§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Burns.]
§ 10 pm
§ Mr. Edward Leigh (Gainsborough and Horncastle)The present regulations on rural dispensing are outdated and, in my belief, need reforming. They do not serve the purpose for which they were originally designed, they do not implement present Government policy of encouraging care in the community and patient choice, and they are divisive of the professions of medicine and pharmacy.
In Lincolnshire, there is a greater proportion of dispensing doctors than in any other part of the country, so my constituency of Gainsborough and Horncastle is especially affected. I can best illustrate the problems by referring to the health centre in Welton, slightly north of the city of Lincoln.
There has been an excellent health centre there for many years. A patient could visit the doctor, who prescribed the medicine required, having all the patient's records at his fingertips. The prescription was immediately relayed to the pharmacy department in the same building, and the patient collected the medicines with little delay. The system worked well and to everyone's satisfaction.
When the villages were small, no pharmacist would consider the district profitable enough in which to open a shop. The doctors were obliged to prescribe and dispense. Now that the villages have expanded, there is sufficient business to make it viable for a chemist to set up. That has made it attractive for an independent pharmacist to apply to open a pharmacy—in Welton's case, a large supermarket, which has a branch in the village and which already has a near-monopoly of the pharmacies in the Lincoln area. I think that that alone is worrying.
As the regulations stand, if the application succeeds, the pharmacy department in the health centre must, by virtue of the regulations, close to all patients except those who live outside a one-mile limit. In Welton's case, that is a very small percentage. However, the first criterion to be considered, as stated in the regulations, is that no loss of service to the patients should be caused by the opening of the pharmacy. Indeed, the intention of Government, as I know, is to improve and extend services.
The procedure was as follows. In 1990, the chain store applied to open a pharmacy. Then it had to prove that the village was rural. Although it would have taken an Act of Parliament to change Welton's status from rural to urban, apparently for pharmaceutical purposes it could simply be declared urban at a hearing. Then the family health service authority considered the situation and turned down the application, on the grounds that, if the pharmacy at the health centre was closed down with the loss of income, services to the public—which should concern us in the House—were bound to deteriorate.
Predictably, the chain store appealed. The appeal was heard by the drugs committee of the Yorkshire—not Lincolnshire—health authority. It consisted of two doctors, two pharmacists and a chairman. Bearing in mind the constitution of the committee, obviously the result turned on the chairman's casting vote, and he, not being a local person, could not possibly have been aware of the strength of local feeling, and anyway he was restrained in his decision by the regulations.
1232 The decision—in favour of the pharmacist in that case—was relayed to the FHSA, which then had to decide whether the new pharmacy, in the words of the regulations, was "necessary or desirable". In so doing, it was not allowed to take into account the wishes of the patients and the doctors or to take note that pharmaceutical services were already available from the health centre.
Let me emphasise how the patients felt about the decision. At a public meeting, nearly 600 people turned up—just in one village—and only six voted for the opening of the new pharmacy. The wishes of the majority were ignored. If I called a public meeting in the village of Welton on whether we should join a single currency, six people would turn up, but 600 people turned up to the meeting on the pharmacy and all but six voted to keep the status quo.
A huge number of letters on the issue were written to me—my postbag was overloaded with them—to councillors and to the FHSA, but I, as the Member of Parliament, the councillors, the FHSA, the local doctors and local people could not do anything.
The regulations give the FHSA no choice but to uphold the appeal, even though the FHSA obviously knew from its earlier decision that the outcome of the appeal would adversely affect local services. It was left with no authority: everything was a foregone conclusion.
The whole process took two and a half years and resulted in thousands of letters, public meetings and a huge amount of antagonism. What is worse, public expectations were built up. People felt that, if they were consulted, as they were, their views would have some effect. In fact, the whole process was a total waste of money and a total sham. It did not offer proper consultation.
It is not surprising that a huge amount of resentment has been built up in just one village on one issue alone. That is what has happened in peaceful, rural and contented Lincolnshire. I hope that my hon. Friend the Minister is aware of that, and will do something about it.
New regulations should incorporate a clause requiring the FHSA or the appropriate health authority to act in an advisory capacity. Many of the current problems could have been avoided if the FHSA had brought the doctors and the pharmacy applicants together to discuss the situation to their mutual advantage. The FHSA should have knocked heads together. The practice had applied to employ a pharmacist, but that application was refused by the FHSA. The doctors were not advised about alternative solutions that would have involved co-operation and avoided all the confrontation that has led to such angst and unhappiness.
The process is now concluded. What has been the result in the health centre? Let us remember that we are not talking just about regulations, pharmacies, doctors or their renumeration. What should concern us in the House is what has happened to the services provided by that particular health centre. First, four partners were reduced to three. Secondly, the senior nurse, who ran the pharmacy department and whose knowledge and advice was well-respected, could no longer be financed.
Thirdly, two other receptionists had to go, and fourthly, surgery times had to be reduced, including before and after work surgeries. Patients attending surgeries must now take time off work which they and their employers 1233 can ill afford. In addition, facilities and security for dispensing at the health centre and maintained by that centre are not now available to approximately 80 per cent. of patients. That process, when repeated many times in the county as well as throughout the country, must represent a huge waste of resources.
All in all, the regulations have produced a system exactly the opposite of that for which they were designed, and of that which is Government policy as stated by my hon. Friend. I urge my hon. Friend that the Government should reform their regulations to allow an open, free market. That is what Conservative Back Benchers and our colleagues on the Treasury Bench presumably believe in—an open, free market. That is our philosophy of government. It is a ridiculous position which allows a grocer to employ a pharmacist while a doctor may not. How absurd that we have got into such a position.
If there was an open market, in which all Conservatives believe, urban doctors as well as those in rural areas would benefit, because they too could employ a pharmacist and open a pharmacy if they so wished. I am not suggesting that it would be possible to move to such a beneficial open, free market throughout the country straight away—I know the pressures that my hon. Friend is under—but perhaps we could start with rural areas.
Until one has experienced the difference between an in-house pharmacy and a trip to the chemist's shop, it is hard to convey what it means to the patient—convenience, privacy, consultations between patient, doctor, pharmacist and patient records; and, perhaps most important, the co-operation between doctor and pharmacist at all levels where now there is division.
Like other professions, pharmacists are fighting for their continued existence, and I have considerable sympathy with them. Outside the NHS, they are obliged to waste their undoubted talents being shopkeepers in order to make a living. Inside the NHS, they can concentrate on being pharmacists.
The argument that doctors should prescribe and pharmacists should dispense is sound, and I am sure that my hon. Friend will make that point when he replies to the debate. It should be used not to separate the two professions, but to bring them together and encourage co-operation between them.
If over-the-counter medicines were available at chemists' shops or health centre pharmacists, there would be simple competition and we believe in that. A great many common drugs, such as aspirin, are available in ordinary shops. The enormous number of drugs now available off prescription would then be available in rural districts. If health centres are to be run on business lines, as encouraged by the Government, the regulations need to be changed.
Dispensing by rural doctors is said to be more expensive than dispensing by pharmacists, because doctors over-prescribe to their own profit, use brand drugs instead of generic drugs, and prescribe more than urban doctors. However, rural doctors claim that; by being able to dispense, they can reduce hospital costs and thus the total cost of providing health services in rural areas. They say that prescribing brand drugs reduces their legal liability when things go wrong.
If the regulations allowed for pharmacists to be incorporated into health centres, a new system could be devised that would be less costly to the NHS and fair to both professions.
1234 As more pharmacy applications are made, legal loopholes in the regulations are being found. Those loopholes do not allow any consultation with doctors and patients, so the views of those most affected may not be taken into account. That increasingly shows that the principles of the legislation have been so totally lost that it is being used merely for commercial purposes, often by retail multiples with potential losses to NHS.
A large number of villages in Lincolnshire—Welton is just one example—have the same problem. Applications are constantly being made throughout the country. There is, therefore, a serious national problem and clearly reform is needed. It is not just a constituency problem, but I am delighted to come to the House and use the example in my constituency to illustrate it.
In preparing my speech, I was anxious to be fair to both sides. Of course, I have had a great deal of pressure from local doctors and local people, but I have also spoken to the secretary of the Lincolnshire local pharmaceutical committee, Mr. Noel Baumber, because I wanted to be fair to his side of the case.
It is worth while to relay the views of pharmacists, as they are also unhappy with the present system. They believe that pharmacists and doctors need to be remunerated on the same basis to remove any incentive on the part of doctors to overprescribe. They say that doctors benefit from a 10.5 per cent. margin on the cost of the drugs they provide, that their fee income is related to the number of prescriptions they prescribe, and that their dispensing income is added to their superannuation.
The chemists argue that such a conflict could not arise if GPs were not given incentives to dispense. They say that Baroness Cumberlege has confirmed that GPs can double their income by dispensing. They also say that dispensing is sometimes delegated to unqualified staff, who are not supervised. I cannot confirm the accuracy of those statements, but I relay them to the House. Lastly, the chemists say that pharmacy dispensing is better and less expensive. That is the views of the two sides.
Let us deal with what is important—us, the patients, the people, the country and the Government. It seems to me that we—the patients and the Government—must find a way to end the dispute between doctors and chemists.
First, the service should be run for the patients, and not for those working in the NHS. We should all believe that cliché, but the chairman of the local drugs committee, Mr. George Sutton, to whom I talked yesterday, told me that, as he attempts to hold the line between doctors and pharmacists, the protagonists seem to forget it as they argue over their remuneration.
It is no longer good enough for the Government to wash their hands of the dispute, Pontius Pilate-like, and say, "Come back to us when you have sorted it out yourselves". The Government should act; at the very least, they should reform the system, so that the FHSA is given proper discretion and the powers to respond to local opinion about what is best for the community. It should give reasons why it accepts or rejects local opinion, so that we can avoid the farcical situation in the village of Welton.
Local doctors have told me that the Minister needs to examine the apparent loophole in regulation 12 of 1992, which appears to allow the free entry of locally established pharmacies without recourse to a hearing. According to Mr. Sutton, the NHS appeals unit should 1235 be discouraged from reviewing a case unless the original hearing is clearly flawed. The FHSA sometimes wonders whether it or the appeals unit is the authority, because apparently all cases go to appeal.
The next step would be to ensure that a doctor's decision about whether to employ a pharmacist will affect only the viability and income of his practice and not him personally. The third step would be to allow rural doctors to continue dispensing, even if a pharmacy opens up in the village. Why not? We believe in competition. The fourth step would be to introduce a full, free and fair market, so that the consumer can make his or her own choice about where to get a prescription. I urge the Minister to reform the regulations, before further damage is done to the rural NHS.
§ The Minister for Health (Mr. Gerald Malone)I am extremely grateful to have the chance to respond to the Adjournment speech of my hon. Friend the Member for Gainsborough and Horncastle (Mr. Leigh). It is an extremely important matter, and I congratulate him on securing the opportunity to raise it.
My hon. Friend always addresses himself to matters in this House with a great degree of elan. He often assaults the establishment, and, sadly, tonight I have the role of the dullard Minister who must respond to him about the technicalities and complex matters which govern how people in rural areas have reliable access to the dispensing of drugs.
Although it may be boring to go through all the complex policy matters, it is important to set them out. As my hon. Friend said, it is a complicated issue. There are tensions between pharmacists and dispensing doctors, because a prime policy role is involved in ensuring that all national health service patients receive the treatment they require. The public must also secure value for money in the way that drugs are dispensed. That has been the continuing policy of the NHS since its inception, regardless of where patients may reside—in urban or rural areas.
I will briefly set out the policy on dispensing. Principally, doctors diagnose and prescribe medication—that is their proper role, as my hon. Friend said—and pharmacists dispense medication. In the Government's view, that makes the best use of the complementary skills and experience of members of both professions, to the benefit of all patients. There should be no question of competition between the two professions, although I know that my hon. Friend has set out a case suggesting that that may exist.
It is Government policy to establish co-operation between the members of an integrated primary care team, particularly in rural areas. It is sometimes difficult to achieve that co-operation, and there may be tensions, but the Government must overcome them and ensure that the patient benefits in the long term.
Pharmacists are, of course, best placed to advise a patient how best to use his or her medicine to get the maximum benefit with the minimum side effect. That is extremely important in a number of contexts, not least of which is the conclusion of a course of drugs. Pharmacists can also advise on the use of medicines that are purchased 1236 over the counter—not only drugs that are dispensed but the increasing range of self-medication to which many people turn instead of using the primary care sector, and that is vital.
§ Mr. LeighWhat if the doctor at the health centre employs a pharmacist? Does not the patient then get the benefit of the advice of both a doctor and a pharmacist on the same premises?
§ Mr. MaloneAs I go around the health system, I see a number of examples. It is not always the case that pharmacists and doctors, be they prescribing doctors or not, are in conflict.
I was, for example, in a health centre in Purfleet, Essex, seven or eight days ago, which was a general practice of six or seven partners and contained a pharmacy. I would suggest that the rules do not prevent that. It is quite possible for such a set-up to work quite happily together, not only to dispense the drugs that the primary carer prescribes but to provide the over-the-counter medication, which I believe will become increasingly important and which is becoming increasingly recognised.
There are models. The rules and regulations do not militate entirely against what I presume my hon. Friend is suggesting—a good market answer to the problems.
Let us move on to NHS dispensing in rural areas. It will be worth while to set out for the House where we are. I shall touch first on the one-mile rule—when pharmacists come into an area in which there are dispensing practices, dispensing practices are obliged to dispense only to those who live outside one mile of the immediate area. That rule was introduced in the early part of the century. Part of the problem that I suppose my hon. Friend is addressing is that there is a great history behind all this. In the 1970s, there were major problems between the professions, and that led to the Clothier committee, which reported in 1977.
It is probably not without significance that the difficulties and the tensions between those involved in primary care and pharmacists is that it took six years before controls on entry in rural areas were introduced in the House, in 1983. I am not quite certain, but I have a suspicion that my hon. Friend and I were probably unwitting partners in 1983—when we both entered the House—to the regulations that implemented those rules. I certainly do not remember precisely when it was, and I suspect that my hon. Friend does not either.
The main features of the controls were that a pharmacy or doctor wishing to start dispensing had to show that it would not prejudice the proper provision of medical or pharmaceutical services. If permission to dispense is granted, it may come into effect over a period, and that is carefully put in place to ensure that the change in income of those who previously dispensed is not sudden. The controls are an attempt to strike a balance between providing the important services of a pharmacist wherever possible and ensuring that patients continue to have access to a dispensing service in areas where a pharmacy could never be viable.
I would ask my hon. Friend to bear in mind the history of the regulations. In the days when there were communities in which no pharmacist wished to set up, because there was no reason to do so, the regulations were introduced to allow GPs to dispense, which was a very important service.
1237 The present arrangements allow doctors to dispense to patients who live in rural areas that are not served by pharmacies, who would have serious difficulty in obtaining the necessary medication from a pharmacy, or who require immediate medication in the course of emergency treatment. In practice, however, the rules also allow doctors to dispense to patients who could easily visit a pharmacy at the same time as visiting their doctor.
In recent years, there has been a gradual increase in the number and proportion of dispensing doctors. During the same period, the average number of dispensing patients per dispensing doctor fell; so the number of dispensing patients has remained virtually the same.
As for the operation of the Clothier regulations, family health service authorities are required to consult—among others—local community health councils. My hon. Friend mentioned consultation; this consultation is important, because it allows patients to express their views. There is also the prejudice test, with which my hon. Friend will be familiar. A family health service authority must consult any person on the medical list who is likely to be affected.
I know—not only from what my hon. Friend tells me, but from the correspondence I receive—that there has been what I would describe as an uneasy truce between the two professions. The relationship is difficult: as my hon. Friend pointed out, tensions exist, and there are two debates. My hon. Friend set out one side of the argument, which is that dispensing doctors benefit unfairly from the arrangements.
I suggest that that is not so. My Department subjects the margins in relation to payments that doctors are able to receive in connection with drugs to close examination, on a continuing basis. My hon. Friend may think that that is a source of tension between dispensing doctors and pharmacists, but it is regularly a source of even greater tension between my Department and dispensing doctors.
I strongly disagree with my hon. Friend's assertion that the system favours the needs of individual pharmacists rather than those of patients. We aim to ensure that 1238 patients living in rural areas enjoy the same range of services as are available to people living in urban areas. That has been difficult to achieve.
My hon. Friend may think that it is simple to make a bonfire of regulations, but it is more difficult than he imagines. A balance of provision has grown up over time; if we simply tore up the regulations that have developed, it would be to the detriment of patients, and would lessen their ability to gain access to and make use of a dispensing service. That is not to say that we should not listen to both sides of the argument—the pharmacist's case and that of the dispensing doctor—and decide how to proceed; that is perfectly proper.
My hon. Friend rightly referred to the free market. With the development of new health centre communities, we are seeing new ways in which dispensing services are provided, and they are free of the tensions that have existed between the professions before. I cited an example earlier that I expect to be repeated increasingly across the country: circumstances in which the medical profession and pharmacists decide that they have mutual interests in regard to both prescribing and dispensing.
I hope that, as time moves on, the tensions to which my hon. Friend referred will diminish. I am alert to the fact that those tensions exist, and have received a number of representations from both sides of the argument. As my hon. Friend knows, a number of issues are currently being considered by the courts, and I shall not comment on those. I shall return to them, however, once the courts have delivered a view.
Finally, I reassure my hon. Friend that it is the Government's overriding intention that all those who require access to drugs, by either prescription or dispensing—the patients—can get them in the most convenient way. I hope that we can proceed in a way that will diminish tensions between the two professions of pharmacy and medicine.
§ Question put and agreed to.
§ Adjourned accordingly at half-past Ten o'clock.