give patients treatment that they do not need, because no money is involved. The doctor gets the same capitation fee from the Health Service whatever he prescribes for his patient.
Let there be limits but very generous limits within which the doctor should be permitted to prescribe. The doctor's freedom to prescribe what he believes to be best for his patient should be paramount. At the end of the day it is the patient in this relationship who matters.
§ Mr. Nicholls
On a point of order, Mr. Deputy Speaker. While placebos are being discussed, should it not be pointed out that there are no hon. Members sitting on the Liberal Benches, despite their great interest in this matter, and that they have not been in their place for a considerable period of time?
§ Mr. Michael Morris (Northampton, South)
It is always a pleasure to follow the hon. Member for East Kilbride (Dr. Miller). He held the attention of the House by emphasising the importance of the patient-doctor relationship. Before I go any further, I should like to declare an interest. Long before the limited list was drawn up I was an adviser to two pharmaceutical companies and I have been married for 24½ years to a dispensing practitioner who is a senior partner in a group practice. I have lived with this industry and the doctor-patient relationship for as long as any hon. Member. May I also pay tribute to Ministers and officials for the courtesy I have received in all the representations that have been made to them. It is right that that fact should be placed on the record.
Originally savings of £100 million were looked for. Those savings have now been reduced to £75 million. Ministers said from the start that there had been extensive consultations following the Greenfield report. The statement made on 8 November by my right hon. Friend came like a bolt from the blue to the Opposition, Conservative Members, the British Medical Association, the pharmaceutical industry, the community health 719 councils and to everybody who takes an interest in medicine in the United Kingdom. At that time my right hon. Friend said that the initial list was open to discussion and that he would give everybody 12 weeks, including Christmas, in which to put forward proposals to modify the list. However, he said that we would not be told what the criteria for that modification would be. When I asked my right hon. Friend about the extensive reports that had been undertaken overseas, I was told that they were confidential to the countries concerned. Some of us were a little sceptical and thought that this was because holes would be found in the reports if they were published.
Ministers also said on 8 November that they had not decided how the review was to be carried out. However, after further reflection an independent review body was set up. There was already in existence the Committee on Safety of Medicines and the Committee on Review of Medicines. A number of other medical organisations were in existence but our party had to set up yet another quango, despite the fact that the Government's own medical advisory committee had recommended against the whole concept. But even that quango was not set up properly. After it had been set up somebody remembered that one-fifth of the savings were to come from benzodiazepenes and that there was no psychiatrist on the panel. He was appointed immediately.
What happened is almost history but the proposals produced the biggest adverse reaction from the pharmaceutical industry, doctors, community health councils and patients that this country has ever seen since the introduction of the National Health Service. Everything stopped for the limited list. Representations were made that it should be abandoned. People flew in from the United States and Europe. Members of the Social Audit and the World Health Organisation rubbed their hands in glee as they saw true Socialism being put into practice.
The consultation period resulted in the limited list being extended from 31 to just over 100 products. The new list bears so little resemblance to the initial list as to make the mind boggle. I ask seriously what possible faith can Members of Parliament, doctors, patients or anybody who takes an interest in medicine in Britain have in the chief medical officer and those who advised my right hon. Friend the Secretary of State on the initial list. Presumably it was not a cockshy; it was meant to be a serious suggestion for a limited list. If it was not, it is a disgrace that it was put forward in the first place.
Now we have a better limited list. By definition, it cannot meet all clinical needs. Every hon. Member who has spoken is right. It may meet 98 or 99 per cent., but it cannot meet 100 per cent. of clinical need.
My right hon. Friends on the Front Bench may be asking why I will not accept the new extended limited list. Let me try and explain. First, it removes clinical freedom from general practitioners. Aneurin Bevan was sensible enough when he set up the NHS to recognise that that was one of the basic principles of a successful doctor-patient relationship.
Secondly, the list is supposed to save £75 million. It will not. Look what has happened in Germany which has a comparable system. The Germans are not fools. They are every bit as efficient as we are in the United Kingdom and in most cases a darn sight more efficient. They set themselves a target of savings of over 500 million deutschmarks. They achieved 50 per cent. of that. They 720 are not idiots in Canada, either. They set themselves a target and they achieved about 50 per cent. of that. What did Holland find? They found that costs rose and they have abandoned the section similar to our limited list. No, we shall not obtain savings anywhere near the figure that is talked about.
I hope that when my right hon. and learned Friend the Minister for Health replies he will explain in some detail what monitoring he will do on the limited list to demonstrate the savings. Some of us will be looking carefully to make sure that the savings on the pharmaceutical prices regulations scheme are not transferred across to the savings that are sought on the limited list.
Thirdly, there is the point about the fallback position. The hospital formularies have such a position, as has been said. I was astounded when I heard my right hon Friend say—I hope that I quote him correctly—that because the BMA has not consulted him he is not in a position tonight, nor will he be on 1 April, to announce a fallback position for those who have intolerances or allergies, which are the two most likely problem areas. That is an irresponsible position but there are enough doctors in the Department to have at least done the groundwork on the fallback position. It would be irresponsible to introduce this scheme on 1 April and make patients suffer because of an argument between my right hon. Friend and the BMA. That is not acceptable to the House and it should not be acceptable to the country.
Fourthly, apparently there are to be amendments to the statutory instrument that we have before us tonight. The Joint Committee on Statutory Instruments highlighted two problems that it had with the proposals. How often will those amendments come forward? Will that be a quarterly process? This statutory instrument has errors and it is questionable to have Parliament push through inaccurate legislation.
Fifthly, what will happen to all the research that is going on in these categories? At present 130 compounds are in some form of trial in Britain. What is the criteria for those products to get back on to the list? Is it to be the nebulous criteria of need that the DHSS has, or is it to be a scientific criteria? It should be a scientific criteria and I hope that when my right hon. and learned Friend the Minister for Health replies he will make that clear.
The list is riddled with errors. The hon. Member for East Kilbride mentioned Capramin and Levius, the cheaper one being the one that is on the black List. Presumably it should have been the other way round, but that is just a minor clerical error. Vitamised iron and yeast tablets have been blacklisted. Vitamised iron tonic tablets with yeast—the same thing the other way round—have not. There are other examples with which I shall not bore the House because representations have been made to the Department. Presumably, in due course, they will be put right, but they should have been right before they were brought before the House.
§ Mr. Morris
Finally, and most insidiously, despite the Minister's disclaimers, there is another force at work. There is substitution of generics for branded products, and that is a vital area. This country needs branded drugs if it is to 721 maintain the industry as a sunrise industry. If we take away the right to brand, we take away fundamental research from this country. If we do that, we begin to undermine the successful exports industry. Then we take away employment, and we take away investment, as my hon. Friend the Member for Warwick and Leamington (Sir D. Smith) said earlier.
I find it incredible that some of my hon. Friends do not understand that there is no such thing as a single generic product. Some of us remember when, not so long ago, the below-specification Indian bandages came into Britain. The country will be flooded with all sorts of different generics. The Minister says that they will all have to be licensed. That is only partially true. The premises of a wholesaler in Belgium or Italy will have to be licensed but no one will check what that wholesaler imports, and he will then export unchecked products into the United Kingdom.
Some of us remember the 1960s and the scandal that the Birmingham medical officer of health exposed over Tetracycline and the imports of sub-standard products from Poland. Could it happen again? Of course it could. While the active ingredients in a generic are supposed to be the same, their palatability, their rate of release and their rate of absorption can differ very greatly.
Every manufacturer in the United Kingdom—and we are all proud of the standards of production of our pharmaceutical industry—is inspected under the good manufacturing practice laws. I ask the Minister: who will do the inspection of the overseas plants? How many inspectors are there? I should be grateful if we could have a firm answer to those questions.
The policy is wrong. The regulations would be open to a charge of hybridity if an affirmative resolution were required this evening; unfortunately, it is not. It may be open to challenge, as has been said, under article 30, dealing with competition. But, whatever challenges may be made, the regulations have been introduced in a shambolic way and put through with unprecedented speed.
I do not believe that the savings are there to be made. The impact of the regulations has already caused loss of employment for one manufacturer and stopped investment —and to what purpose? Patients are worried, and they will be even more worried after 1 April. They may settle into the new regime—let us hope they do—but at best many thousands will have to move from a settled regime into an unsettled one. Others, whether my right hon. Friend likes it or not, will be forced to buy, so for the first time we shall have, even if in a modest manner, a two-tier Health Service.
When 10,000 people in Northampton, with no instigation from me, sign a community health council petition complaining about the regulations — [Interruption.] I hope that the Secretary of State is not making an adverse comment about my constituents or about the community health council in Northampton. He can make comments about my speech, and sometimes the truth does hurt. Ours is supposed to be the party of enterprise with a caring face. We should hide our faces with regard to these regulations. If they are not rejected, as they should be, they will return to haunt the Government as amendment after amendment is laid before 722 the House, night after night, as the savings fail to materialise, as the adverse drug reaction reports increase, as people lose their jobs and investment goes elsewhere.
§ 10 pm
§ Mr. Eddie Loyden (Liverpool, Garston)
I take part in the debate for two reasons. First, like my hon. Friends, I believe that the Government's handling of this matter has been ham-handed and arrogant, to say the least. They have caused great but avoidable distress and concern among many people who have been confused by the statements. It is no good the Government arguing that either the drug manufacturers or anybody else has overreacted to their statements. The fault clearly lies with the Government because of the way that they have handled this matter.
A great deal has been said about the effects of the regulations on the drugs industry, doctors and so on, but little has been said about the effects on patients. Most hon. Members have received letters which show that many people are concerned and will remain concerned while this list prevails.
Secondly, I have an interest in that I have a drug manufacturing company in my constituency and I am concerned about the jobs of constituents. I do not apologise for saying this when there are 4 million unemployed. It was not the will of those employed in the drug industry to join that industry. Like most working people, they found their way into it because of the communities in which they live and the job opportunities there. They have no control over their destinies. Therefore, it is my responsibility to fight for the jobs of those people, and I hope that my hon. Friends will agree with me.
We have seen the reaction of people who have spent many years in the drugs industry, who have been unnecessarily concerned and disturbed by the Government. Regardless of what the Government have been saying, this measure is merely a way to cut Health Service expenditure, and the hand of the Treasury is involved in the affair. There is no medical or other justification for the arguments advanced by the Government, and this is clearly a Treasury policy. We all know where that policy will lead us.
There has been a move towards great dependency on drugs, and that is part of how we approach health matters. There has been no serious attempt to seek alternatives, and maintaining dependency on drugs has become part of the role of the NHS. I have seen or heard nothing under this Government to suggest that there are positive and acceptable alternatives to the drugs industry. Unless those alternatives have been pursued and established, we shall have to depend on the manufacture and use of drugs. In other countries many lessons have been learnt.
We should not let this occasion go by without expressing some concern about the way in which drugs are monitored and about how the drug companies and the Committee on Safety of Medicines appear to disregard the extensive misuse of drugs. However, those are not the issues under discussion in this debate.
If there is to be a movement away from drug dependency, and if we see more moves towards preventive medicine, we should join Conservative Members if they say that that is the direction that they intend to take. However, there is no evidence that that is the reasoning behind the Government's proposal.
723 More and more people are becoming aware that the main, if not the only, purpose of this exercise is in the first instance to cut the costs of the National Health Service. There is no suggestion that there will be any benefit in the longer term.
The National Health Service has been under constant attack from this Government since 1979. The Secretary of State and his junior Ministers always argue that more money is being spent on the NHS. However, the right hon. Gentleman should recognise that we have an aging population and that there are new illnesses which need the constant attention of the service. As new remedies for, new methods of curing and new ways of stabilising diseases are brought in, they will bring in their wake further costs. There should be no limit on our perspective of the needs of the Health Service. It must be primarily to improve the health of the people.
The Government's proposal is a ham-handed way of dealing with the problem. I hope that the House will consider most carefully what is being said by hon. Members on both sides of the House. If nothing else does, the contributions that we have heard from Government supporters ought to influence the Secretary of State.
I take into account at all times the jobs of those employed in the pharmaceutical industry, for the reasons that I have stated already. The Government's proposal will have a widespread effect throughout the drugs industry. Until there are alternative jobs, I shall continue to take that line.
§ 10.8 pm
§ Mr. Douglas Hogg (Grantham)
When the provisional list was published last November, I had grave anxieties about it. I found it objectionable on two counts. First, it did not pay sufficient heed to the needs of people in rural areas. Secondly, I thought that the list of 30 medicines within the seven classes was insufficient to meet clinical needs. The House has to decide whether the revised list takes account of those two major criticisms.
The first of them clearly is met. My right hon. Friend has made it clear that in a rural area a dispensing doctor will now be permitted to prescribe and supply to a patient drugs which are not on the National Health Service.
§ Mr. Hogg
I shall give way in a moment.
But a much more serious anxiety is whether a list of medicines, set by the Government, can meet the clinical needs of patients. I have little doubt that when we were dealing with the list of 30, the answer was no. The criticism was powerful and vociferous. It concentrated on pain-killers and laxatives. It was pointed out that there was an inadequate range of both. Had the list remained unexpanded, I would have voted against it. But the Government have moved substantially and we now have, I think, 128 on the white list. We must ask ourselves whether that list meets the patients' needs. That is a matter of judgment. Unlike the hon. Member for East Kilbride (Dr. Miller), I am not a doctor, but I have talked to doctors 724 in my constituency and read the literature. I have also tried to listen to sensible criticism. I think the ultimate judgment is that for the vast majority of patients, their clinical needs will be met by the drugs—
§ Mr. Hogg
If the hon. Member for Falkirk, East (Mr. Ewing) does not mind, I shall take the argument in stages.
I am confident that well over 90 per cent. of patients will find that their needs are met by the white list. I accept that that leaves a small number of patients for whom the white list may not be adequate. We cannot quantify it, but I think that more than 90 per cent. will have their needs met. I suspect, therefore, that we are dealing with a core of 3, 4 or 5 per cent. The House must pay attention to that real and serious figure, but it is, nevertheless, small.
We must then ask where we go from there. Does that fact disqualify the policy, or can the problem be met in some other way? My conclusion is that it can be met in some other way, and that the problem does not disqualify the policy. The other way is the appeal system. My right hon. Friend the Secretary of State will know that ever since publication of his provisional list, I have pressed him for an appeal system. One can call it various things—residual discretion, or whatever—but it is quite clear that an appeal system is needed. Without it, the policy is not particularly attractive.
We have to face the fact that we are going into this policy without an effective appeal system. After all, there will not be an appeal system on 1 April. The question that then arises is whether, as an appeal system will not be available on 1 April, we should refuse to support the policy. But again, the answer to that must be no.
There are two reasons why the absence of an appeal system is not fatal. First, I do not believe that an appeal system can be made to function efficiently, or will be acceptable to the medical profession, if doctors have not played a part in devising it. The BMA has not been active in consultations with the Government. I suspect that until these regulations are passed, the BMA will not be ready to enter into negotiations with the Government. Therefore, it is the BMA's fault that has prevented an agreed appeal system from being put into place.
§ Mr. Nicholls
I, too, have pressed the Minister to adopt an override position to take account of the problem. If the BMA ultimately decides not to co-operate, surely it cannot be allowed to hold the whip hand over the working of this proposal. Does my hon. Friend agree that if it will not co-operate, the appeal procedure may have to be forced upon it?
§ Mr. Nicholas Winterton
What knowledge does my hon. Friend have of the industry? Because the Government have displayed very little, we have little confidence.
§ Mr. Robert Hughes
On a point of order, Mr. Deputy Speaker. I am seeking to follow the hon. Gentleman's argument closely, but unfortunately when he turns his back on me I cannot hear what he says.
§ Mr. Hogg
I apologise to the hon. Gentleman. I hope that he will accept that I meant him no discourtesy.
725 I was accepting the point made by my hon. Friend the Member for Teignbridge (Mr. Nicholls) about the appeal system. If the medical profession is unwilling to negotiate a workable appeal system, I hope that my right hon. Friend the Secretary of State will impose one. But I do not think so ill of the medical profession. I am fairly confident that when these regulations are passed, a viable appeal system will be negotiated with the doctors.
§ Mrs. McCurley
Does my hon. Friend agree that the Government set out, in their policies for two general elections, to rid the country of bureaucracy? What my hon. Friend suggests is tantamount to additional bureaucracy. It will cost a great deal and it is extremely complicated.
§ Mr. Hogg
That is a fair argument generally, but we must consider the appeal system in the context of the proposals. I think that the proposals are good, subject to the existence of an appeal system. I see no reason why that appeal system should be bureaucratic. I see no reason why it should not be expeditious and accepted by the medical profession. If it meets those criteria, the appeal system will be viable. I hope that the medical profession and the Government come to terms quickly on the question of an appeal system.
§ Mr. Geoffrey Lofthouse (Pontefract and Castleford)
Is the hon. Member for Grantham (Mr. Hogg) saying that he is satisfied that no one will be denied the drugs that their doctors believe they need because they cannot afford them?
§ Mr. Hogg
That is what I am saying. If there is a viable appeal system, and since we are talking about a greatly expanded list, nobody will suffer.
I do not believe that this is an unwarrantable attack on a profession. All professions accept some constraints on their ability to act as they wish. For example, in my profession no one asserts that a solicitor or barrister should have an unqualified right to prescribe legal aid simply because a person comes within the financial eligibility criteria. That is left to the legal aid committees, and we accept that.
No one suggests that doctors are entitled to order as many kidney machines as they want simply because patients need them. We accept financial constraints and that the taxpayer and the Government have a voice.
My hon. Friend the Member for Warwick and Leamington (Sir D. Smith) is rightly anxious about the drugs industry. But is his anxiety realistic? We are dealing with only seven classes of drugs. They are not the major drugs, but drugs that cover about 10 per cent. of the market. Exemptions total about 70 per cent. The drugs industry is international in its scope. The seven classes do not involve the major life-enhancing, life-preserving drugs on which major research is being conducted. I have respect for my hon. Friend, but he overestimates the danger that could be done to the drugs industry.
I am sorry that my hon. Friend the Member for Thanet, South (Mr. Aitken) is not here, because I agree that we are dealing not with an issue of great principle but with a pragmatic issue. If it be right that the saving is real—
§ Mr. Winterton
On a point of order, Mr. Deputy Speaker. My hon. Friend the Member for Grantham (Mr. Hogg) has described me as a dishonourable Member of the House, and I ask him to withdraw his remark immediately.
§ Mr. Hogg
If I so described my hon. Friend, I withdraw my remark. However, I was not conscious of doing so.
We are dealing with a pragmatic issue. If there is to be a substantial saving—and I believe that there is—if there is no real danger of injury to patient care—and I do not think that there is—and if the fears of my hon. Friend the Member for Warwick and Leamington about the drugs industry are misconceived—and I think that they are—the proposals are sensible and should attract the support of the House.
§ Mrs Renée Short (Wolverhampton, North-East)
My hon. Friends the Members for East Kilbride (Dr. Miller) and for Carmarthen (Dr. Thomas) are two doctors who grace the Opposition Benches. They emphasised strongly that in trying to bring about the changes that the Secretary of State is introducing, he has gone about it the wrong way if he wished to win the support of the medical profession.
That is rather surprising because it is the Opposition who are usually accused of not knowing how to talk to doctors, how to deal with them or how to carry them with them. We have had a lesson in how not to gain the support of the doctors from the Government on the issue of drugs. Had the medical profession been consulted in the first place, it would have gone along with the proposals. The fact that the Secretary of State did not consult the medical profession has created unnecessary opposition and animosity that has led many people to believe that the proposals have no merit.
I do not go along with that view because I believe that the proposals are very much in line with many of the ideas put forward by the Opposition. We support generic prescribing while at the same time understanding that that will create difficulties for the drugs industry.
As my hon. Friend the Member for Liverpool, Garston (Mr. Loyden) said, employment problems are involved. Indeed, members of my union — the Transport and General Workers' Union—are widely employed in the drugs industry and we must take their problems on board.
The Health Ministers have shown ineptitude, which is rather surprising, in their handling of the problem. How could they have thought that by coming to the House on 8 November to announce their limited proposals they would get away with it? The British Medical Association was represented on the working party which produced the Greenfield report in 1983. The report recommended that limited lists should not be introduced. The Minister for Health said on 22 November 1983:We are not convinced that such a list confining the judgment of doctors would be in the best interests of patients." — [Official Report, 22 November 1983; Vol. 49, c. 112.]727 What has happened since then to change his mind? It is certainly not an animated discussion with the profession. We know that neither Ministers nor their officials have consulted with the profession about the prescribing of drugs since January 1983.
The Opposition support the Greenfield report. If it had been handled properly, many doctors would have cooperated in the introduction of its proposals.
It has not been made clear to interested parties that the Government are proposing a swingeing increase in prescription charges. The Secretary of State did not mention prescription charges today. I understand that it is proposed that there should be a charge of £2 per item—not per prescription. Therefore, it will be a higher increase than that indicated by Ministers.
According to my information, a large number of commonly prescribed drugs on the Minister's list cost much less than the proposed prescription charge. Some cost as little as 79p for a month's supply. A month's supply of digoxin would cost only 40p and a month's supply of the diuretic bendrofluozide would cost only 14p. It is clear, therefore, that a prescription charge of £2 per item would be a rip-off for the patient. The Minister must realise that patients cannot be exploited in that way by what would effectively be a tax on patients.
Even if the House approves the Government's highhanded action, I understand from my hon. Friend the Member for Oldham, West (Mr. Meacher) that the proposals will have to go to the European court. Perhaps the Minister for Health will tell us how much delay that will entail.
I hope that the Minister will be persuaded that he has handled this matter incompetently and that he will have continued difficulties with the medical profession if he does not consult it. I hope that he will go back to the profession to discuss how the proposals should be introduced to ensure that the necessary drugs are provided for all patients in the relevant categories and that the cost will be presented in such a way that patients are not out of pocket, paying £2 per item when that is exorbitant compared with the actual cost of the drugs.
§ Mrs. Anna McCurley (Renfrew, West and Inverclyde)
I am seriously disappointed that a great gulf has become evident between a large section of the medical profession, the DHSS and the Scottish Home and Health Department.
I can understand why doctors used the form of lobbying that they did. They are not politicians and they are usually very slow to rise to the bait. On this occasion, however, there was so little time to consult that they found themselves led by the nose by others lobbying against limited list prescribing.
Many general practitioners are satisfied — although not all of them are convinced—that the revised limited list covers most eventualities. More particularly, certain groups of hospital doctors believe that they will be seriously hampered by the list. In the past few weeks I have spoken to consultants and junior hospital doctors in Scotland. Unlike some of the panel who made these controversial decisions, those doctors see and treat patients every day. They have a very heavy clinical load, so they know what they are talking about. Those who are particularly anxious about the restrictions are 728 psychiatrists, those responsible for the care of the elderly in hospital, and those who treat painful arthritic conditions, cancer, stomach disorders, and so on.
It would be most unwise for the Government not to listen to what those doctors say as they are the main prescribers of the categories of drugs subject to axing. Personally, I cannot avoid listening because my husband is a consultant psychiatrist of many years' standing. Even at a distinguished level in politics there is woeful ignorance about the nature of psychiatry and geriatric medicine, so I shudder to think what it must be like at other levels. Failure to distinguish between psychiatry, psychology and psychoanalysis has bedevilled the profession in the public mind, so I take this opportunity to make Members of Parliament aware of the situation.
I was amused when I saw some of the glorious remedies on the revised list. I saw on the proscribed list some of the remedies that my grannie used as patent medicines. At that stage I did not believe that they had ever been subject to Health Service prescription charges. At first I thought, "Good show. That is right. We should get rid of those things." However, when I consulted members of the profession, they told me that they could not prescribe those medicines anyway. It was then that I thought that the list was a bit of a con.
Everyone has had a good laugh at the oddities that are still available in the original published list of banned substances, but it should he realised that many of the substances are effectively banned either because they fall into the non-prescribable preparation category, such as foodstuffs, or are not advised, being directly publicly advertised.
Everyone is in favour of rational drug prescribing and ensuring the best uses of finite resources. It is widely accepted that part of this is generic prescription. The Government are right to attempt to restrict the list, but the list before us is another matter and to many it is unacceptable. Setting aside the unacceptability in principle, I believe that the administrative structure that would have to be set up for continuous review of appeal and rejection beggars description.
Doubtless such a structure and the time that it would involve would prove a delight to the bureaucrat, but it would be unacceptable to the patient and his doctor. I believe that that would be the view of many hon. Members were they to be aware of it. Family doctors and hospital medical staff alike will be affected. A significant number of prescriptions for proposed banned drugs are initiated by hospital consultants, either as a continuation of treatment after discharge or as a recommendation following outpatient or domiciliary consultation.
The National Health Service consultant will therefore be clearly restricted in his choice. Here is a problem that he might face if a drug is not on the limited list and is decided to be appropriate. Should the patient be in a privileged position to pay, how can that be administered within hospitals? Patients successfully maintained on a banned analgesic or laxative must be allowed to continue after hospital admission to use that drug. If drugs are available privately to outpatients, they must be available also to inpatients. Do the Government therefore propose to set up two separate prescribing systems which invariably mean twice the cost, twice the administration and twice the risk? Is it envisaged that hospital 729 pharmacists will deal with private sales, or will the relatives of some patients be sent out for a "take-away" from the high street chemist? Monitoring on the ward which drugs are owned by the patient and which are the property of the hospital would be well nigh impossible. The overall cost of implementing any of these schemes would be considerable. The benzodiazepine tranquillisers have a particularly poor public image and we know that at times they have a justifiably bad press. Indeed, I have many times counselled my constituents—some of whom have come to me in a frightful state—against the use of just such tranquillisers. I do not know whether it is ethical or not to do so. However, misuse is a continuing cause for concern. Restriction would not improve matters as the chosen few are very popular on the illicit market. Benzodiazepines are not merely crutches for the mildly anxious. In various forms they are essential for anxiety states and other forms of mental disorder and for the relief of a number of physical conditions. I believe that quite recently skin diseases have been treated by them. There is considerable variation in these drugs, and restriction to the present proposed list is unacceptable to many.
Paradoxically, one member of the group—Clobazam — may be prescribed for epilepsy only. Are random checks on GPs proposed? Will neurological evidence be demanded in each case? Faced with the restricted list, the prescribing doctor might end up having to prescribe from another category of substances to avoid the restriction to achieve the symptoms of relief. Barbiturates, from the unrestricted list, would be a bad buy for the Health Service if chosen in preference to the benzodiazepines. Similar cases can be made for analgesics and laxatives. Regrettably, the restricted list applies to groups of compounds which superficially appear unimportant but which are often vital in treatment, especially in the elderly.
The Bulletin of the Royal College of Psychiatrists states:The proposals put forward are unacceptably rigid in view of the range of widely differing clinical conditions that are treated with one compound and of the complex and varied nature of compounds that may be needed to treat a single clinical condition. For instance, in the case of benzodiazepines, what applies to the treatment of a neurosis does not necessarily apply to the treatment of epilepsy or spastic paraplegia, nor is it appropriate to their use in intubation procedures. Benzodiazepines vary widely in their profile of action, their formulation and aspects of pharmacokinetics. Moreover, the pharmacokinetics of drugs varies in sometimes unpredictable ways, e.g. in the elderly.Combination drugs cannot be done away with. Any doctor who is treating arthritis will say that. One GP in my constituency told me that he took more than 20 shots to get the correct medicine for a sufferer. That is not as bad as it sounds. It is an example of a careful doctor who understands the nature and variety of medical products Even then, especially in the elderly, tolerance of drugs alters and the search for another appropriate drug which will ease a condition begins again. To take away the doctor's choice is not good for the patient.
Some hospital doctors whom I know think that there is no logic to the list. I am speaking of some who are involved in research as well as clinical work. It worries them that the analgesics available are of the opiate, or addictive, variety. Rheumatologists to whom I have spoken and who use non-steroidals say that they do not do 730 everything and that they require the use of a variety of analgesics. The opiates cause constipation, as do some antacids. A wider variety of laxatives is needed, especially for cancer patients for whom constipation is often a result of drug therapy and primary disease. The same is true for patients with hiatus hernia and stomach ulcers. The number of antacids has been chopped, but each antacid has specific side effects. Sometimes constipation and sometimes the opposite results.
To treat a patient as an individual requires a broad spectrum of drugs. Many hon. Members might say that too many are produced, but I hope that they remember that, for every one drug that sees the light of day, 10 are rejected at the research stage. Of those that appear, those which are unpopular or are regarded as less than efficacious by the medical profession get withdrawn.
Many of my hon. Friends have been supportive of drugs companies. I am not a hack in this—I have no interest in drugs companies. Dista makes Distalgesic, which has been taken off the prescribing list, but, through its profits from that drug, it has made another drug called Penicillinamine. That drug is kept on the market, at no proft to the company, to help a few specific patients who are suffering from the very rare Wilson's disease—an accumulation of copper in the body. Sufferers of rheumatoid arthritis also benefit from it.
Another drug, Prostcyclin, which has given us the means to understand better how the body and blood vessels work, is a natural substance discovered by researchers at Wellcome, who won the Nobel prize for their work. It is used in cardiac transplants, and Wellcome ploughs the profits from other drugs into research on such products. Hospitals do not have that sort of money and researchers in the NHS do not have the money that drugs companies have. We depend on drugs companies to do the research for us and the restrictions of the limited list will, I fear, severely curtail their ability to do such research.
I am upset that the problem has induced fear in the elderly. I strongly encourage the Government to explain matters properly, at least in a leaflet, to the elderly patients who have been caused most anxiety by the upheaval and give them at least a little comfort.
I hope that we never find that drugs are available to private practice but not to the NHS. It would be a difficult ethical conflict for doctors to choose between prescribing the best treatment available for patients and prescribing the treatment that patients could afford. I hope that we can ensure that that does not happen.
I urge the Minister to have another look at the list. After all, mistakes have already occurred. The British Pharmaceutical Journal wrote:It is unfortunate that the draft black list contains the no doubt inevitable crop of errors, which illustrates the difficulties of bureaucratising medicine. Thus, Optimax, possibly because of its vitamin components, is erroneously included. For the same possible reason, Reactivan is black listed, contrary to any indication in the original limited list proposal that it would be. What is to be made of the fact that Frisium capsules are black listed but apparently to be available for treatment of epilepsy without doctors having to indicate the diagnosis but having to indicate the Schedule that refers to epilepsy! The drug is white listed, but black listed under its brand name, under which name it can be supplied. Again, dextropropoxyphene and paracetamol tablets are in the white list, but Distalgesic and Cosalgesic which are the only products of the stated formula available on the market are black listed! So the medicine cannot be ordered as Distalgesic or Cosalgesic but can be supplied as such.731 That seems to be a strange anomaly in the system and I hope that it will be ironed out.
I believe the medical profession when it says that it is anxious to cut the drugs bill. I hope that it will do that, but we must ensure that patients who have come to expect and deserve the best from the Health Service continue to enjoy that right.
§ Mr. Willie W. Hamilton (Fife, Central)
Unlike the hon. Member for Renfrew, West and Inverclyde (Mrs. McCurley), I propose to make a party political speech, because the debate is about the Government's approach to the National Health Service and to the principles on which it is based and on which the Labour party wishes to treat it.
Aneurin Bevan would turn in his grave if he had heard the speech of the Secretary of State who whinged on about the savings that he would make and would transfer to the patient. We know that neither proposition bears a minute's examination.
We all remember when the Minister for Health made extravagant claims about charging overseas visitors, and what a cock-up that was. The hon. Member for Northampton, South (Mr. Morris) made a devastating attack on what he sees as the creation of a two-tier system: a first-class Health Service for the rich, who can afford to pay whatever is asked, and a second-class service for the poor, the unemployed and the old. That is why, especially in Scotland, there has been the most enormous turmoil since the scheme was announced in great haste and without any sort of consultation with doctors, patients or anyone else.
Simply because the fellow who will be the star tomorrow wants £100 million from the Secretary of State, the Secretary of State thought that this was the best way to find it and, as every hon. Member knows, almost overnight announced this take-it or leave-it scheme. After that, he discovered that his sums and the number of drugs included were all wrong, and so he tripled them. He had a row with the Secretary of State for Scotland because he did not realise that the Health Service in Scotland and its problems were completely separate and needed separate treatment. It is a great tragedy that we are not having a separate Scottish debate and a Minister replying for Scotland, because there are particular Scottish aspects of the matter.
The Parliamentary Under-Secretary of State for Scotland was written to by one of my constituents, Dr. G. Lindsay Smith MB ChB D Obst, but he did not reply to the specific questions that he raised. When we put the specific cases to the hon. Gentleman, he drafted a circular letter which he sent to all Scottish Members, without fail, irrespective of our specific representations. That was a contempt of hon. Members who sought to do their jobs. The doctor was treated no less cavalierly by the hon. Gentleman.
On 21 January the doctor wrote back to the Parliamentary Under-Secretary and saidI must stress the following points:—No one can deny that. He continued1. For N.H.S. patients, the statutory list of drugs must alter the doctor/patient relationship by seriously interfering with a doctor's clinical freedom.2. The treatment of individual N.H.S. patients will be constrained by the rigidity of a statutory list.732 It is not Willie Hamilton who writes that, but a doctor of consequence who knows what he is talking about and who is at the sharp end. He continued:3. The machinery for a national list can only he slow to respond to meet changes in clinical practice and new therapies.4. Rather than use simple cheaper therapies, more expensive and complicated drugs may be used in an effort to reduce patients' financial hardship. These may well cost a great deal more.5. Once this list has been introduced there is nothing to prevent the Government extending it to cover other groups of drugs.Despite the Minister's assurance this afternoon, we do not believe him. Despite what he says, this is the thin end of a sinister wedge.
The letter continued:As to the question of generic prescribing I myself will be willing to do so once the Government has shown that it has taken steps to ensure the quality of imported drugs.We all accept that, do we not? I have had experience of the prescribing of generic drugs, which did not provide adequate treatment when compared with the branded alternative. I have quoted that letter to show the reaction of a responsible doctor to the absurd and irresponsible treatment of Members of Parliament and doctors by the Scottish Office, which did not reply to questions about genuine problems.
In passing, I should say that one or two Conservative Members have declared a financial interest in Boots and other drug companies.
§ Mr. Hamilton
I heard only two. There is an enormous pressure group in the House, comprised mainly of Conservative Members, which plugs the line of the drug companies. One of them read the apologia for the drug companies tonight. I hope he earned his corn. We do not know what fees the companies pay them, but we have a right to know what sort of pressure groups are operating in the House on such matters.
I agree with the Secretary of State to this extent: in this matter, the drug companies have displayed a despicable attitude in trying to pretend that they are looking after patients' interests. They are looking after their shareholders' interests, and nothing else. To their great shame, general practitioners have allowed themselves to be used, to some extent, by the drug companies. Some general practitioners in Fife sent me the petition forms that were provided by the drug companies. There was no comment on them; they simply put out the forms in their surgeries, got their patients to sign them and then sent them to me. It was counterproductive. I wrote back to the doctors and said, "If you want to influence me, do not send me petitions that were handed to you by the drug companies." If the Secretary of State wants to save money, he need look no further than the balance sheets of the drug companies, which have made fortunes out of the National Health Service. I was a member of the Committee on Public Accounts when it received confidential information from the drug companies, which was excluded from our reports because the profits were so large that it would be devastating if the House knew precisely what they were. Some of them were making well over 100 per cent. profit on some drugs. The Secretary of State has a fertile furrow to plough if he wishes to save money in the NHS. Do not consider cutting out patients' drugs; consider the profits 733 of the drug companies. We cannot even test their efficiency, because many of them are international companies over which we have no control.
At a dinner given by the Institute of Chartered Secretaries and Administrators — I expect the Minister was talking to them because they will have to administer the scheme—the Minister for Health described the drug companies as, "hysterical," "alarmist" and "misleading." I congratulate him on being right on all counts. But the Government's response is not to tackle them. They try to save money through a bureaucratic nightmare, as the hon. Member for Renfrew, West and Inverclyde said. Incidentally, I hope that she will vote against the Government tonight. If her speech was her vote, she would be in our Lobby. However, I suspect that she will not, because she expects a little promotion and must behave herself. The hon. Member for Northampton, South (Mr. Morris) can say goodbye to any promotion prospects that he may have had.
§ Mr. Nicholas Winterton
The hon. Gentleman has made a vicious and I believe unjustified attack on the pharmaceutical industry. I wish that he would spell out some of the accusations that he makes about it. I would say only that ICI, the largest single employer in my constituency, has just contributed £130,000 from its profits to the East Cheshire hospice, which is being constructed for the terminally ill. Does he believe that that is obscene?
§ Mr. Hamilton
No, it is the profits that are obscene. ICI can give away that money only because it has got a nice, cosy relationship with the Department of Health and Social Security, which guarantees it a profit of 20 per cent. It is the only industry in Britain that is guaranteed an overall profit of 20 or 21 per cent. It is even more mollycoddled than the farmers. Reference was made earlier to money not growing on trees. Sometimes I think that it does. The Government say that it is important to save £25 million or £50 million on the National Health Service but in 1985–86 this country is to spend £552 million on protecting 1,200 Falkland islanders who live 8,000 miles away. In 1986–87 £450 million will be spent on those 1,200 people and in 1987–88 we shall spend another £300 million on them, a total for those three years of £1,300 million.
§ Mr. Butterfill
On a point of order, Mr. Deputy Speaker. Does consideration of the expenditure on the Falkland Islands have any relevance to this debate?
§ Mr. Hamilton
The hon. Gentleman may not like these figures but it behoves the Opposition to repeat them time and time again whenever the Government attack the social services. If only a fraction of that expenditure were to be translated to the National Health Service for the protection of the good health of the people of this country instead of for the protection of 1,200 people who live 8,000 miles away, there would be no talk about penalising the old and the poor and those who will suffer because of this nightmare of a scheme. The Government have made a cock-up, they know that they have made a cock-up and they should withdraw the regulations. If the Minister were to say that the Government propose to withdraw them, he would be greatly thought of by the people of this country. 734 They would say, "There's a man who is big enough to realise what a monstrous nonsense this is and who is willing to confess."
§ Dr. Brian Mawhinney (Peterborough)
I hope that the hon. Member for Fife, Central (Mr. Hamilton) will forgive me if I do not take up his remarks, but it is very hard to debate a matter with someone who categorically refuses to believe the statements of right hon. and hon. Members. However, he referred to one matter which was mentioned by the hon. Members for Oldham, West (Mr. Meacher), to whom I always listen very carefully, and for East Kilbride (Dr. Miller). They said that they would prefer a policy that led to a continuous reduction in the profits of the pharmaceutical companies. The problem with a policy of that kind is that it allows the pharmaceutical companies to decide whether they should reduce the number of drugs manufactured in a balanced way or whether they should leave some areas of clinical concern totally uncovered. I do not believe that such a policy would commend itself to the Government.
My comments will be directed towards the medical profession and the role of the profession in the development of policy. General practitioners in particular have had a bad press. That is unfair because there are many good general practitioners in Britain whose reputations have been damaged by the actions of a minority. I say that asking the House to bear in mind that I have spent all my working life teaching medical students. So I have a commitment to the medical profession in its training which cannot be gainsaid and which does not put me in the corner of being an antagonist towards the medical profession.
That having been said, it is a matter of considerable service that a number of general practitioners have behaved in the way that they have in the past few months. We have rightly castigated La Roche for sending out that letter to general practitioners to be forwarded to Members of Parliament. The fact is that general practitioners accept that letter and they bear the responsibility for that lack of judgment. Some of them, as has been mentioned, have improperly influenced people, particularly elderly constituents, inducing a state of fear that in many cases has been quite misplaced. I remember being told some weeks ago by a doctor with great glee that he had just told an elderly patient that morning that the drug that he was prescribing would not be available to her after 1 April. I asked him for the basis for that statement and he had none.
The third thing that has brought disrepute on all the profession has been the activities of the leaders of the BMA. I say "the leaders" because again many general practitioners in my constituency and elsewhere have taken the opportunity of consultation to write to my right hon. Friend the Secretary of State, to respond to the consultation list, to make sensible suggestions and to express genuine concerns which were taken into account in the production of the extended list. I can understand that the BMA may have felt that it should have had more consultation, but there comes a time —I hope Labour Members will accept this—when a refusal to consult and take part in the consultation process on behalf of patients becomes a self-indulgence, and that is what we have seen in recent weeks.
One must ask why that is the case. It is the case in part because the medical profession has, rightly, a privileged place in the NHS, which could not exist without it, and in 735 relation to the Government. I think that my right hon. and learned Friend the Minister for Health would agree that over the years when the medical profession has clashed with succeeding Governments it has frequently been the Government who have given way rather than the medical profession. I think, for example, of the recent dispute over where consultants' contracts should be held, on which, as my right hon. and learned Friend knows, I believe the Government made the wrong decision, and the many additional payments to the tune of almost £100 million a year to general practitioners for doing what many of us would think was part of their normal contract.
I am pleased that the Government have reaffirmed to the medical profession that while they wish to consult, and while they wish and need to take the profession with them, ultimately it is the Government and Parliament who govern, not the medical profession.
A minority of the medical profession have got themselves into that particular difficulty because of their special relationship as medical practitioners with the drug companies and because they have what I can only term a spurious belief that in some sense their clinical freedom is threatened. That is not the case, and I agree with my hon. Friend the Member for Grantham (Mr. Hogg).
In the hospital sector consultants have come together and have voluntarily agreed in many cases to forgo the drug that they would have chosen in order to come up with an agreed list. It could be argued that that was an abrogation of their clinical freedom. The fact is that nothing in principle that is different is being asked of the general practitioners than is already voluntarily agreed by the hospital consultants. That is why I say to my right hon. and learned Friend that his appeal mechanism is necessary, and I greatly welcome it. Just as the hospital consultants found it necessary to have an appeal mechanism for 3 or 4 per cent. of the cases where the doctors wanted to prescribe, so I accept that there will be a minority of cases with general practitioners that need to be covered by an appeals mechanism. Therefore, I welcome it. The BMA has given a commitment that after tonight it will cooperate with my right hon. and learned Friend. If the will is there on both sides, I believe that an appeal mechanism could still be in place by 1 April.
Doctors are central to the Health Service, and it is a matter of considerable concern that at present relations between Government and Parliament, on the one hand, and the profession, on the other, are such that the degree of mutual trust and credibility that is necessary for the benefit of our constituents who are patients has been damaged. The BMA leaders appear no longer to believe Ministers when they speak. That position must be changed. It must be made clear to doctors that their position is not threatened but that they are not on a pedestal which puts them above the democratic will of this House. It needs to be brought home to them that they have a greater economic accountability than they seem to perceive. Changes in medical education are needed to bring home that economic accountability. Our constituents who are patients also need to be educated as to the limits of what medicine can achieve.
The House should understand that, while the limited list will make a substantial contribution to saving, it is not the end of the story. There will be need to direct our attention again to the prescribing habits in the primary sector. To that end I would encourage my right hon. and learned Friend to think next time by way of incentives to the 736 doctors to co-operate — perhaps financial incentives, because most people respond to financial incentives. [Interruption.] Some thought needs to be given to the way in which we can build on this initiative in order to tackle, at an even more fundamental level, the prescribing habits in the primary sector.
§ 11.7 pm
§ Mr. Charles Kennedy (Ross, Cromarty and Skye)
The hon. Member for Peterborough (Dr. Mawhinney) seems to want to save money, yet he concludes with a proposal that would seriously undermine any potential savings to be made from the new regulations. He wants to have his cake and eat it.
I heard one or two speeches from the Conservative Benches in favour of the Government but, despite those efforts, the handling of the issue by Health Ministers has been both insensitive and inept. As the alliance has prayed in particular against the Scottish regulations, I should like to go back to the references that were made on points of order, at the beginning of the debate, to the incompetence with which the Health Minister for Scotland has handled the issue. It gives rise to very great concern.
I object strongly to the approach adopted by Back Bench Members and by Ministers—that somehow the public, the elderly and the sick are so stupid as to be completely duped by the propaganda of the pharmaceutical industry. They are also questioning the ability of hon. Members of this House, when they receive mail from their constituents, to discriminate between a campaign inspired, organised and oriented with the purpose of trying to frighten Members of Parliament, and the genuine concern being expressed by patients.
To hear the Secretary of State for Social Services, who sits in a Cabinet that owes so much to Saatchi and Saatchi, saying that it is intolerable that marketing methods are being brought into the world of politics, and that it is unacceptable that doctors should threaten Members of Parliament by saying that they will pin up the Member's reply in their surgery so that the public know what he thinks about an issue, is to know the contempt that Health Ministers feel.
The evidence given to the Joint Committee on Statutory Instruments by the official from the Department of Health and Social Security was that the Scottish Health Minister, at the time of the revised limited list, had said:I am confident that the assurances that I have given all along that the final list will meet all medical needs have been fully honoured.That can be compared with what the assistant secretary at the Department said when giving evidence. He said:I think that there may be difficulties, but we cannot at the moment gauge the extent of that. This has only just been drawn to our attention, and we have not had an opportunity to collate it in any detail.The Minister of Health shakes his head, but I can quote from the report, as I have done. It is disgraceful that he is lounging on the Treasury Bench shaking his head, when the Scottish Health Minister should have been at the Dispatch Box explaining the shambles and administrative chaos that his Department has created by this proposal.
What should have been introduced is what the alliance has argued for all along—generic substitution, which need not be indiscriminate and need not damage the interests of the pharmaceutical industry. As my hon. Friend the Member for Leeds, West (Mr. Meadowcroft) 737 made clear, the important thing to look at is patent life and the amount of return that the pharmaceutical companies will get on their research.
Ministers are surprised, but are they not aware of what the Department of Trade and Industry is doing? In a written reply to me last week, the Under-Secretary of State told me concerning drug patent life that the Government's standing advisory committee on patents is seeking the opinions of the industry with a view to trying to seek to extend them.
In other words, the Government are realising, in reverse order, that instead of trying to go for a limited list, they should first have gone for the conference to which the Secretary of State referred, then examined patent life extensions for the industry, and then, with those reassurances, started off towards a sensible system of generic substitution, based on the Greenfield report. That would have commanded support across the Floor of the House and would have allayed many fears that have been unjustifiably, and ridiculously, aroused by Ministers by the way in which they have handled the matter.
The way that Ministers have handled this matter is nonsensical. The fact that the person who seems to be presiding over the greatest administrative chaos of all, at the Scottish Home and Health Department, is prepared only to make remarks from a sedentary position, and does not have the guts to come to the Dispatch Box, is a poor show for the Health Service in Scotland. On that basis alone, I and my hon. Friends will oppose the regulations.
§ Mr. Frank Dobson (Holborn and St. Pancras)
I shall not attempt to summarise all the speeches that have been made in opposition to the Government's proposals—virtually every speech that has been made.
The Labour party objects to the Government's proposals for four major reasons. First, they have been a bodge-up. Secondly, they undermine the principles of the NHS and will damage patient welfare. Thirdly, the main savings from the proposals will result not from people getting cheaper drugs but from many of the most badly off patients getting no NHS drugs. Fourthly, they will lead to even more unethical and objectionable activity by some drug companies. If people think they can smear us by some form of pharmaceutical McCarthyism on grounds that we are in cahoots with the drug companies and they listen to what we say, they will soon discover that our interests are different from theirs.
I deal first with the bodge-up. The first extremely limited list produced by Ministers was totally indefensible, so much so that even they have not attempted to defend it. Then we had a shambolic consultation arrangement. For a year before the Government introduced these proposals, they had not talked to the medical profession about restraining drug costs. Not a word had passed between them. Then they suddenly announced what was to happen, and they expected everyone to say, "We accept the principle. We are bound to. We should just like to make a few minor adjustments." Those who object on principle do not like making minor adjustments. But what reveals the Government's incompetence most clearly is their failure from the outset to recognise the need to establish local appeals machinery before the list came into operation.
738 It is no good Ministers blaming the British Medical Association for not coming up with proposals. Ministers are responsible for the organisation of the National Health Service, and they are responsible for prescribing, as they are demonstrating by these proposals. They are responsible for the arrangements necessary to protect patients. They have quoted all sorts of arrangements for limited lists made abroad. Each of those systems has an appeals machinery for those limited number of people who cannot cope with the drugs on whatever limited list prevails.
Finally, we have had the farce revealed today of the inconsistency between the Scottish and England lists. We discover, for instance, that a Scottish doctor, presumably in Scotland, can dispense Vicks cold care capsules but that his English equivalent cannot. Conversely, the English doctor can dispense Vicks inhaler, but the Scottish doctor cannot. I am not suggesting that the old rieving instinct is so dominant in the Borders that we shall have cross-border drug running as a result of the Government's incompetence. But it is an indication of how stupid their proposals—
§ Mr. Home Robertson
As my hon. Friend knows, I live very close to the English border. I am registered with a general practitioner from across the border in Berwick-upon-Tweed, in England. When I get a cold, what will he be able to prescribe for me? Will it come out of the Scottish list or the English list?
§ Mr. Dobson
I am afraid that I cannot help my hon. and somewhat bifurcated Friend. If he really wants to know, he must ask Bodgers Anonymous on the Treasury Bench.
The National Health Service is based on the principles that the best health services should be available to all and that money should not be the passport to better treatment. Most people accept those unimpeachable principles, and no one in political life dares challenge them—at least in public. Unfortunately, some people, including the Government, seek to undermine those principles by stealth.
When considering these proposals, we should bear in mind that this Government have promoted the establishment of commercial hospitals, they have promoted private insurance, they have abolished National Health Service spectacles, and now they are proposing two-tier prescribing.
The limits proposed by the Government will apply only to drugs prescribed on the National Health Service. Doctors will be able to prescribe any drug but, if it is not on the list, the patient will have to pay for it.
That is the main reason for Labour's opposition to these proposals. They would bring back two-tier care into every National Health Service surgery, from which we all thought it was banished permanently in 1948. Patients who cannot afford to buy privately are bound to be disadvantaged.
If a drug is worth while, it should be available on the National Health Service. If it is not worth while, it must be dangerous, fraudulent or superfluous and consequently should not be available to any patient, NHS or private. I 739 also believe that the Government's approach reflects a lamentable ignorance of real life. But there is nothing novel about that. They proclaim that their current proposals do not affect the more important or life-saving drugs. So what? Most health care is about not life and death, but pain and relief from pain, and comfort instead of discomfort. I do not know when the Ministers here tonight last went to see their doctors, but it is highly unlikely that their lives depended on the outcome.
It must be accepted by all those who consider the problem that there has been too much unnecessary prescribing, heavily promoted by the pharmaceutical industry. Everyone knows that. It should be reduced as a result of action by doctors, restraint by the drug industry and a better informed public. We need to get away from people thinking that they have not been treated properly if they come away from the doctor without a prescription. But we can do that only by starting with younger people. The Government's proposals to outlaw the prescribing of proprietary medicines, obtainable without a prescription, will start at the wrong end, among the old. For most of their adult lives they have been used to obtaining prescriptions every time they visit their doctors. No less than 81 per cent. of those who obtain proprietary brands on prescription get them on free prescriptions. Their decent, kind, humane, and sensible doctors provide them, for example, with free cough mixtures to stop them from coughing all night.
Despite the Government's efforts to divert public attention, it is clear that many familiar remedies, particularly for the old, for symptoms of minor ailments, will no longer be available, and people will have to go without. For a rich society such as ours—we are still one of the richest countries in the world—to target its efforts to cut the drugs bill on free remedies for the oldest and poorest, seems perverse, even by this Government's standards.
It is also safe to predict that if the current proposals go through, the drug companies will respond by stepping up their promotion, on television and elsewhere, of the excluded products. At a drugs industry conference on 22 January, which was addressed by the Parliamentary Under-Secretary of State, delegates heard lectures from leading marketing experts onLimiting the Damage—the Marketing Optionsand onDeveloping the Market for Private Prescriptions—Can it be Done?As people at that conference were paying £137 a throw to attend, I can assure hon. Members that the marketing experts did not say, "I'm sorry lads, you'll need to throw the towel in." Their object is to create a demand which cannot be satisfied within the NHS, but which can be met by more over-the-counter sales and private prescriptions.
In case anyone should doubt that—apparently there is a doubting Thomas or Fred on the back row—I shall quote what one of the marketing consultants said. He said that only about 2,500 of the 30,000 general practitioners regularly write private prescriptionsbut that number is going to increase and you will get your share if you think creatively.That marketing consultant also said that doctors should be offered free samples with "starter packs" for patients, and with leaflets and posters in doctors' surgeries and chemists shops to encourage them to seek private prescriptions. Sales forces should apparently "educate" — note that 740 word — doctors' receptionists on the cost of private prescriptions when patients seek repeat prescriptions of drugs that are banned. Health insurance companies should apparently be approached to provide reimbursement for drugs, and banned products should be attractively repackaged to persuade patients that they are getting value for money if they buy drugs privately.
The other person giving such advice—a Mr. Ron Clifford, marketing director of Eli Lilly, another drug company, said that companies should consider free gifts, redeemable coupons, and advertising allowances to chemists to "entice" people to buy over-the-counter medicines, and should use a much wider range of press and television advertising. For those reasons, we are convinced that, whatever the Government's motives, the introduction of a limited list within the NHS will lead to grotesque unethical promotional activity by drug companies whose products are excluded from the list.
The Labour party has made it clear for some years that it does not object in principle to a selected drug list. However, if it is to be anything other than voluntary, conditions must be imposed. First, it should apply across the board, not just to drugs prescribed under the NHS.
Secondly, the criteria for including drugs should be made public, not furtively in private. The criteria should include safety, efficacy, the ease with which the drugs can be administered and palatability, even if that means using a branded product. The cost should be secondary.
Thirdly, machinery for selecting and assessing drugs for inclusion in the list should be established. That machinery should involve representatives of the drug companies, the relevant trade unions and patients, as well as the Government. The machinery should provide for the open assessments of drugs. The organisation should be empowered and equipped with the resources to deal with applications for inclusion in the list, appeals against exclusion from the list and, if necessary, to commission or conduct clinical trials. The machinery should also be able to establish local and national means of meeting the needs of the small number of patients who need drugs outside the list. Unfortunately the Government's proposition meets none of those sensible criteria.
The Government's desire to save money by reductions in the prices paid to drug companies and by the extension of generic substitution is recommended in the Greenfield report. The propositions in that report command the support of almost everyone in the medical profession, yet they have been rejected—for reasons that no one seems to understand.
If the Government are interested in rational prescribing, they could help GPs to improve their prescribing. Doctors are hampered by the absence of regular and easy access to their own prescribing data, because the prescribing pricing authority has not yet been computerised.
The Government have referred to support from some peculiar outfits. The Minister of State gave a most curious reply to the hon. Member for Hazel Grove (Mr. Arnold), who asked fora statement on the conclusions of the article, 'Prescribing: the Power to Set Limits', by J. M. Harding and others in the British Medical Journal of 9 February, a copy of which he has received.The Minister of State said:The article referred to by my hon. Friend concludes that generic prescribing and a limited list of drugs may improve the quality of prescribing and be the only way to curb prescribing costs.741 For good measure, he added:We fully agree with these conclusions." — [Official Report, 25 February 1985; Vol. 74, c. 65.]Unfortunately for the Minister, those who prepared the paper have written to me from their practice in my constituency. The most material sentence states:We are extremely angry that our paper has been misrepresented in this way to support a position in complete contradiction to the one we hold.So much for the Minister's reading of these articles.
When Conservative Members denounce the response of the BMA and of the Royal College of General Practitioners as wholly reactionary and unhelpful, all I can say is that it is not the most reactionary doctors who have made the strongest representations to me, it is the extremely progressive doctors working in good premises, running group practices and, in many cases, with their own voluntary selected list of drugs. They are the doctors who are most violently opposed to the imposition of the Government's ill-thought-out list.
Something else that we cannot ignore is the impression that the Government have created that if they do this everything will be all right with prescribing, dispensing and the pharmacy aspects of the NHS. The fact is that in many parts of the country many people still have difficulty obtaining their prescriptions. Rural pharmacies are still in retreat and dispensing doctors remain dissatisfied with their position. All sorts of things are wrong with that part of the NHS. The Government are doing precious little, other than to introduce this scheme.
We believe that, in the long run, the public interest would be served by taking a major stake of the British pharmaceutical industry into the public sector. Just as the NHS and its non-competitive principles have produced a better health service for our people than any competitive commercial system anywhere in the world, we are convinced that those principles could be applied to substantial parts of the pharmaceutical industry.
The Government complain about escalation in drug prices. Let them remember the largest escalation. When they first took office, prescription charges were 20p per item. They are now £2 per item. There is not one item on the drugs bill that has shown an increase of 1,000 per cent., yet that is what we have had from the Government.
The Government's proposals are unacceptable. They were ill thought out in the first place, they will damage the NHS, they will undermine the welfare of the patients and the burden of the savings will fall on those least able to bear it. There is nothing odd about that. That has been the Government's attitude to everything relating to the NHS, social security and the social services since they took office. This proposition is on all fours with what they have been proposing. We believe that these ill-thought-out and ridiculous proposals should be rejected and that the House should stick by the basic principles of the NHS which have served us so well until now. They are that the best health service, including the best pharmaceutical aspects, should be available to all and that money should not be the passport to better services.
If the Minister really believes in these proposals, he should insist that they apply to the private sector also. But he will not do that, because, like his colleagues, he is committed to a two-tier system. This is part of that story, and that is why we reject it.
§ The Minister for Health (Mr. Kenneth Clarke)
At times the speech of the hon. Member for Holborn and St. Pancras (Mr. Dobson) reminded me of one of the blacklisted drugs. The marketing and packaging were rather better than were justified by the contents, some of which seemed a little out of patent—old and familiar arguments which, had they been adopted, would have resulted in unnecessary public expenditure.
At times, however, the hon. Gentleman seemed to be drifting very close to agreeing with us, leading one to wonder why we were debating this prayer at a not altogether civilised hour with a view to dividing the House at the end of it. I am not surprised about that as almost all our vehement critics — especially those in the Opposition, who find themselves in embarrassing alliance with the more extreme critics in the industry — sail rather close to supporting roughly what we have proposed. That is also not surprising. There should not be differences in the House on this, let alone the ferocious differences shown by some sections of the professions and the industry.
I do not know whether anyone can contradict this, but I have not yet met a doctor or a pharmacist in practice who does not agree that something ought to be done to reduce the growth of the NHS drugs bill. That should be the starting proposition for the whole debate. At present the bill is £1.5 billion, rising each year by about 5 per cent. more than inflation. As my hon. Friend the Member for Birmingham, Edgbaston (Mrs. Knight) has said, we all know and can describe, either anecdotally or as a result of drug recall schemes, that a great deal of wasteful overprescribing of all kinds has been going on.
The starting point should be that we are searching, in the interests of the NHS, for some greater economy than has been achieved so far in the total drugs bill. I have been at the Department for about three years and my right hon. Friend the Secretary of State for about three and a half years. Throughout that time we have had substantial discussions about economies in the drugs bill. Just about every interest has been mentioned repeatedly throughout those discussions, as well as in debates in the House.
Before my right hon. Friend the Secretary of State made his announcement we had reached the stage when people were all very clear about what they were against when it came to doing anything to achieve greater economies in the drugs bill, but it was difficult to find any clear consensus about what people supported, which would have real, practical consequences of benefit to patient services.
For that reason, we concluded that it was time for a decision to be taken. Contrary to the assertions of the hon. Member for Holborn and St. Pancras, the interests of the service itself demanded that somebody should take a decision that would work. We set out a policy with one clear purpose — none of this two-tier rubbish that the hon. Member for Holborn and St. Pancras always argues about and none of the sudden streaks of hostility towards the industry that one or two of my hon. Friends thought that they saw behind it. Our purpose was to achieve a saving of up to £100 million—it now seems more likely to be about £75 million—for the NHS each year without damaging patient care. By avoiding unnecessary expenditure on drugs dispensed, the money could go into developments in other forms of care.
§ Mr. Richard Hickmet (Glanford and Scunthorpe)
I support the Government's policy on this issue but inasmuch as the drugs bill amounts to £1.4 billion, or whatever the figure may be, and inasmuch as within that figure about 9 per cent. is represented by promotion—£135 million — 21 per cent. — £32 million — by advertising, £60 million by representatives and 11 per cent. —£17 million—by literature, will my right hon. and learned Friend examine that area for savings? Could we not find £100 million there as well?
§ Mr. Clarke
We have examined that area—we are continuing to do so — and we have acted upon that examination. We are reducing by 10 per cent. the amount of promotional activity that is supported by NHS drug prices in the forthcoming year. We cannot make savings of the order that my hon. Friend describes but he has referred to an area that is ripe for savings and it is one in which we have acted. The drug companies spend a great deal of money on promotion and this has some good effect in that new drugs are introduced to the market. The companies persuade quite a few members of the medical profession vehemently to campaign on their behalf when the companies' interests are threatened. Indeed the companies, have an easy sell in the form of the hon. Member for Oldham, West (Mr. Meacher), who appears to use the marketing and promotional activities of the ABPI when it comes to putting together his speeches on this subject.
It is clear that our policy is aimed at saving £75 million. That is the sum that will be available for other forms of basic care in the service. Every time that the Government come forward with such proposals there is a tendency for everyone to urge us to spend more upon the NHS, despite the fact that Government spending is now 20 per cent. ahead of inflation compared with the spending of the previous Labour Government. Every time that we do anything that might raise additional revenue — for example, examining charges—we receive criticism from Labour Members. Whenever we examine any measures that might save expenditure within the service by avoiding unnecessary spending, thereby diverting money to better patient services — for example, when we discuss tendering or residential services — we find critics, invariably on the Opposition Benches—but sometimes on the Government Back Benches as well. They all declare a constituency interest or a personal, financial one in the pharmaceutical industry. It seems that they are somewhat worried when we start to examine expenditure in this area.
We are pursuing a saving of £75 million for the Health Service and its patients in an area where, so far as I am aware, every professional agrees that savings can and should be made. Our critics should be saying that it is about time that something was done and that positive action should have been taken before now instead of raising objections and preparing to vote against the proposal that is before us.
We have spent a protracted time in discussions to seek an effective method of making savings that will not jeopardise patient care. We had many discussions before the Greenfield report and we had many after it. Generic substitution was recommended by the Greenfield committee and rejected by the BMA, the industry and by us, the Government, for reasons to which I shall return. Thereafter, we continued to search for ways in which we 744 might be able to make advances without jeopardising professional or industrial interests that are important to Britain.
I have been accused of rejecting a limited list in responding to the hon. Member for Carmarthen (Dr. Thomas). I rejected the concept in reply to a parliamentary question from the hon. Gentleman and I still reject it across the entire range of therapeutic categories. Before we made our announcement shortly before Christmas, we decided that the selected list approach was not justified across every therapeutic category. Had we gone outside the categories that we have chosen—tonics, vitamins, cough medicines, tranquillisers and sedatives, for example—we would have threatened research into life-saving drugs and entered very much more difficult professional areas. I do not regret the reply to the parliamentary question which has been much quoted by the ABPI and, therefore, by Labour Members this evening.
We also examined international experience which, again, has been much misquoted today by the use of briefs. The hon. Member for Oldham, West talked of Sweden. Sweden is much more restrictive than we are in its use of drugs. It has a licensing system which requires safety and efficacy and will not license products unless there is a demonstrated need. It has a selected system across the whole range of therapeutic products.
Nor is it true, as has been suggested, that the Netherlands is abandoning the selected list system. It is making one change and keeping to the system. I do not agree with those who say that the Germans cannot demonstrate any savings. That is not the opinion of the German Government, but that of some of the lobbyists who have been briefing some hon. Members who have taken part in this debate. It is not true tht arrangements such as this wiped out the industry in Canada. There was a change in the licensing system in Canada, not just a change in the selection of products.
International experience shows that we are unique in taking the full range of products at the behest of each practitioner—all paid for on the NHS. I even got an executive of an American drug company to admit that our arrangement—by which we take any product that comes on the market at any price so long as a doctor can be induced, often by heavy promotion, to prescribe it at the expense of the NHS—is pretty silly. We examined the practice of other countries and endeavoured to introduce a variant of other systems that we think appropriate to the NHS.
Of course, we noticed that 40 per cent. of hospitals have formularies that extend across the full range of therapeutic categories. They are far more extensive than what is proposed. We also considered the fact that many good general practices, including the ones mentioned by the hon. Member for Holborn and St. Pancras have their own formularies. On that basis, my right hon. Friend made his announcement in November. Thereafter followed a process of consultation, discussion and consideration of the proposal, which produced our final selected list a few weeks ago.
The Government believe in consultation. I believe that consultation improves the quality of decision-making. We all know what happens when one consults on such matters. There is an inevitable tendency for those who do not like the drift of policy to demonstrate or mount expensive and irresponsible press campaigns rather than discuss while the policy is evolving. We consulted and got a substantial 745 number of the medical profession to respond. We got agreement from some royal colleges. Others, which oppose us, gave opinions about the content of the list.
I actually met the BMA. It has been one of those occasions when an organisation refuses to consult and discuss, but which one nevertheless meets with embarrassing frequency. I have attended three formal meetings with my right hon. Friend or officials and I have addressed the BMA at Tavistock house. It restricted what it would talk to us about, but that was its choice. I met the Pharmaceutical Society of Great Britain and the pharmaceutical services negotiating committee. We did not make a political judgment about the contents of the final selected list, but put together an expert panel.
I can tell my hon. Friend the Member for Renfrew, West and Inverclyde (Mrs. McCurley) that each member of the panel was a practising clinician. Three were GPs, one a pharmacist and another a psychiatrist—the interest she mentioned — and we accepted the unanimous professional view of that panel based on the reactions to the consultation about what ought to go on the list. That was sensible, and I discover to my astonishment that the Liberal party, and, if we believe the last speech from the Labour party, the Labour party, favour a list, but believe that the manner in which we have put ours together entitles them to vote against this one.
§ Mr. Robert Hughes
The Minister makes much of consultations, but I sent him a number of letters—not standard letters — from GPs who were worried about their own specific patients because certain drugs were left off the list. They asked for a clinical explanation, but I have not had a single reply from the Minister. That is why the Government's proposals stand condemned.
§ Mr. Clarke
It is in the nature of organised letter-writing campaigns that it becomes impossible to give detailed replies to each letter. Hon. Members were objecting earlier to standardised replies. If one gets thousands of standardised letters, one sends standardised replies.
Many of the letters from individual patients who had been told that their drug was not available were based on untruthful allegations, because the consultation and the final selection of drugs had not taken place. Many of the drugs cited by GPs or by patients who had been advised by GPs were not affected by our proposals.
§ Mr. Clarke
No, I am not giving way again.
I think that, with the exception of my hon. Friend the Member for Renfrew, West and Inverclyde, every one of my hon. Friends who spoke against our proposals declared an interest in the pharmaceutical industry, on either a constituency or a personal basis. I do not object to that; the industry is important to our economy and requires the protection of the DHSS, as the sponsoring Department, not least because it has considerable export earnings and provides considerable employment.
However, the facts that the DHSS is the sponsoring Department, that the industry has been successful during a recession, that it earns considerable sums for this country and that we need to foster a strong, research-based industry to gain export earnings do not mean that the industry's 746 profit margins and promotional activities are inviolate or that the NHS can never be free to consider the product range. We have a twin duty — to look after the legitimate interests of the industry and to make sure that the NHS does not buy products that it does not require or pay excessively for those products. We are following that balance of interests.
I have been questioned about profit margins and promotional costs and asked whether we will look for alternatives.
§ Mr. Malcolm Thornton (Crosby)
As someone who has neither a constituency nor a financial interest in the pharmaceutical industry, may I tell my right hon. and learned Friend that the industry is a little worried about the somewhat arbitrary nature of the way in which certain products have been excluded from the list or included in it? There are some major inconsistencies. Will my right hon. and learned Friend give an assurance that the review body or the appeals machinery will allow that matter to be looked at carefully?
§ Mr. Clarke
It has certainly not been done arbitrarily. The final selection of the list was made on clear criteria which have been set out in answers to parliamentary questions. The selection was made by members of a professional panel using their medical and scientific judgment. They received submissions from all the companies affected, making claims for the therapeutic quality of their products. Of course companies argue about inconsistencies if they find that their products have been unsuccessful compared with others.
The review procedure, which we shall set up as soon as we can, when we have consulted about its details, will be able to keep the list under continual review. It will be able to look at cases if people wish to return to the argument with the review committee. But the decisions will be made on professional, medical and scientific grounds and we shall put a drug on the white list—that is, those selected for prescription on the NHS—only if we are satisfied that it meets a clinical need that no other product can meet or that it meets more cost-effectively a clinical need that is also met by other products.
We are looking at the price we pay and the profit margins we allow under a system that we inherited from the Labour Government. We took over from that Government the PPRS scheme which had not been reviewed for many years and was producing extremely generous returns for an industry which most Labour Members usually curse. They often threaten to nationalise substantial parts of that industry. We have reduced the target rate of return for the industry from 25 per cent., which was appropriate when we had higher inflation, to between 17 and 18 per cent. now. Profit margins and price levels must be reduced. A 25 per cent. target rate of return when inflation was at 15 per cent. or more, is no better than a 15 per cent. rate of return now, although it has not decreased so far. The profitability of the industry was increasing while inflation fell, and we cannot be accused of being hostile by reviewing profit levels. If promotional activity reaches £130 million, the time has come to check it.
The climate remains favourable for investment—
§ Mr. Dobson
Does the right hon. and learned Gentleman agree that he means that in real terms the profits of the drug companies have increased, although their notional profit levels have been reduced?
§ Mr. Clarke
The profits of the drug industry remain fair because, unlike the Labour Government, we have reviewed the PPRS. We are adjusting prices, not revealing a new hostility to the industry. We believe that the industry is valuable, and that investment will continue to be attracted to the United Kingdom because of the reputation of the NHS, our licensing arrangements, and the attraction of the United Kingdom as a base for research and for academic work, on which so much of the drug industry depends.
I agree with my hon. Friend the Member for Thanet, South (Mr. Aitken) that one must make a practical judgment about how to create a fair climate for the industry, but that does not rule out changes of policy of this sort, which hold the balance fairly between the industry and the NHS. The industry suggested, not alternative ways of saving money, but ways of raising £70 million or more, not at the expense of the companies. It suggested reducing wholesalers' profit margins and stopping the NHS supply of medicines for trivial and self-limiting conditions. It wanted to take products off the NHS list and to attack the exemptions for children and the elderly.
Neither of the Opposition parties nor that part of the medical profession which is opposed to the proposals have put forward alternatives. I expected arguments in favour of generic substitution, but only the hon. Member for Ross, Cromarty and Skye (Mr. Kennedy) believes that that is still his party's policy. Generic substitution suggested by Greenfield was opposed by the BMA and ABPI. It would create great problems if a doctor prescribed one drug and a different formulation was dispensed by a chemist, and those problems could not be resolved. It would have damaged research in key areas. Given that the BMA and, I thought, the Labour party were advocating voluntary generic prescribing, and that compulsory generic prescribing can save only between £30 and £35 million, voluntary generic prescribing would save peanuts.
We can answer the criticisms of the hon. Member for Holborn and St. Pancras by setting up the appeals mechanism of the sort that we have said we are anxious to discuss with the BMA. I am sorry that the BMA has come so late. In the past the appeals mechanism has been mentioned by many doctors, but they suggested one when the full list was available. At that time, the list had not been subjected to the opinion of the panel and was not extended to its present full selection. We have since received a few letters, and last Thursday the BMA responded to our invitation to talks about an appeal mechanism. We shall certainly hold such talks.
I therefore believe that we have handled the policy as well as possible. We seem to be strikingly near to the policy of both Opposition parties, who are finding foolish reasons for opposing the measure. The hon. Member for Leeds, West (Mr. Meadowcroft) made it clear that the alliance is in favour of a selected list approach. Certainly, I read a speech by the right hon. Member for Plymouth, Devonport (Dr. Owen), whose absence today is notable, which set out, in the ABPI's propaganda, his clear views that the time had come to get rid of "me-too" drugs and 748 those which had enjoyed a spurious form of protection. But the Labour party suddenly set out criteria for a limited list system today, which comes late in the day.
Another Member whom we have missed is the right hon. Member for Stoke-on-Trent, South (Mr. Ashley), who normally has considerable influence in the Labour party on such matters. On 27 November 1984 he said to my right hon. Friend the Secretary of State:Is the Secretary of State aware that his first attempt to introduce a rational prescribing policy is to be very warmly welcomed, that he should strongly resist the selfish and distorted propaganda of the pharmaceutical industry, which is now screaming blue murder, and that the only advice he should accept about implementing this very good proposal is independent advice?"—[Official Report, 27 November 1984; Vol. 68, c. 761.]The right hon. Gentleman may have had an excellent reason for staying away, but it was probably out of shame at what the Labour Front-Bench spokesmen said.
The hon. Member for Fife, Central (Mr. Hamilton) cited Nye Bevan. I am sure that Nye Bevan would not have liked the speech of the hon. Member for Oldham, West, which was taken from an ABPI brief—
§ It being Twelve o'clock, MR. DEPUTY SPEAKER put the Question pursuant to order [12 March].
§ The House divided: Ayes 205, Noes 332.
|Division No. 160]||[Midnight|
|Adams, Allen (Paisley N)||Craigen, J. M.|
|Alexander, Richard||Crowther, Stan|
|Alton, David||Cunliffe, Lawrence|
|Anderson, Donald||Cunningham, Dr John|
|Ashley, Rt Hon Jack||Dalyell, Tam|
|Ashton, Joe||Davies, Rt Hon Denzil (L'lli)|
|Atkinson, N. (Tottenham)||Davies, Ronald (Caerphilly)|
|Bagier, Gordon A. T.||Davis, Terry (B'ham, H'ge H'l)|
|Banks, Tony (Newham NW)||Deakins, Eric|
|Barnett, Guy||Dewar, Donald|
|Barron, Kevin||Dixon, Donald|
|Beckett, Mrs Margaret||Dobson, Frank|
|Beith, A. J.||Dormand, Jack|
|Bell, Stuart||Douglas, Dick|
|Benn, Tony||Dubs, Alfred|
|Bennett, A. (Dent'n & Red'sh)||Duffy, A. E. P.|
|Bermingham, Gerald||Dunwoody, Hon Mrs G.|
|Bidwell, Sydney||Eastham, Ken|
|Boothroyd, Miss Betty||Ellis, Raymond|
|Boyes, Roland||Evans, John (St. Helens N)|
|Bray, Dr Jeremy||Ewing, Harry|
|Brown, Gordon (D'f'mline E)||Fatchett, Derek|
|Brown, N. (N'c'tle-u-Tyne E)||Faulds, Andrew|
|Brown, R. (N'c'tle-u-Tyne N)||Fields, T. (L'pool Broad Gn)|
|Brown, Ron (E'burgh, Leith)||Fisher, Mark|
|Bruce, Malcolm||Flannery, Martin|
|Buchan, Norman||Foot, Rt Hon Michael|
|Caborn, Richard||Forrester, John|
|Callaghan, Jim (Heyw'd & M)||Foster, Derek|
|Campbell, Ian||Foulkes, George|
|Campbell-Savours, Dale||Fraser, J. (Norwood)|
|Canavan, Dennis||Freeson, Rt Hon Reginald|
|Carlile, Alexander (Montg'y)||Freud, Clement|
|Carter-Jones, Lewis||Garrett, W. E.|
|Cartwright, John||George, Bruce|
|Clark, Dr David (S Shields)||Gilbert, Rt Hon Dr John|
|Clarke, Thomas||Godman, Dr Norman|
|Clay, Robert||Gould, Bryan|
|Clwyd, Mrs Ann||Gourlay, Harry|
|Cocks, Rt Hon M. (Bristol S.)||Grylls, Michael|
|Coleman, Donald||Hamilton, James (M'well N)|
|Conlan, Bernard||Hamilton, W. W. (Central Fife)|
|Cook, Robin F. (Livingston)||Hancock, Mr, Michael|
|Corbett, Robin||Hardy, Peter|
|Corbyn, Jeremy||Harman, Ms Harriet|
|Cowans, Harry||Harrison, Rt Hon Walter|
|Cox, Thomas (Tooting)||Hart, Rt Hon Dame Judith|
|Hattersley, Rt Hon Roy||Owen, Rt Hon Dr David|
|Healey, Rt Hon Denis||Park, George|
|Heffer, Eric S.||Patchett, Terry|
|Hogg, N. (C'nauld & Kilsyth)||Pendry, Tom|
|Holland, Stuart (Vauxhall)||Penhaligon, David|
|Home Robertson, John||Prescott, John|
|Howell, Rt Hon D. (S'heath)||Radice, Giles|
|Howells, Geraint||Randall, Stuart|
|Hoyle, Douglas||Redmond, M.|
|Hughes, Robert (Aberdeen N)||Rees, Rt Hon M. (Leeds S)|
|Hughes, Roy (Newport East)||Richardson, Ms Jo|
|Hughes, Sean (Knowsley S)||Roberts, Ernest (Hackney N)|
|Hughes, Simon (Southwark)||Robertson, George|
|Janner, Hon Greville||Rogers, Allan|
|John, Brynmor||Rooker, J. W.|
|Jones, Barry (Alyn & Deeside)||Ross, Stephen (Isle of Wight)|
|Kaufman, Rt Hon Gerald||Rowlands, Ted|
|Kennedy, Charles||Ryman, John|
|Kilroy-Silk, Robert||Sedgemore, Brian|
|Kirkwood, Archy||Sheerman, Barry|
|Lambie, David||Sheldon, Rt Hon R.|
|Lamond, James||Shore, Rt Hon Peter|
|Leadbitter, Ted||Short, Ms Clare (Ladywood)|
|Leighton, Ronald||Short, Mrs R.(W'hampt'n NE)|
|Lewis, Ron (Carlisle)||Skinner, Dennis|
|Lewis, Terence (Worsley)||Smith, C.(Isl'ton S & F'bury)|
|Litherland, Robert||Smith, Sir Dudley (Warwick)|
|Lofthouse, Geoffrey||Smith, Rt Hon J. (M'kl'ds E)|
|Loyden, Edward||Snape, Peter|
|McCartney, Hugh||Soley, Clive|
|McDonald, Dr Oonagh||Spearing, Nigel|
|McGuire, Michael||Stewart, Rt Hon D. (W Isles)|
|McKelvey, William||Stott, Roger|
|Mackenzie, Rt Hon Gregor||Strang, Gavin|
|Maclennan, Robert||Thomas, Dr R. (Carmarthen)|
|McNamara, Kevin||Thompson, J. (Wansbeck)|
|McTaggart, Robert||Thorne, Stan (Preston)|
|McWilliam, John||Thornton, Malcolm|
|Madden, Max||Tinn, James|
|Marek, Dr John||Torney, Tom|
|Marshall, David (Shettleston)||Wallace, James|
|Martin, Michael||Wardell, Gareth (Gower)|
|Maxton, John||Wareing, Robert|
|Maynard, Miss Joan||Weetch, Ken|
|Meacher, Michael||Welsh, Michael|
|Meadowcroft, Michael||White, James|
|Michie, William||Williams, Rt Hon A.|
|Millan, Rt Hon Bruce||Wilson, Gordon|
|Miller, Dr M. S. (E Kilbride)||Winnick, David|
|Mitchell, Austin (G't Grimsby)||Winterton, Mrs Ann|
|Morris, Rt Hon A. (W'shawe)||Winterton, Nicholas|
|Morris, Rt Hon J. (Aberavon)||Woodall, Alec|
|Morris, M. (N'hampton, S)||Young, David (Bolton SE)|
|Nellist, David||Tellers for the Ayes:|
|Oakes, Rt Hon Gordon||Mr. Frank Haynes and|
|O'Brien, William||Mr. Allen McKay.|
|Orme, Rt Hon Stanley|
|Adley, Robert||Benyon, William|
|Aitken, Jonathan||Best, Keith|
|Alison, Rt Hon Michael||Bevan, David Gilroy|
|Amery, Rt Hon Julian||Biffen, Rt Hon John|
|Amess, David||Blackburn, John|
|Ancram, Michael||Blaker, Rt Hon Sir Peter|
|Arnold, Tom||Body, Richard|
|Ashby, David||Bonsor, Sir Nicholas|
|Aspinwall, Jack||Bottomley, Peter|
|Atkins, Rt Hon Sir H.||Bowden, A. (Brighton K'to'n)|
|Atkins, Robert (South Ribble)||Bowden, Gerald (Dulwich)|
|Atkinson, David (B'm'th E)||Boyson, Dr Rhodes|
|Baker, Rt Hon K. (Mole Vall'y)||Brandon-Bravo, Martin|
|Baker, Nicholas (N Dorset)||Bright, Graham|
|Baldry, Tony||Brinton, Tim|
|Banks, Robert (Harrogate)||Brittan, Rt Hon Leon|
|Batiste, Spencer||Brooke, Hon Peter|
|Beaumont-Dark, Anthony||Brown, M. (Brigg & Cl'thpes)|
|Bellingham, Henry||Browne, John|
|Bendall, Vivian||Bruinvels, Peter|
|Bryan, Sir Paul||Hargreaves, Kenneth|
|Buchanan-Smith, Rt Hon A.||Harris, David|
|Buck, Sir Antony||Harvey, Robert|
|Budgen, Nick||Hawkins, C. (High Peak)|
|Bulmer, Esmond||Hawkins, Sir Paul (SW N'folk)|
|Burt, Alistair||Hawksley, Warren|
|Butcher, John||Hayes, J.|
|Butler, Hon Adam||Hayhoe, Barney|
|Butterfill, John||Heath, Rt Hon Edward|
|Carlisle, John (N Luton)||Heathcoat-Amory, David|
|Carlisle, Kenneth (Lincoln)||Heddle, John|
|Carlisle, Rt Hon M. (W'ton S)||Henderson, Barry|
|Carttiss, Michael||Heseltine, Rt Hon Michael|
|Cash, William||Hickmet, Richard|
|Chalker, Mrs Lynda||Hicks, Robert|
|Chapman, Sydney||Higgins, Rt Hon Terence L.|
|Chope, Christopher||Hill, James|
|Churchill, W. S.||Hind, Kenneth|
|Clark, Hon A. (Plym'th S'n)||Hirst, Michael|
|Clark, Dr Michael (Rochford)||Hogg, Hon Douglas (Gr'th'm)|
|Clark, Sir W. (Croydon S)||Holland, Sir Philip (Gedling)|
|Clarke, Rt Hon K. (Rushcliffe)||Hordern, Peter|
|Clegg, Sir Walter||Howard, Michael|
|Colvin, Michael||Howarth, Alan (Stratf'd-on-A)|
|Conway, Derek||Howell, Rt Hon D. (G'ldford)|
|Coombs, Simon||Howell, Ralph (N Norfolk)|
|Cope, John||Hubbard-Miles, Peter|
|Cormack, Patrick||Hunt, David (Wirral)|
|Corrie, John||Hunt, John (Ravensbourne)|
|Couchman, James||Hunter, Andrew|
|Cranborne, Viscount||Hurd, Rt Hon Douglas|
|Critchley, Julian||Jackson, Robert|
|Currie, Mrs Edwina||Jenkin, Rt Hon Patrick|
|Dickens, Geoffrey||Jessel, Toby|
|Dicks, Terry||Johnson Smith, Sir Geoffrey|
|Dorrell, Stephen||Jones, Gwilym (Cardiff N)|
|Douglas-Hamilton, Lord J.||Jones, Robert (W Herts)|
|du Cann, Rt Hon Sir Edward||Jopling, Rt Hon Michael|
|Dunn, Robert||Joseph, Rt Hon Sir Keith|
|Durant, Tony||Kellett-Bowman, Mrs Elaine|
|Dykes, Hugh||Kershaw, Sir Anthony|
|Edwards, Rt Hon N. (P'broke)||Key, Robert|
|Eggar, Tim||King, Roger (B'ham N'field)|
|Emery, Sir Peter||King, Rt Hon Tom|
|Evennett, David||Knight, Gregory (Derby N)|
|Eyre, Sir Reginald||Knight, Mrs Jill (Edgbaston)|
|Fallon, Michael||Knowles, Michael|
|Farr, Sir John||Knox, David|
|Fenner, Mrs Peggy||Lamont, Norman|
|Finsberg, Sir Geoffrey||Lang, Ian|
|Fookes, Miss Janet||Latham, Michael|
|Forman, Nigel||Lawrence, Ivan|
|Forsyth, Michael (Stirling)||Lee, John (Pendle)|
|Forth, Eric||Leigh, Edward (Gainsbor'gh)|
|Fowler, Rt Hon Norman||Lennox-Boyd, Hon Mark|
|Fox, Marcus||Lester, Jim|
|Franks, Cecil||Lewis, Sir Kenneth (Stamf'd)|
|Fraser, Peter (Angus East)||Lightbown, David|
|Fry, Peter||Lilley, Peter|
|Gale, Roger||Lloyd, Ian (Havant)|
|Galley, Roy||Lloyd, Peter, (Fareham)|
|Gardiner, George (Reigate)||Lord, Michael|
|Gardner, Sir Edward (Fylde)||Luce, Richard|
|Garel-Jones, Tristan||Lyell, Nicholas|
|Glyn, Dr Alan||McCrindle, Robert|
|Goodhart, Sir Philip||Macfarlane, Neil|
|Gorst, John||MacGregor, John|
|Gow, Ian||MacKay, Andrew (Berkshire)|
|Gower, Sir Raymond||MacKay, John (Argyll & Bute)|
|Greenway, Harry||Maclean, David John|
|Gregory, Conal||McNair-Wilson, P. (New F'st)|
|Griffiths, E. (B'y St Edm'ds)||Madel, David|
|Griffiths, Peter (Portsm'th N)||Major, John|
|Grist, Ian||Malins, Humfrey|
|Ground, Patrick||Malone, Gerald|
|Gummer, John Selwyn||Maples, John|
|Hamilton, Hon A. (Epsom)||Marland, Paul|
|Hampson, Dr Keith||Marlow, Antony|
|Hanley, Jeremy||Marshall, Michael (Arundel)|
|Hannam, John||Mates, Michael|
|Maude, Hon Francis||Shelton, William (Streatham)|
|Mawhinney, Dr Brian||Shepherd, Colin (Hereford)|
|Maxwell-Hyslop, Robin||Shepherd, Richard (Aldridge)|
|Mellor, David||Sims, Roger|
|Meyer, Sir Anthony||Skeet, T. H. H.|
|Miller, Hal (B'grove)||Smith, Tim (Beaconsfield)|
|Mills, Iain (Meriden)||Soames, Hon Nicholas|
|Mitchell, David (NW Hants)||Speed, Keith|
|Moate, Roger||Spencer, Derek|
|Monro, Sir Hector||Spicer, Jim (W Dorset)|
|Montgomery, Sir Fergus||Spicer, Michael (S Worcs)|
|Moore, John||Squire, Robin|
|Morrison, Hon C. (Devizes)||Stanbrook, Ivor|
|Morrison, Hon P. (Chester)||Steen, Anthony|
|Moynihan, Hon C.||Stern, Michael|
|Mudd, David||Stevens, Lewis (Nuneaton)|
|Neale, Gerrard||Stevens, Martin (Fulham)|
|Needham, Richard||Stewart, Allan (Eastwood)|
|Neubert, Michael||Stewart, Andrew (Sherwood)|
|Newton, Tony||Stewart, Ian (N Hertf'dshire)|
|Nicholls, Patrick||Stokes, John|
|Normanton, Tom||Stradling Thomas, J.|
|Norris, Steven||Sumberg, David|
|Onslow, Cranley||Taylor, John (Solihull)|
|Oppenheim, Phillip||Taylor, Teddy (S'end E)|
|Oppenheim, Rt Hon Mrs S.||Tebbit, Rt Hon Norman|
|Ottaway, Richard||Temple-Morris, Peter|
|Page, Sir John (Harrow W)||Terlezki, Stefan|
|Page, Richard (Herts SW)||Thatcher, Rt Hon Mrs M.|
|Parris, Matthew||Thomas, Rt Hon Peter|
|Patten, Christopher (Bath)||Thompson, Donald (Calder V)|
|Patten, J. (Oxf W & Abdgn)||Thompson, Patrick (N'ich N)|
|Pawsey, James||Thorne, Neil (Ilford S)|
|Peacock, Mrs Elizabeth||Thurnham, Peter|
|Percival, Rt Hon Sir Ian||Townend, John (Bridlington)|
|Pollock, Alexander||Tracey, Richard|
|Porter, Barry||Trippier, David|
|Portillo, Michael||Twinn, Dr Ian|
|Powell, William (Corby)||van Straubenzee, Sir W.|
|Powley, John||Viggers, Peter|
|Prentice, Rt Hon Reg||Waddington, David|
|Price, Sir David||Wakeham, Rt Hon John|
|Prior, Rt Hon James||Waldegrave, Hon William|
|Proctor, K. Harvey||Walden, George|
|Pym, Rt Hon Francis||Walker, Rt Hon P. (W'cester)|
|Raison, Rt Hon Timothy||Wall, Sir Patrick|
|Rathbone, Tim||Waller, Gary|
|Rees, Rt Hon Peter (Dover)||Walters, Dennis|
|Rhodes James, Robert||Ward, John|
|Rhys Williams, Sir Brandon||Wardle, C. (Bexhill)|
|Ridley, Rt Hon Nicholas||Warren, Kenneth|
|Ridsdale, Sir Julian||Watson, John|
|Rifkind, Malcolm||Watts, John|
|Rippon, Rt Hon Geoffrey||Wells, Bowen (Hertford)|
|Roberts, Wyn (Conwy)||Wells, Sir John (Maidstone)|
|Robinson, Mark (N'port W)||Wheeler, John|
|Roe, Mrs Marion||Whitfield, John|
|Rossi, Sir Hugh||Whitney, Raymond|
|Rost, Peter||Wolfson, Mark|
|Rowe, Andrew||Wood, Timothy|
|Rumbold, Mrs Angela||Woodcock, Michael|
|Ryder, Richard||Yeo, Tim|
|Sackville, Hon Thomas||Young, Sir George (Acton)|
|Sainsbury, Hon Timothy||Younger, Rt Hon George|
|St. John-Stevas, Rt Hon N.|
|Sayeed, Jonathan||Tellers for the Noes:|
|Shaw, Giles (Pudsey)||Mr. Carol Mather and|
|Shaw, Sir Michael (Scarb')||Mr. Robert Boscawen.|
§ Question accordingly negatived.