HC Deb 10 February 1999 vol 325 cc295-303 1.29 pm
Mr. Keith Simpson (Mid-Norfolk)

This subject has been brought to my attention by a wide variety of constituents: doctors, pharmacists, people in the health authority and, of course, members of the public. It is an issue not just in my constituency and the rest of Norfolk—I acknowledge the presence of my hon. Friends the Members for North Norfolk (Mr. Prior) and for Wantage (Mr. Jackson); it has been brought to the attention of many hon. Members with rural constituencies.

The question of dispensing doctors and pharmacists has for many years aroused heated debate both between the two professions and within each of them. My purpose in raising the subject is not to take sides; I believe that it would be a very foolish politician who did so, and I can see that the Minister agrees. I want to bring to the Minister's attention the concerns of my constituents who, as patients, are rightly worried, and to find out whether he—a recently appointed Minister in a relatively new Government—has any intention of either amending the National Health Service (Pharmaceutical Services) Regulations 1992 or using his good offices to help to resolve a dispute that has been rumbling on for years, if not decades.

I recognise that, for some time, the General Practitioners Committee and the Pharmaceutical Services Negotiating Committee have been trying to resolve areas of dispute. I hope that what is said here will be constructive and not impede those talks. It has been a principle since the health service was established that it is for doctors to prescribe and pharmacists to dispense, although that has often been more in principle than in practice; in theory, patients get the benefit of the expertise of both professions.

In certain circumstances, doctors are permitted to provide pharmaceutical services for their patients rather than referring them to a pharmacist. The relevant legislation is in regulations 19 to 21 of the National Health Service (Pharmaceutical Services) Regulations 1992. The first circumstance in which that applies is when the patient lives in what is called a controlled locality—an area designated as rural by the local health authority—and is more than one mile from the pharmacy. In that case, the general practitioner can apply for outline consent. The regulations deal with how areas are designated as rural by the health authority and make provision for the local medical or pharmaceutical committee to appeal against the authority's decision.

The second circumstance is when patients satisfy their health authority that they would have serious difficulty obtaining the drugs or appliances from a pharmacy by reason of distance or inadequacy of means of communication". In that case, the regulations do not specify what distance would constitute serious difficulty, so the discretion is left to the health authority.

Because GPs in rural areas often depend on their dispensing for a significant part of their income, in support of their practice, it clearly has been and will continue to be a matter of grave concern to them if a pharmacist applies to open a pharmacy in their area. We should all be aware of that fact, which has been brought home to me by several doctors in my constituency. It is undoubtedly a crucial factor, and we should not duck it.

When it appears that a change is to be made to a doctor's dispensary, there is great upset and resentment among patients, many of whom are elderly, invalids or with limited transport. I have heard about that at at least one public meeting, and it is a matter of heartfelt concern to many patients.

Mr. Robert Jackson (Wantage)

There is a similar problem in Shrivenham in my constituency. The arrangements seem to leave everyone dissatisfied. The pharmacists do not have commercial freedom and doctors and their patients—my constituents—have found the procedure for appeal very remote. I strongly support my hon. Friend's efforts to get the matter reviewed.

Mr. Simpson

I thank my hon. Friend; he and I had discussions on this matter with the hon. Member for South Swindon (Ms Drown) several weeks ago.

My constituency fulfils many of the main criteria for a rural constituency. It is 60 miles wide and 20 miles deep, resting like a large banana astride Norwich, with four main towns—Dereham is the largest, with 16,000 inhabitants, and Reepham, where I live, the smallest, with 3,000—and many villages and hamlets. There is no centre to my constituency except me.

Mid-Norfolk forms part of East Norfolk health authority, which has kindly provided me with up-to-date statistics for the whole area, but I suspect that the profile can be applied more narrowly to my constituency. The statistics give us a framework on which to work. As at 31 January, there were 104 pharmacies in contract with Norfolk Health, of which 56 are branches of a national chain, 12 branches of a local chain, 32 independent and four co-owned by GPs; 39 are located in towns or city centres, 29 in local shopping or residential areas, 19 in village centres, 10 in or adjacent to GP surgeries and seven in supermarkets.

There are 87 medical practices in contract with Norfolk Health, of which 42, or 48 per cent., are dispensing practices. That is a high and significant percentage. There are 636,477 patients—at least, there were last night—registered with Norfolk Health medical practices, of whom 141,554, or 22 per cent., receive a dispensing service. Nearly all those are in the rural area.

How can we help to resolve what has been in many, but not all, cases a dispute between dispensing doctors and pharmacists? Frankly, successive Health Ministers, aware of the potential minefield, have clung to the regulations and, understandably, not wanted to get directly involved. I consulted a former Health Minister last night, who said, "If only you had spoken to me earlier; I would have suggested that you did not raise this in an Adjournment debate. It is a minefield." Be that as it may, I have done so willingly.

The Minister's immediate predecessor, now elevated as Chief Secretary to the Treasury, where he will undoubtedly take a different view of health expenditure, wrote to me on 16 November 1997, in reply to points raised by a constituent of mine about the possible loss of a dispensary in one of our rural surgeries. He said: Ministers are aware of the complex issues surrounding rural dispensing and of how strongly local communities feel about the provision of pharmaceutical services in these areas. Decisions on applications to dispense under the NHS in rural areas are made by the local health authority, and an appeal by the Family Health Services Appeal Authority, under regulations. These regulations were developed after many years of dispute and argument between the medical and pharmaceutical professions. You will appreciate that Ministers will be very wary of making any changes to the regulations that could potentially usher in a further period of inter-professional disharmony"— a marvellous civil service phrase— similar to that which was prevalent in the past.

Mr. David Prior (North Norfolk)

Does my hon. Friend agree that the huge number of applications for new supermarkets in both his constituency and mine is likely to increase the disharmony, as the traditional business done by pharmacists comes under increasing pressure?

Mr. Simpson

That is a powerful point. Such competition will indeed bring even more disharmony.

The highly emotive issue of dispensing doctors and pharmacists is, I believe, primarily about public perceptions, especially in rural areas, where many patients cannot recall receiving the service other than at their local surgery. It is a question of the provision of the best possible medical support for patients. It is also about money, and we should not duck that. It involves not only profit and loss for doctors and pharmacists but the NHS budget. It is something for which taxpayers should be aware they are all paying.

Finally, all involved—the Department of Health, health authorities, doctors and pharmacists—need to recognise that they provide a service to the public, who must come first, whatever the professionals' strong feelings. However, I do not underestimate the fact that doctors and pharmacists aim to provide the very best medical cover and support.

I conclude where I began—on, I hope, a constructive note. The issue has aroused interest and passion in my constituency, in other rural constituencies—as my hon. Friends the Members for Wantage and for North Norfolk mentioned—and on both sides of the House. I hope that the General Practitioners Committee and the Pharmaceutical Services Negotiating Committee, which will be tackling the problem, will take note of this debate and will take heart from the fact that Members of Parliament, speaking on behalf of their constituents, desire that a real effort be made to solve the problem.

The Minister has a responsibility—first, through his guardianship of the regulations and, secondly, through his ability to use his good offices—to further the negotiations between two highly respected professional bodies which may soon approach him with, we hope, constructive ideas on how best to take the matter forward. Success will benefit my constituents and those of other hon. Members.

1.41 pm
The Minister of State, Department of Health (Mr. John Denham)

I congratulate the hon. Member for Mid-Norfolk (Mr. Simpson) on securing this debate and thank him for the constructive way in which he asked his questions and acknowledged some of the difficulties involved. As he said, I am relatively new to my job, and Adjournment debates perhaps have the effect of drawing to my attention some of the particular, but none the less important, nooks and crannies of the national health service and the way in which we deliver our primary care services.

General practitioners and community pharmacies make a vital contribution to primary care in rural areas, and to the national health service in general. Most people recognise that the best primary care is provided when the skills of all professionals—GPs, pharmacists, nurses and others—are deployed together as part of a co-ordinated, seamless service which focuses on patients, not on organisations or administrative structures.

High-quality primary care is central to our agenda for the new NHS. That is as true for country areas as it for towns and cities. Our vision of the NHS is inclusive—we want the highest possible standards of quality and efficiency throughout the country.

Rural areas are relatively well provided with GPs. They tend to have lower morbidity than urban areas, and rather more GPs on a weighted capitation basis. The reimbursement of surgery premises costs and some staff costs means that there is no disincentive to GPs to practise in expensive areas. Also, specific elements in the GP pay system recognise the additional costs of providing family doctor services in rural areas. Chief among them are the rural practice payment schemes. There are other forms of assistance for rural GPs. Isolated single-handed doctors can benefit from an allowance that helps them meet the cost of employing a locum while they are on training courses, and there is also an allowance to help single-handed GPs to employ an associate doctor.

Community pharmacies are an equally important part of the NHS primary care network. Pharmacies do more than dispense medicines; they provide a source of easily accessible advice on a range of health and health care matters; they sell a range of over-the-counter medicines to help people self-medicate and look after their families; and they provide a source of expertise on prescription medicines, both for patients and for local prescribers.

There are nearly 9,800 NHS community pharmacies in England, a number that has stayed more or less steady for several years. Around 250 of those, including many in rural areas, take advantage of the essential small pharmacies scheme, which ensures a minimum level of NHS income for pharmacies that provide a valuable service but might not otherwise be viable.

General health service policy is that doctors prescribe medicines and pharmacists dispense them. Wherever possible, the aim is for patients to have the benefit of the expertise and services of doctors and pharmacists. As the hon. Member for Mid-Norfolk acknowledged, this has been true since the inception of the national health service.

However, in rural areas where a pharmacy would not be viable, GPs may be required or permitted to dispense. About 16 per cent. of all GPs in England—around half those in East Norfolk health authority—dispense to around 3.2 million patients between them. Naturally, dispensing doctors are mainly concentrated in rural or semi-rural health authority areas.

In general, GPs are allowed to dispense only to patients who live in rural areas and more than one mile from the nearest pharmacy. Therefore, if a pharmacy opens locally, GPs stop dispensing for some or all of their patients.

Pharmacies are not generally allowed to open in rural areas if the health authority is convinced that their doing so would prejudice the local provision of general medical services. This is commonly known as the prejudice test. Similarly, GPs cannot acquire new dispensing rights if that would prejudice existing NHS pharmacy services. The aim is to make sure that changes in dispensing do not destabilise existing, necessary patient services. In both cases, where applications are granted, the health authority can impose transitional arrangements, requiring GPs gradually to increase or reduce the number of their dispensing patients. The regulations are designed to ensure that these important decisions are taken openly and fairly.

Often, the health authority will hold a full oral hearing to ensure that the parties have a chance to make their case. The rules ensure that no one directly involved in either GP or pharmacy services can take part in the decision. There are appeals at each stage to the Family Health Services Appeals Authority, which acts on behalf of the Secretary of State.

The number of applications with which English health authorities deal under the pharmaceutical services regulations fluctuates but, in the six months to September 1998, 720 applications were received—an average of about seven per health authority. More than half were for minor relocations or change of ownership; only 61 related to rural areas.

Health authorities consider applications within the framework of the regulations, which are intended to ensure that, where possible, communities benefit from both GP and pharmacy services. In doing so, they are required to take account of all relevant factors, and to consult local community health councils, as well as local GPs, pharmacists and their representatives. Community health councils represent the interests of local patients.

As I said, local primary care is most comprehensive where communities can be served by family doctors and community pharmacists. Of course, there are some rural areas where a pharmacy may simply not be viable. In those cases, GPs provide a valuable extra service by dispensing medicines themselves. That is a service that we greatly appreciate, and for which additional fees and allowances are paid.

Dispensing by GPs is essential if people in sparsely populated rural areas are to be able to get their medicines without difficulty. I am sure that dispensing doctors take very seriously the extra responsibility that that carries, and I know that their services are generally much appreciated by their patients. However, dispensing by doctors rather than pharmacists is, and has always been, a pragmatic response to the special circumstances of rural areas. It has not been promoted as an equal and rival model of pharmaceutical services.

When a new pharmacy opens in a rural area, the effect is to widen the professional expertise available to the local community, but I recognise that decisions about the opening of new pharmacies in areas currently served by dispensing doctors can become the source of great local controversy.

As I explained, decisions on individual applications are made by health authorities in accordance with regulations and after consultation with various local interests. On appeal, applications are decided by the Family Health Services Appeals Authority.

Mr. Robert Jackson

That was a particularly difficult issue for my constituents at Shrivenham, who felt that the appeal procedure was extremely remote and inaccessible and did not pay sufficient attention to them. Will the Minister comment on that?

Mr. Denham

The hon. Gentleman will understand that I am not familiar with that particular case. The system is designed to ensure, by virtue of the range of bodies and organisations consulted—including community health councils—that patients' views are adequately heard. If the hon. Gentleman would like to draw to my attention elements of his own local experience, perhaps by letter, I should be more than happy to look into the way in which the system operates. However, it would be going too far today to anticipate any possible changes.

In general, I must say that it is a great shame that disputes over dispensing rights too often become bitter and pit professionals against each other, when we want them to co-operate for the benefit of patients. I know that there are people who feel that disputes are in part caused by deficiencies in the existing regulations.

Pharmacists, for example, often say that they do not understand why the regulations can lead to GP practices in the centre of small towns operating a dispensary in competition—as they see it—with a nearby pharmacy. They point out that that pharmacy might even be located next door to the surgery. I am told that that is generally known as the market towns issue.

On the other hand, GPs have asked why different rules apply when a pharmacy already operating in a health authority's area applies to open a new branch in a rural area. In particular, they have asked why, in such cases, pharmacy applicants do not have to pass the so-called prejudice test.

I know of no evidence that suggests that the rules operate in a way that prevents patients from getting access to the medicines that they need. Indeed, the regulations are designed precisely to ensure that change is managed in a sensible way, without putting necessary services at risk. I agree, however, that it would be desirable if improvements could be made so that there are fewer disputes in future. Reducing the number of disputes can only be good news for patients.

However, the House will understand that, like many Ministers before me, I am reluctant to appear to intervene on one side or the other in the debate over the minute detail of rural dispensing rules. That reluctance stems from a fear of stirring up yet more wasteful dispute. I say "wasteful", because the long and sometimes bitter history of dispute between the professions over this issue can have done nothing to promote the climate of co-operation and collaboration that is necessary if primary care services are to deliver the best for their patients.

My predecessors have said to both professions that we will consider sympathetically any joint proposals that they bring to us for tidying up the regulations—provided, of course, that any changes proposed are in patients' best interests. I am happy to repeat that offer today.

Indeed, I believe that, over the past year or so, there have been increasingly encouraging signs that the leaders of the two professions are beginning to work more closely together on many issues. I am told that, in the East Norfolk health authority area, relations between the professions are generally close and fruitful. Members of both professions have been involved in the development of a successful local health care guide, as part of the health authority's charter mark winning commitment to providing people with high-quality information about local NHS services.

Good relations between the professions are very much to be welcomed. Partnership is one of the four key themes in our vision for a new, modern and dependable national health service. It underpins excellence, efficiency and performance. We took office determined to get rid of the divisiveness of the old national health service and its internal market. Collaboration, not competition, is the key to improving patient care. By implementing our vision of the new national health service, we are breaking down barriers that artificially divide those who need to work together for the health and well-being of local communities.

The national health service, local authorities and local communities are now discussing the first health improvement programmes—real strategies for local health. Our programme will improve services throughout the country, for people living in rural areas as much as those in towns and cities. By the year 2000, everyone in England will have access to the NHS Direct 24-hour nurse advice line. In hospital, all people with suspected cancer will be able to see a specialist within two weeks of their GPs deciding that they need to be seen urgently. That target will be achieved by April 1999 for suspected breast cancer, and by 2000 for other cancers.

We have backed up our ambitious programme with the biggest-ever increase in resources for the national health service—an average of 4.5 per cent. over the next three years. Our vision extends equally to community pharmacy. My right hon. Friend the Secretary of State for Health has said that he will be publishing a strategy document on ways of exploiting more fully the potential for community pharmacy to contribute to better care, close to people's homes.

That strategy document, like our entire vision for the national health service, will be about harnessing individuals' skills within a context of ever-greater co-operation and shared endeavour. That, surely, is where we should be focusing our energies. Division and dispute belong to the old NHS.

It being before Two o'clock, the motion for the Adjournment of the House lapsed, without Question put.

Sitting suspended, pursuant to Standing Order No. 10 (Wednesday sittings), till half-past Two o'clock.