INDICATIVE BUDGETS FOR DOCTORS' PRACTICES (Hansard, 27 June 1990)

§ Mr. Kenneth Clarke
I beg to move, That this House doth agree with the Lords in the said amendment.

§ Mr. Deputy Speaker
With this, it will be convenient to discuss Lords amendments Nos. 15 to 19 and 53 to 57.

§ Mr. Clarke
This group of amendments changes the terminology in the Bill. What were previously described as indicative prescribing budgets will be called, if the amendments are agreed to, indicative prescribing amounts. This remains the same GP prescribing scheme as we have debated frequently before, but I hope to persuade the House that the change in nomemclature is desirable—as their Lordships were persuaded that it was.
There are two reasons for the change. First, it puts behind us the extraordinary campaigning and the fears aroused by the arguments about indicative prescribing budgets last summer. Hon. Members will recall that, when we first produced our reforms, various interests outside took the view that if the patients could be terrified enough about the prospect of change it would be possible to stop any reforms of the way in which the NHS is run.
Those interests invented a scurrilous claim that indicative prescribing budgets would lead to patients being deprived of medicines that they might require because their doctors would run out of money to prescribe their drugs. I regret to say that huge sums of money were put into the campaign and a great deal of effort was expended on frightening a lot of elderly and vulnerable patients into believing that they might not get the treatment they required. Eventually, I am glad to say, the BMA was persuaded to withdraw the claim and to agree that there was nothing in the Government's scheme that gave rise to any risk of any doctor ever having to refuse a patient medicine.
Unfortunately, the Labour party took longer to come round, because its members had leapt on to this nasty bandwagon and hence took some time to get off it. We all accept now that nothing in the proposals before us in any way imperils patients always being able to receive the medicines regarded as necessary by their doctors. In any case, all our previous debates and the campaigning about indicative prescribing budgets may be put behind us by going over to the word "amounts".
There is another, practical, problem. Much of the debate about my health service reforms keeps turning on budgets of various sorts. I accept that there is sometimes genuine confusion in the arguments of supporters, and frequently in the arguments of critics, about the sort of budgets that will be given to GPs who choose to become fund holders—what we call GP practice budgets—and about indicative prescribing budgets, which are budgets given to all GPs as an indication of what their prescribing costs would be expected to be if they incurred the ordinary and desirable level of costs for the patient mix on their lists.
It will be helpful for the prescribing scheme if we change to the term "indicative prescribing amount", leaving the word "budget" to describe the sums of money that will be negotiated with GPs who choose to become fund-holding GPs because they believe that, by controlling that amount of money, they will be able to influence the development of local services in a way that best suits their practices.
There is no change of policy—merely a desirable change of nomenclature. The Government firmly believe that it is necessary to eliminate wasteful expenditure on drugs in cases in which unnecessary amounts or too expensive drugs are prescribed. It is also sometimes necessary to eliminate dangerous over-prescribing in cases of large quantities of, say, tranquillisers being poured 389 down the throats of patients for long periods on repeat prescriptions without the patient having to see the doctor who was originally responsible for the prescription.
All hon. Members agree that we should cut out wasteful and dangerous prescribing. Everyone pays lip service to the idea that we should keep down the drugs bill to what it is necessary to spend—no more and no less. I hope that we shall have no more scurrilous attacks on the Government of the sort that we heard last year, and that people will campaign in line with what they say and want. The new scheme will take us nearer to the health service spending only as much as is necessary on drugs. If we can get the scheme running and if the amendments are agreed to, I believe that the phrase "indicative prescribing amounts" will make the scheme better understood.

§ Mr. Michael
These amendments appear to be a concession; the Government seem to be agreeing to delete all reference to GP drug budgets. But I warn the House that all is not what it seems. I also challenge the Minister to respond to this brief debate with a commitment that the Govenment have refused to write into the Bill.
The only fictitious and scurrilous aspect has been the Secretary of State's appalling series of attacks not only on the Opposition but on every professional group in the NHS, during the debate on this and on virtually every other aspect of the Bill.
In his opening remarks, the Secretary of State gave away the true position—in his words, there is no change of policy. In his words, this remains the same GP prescribing scheme. The Opposition have acted responsibly in warning the professionals and the public what to expect if the Secretary of State is allowed to get away with his changes to the national health service.
We have to deal not only with what is in the Bill but with what is not. The removal of waste and the elimination of over-prescribing or under-prescribing are fine aims, and in due course the Opposition will seek to tackle those matters. The trouble with the GP prescribing scheme, as the Secretary of State described it, is that the Bill does not assert the primacy of patient care in deciding what medication should be given to a patient. The Secretary of State failed to write that into the Bill. That point has been made to me most strongly by doctors.
8.30 pm
Another point made to me is that the Lords amendments make only cosmetic changes to the legislation. It looks like an improvement to have the word "budget" replaced by the word "amount" in clause 18, but is it really? Is there any real change in the meaning? The Secretary of State says that there is not. Will the law when it is enacted be different as a result of this change? Again the Secretary of State says no. This is the result of a game of word search on a word processor to find a different way to say the same thing.
In recent working papers, we have seen a softening of the rhetoric, just as we saw a softening in the Secretary of State's style in this debate. While the legislation does not explicitly threaten the cash limit, there is no guarantee that a Secretary of State for Health or a Secretary of State for Wales or for Scotland will not impose explicit cash limits in future.
Amendments offered to the Minister in Committee were rejected. That rejection clearly demonstrated the Government's refusal to give the precise and simple 390 reassurance in law that the Opposition, doctors and patients want, need and deserve. I remind the Secretary of State of the two amendments that he rejected. The first said: there will be no sanction, financial or otherwise, applied against a practice which exceeds its indicative drug budget. "Drug amount" is the term that the Secretary of State prefers. The second amendment stated: nothing in this section shall interfere with a medical practitioner's decision to supply pharmaceutical services according to his clinical judgment. We sought such protection in law, but it has not been given. Those amendments were important, because they sought to protect the doctor's right to prescribe in the patient's best interest. The traditional confidence of the patient in the doctor is the basis of our national health service. It is incredible that the Government are prepared to put that at risk. Public and patient confidence is important.
We drew the Secretary of State's attention to the 1989 poll showing that nearly 25 per cent. of the sample believe that the plan to give doctors a drug budget—or drug amount—would lead to doctors failing to prescribe expensive drugs even when they were necessary. Half the poll sample thought that the drug budget would make doctors more careful, but in what way would they be more careful? They would be more careful not in terms of care in prescribing but in the way in which they controlled the finances. In this matter, as in so many others, the Secretary of State has claimed that we were crying wolf and raising unreal fears.
Since our debates in Committee, we have seen the truth. We have also come to understand why the Government are willing to accept the Lords amendments. They do not need drug budgets in the Bill to undermine patient care, because that is happening already. The damage has already been done to our beloved NHS. The accountants and the computers are already taking over. The examples are manifold, but I will give just a couple. A Cardiff woman went to her doctor for a repeat prescription for an inhaler for asthma. She was told that she could not have that one any more because it cost £17 and the GP could not afford to prescribe it under her budget. The patient was told that she would have to have a cheaper inhaler. A Welsh GP tells of the family practitioner committee producing its estimated budgets for this year and being given only half the budget needs, based on experience.
We hear of more and more people having to have a full medical examination before a doctor will accept them on his list. I do not entirely blame the GPs for that, because a doctor has to consider existing patients. The Government and the Secretary of State are to blame for placing GPs in a dilemma by introducing distortions in the operation of the National Health Service which are wrong in principle and wrong in practice.
The Bill gives great powers to the Secretary of State. He could promise that this shell Bill and the proposed reforms will not stop patients getting the medication that they need, but sadly, that would be an empty promise. The threat to patient care will not be removed by the amendments. The damage is being done and the Bill still fails to offer the positive protection of patient care, which will have to await the general election and a Labour Government.

§ Mr. Kennedy
I do not want to go into matters as deeply as the hon. Member for Cardiff, South and Penarth (Mr. 391 Michael). In an emollient way, the Secretary of State described why he was replacing the word "budget" with the word "amount". Presumably a civil servant or the Minister or a policy adviser thought of this change. Was it thought up by the same person who tried to get everybody to use the term "community charge" rather than the term "poll tax"? If so, may we have that person's name?

§ Mr. Kenneth Hind (Lancashire, West)
I support the amendment. It is sensible because it strikes at one of the main propaganda weapons of the Opposition. They and many of their supporters have many times deployed that weapon against the Bill and it has caused great upset and distress to elderly patients and the chronically sick.
Conservative Members are constantly faced in their surgeries with people who say that, if the Bill goes through, the doctor will not be able to prescribe drugs or give the necessary treatment. That has caused great anxiety, and, despite the Government's reassurances, the Opposition have peddled that argument time and again in an attempt to creat anxiety for political purposes. The beauty of this change of name to deal with the drug budget is that it finally buries what I can only describe as that calumny. Eventually the Opposition will come round to recognising that we are not out of our minds and will not deny sick people the drugs that are necessary to cure them. The constant repetition of that calumny has raised totally unjustified anxieties.
I welcome, as I think do all hon. Members, the desire to deal with waste and the need to encourage under-prescribers to prescribe drugs for their patients. No one will interfere with a doctor's right to prescribe what he thinks is necessary for a patient. That must underpin any decision that is made by a doctor and it underpins the Bill. Making it clear that this is not a budget but an amount underlines that and gives much needed reassurance to the patient.

§ Mr. Kenneth Clarke
The hon. Member for Ross, Cromarty and Skye (Mr. Kennedy) asked who thought up the change of nomenclature. I assume that it was thought up by Lord Butterfield, the Cambridge professor of physic, who moved in another place the amendment that was accepted by the Government. I shall spare the hon. Gentleman most of my strictures, because I think that the campaign waged by the Labour party has been much worse than his. He showed an unfortunate and unintended lapse of taste when he suggested that the Cambridge professor of physic, a distinguished member of another place, was engaged in some sort of public relations exercise.
The amendment makes a sensible change. I presume that the hon. Member for Ross, Cromarty and Skye, like my hon. Friend the Member for Lancashire, West (Mr. Hind) and me, wants to turn the page on some of the campaigning that we have seen on the subject. That caused much harm and frightened many elderly and vulnerable patients.
The hon. Member for Cardiff, South and Penarth (Mr. Michael) continues to move round the subject. There is not and never has been any question of a doctor being put in a position where he could not prescribe the necessary medicine for his patients. It is total nonsense to suggest that that was ever in question. There is no question of any 392 sanction being applied to a general practitioner who prescribes a necessary medicine. The only scrutiny to which a doctor will be subjected by other doctors is an inquiry into the possibility of wasteful, dangerous or out-of-date prescribing. The prescribing doctor will be expected to correct such prescribing if it is found. The introduction of the change is already having some beneficial effects.

§ Mr. Michael
Will the Secretary of State give way?

§ Mr. Clarke
I shall give way in a moment.
The only good thing about the campaign last summer was that it drew more attention than ever before to prescribing costs. The hon. Gentleman said that the labour party had always been against wasteful prescribing. In all the time that I have been connected with health, the Labour party's voting and actions have never supported that bland assertion. The Labour party has resisted our every attempt to reduce the level of waste in prescribing. As a result of that attention and the new data and information available to doctors, there is already evidence that in preparation for the change doctors are examining their prescribing practices. Those who are wasteful in comparison with their colleagues are taking action. The growth in the cost of drugs to the health service is markedly slower this year than in past years and we have not yet introduced the change. Doctors who know that they will be exposed as over-prescribers are taking action to ensure that the "prescribing amounts" do not catch them out next year.

§ Mr. Michael
The Secretary of State confirms my point on the extent to which administrative action and fear are already having an effect. I invite him to confirm one point. He said that the only judgments made will be by doctors. In Committee we asked for that assurance and it was never given. We were told that the family practitioner committee or a successor body would make the judgment, and that it would be an administrative decision, although taken with the advice of doctors. Tonight he said that doctors would make the judgment. It will be only peer review, if the Secretary of State's sentence is taken at face value. I invite him to say whether he meant it entirely in that way, because I should not like to misrepresent what he said.

§ Mr. Clarke
I reached an agreement with the profession some weeks ago that the relevant committee of the family practitioner committee would be composed of other doctors. We have reached an agreement on the composition of these committees. With great respect, the hon. Gentleman is amazingly mealy-mouthed in his retreat from last summer's ruthless and unscrupulous campaign. At one point, he said how important it was that every patient had full confidence in the ability of his or her doctor to give all the treatments required. I have never been persuaded by statements made by spokesmen from either the Labour party or the British medical Association that it is important that patients have confidence in their doctors. A great deal of money and effort was put into destroying that confidence last year. A great deal more money was spent on opinion polls to see how effectively patients had been frightened. That was then claimed as a judgment on the reforms of the NHS.

§ Mr. Tom Clarke (Monklands, West)
Will the Secretary of State give way?

§ Mr. Clarke
I shall give way in a minute.
The hon. Member for Cardiff, South and Penarth raised two entirely fresh calumnies which he clearly intends to pursue. He quoted the case of a Cardiff doctor who had told a patient that she could not prescribe a particular appliance because she could not afford it under her budget. The hon. Gentleman knows that that example cannot be genuine because budgets have not been introduced. If the hon. Gentleman had such a case, instead of encouraging and airing it, he should have told his patient that it could not be true. I do not know whether any doctor said that she could not prescribe something because it was not within her budget. But as there are no budgets in place, the hon. Gentleman knows that it must be untrue.
The Daily Mirror follows a practice similar to that of Labour Members. It publishes the most fictitious rubbish in the paper. As evidence in support of its allegations it produces letters from patients saying, "I do not care what my doctor said, I believe that he could not afford to do what he said he could do." That is regarded as evidence to support the Daily Mirror's claims that doctors cannot afford to prescribe certain drugs.
The hon. Member for Cardiff, South and Penarth also suggested that doctors turn patients off their lists because they cannot afford them. The hon. Member for Peckham is also fond of all this. We have explored all the allegations to which the Daily Mirror gives terrific support. So far not one has turned out to be truthful or accurate. The accounts given by the hon. Member for Peckham on the Floor of the House usually turn out to be a ridiculous description of the case about which she is campaigning. I do not believe that anyone has yet found a patient anywhere in the country who was turned off a doctor's list because of the introduction of the NHS reforms. But Labour Members keep saying that they have.
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The hon. Member for Cardiff, South and Penarth made a particularly witty contribution. He said that his patients were discovering that when they went to a new doctor they were given a full medical examination so that the doctor could decide whether they were old and frail and if so throw them off. The hon. Gentleman knows perfectly well that one feature of the new GP contract, which his party bitterly fought, is that GPs are required to offer a full medical examination to new patients. It is a popular innovation with patients. It is an improvement of our family doctor service.
Patients are given a full medical examination to enable the GP to obtain information about his new patient and be appraised of his or her possible health needs. What does the hon. Member for Cardiff, South and Penarth do? Cynicism knows no bounds in opposing the NHS reforms. He tells his constituents that the improvement in the service implies that they are given an MOT test to find out whether they are too expensive. That is how the Labour party won the Vale of Glamorgan by-election. That is how they propose to fight the consultation process over the summer.
Eventually, the more responsible Members of the Labour party will feel ashamed of themselves for aligning themselves with all the more reactionary and backward-looking elements in the NHS. By doing so, they have covered up their lack of policy. Even when mild 394 amendments are proposed by Lord Butterfield in another place, they take the opportunity to arouse public fears which they know are unreal for unscrupulous objectives.

§ Mr. Nicholas Winterton (Macclesfield)
rose—

§ Mr. Hind
rose—

§ Mr. Tom Clarke
rose—

§ Mr. Deputy Speaker
Order. Is the Secretary of State giving way?

§ Mr. Clarke
I give way to the hon. Member for Monklands, West (Mr. Clarke).

§ Mr. Tom Clarke
I am grateful to the Secretary of State, even though I have almost forgotten the point on which I wished to intervene. The Secretary of State has left me, if not other hon. Members, with a distinct dilemma. I hope that he will not worry if I tell him that some people detect in him a degree of over-sensitivity and almost paranoia. All afternoon he has said that the Government have involved themselves in an exercise of consultation. Yet when we identified the points on which various individuals, distinguished professional bodies and even the Labour party disagreed with the Government, it became a campaign and it became disreputable. What is the difference between consultation and a campaign?

§ Mr. Kenneth Clarke
With great respect, I said that we have always promised public consultation on self-governing trusts. We promised it throughout Second Reading, throughout the five and a half hours of debate about it on the previous occasion when the Bill was debated in the House and I have repeated the promise during three hours of debate tonight. Without anyone contesting it, I have introduced the statutory provisions to enable it to take place. I look forward to serious consultation.
As the Opposition chose to discuss these drafting amendments by going back to yet more complaints about prescribing, I chose to give my view yet again of their campaigning on a sensitive subject such as NHS care.

§ Mr. Tom Clarke
The Secretary of State is paranoid.

§ Mr. Kenneth Clarke
I am not paranoid. The British Medical Association campaign collapsed in ruins last autumn and the Labour party's campaign ground to a halt shortly thereafter. Now it is trying to get going again.

§ Mr. Nicholas Winterton
rose—

§ Mr. Hind
rose—

§ Mr. Clarke
All that I am anxious to do is to persuade Labour Members from now on in their undoubtedly equally ineffective debating, they avoid methods of campaigning which frighten innocent members of the public.

§ Mr. Winterton
While I accept the assurances of my right hon. and learned Friend, before he finishes his speech on this amendment, will he pay tribute to the pharmaceutical industry of the United Kingdom, which has played a major role in the balance of payments, provided employment and has always been responsible? It has made a major contribution to improving the health of people in the United Kingdom. Furthermore, does he agree that a majority of doctors has always prescribed 395 responsibly? If my right hon. and learned Friend's assurances are to carry weight, he must ensure that the good work of the pharmaceutical industry and doctors can continue.

§ Mr. Clarke
I hesitated to give way to my hon. Friend because he is a persistent critic of mine and he has only just come in to the Chamber. I was trying to shorten the debate. However, I gladly agree with all the points that he made. The pharmaceutical industry took no part in last summer's campaign. All the people I know in the pharmaceutical industry are in favour or responsible prescribing. No one in the industry makes a case for wasteful and unnecessary prescribing.
That is true of the vast majority of doctors. Last year many of them used leaflets that told a lot of lies about the scheme and frightened many of their patients. A majority of doctors put excessive faith in the accuracy of the literature that they are provided with by the BMA. The leaflets and the allegations have completely disappeared. This minor drafting amendment puts that chapter behind us. Responsible doctors and other responsible people connected with the industry are in favour of spending as much on drugs as is necessary—no more and no less. We are introducing a scheme that will enable us to implement that desire. The Labour party always pays lip service to that, but in its actions and campaigns it does everything possible to undermine every attempt to get NHS prescribing costs under control.