§ 5.50 p.m.
§ VISCOUNT ALEXANDER OF HILLSBOROUGH rose to call attention to the—
- 1. National Health Service (Charges for Drugs and Appliances) Regulations, 1961;
- 2. National Health Service (Pay-Bed Accommodation in Hospitals, etc.) Regulations, 1961:
- 3. National Health Service (Charges for Drugs and Appliances) (Scotland) Regulations, 1961;
- 4. National Health Service (Hospital Charges for Drugs and Appliances) Regulations, 1961; and
- 5. National Health Service (Hospital Charges for Drugs and Appliances) (Scotland) Amendment Regulations, 1961;
§ Noble Lords on this side of the House, in co-operation with our colleagues in another place who hold the same views as ourselves, wish to take strong objection to the policy which the Government have introduced. We think that it is untimely and that the larger proportion of charges will make it exceedingly difficult for those who are at the wrong end of the income scale. We think that the increased charges are a main departure from what was intended in the welfare scheme, envisaged by the Government of which I was a member, and in which the noble Lord, Lord Beveridge, who speaks from the Liberal Benches, had a hand.
§ I am not going to speak on the merits or demerits of the provisions of these Orders. I wish to register my own pretest against the charges now being made, which may well cost those who participate in the benefits of the scheme tens of millions of pounds more than was previously paid. By the additions made to our ranks on this side of the House, I am fortunate in now having noble Lords, who were not available to me before and who are expert in the details of these matters; and, having explained to your Lordships the reasons for putting this matter on the Order Paper, I am going to hand over to my noble friends who know more about the details of this matter, though certainly they have no more fervent objection to the proposals than I have.
§ 5.53 p.m.
§ LORD DERWENT
My Lords, may I start by publicly apologising to the noble Viscount the Leader of the Opposition, as I have already done privately, because I shall have to leave before the end of the debate? I have not spoken previously on this subject in what we may 563 now term a series of debates, and in particular on the raising of the prescription charges. The reasons I have not done so before is that when the information about what was intended was first given to us and when these debates first started, I frankly did not have sufficient knowledge to try to form a balanced view for myself. I have listened to every speech in your Lordships' House on the subject, and I have read most, if not all, of the speeches in another place, because I felt strongly that if this is a matter which affects everyone in the country it is a matter on which one should try to be instructed. I hope that it will not be considered presumptuous, therefore, if I claim to speak as a man in the street, because any man in the street could have tried to acquire his knowledge in the same way as I have done, except that he would have to read the speeches made in your Lordships' House, instead of listening to them.
It appears to me that the two things about which one wanted to learn are these: why the Minister was raising these charges and what adverse effect the increases might have on a section, perhaps large, perhaps not large, of the community. From what I have heard and read, there appear to be two reasons. The first one seems to me to be the less important—namely, that the Minister feels that certain abuses, which undoubtedly go on under the method of prescription in the National Health Service, will be considerably reduced. Frankly, I have not made up my mind whether they will be reduced or not. The more important point seems to me to be the financial one. Any Minister can have only what is called a "slice of the national cake." I am not going to weary your Lordships with the argument—though I could do so—but I believe that at the present time the Minister of Health has about the right percentage of the national "cake." Obviously, there has to be a limit to every share.
The Minister says that he can save a good many millions of pounds by raising the prescription charges, and that this money can be better spent on other projects, still inside the National Health Service and still for the general good. I seem to remember, in this connection, that there is about £13 million involved. The Minister goes further and says that 564 if he does not get this money from this source, there are no other convenient sources from which he can get the money for the things he wants to do, because he is not going to get any further money from the Chancellor of the Exchequer. In my view, that is a reasonable argument and the Minister of Health has made his case.
I come to the other side of the question. Is this going to have a major adverse effect on a reasonably large number of people? I do not pretend that there will be no hard cases. There is never any legislation that does not cause one or two hard cases, but I think that we ought to accept that the general good must outweigh one or two hard cases. I find it difficult to believe, as the prescription charges were raised by 1s. some years ago, that, with the general increased wealth enjoyed by the bulk of the population, a 2s. charge will cause undue hardships. The question is how many people will be caused hardship.
Noble Lords opposite have painted a quite horrifying picture, which wrung my heart. But I wonder quite how genuine some of the arguments were. The people who are going to suffer, as I understand the argument, are really three-fold. There are those who are unable to understand how they can get their money back if they are in a category where they need not pay the full subscription. Undoubtedly there are such people, though I do not believe that there are very many of them. One of the things that even people who are not very intelligent seem to find their brains working quickly about is the getting hold of their own money. Let us be quite frank about it: they have only to ask a chemist what the procedure is. So it is really not so difficult as is sometimes suggested.
The second class, I am told, who may find it difficult to get their money back, if they are entitled to do so, are those who are bedridden or confined to their homes. I wonder (I do not suppose anyone can tell me) how many people there are of that kind who have no friends, are never visited, and have absolutely nobody in the world to help them—because if that really is the situation, they will starve. I just do not believe that there are—I do not say any, but certainly many of that kind.
§ LORD STONHAM
My Lords, may I interrupt the noble Lord? It is quite impossible to give numbers, but I can tell him that some enlightened local authorities have found it necessary to supply old people with cards which they can drop through the letter box, to be seen outside, so that if they are incapacitated people can go in. There are a very large number of old people who live alone and have no friends or relatives who depend on that scheme. But not all local authorities adopt the device I have mentioned, and some of these people will starve.
§ LORD DERWENT
The noble Lord says there are these people, and that they are looked after by the local authorities. So those who are not looked after at all must be only a very small number. That is my argument.
The third category, we are told, are those who are too proud to go to National Assistance and get their money back. In one way one cannot help admiring their pride, though it is very foolish. There are a certain number of people of that kind, but I think there are fewer than there used to be. A Government cannot really legislate for people who are too proud to take advantage of what they can easily get. During the last few weeks I have made inquiries of various people among what I might term the poorer sort. I at once admit that none of them, because the opportunity did not offer, was among the very poor, but I have the feeling that under the Welfare State those whom I describe as the poorer sort often do rather worse than the very poor. I may have asked the wrong people, but they were what I should call poor people or the poorer sort. I asked them how they thought these increased charges were going to affect them. It was only a small selection, I agree, and they were taken rather out of the blue. I got the same sort of answer from all of them: "I do not think this is going to make very much difference to me." Perhaps I was lucky or unlucky in the people I asked, but I did my best to talk to the people who I thought might be seriously affected.
I find that the case built up by noble Lords opposite and by their Party is exaggerated. I find, so far as I have been able, that, although their case is 566 genuine in certain instances, the number of cases which they say exist do not, in fact, exist. I believe that they have overstated their case. It seems to me that the sound and fury—or, should I say, the oratory of noble Lords opposite, and the sound and fury in another place—have really struck no spark, except among the more ardent supporters of noble Lords' Party in the constituencies, who, of course, are always tinder-dry. In the rest of the country no spark seems to have been struck, and I can find very little interest, generally speaking, in this matter. My own view is that the case for the Opposition is grossly overstated. I believe that the Minister is going to use the money to better advantage, and I do not believe he is going to cause undue hardship, except in a very few cases.
§ 6.7 p.m.
§ LORD BEVERIDGE
My Lords, I must begin by thanking the noble Lord, Lord Stonham, for allowing me to rise before him. I must apologise to the subsequent speakers by assuring them that I shall on this occasion be shorter even than usual—and I will explain in a moment why my name was not on the list of speakers. In the first debate which took place on February 13 on these Health Service charges I found myself in a middle position between Her Majesty's Government and the noble Lord, Lord Silkin, who had moved the Motion on behalf of the Labour Party. I did not feel able to join the noble Lord, Lord Silkin, in condemning the Government offhand for making people with inflated incomes pay more for Health Service benefits; but I did not feel at all happy about the harmful effect of these charges upon people whose incomes had not been inflated, and above all, upon the old and disabled.
I made some very definite suggestions as to what I thought the Government ought to do to make certain that all these people, mainly the old and disabled, were cured, if they could be cured, by necessary treatment. Let me add that I do not feel any happier as a result of the Answer which the Government gave, through the noble Lard, Lord Newton, to the Question which my noble friend Lord Ogmore asked them on February 28; and I am not yet 567 happy, in spite of hearing the conclusions to which the noble Lord, Lord Derwent, has already come, as to the position of the old and disabled people.
Noble Lords may remember that in the debate on February 13 I said that I hoped to make a study of the aged and lonely poor in an affluent society, and to make that study my next immediate task, particularly in regard to health, and what the State ought to do to secure health for everybody, irrespective of want, ignorance or carelessness. Let me say that I have begun that study. I was engaged on it this morning, and that was the reason why my name did not appear on the first list of speakers. In that study I have discussed with four of the agencies of national scope, all concerned with old and disabled people, the position in which the old find themselves today. On the results of that study, I hope to publish my views, not in a great hurry, but in a substantial form, soon after the middle of April. What those views will be will depend, naturally, upon whether the Government can before then show a more conciliatory attitude and a greater readiness than they have done hitherto to consider the seriousness of the danger to old people. May I express the fervent hope, not for my sake but for the sake of the old people, that the Government may by that time have come to a better understanding of the problems that are facing the old and disabled people?
§ 6.12 p.m.
§ LORD STONHAM
My Lords, I shall not burden the noble Lord, Lord Derwent, with my oratory on this subject. I do not know that I am capable of oratory at all, certainly not in your Lordships' House. The only thing I can say is that I did not speak in the previous debate, and therefore I have not wrung the noble Lord's withers. I am rather regretting that I shall not have the opportunity to do so tonight, because the noble Lord has had the courtesy to inform me that he must go away to keep another urgent engagement, so I can only hope he will read what I say tomorrow, because at least some of the things I have to say will deal with the points which he has raised.
The basic objection which we on this side of your Lordships' House have to 568 these proposals is that they are a further erosion of the fundamental principle of the Health Service, that it should be "free at the time of use". It is no answer to say that unfortunately the process of erosion began under the Labour Government. That has been seized upon by successive Conservative Governments as an excuse to destroy further the principle of the Health Service, "free at the time of use". A great disadvantage about the increase in the prescription charges is that the incidence of them falls precisely at the time when people are ill, and, of course, it falls most heavily on just those classes of people that the noble Lord has described—the elderly sick and the frail people. I have already known the noble Lord far too long not to be aware that if he were really conscious of the measure of that suffering he would not have said the kind of thing he has now said and dismissed it with a feeling that, after all, only a very small number of people are affected.
In my view, the greatest social problem to-day is the need of elderly people—their need for housing, companionship and care. There is too little awareness of the fact that when a person becomes old it is the same brave eyes looking out from, the same active brain working in, an enfeebled body. These people have too much pride—not pride in the ordinary sense, but the kind of pride which shrugs off the world—they are too unconscious, too obtuse and ignorant, to realise what is facing them. Any noble Lord who has been a Member of another place in the last ten or fifteen years—and there are many in your Lordships' House—who conducted weekly "surgeries" and who went round visiting in the homes of his constituents, will have been aware of countless examples of old people whose first answer to the question, "How are you getting on?", was "I mustn't grumble." Then, when you begin to inquire tactfully into their circumstances, you find what an enormity of problems they must not grumble about.
It has been my lot on many occasions to find that it is not merely a question of pride, ignorance, inertia or immobility it is a combination of all those things, which prevents these people from applying. When you say to them: "But help is available—not necessarily merely over prescription charges, but for blankets, 569 coal, oil and all sorts of things", they say, "Shall I have to go and fill in a form or see anybody?". You tell them, No you will not have to do anything. A very charming man or lady will come round and talk to you and it will be all right." In those circumstances it is all right, and they are perfectly happy about it.
But people to do this work have to be found. In constituencies I have represented I have set up voluntary organisations of that kind to find out where the old people are and what their needs are, so that what is necessary can be done gently. I assure the noble Lord that there is real and increasing hardship, and that this great social problem—which is one which will affect most of us if we live long enough—has seriously to be tackled. The noble Lord, Lord Derwent, approached this problem, if I may say so with respect, in a sound and constructive way. He asked what I regard as the right and important questions. He said that the Minister was activated in raising these charges by two considerations: first, would certain abuses be reduced? The noble Lord said that he had not made up his mind whether they would be reduced or not. One of the most important abuses is over-prescribing. I would say that these proposals are certainly a factor which will increase the abuses, and not reduce them. Most doctors, particularly G.P.s, are the friends of their patients and want to help them. It goes very much against the grain for doctors, whose patients are old men or old women who perhaps are bronchitic or suffering in some similar way, as so many of them are, to prescribe for them when it is 2s. 0d. a prescription; and so they tend—and I expect them to—to prescribe a bigger quantity, so that the patients do not have to come so often. I say to noble Lords opposite seriously that, at the end of the day, I very much doubt whether the savings hoped for by the Minister will be achieved, because there will be those extra costs. So on the first point raised by the noble Lord about abuses being reduced, I think that is a horse that will not run.
Then the noble Lord suggested that the Minister had decided that he already had about the right slice of the national cake, and that it was no good going to the Chancellor of the Exchequer for more money; and that if he did not get 570 it from somewhere else certain other portions of the Health Service would go and certain developments which we should like to see would not come about. He believes he is going to save millions of pounds by raising prescription charges. If a good many million pounds are going to be saved—the noble Lord said £13 million—they are not going to be saved by the extra charges. They can be saved, if the money is to be made good in that way, only by less medicine; and if there is less medicine then there are people who, in the opinion of their doctors, ought to have medicine but who are not going to have it. The suffering will be on a considerable scale, and what the nation will reap will be more bad health and more neglected old people dying quicker than they might otherwise have done.
I strongly contest the view of the Minister, but if it is true—and I do not accept it, because there is an enormous amount of money wasted on medical service—that he should not get this money elsewhere, then I should like to know why his Department has not taken serious steps to get the money out of the global expenditure on drugs and dressings, because the whole thing is a scandal and it has been a scandal for years. When I was a member of the Public Accounts Committee in 1956 and 1957, and again in 1958, these matters came up before us, and we examined the Permanent Secretary on them.
I am not now going to talk about the infamous profits made by some of the wholesale druggists. My noble friend, Lady Summerskill, will remember, as I do, that one evening when we were invited—she and I and one other noble friend—to meet some of these gentry, we met them in a large room downstairs, and they were the hardest-faced bunch that I have seen in one small collection. Almost the first thing said to us was that it was not very comfortable or convenient to discuss business in that room, and could not they arrange a pleasant dinner for us. That was one dinner that did not come off. Some of the results of that attitude are exposed in the Public Accounts Committee. We learned that it was impossible at that time for the Minister to determine 571 profits, and we know all the hopeless arguments about the export price being used to decide the level of what they should charge; they have moved a little way from that but that position is still bad. I am not so much concerned about that, because I know the matter has been ventilated earlier in discussion by my noble friend.
But there are other ways where money could be saved. We are considering five Orders to-night. Two of them are for Scotland. I should like to ask the noble Lord, Lord Newton, what is the possible justification for the earnings per prescription of a chemist in Scotland to be so much higher than in England? Why is it, for example, that they can charge so much more for a glass medicine bottle in Scotland than in England? Why are they allowed so much more? After all, these bottles are bought from the same manufacturers, the United Glass Bottle Manufacturers or somebody else. They cost exactly the same to the chemist in Scotland as in England, but in Scotland they get—I am speaking from memory—I think double for the glass bottle. The allowance fee, we will call it, although it is really a profit, that the chemist gets for a prescription in Scotland is considerably higher than in England and Wales. Large sums of money are lost in that way, and the Minister should have looked into that matter before he took the money out of the old people.
Then there is the question of profit per prescription being exactly the same, whether the man dispenses 500 or fewer a month, or whether he dispenses 5,000 or 10,000 prescriptions a month. I am not going to argue that the fee for the small chemist who dispenses very few prescriptions is too high. It may not be. But if it is fair for him, then it is grossly unfair for the big-scale chemist. There is no question about it whatever. I have never heard any kind of satisfactory argument why there should not be fees graduated according to the number. It is no use Ministers or their noble friends getting up and saying the money cannot be found anywhere else, when we know, beyond peradventure, and it has been proved in public time and time again, that money is wasted wholesale and nothing is done about it except for offering a few unconvincing excuses. I hope, therefore, that when the noble Lord, 572 Lord Newton, comes to reply, he will tell us about these matters.
And I should like him to tell us this also. Why is it that no allowance is made, when the cost of prescription and the cost of drugs in a prescription are computed, for the so-called discounts which almost every chemist enjoys? The cost is computed on the list price, but of course there are discounts up to 20 per cent. for a modest quantity. The noble Lord can look up the question in the Report of the Public Accounts Committee. I remember that I asked the Permanent Secretary to the Ministry what were the normal discounts enjoyed, and he said that he could not tell me; that they could not be ascertained. I said, "Of course they can be ascertained; they can be ascertained in five minutes on the telephone". At a subsequent sitting of that same Committee, I produced the wholesale discounts myself, having got them from a chemist, as anybody else could do. I can assure the noble Lord they were roughly 20 per cent. But my information is that the cost per prescription is still computed on the list prices, so that all those discounts are enjoyed as so much extra profit, and so much more which we have to pay. Those are a few replies, I hope, to the questions raised by the noble Lord, Lord Derwent—and very good questions they were, too.
I come to the last question which he said he asked himself: will these increases have a major adverse effect on a large number of people? He said that of course there will be hard cases, but he wondered how genuine were the arguments adduced from this side, which had so wrung his withers. There are in this country a very large and increasing number of old people, and those of us who are connected with hospitals know the pressure on our geriatric hospitals. They know the grave shortage of local authority hostel accommodation, so that our chronic hospitals become ever more crowded by cases that cannot be improved yet cannot move out. They know, too, the increasing amount of work done by local authorities, and the increasing anxiety.
When I was a Member of another place I had the honour to be connected with the Borough of Finsbury for some time. That was a borough which was a 573 pioneer in starting work centres for old people, and it was that borough to which I referred (in an intervention which I made when the noble Lord, Lord Derwent, was speaking) in regard to the practice of having special coloured cards, printed cards, which old people can drop through their letter box when they are in difficulty or trouble or sick, so that somebody can come to them. We found that was necessary, even in a London borough with one of the smallest populations of any of the London boroughs. We found a large number of old people who needed that kind of help because they had no relatives or friends, or anyone else to look after them. Unfortunately, that is one of the few boroughs which does that kind of thing, and which has such a highly specialised service for old people.
The difficulty in matters of this kind is that the old people, when they are sick and alone, begin to think that things are hopeless; that we are against them, and that there is nobody for them. And the Government have made it more difficult for them—there is no argument about this—to get medical care, which means one more piece of hopelessness for them. I regard that as a serious indictment. I do not care if the number is only two million. That is a lot of old people, helpless people, with nobody to speak up for them. I regard that as a very large number indeed. Even if there were only one-tenth of that number, it would still be, to me, a very large number indeed; and that is the core, the gravamen, of OUT objection to these charges.
The Government are progressively destroying the principle of a National Health Service free at the time of use. The present proposals are utterly unprincipled and indefensible. If the money had to be found out of the Health Service it could have been found by economies in other directions without affecting the Service as such. The Minister has lacked the courage to stand up to the harder elements among the suppliers; he has lacked the courage to stand up to the various trade and selling associations. It did not need any courage to take it out of the old people. I should like the noble Lord, Lord Newton, when he comes to reply, to tell us, not what the Minister has done in this matter (because he has done nothing) 574 but what the Government intend to do to deal with the people whose activities I have mentioned.
§ 6.31 p.m.
§ LORD AUCKLAND
My Lords, like my noble friend Lord Derwent, I do not declare any interest in this matter so far as professional and financial interests are concerned. But the more I hear the Party opposite criticising the Government on these increased charges, the less convincing I find their case. I should like to quote from an article by a Socialist correspondent in the Perthshire Advertiser of a week ago, in answer to an article by the Member of Parliament for Perth, who is a personal friend of mine and who wrote a most cogent article on this matter. The article reads:The latest increases are in keeping with Tory policy. Costs are more important than people, and the burden of financing the Health Service is gradually being passed to those least able to bear it, while the free enterprise drug industry continues unmolested to amass ever increasing profits.There are many medical experts on the Benches opposite, and I do not pretend to have more knowledge than they on medical matters, but, as I understand it, elaborate arrangements are being made for elderly people to recoup the charges, and war pensioners and old age pensioners will surely not be among those least able to bear them.
I myself am not entirely happy about these proposals, for two reasons: first of all, I feel that the charges should be levelled most at those who have just left school and are in employment, up to those who are on the verge of retirement. I should have liked to see an increase of more than 2s., perhaps half-a-crown, on prescription charges for these people, and an exemption in the case of children of five or under, particularly where there are three or four in a family. If an epidemic of illness breaks out simultaneously among all the children, obviously there is going to be hardship forced on the family, especially if the illness is of a type like pneumonia. I said that on Second Reading, and I make no apology for mentioning it again. I hope the noble Lord, Lord Newton, may have some observations to make on it.
Let me for a few moments turn to the question of drugs. I have consulted a local doctor friend of mine and, with 575 your Lordships' permission, I am going to quote some figures. The average total cost of penicillin per capita per week is 10s. That is for the injection type of penicillin, assuming it is being used four times a day, 400,000 units. Oral penicillin costs 24s. a week; aureomycin £3 a week and cortisone 38s. 6d. a week. Phenobarbitone costs 8s. a week. To-day infant mortality due to pneumonia is practically nil. Before the discovery of penicillin, which I believe, if my memory serves me correctly, was in 1953—I stand to be corrected if I am wrong—
§ LORD AUCKLAND
I beg your Lordships' parclon—mortality was 10 to 20 per cent. While I would agree that there is a case for some kind of inquiry into the drug industry, I cannot help feeling that the most exaggerated figures are being given of these vast profits that it is said are being made. Indeed, I have spoken to one or two people in the drug industry and they have said that they would welcome an inquiry—that they have not all that much to hide. To have life-saving drugs such as aureomycin, chloromycetin and cortisone and so on, costs money. A good proportion of drugs is produced in this country; a number go to help our export trade, and we are importing fewer and fewer drugs at the present time. New plants are being set up. The Armour Laboratories have built a large factory just outside Eastbourne, and new plants are being established by smaller companies. But it seems to me that there has been some rather exaggerated talk about increased profits—
§ BARONESS SUMMERSKILL
My Lords, may I ask the noble Lord a question? I am rather surprised that he is speaking on this subject. He says that he has not made a careful inquiry. Would he read the report of the Senate Committee in the United States, of which Mr. Kefauver was chairman and in which the whole question was examined? Those firms which he castigated strongly all have subsidiaries here.
§ LORD AUCKLAND
I will certainly read the Report, and I do not doubt what the noble Baroness says. But I come back to my point; that the drug industry is carrying out a great pro- 576 gramme of research and that there is a great deal of irresponsible talk about great profits.
§ LORD CROOK
By "research" does the noble Lord mean the mere addition of some further drug to a compound already in existence, so that it can be given a new name, advertised to doctors and sold at an inflated price?
§ LORD AUCKLAND
My information is to the contrary. In a great many cases new drugs are being produced. I believe (I am not sure) that aureomycin was the successor to penicillin. The noble Lord, Lord Taylor, who is I believe the expert on the opposite Benches, will correct me if I am wrong. A great number of lives have been saved by the use of such drugs. While I should be the last to defend any excessive and rampant profiteering by the drug industry, I think that insufficient credit has been given to the part which they have played in reducing mortality, particularly among children. I should like to come to the question of the diabetics, a subject which I and several noble Lords raised on Second Reading. I feel that here there is a great case for an exemption from prescription charges. Diabetes is an illness which is very different from a great many others, and insulin cannot always be kept for long periods of time without losing its strength. So I think there is a case for some adjustment there.
A great deal has been said about these increased charges in relation to more or less medicine being dispensed. Most medicine chests in this country, or at least a good many, are tremendously over-filled with all kinds of concoctions, and anything that can be done to lessen this is always very welcome. The noble Lord, Lord Stonham, mentioned the point about bottles costing more in Scotland. I do not pretend to be able to answer his question satisfactorily but, coming from Scotland myself, I would put the point that there are far fewer chemists in Scotland. Often one has to travel a good many miles, particularly in places like Ross-shire and Sutherland, to get to a chemist; and, after all, these chemists have to get a livelihood. Whether or not this cost should be passed on to the consumer is another matter, but if the implication was an attack upon the actual pharmaceutical chemist, I would say that it is a little unmerited.
577 There is no doubt that mortality, among infants, mothers and old people, is on the decrease, and I think it is quite wrong to suggest that the Health Service is being slashed. I attended some of the debates in another place and heard the word "cut" and also, I believe, the word "slashed"; but that is quite wrong. We are spending more money on the Health Service in the current year than was spent in any previous year. Whether or not the money is being spent in great wisdom in every direction is another matter. But I feel that a case has been made out for these increased charges. Better health, more advanced drugs, more hospital building and equipment must be paid for somehow. In all our welfare services, in health and education, we are seeing more and more money being spent—and quite rightly; and the results are, in the main, satisfactory, though I would say that in some directions more could be done. But I certainly think the Opposition's case against these increased charges is wholly unconvincing.
§ 6.44 p.m.
§ LORD TAYLOR
My Lords, I have great hope for the noble Lord, Lord Auckland. He has a kind heart and some jolly good ideas, and he goes out and sees for himself—which I always think is a most attractive feature of his speeches. I am going to predict that the noble Lord will have a "dusty answer" from Her Majesty's Government to his very good suggestion. I may be wrong—I hope I am—but I believe he will; and if he will consider what he has said I think he will see that he ought to have been supporting us. What the noble Lord asked for was really a graduated charge, with no charge for the period under the age of five, and then the charge starting and going rather higher when one started to earn wages, and continuing throughout one's earning life, stopping in old age. I hope that I am not misrepresenting the noble Lord. That is not a bad idea. But the best way to do that is to finance the Health Service out of income tax, which we have always said is the proper way to do it. Administratively, the scheme is, I think, too difficult to work, and the proper thing is to pay this out of tax, as we say. That is the only fair and right course.
578 The second point which the noble Lord made was about the drug industry. He said we had perhaps not given all the credit that should have been given to the pharmaceutical industry for the good work they have done. I have not been backward in giving credit to the pharmaceutical industry. They have done some very good research work, but they are very wasteful, as we tried to show in the last discussion, particularly in the multiplication of research. The fact that there are so many firms competing, and not co-operating, in the research sphere leads to wasted research effort. Also, it becomes necessary for perfectly good, honest and honourable firms, in order to keep going, to keep producing new products, which they do by minor modifications, not all of which are any advance on earlier products. This is a purely commercial situation. I do not blame them for coping commercially with it. That is what they have to do in order to keep going and make profit.
A third thing (and this is a result of competition) is that they unload on the unfortunate medical profession a vast load of paper which comes through my letter box every morning, and that of my noble friend Lady Summerskill and so many others. It has been estimated that it probably costs about £10 million to do this postal advertising. It must have some effect. It must work in some way, or presumably those firms would not do it. But that advertising can only influence the most ignorant and credulous doctors, and it would be a very good thing if this could be stopped. The cost to the nation, that £10 million of which I spoke, could be saved straight away, and we could have a simple bulletin issued each month by the Ministry of Health, giving us the facts. That is all we need to cope with that situation.
Then Lord Auckland's heart was open to the diabetic; and I believe that he is quite right to feel passionately and warmly about the needs of diabetics. But there are many other folk in an exactly similar situation, people who have to take regular doses of some kind of medicine or tablets, daily, or perhaps twice daily, in order that they may remain in good health. There are epileptics for example, who must take Epanutin. Epileptics nowadays do not have fits, and it is very rare indeed to see an epileptic fit—thank goodness!;—whereas 579 when we were young it was a very common sight. Now that has disappeared because of the use of this excellent drug. Again let us give the drug firm responsible the credit for that. But it means that the epileptic person has to buy that drug, or get it through the National Health Service for the rest of his or her life; and those people are not usually the highest wage-earners. Therefore, while the noble Lord is absolutely right, I would say that he is seeing a part of the picture but not the whole picture. And the more one looks at the whole picture the more one feels all these people need help.
Finally, the noble Lord said he hoped the charges would reduce the volume of medicine dispensed (I believe I am right in saying that), and he regretted the over-stocking of the family medicine chest. I must say that I agree with him about that. I have recently tried to work out what a family medicine chest ought to contain. I reckon that it ought to contain not more than three items: first, aspirin, or aspirin, phenacetin and caffeine tablet.
§ LORD TAYLOR
No; a packet, a box, price 9d. or 1s. Also, a packet of some form of cough or cold-relieving substance—for example, some sort of simple throat pastille—and some form of indigestion-relieving tablet, bismuth or magnesium trisilicate. I do not think it should contain very much. I do not think there is much of a case for keeping purgatives in one's medicine chest. I think that that is all we need in our home medicine chest, just those three things. The reason why I am driven to this conclusion is that I have had to equip first-aid boxes in factories where I have found all sorts of rubbish accumulated by the first-aid workers. I have "kicked out" all this rubbish and just given them those three items, and the people do well on them.
My noble friend Lord Stonham referred to bottles in Scotland being double the price of bottles in England. There is a strange concomitant to that fact. Medicines in Scotland are half the price of medicines in England. Why Scottish doctors are so economical in their prescribing I do not know. Perhaps your 580 Lordships can guess for yourselves. But they have always, I believe, been very much lower in their prescribing costs than have the English doctors.
§ LORD TAYLOR
No; I cannot accept that. The noble Lady suggests that Scottish doctors are better. I would say that the best of both are very good.
The noble Lord, Lord Derwent, really put the best possible case for the Government on this matter, but it was not very convincing. He asked, first, why the Minister had raised these charges. He thought it was probably to reduce abuses, but he was not very sure about that. As a matter of fact, he had only to refer to the Hinchliffe Committee's Report to see that the Hinchliffe Committee were satisfied that charges had not stopped prescribing: that there were virtually no abuses, and that they certainly had not reduced the amounts prescribed, but, rather, as my noble friend Lord Stonham said, had increased the amounts prescribed. Then he went on to say that the second reason, and probably the real reason, was financial, and that, given that the Government had the "slice of the cake" of the National Health Service about right, the Minister needed some more money for "other projects"—in "quotes".
We have heard of these "other projects" from the Minister of Health himself, but we have not heard what these other projects are. If the noble Lord, Lord Newton, can tell us we shall be very interested indeed. We know that in the next year the extra cost for hospital construction is going to be £5 million, but the extra yield from these charges plus the raised contributions is going to be £65 million. That is a big difference. We all know where that money is going: it is going to pay for the extra salaries of the doctors as a result of the Royal Commission's award. That is what is happening, and that is why we have to pay these extra charges. I would quote this extract from the Medical World Newsletter:The major part of the increase in the Health Service estimate is due to the implementation of the Royal Commission's recommendations. Additional contributions and charges are imposed to meet these increases. Must the patients now be required to pay £12 million p.a. more for his medicines"—581 that is these charges we are discussing—in order that the doctors should obtain their due? We doubt very much whether our profession would have urged its cause so strongly if it had known that the Government would require the patient to meet the bill"—at the time of sickness. That is really what has happened, my Lords: it is nothing to do with increased facilities in the service. Alas! I wish it were.
The noble Lord, Lord Derwent, went on to outline the people who are going to suffer hardship, the existence of whom he doubted. He is quite right in supposing that these charges bear hardly only upon the poor people. For the middle group of the population and the upper group, perhaps three-quarters of the population, or even four-fifths, they are not going to be a very great hardship. But what are the causes of poverty in our society to-day? They are two. As the noble Lord, Lord Beveridge, was mentioning, one is old age. If we take the poor people of to-day, we find that they are the old people, by and large. The second group are those families in which the chief wage-earner is either acutely for a short period or chronically for a long disabling period.
So the main categories of poverty today are due either to prolonged illness or old age. These are the people on whom we are placing this extra burden. And remember that any of us can pass into one or other of those groups, particularly if we are weekly wage-earners. It is very easy if one is a weekly wage-earner, and most weekly wage-earners do not get their money made up by their firms. They go on to the ordinary National Health Service benefit. They carry on as best they can, and if they have a prolonged illness they have to go to the National Assistance Board and get some National Assistance to help them with the rent. They try to avoid doing that, as a rule, for as long as they can—perhaps mistakenly, though I think for good and reasonable reasons. Those are the folk who are going to find these charges hard to bear.
§ LORD TAYLOR
My Lords, I would not argue, but I cannot confirm that. Professor Titmuss has said this in a very good article of February 2:The new health charges … do not make any real saving for the Community. It simply 582 switches the payment for the Health Service from one form to another: from general taxation on to the shoulders of those who can afford it least. I calculate that those who are now living perilously near the margin of poverty represent about one-fifth of the nation.That one-fifth we do not see a great deal of, but they are largely the old and poorly-paid workers.
These charges have been in operation now for just over a week, and it is too early to say what their real effect is, but I have made some inquiries of my medical friends to see what is happening. The first thing that is happening is that doctors who are called dispensing doctors are in some difficulty. Most doctors do not dispense; they write out the prescription, and the patient takes it to the chemist and gets it dispensed by the chemist. But in country areas and in small country towns doctors themselves still dispense. They do it as part of the National Health Service, and it is not a very profitable occupation for the doctors. They do it really as a form of social service, because there is nothing, or very little, to be made out of dispensing. It takes a lot of time. They may have to employ a dispenser, and they are lucky if they break even. They have had to charge 1s. for every bottle of medicine or packet of pills in the past. Now the charge is 2s.
The effect of this is that patients are asking them to dispense bigger quantities. In the case of a doctor who writes a prescription which the patient takes to the chemist, it does not affect the doctor if he dispenses double quantities, except that it pushes up his average dispensing costs. These are analysed at the end of the quarter, or whenever it may be. In the case of the dispensing doctor, however, he has to buy the stuff, and he does not get more money, unless he happens to operate an elaborate system of costing, just because he dispenses more to help the situation of the patient. Most dispensing doctors have rather low dispensing costs because they tend to be economical, not only from their patients' point of view but from the point of view of making ends meet. That is the first thing that happens. These doctors are going to be in some difficulty, and I think the Government will have to look at it. However, I would not ask them to look straight away, because much more time must elapse before 583 they can say how this situation will develop, and whether it will lead to serious hardships and difficulties for the dispensing doctors.
For the ordinary general practitioners, it so happens that, in the areas I know best, the number of prescriptions dispensed has gone rapidly down during the last week. But there is another reason for this. The coming of the new charge happens to coincide with the end of the measles and 'flu epidemic; and, so far as I can see, the fall in the number of prescriptions dispensed may be entirely due to that. However, there have been some rather odd things happening. The patients have been asking their doctors the price of each medicine on the prescription, because they say, "I do not want you to write me out something that would cost only 1s. 9d. at the chemist's and find that I have to pay 2s. on the prescription". This means that the doctors have now to add to their medical and social knowledge an expert skill in retail price manipulation, as it were, which they have to bring into play—one more thing to do at a crowded surgery, which is not very good, and certainly a little trying though it would not be fair to say that it is a serious inconvenience.
Another thing that is happening, so far as I can see, is that some more old-age pensioners are realising for the first time that they can fleet National Assistance. That is a good thing, though a rather inverted good thing. It is certainly adding to the national costs, because these people who were struggling before are now going to their doctors and are saying, "Can I possibly get this 2s.?", and they are being told "Yes, you can. What is more, you should have been getting the rent as well." They say, "I have not been getting that", adding, "I do not want to get the National Assistance". The doctor says, "Don't be an idiot; you are entitled to it. You can get National Assistance not only for the 2s., but for the rent as well". That is a bit of good coming out of evil, anyway. Perhaps the Government think it is good coming out of good; but we are very pleased to see that that is happening, whatever the cause.
Thirdly, there are the poly-family-syndromes, which are familiar enough 584 to any doctor. These are the "mums" with lots of kids—four, five or six children under school age. No; that is a bit of an exaggeration; it would be difficult to have six children under school age, but three or four under school age, and two or three above school age. These folk, of course, have a very tough time financially. Their husbands are usually of the labouring class, or in the building industry. If they are in the building industry, they are better off than if they are in the labouring class—I am sure my noble friend Lord Stonham will bear me out there. They have to budget very tightly, and towards the end of the week they run out of money; or at least it gets very tight. I have heard such "mums" saying, "I don't think I can afford to go to the doctor on Thursday, because if he gives me a prescription with two items for my little boy or girl, we cannot afford it. It will mean cutting into the food for the next day". That is an absolutely genuine situation. You may say that these people are feckless and should not have all these children, or should be better managers; but they are not, in many cases, good managers. They are, in fact, the hardest up, They are the hardest cases of all, and certainly they are being hit by these charges.
I am not going to recapitulate the arguments I used when we were debating these charges before, but before I end I want to ask the noble Lord, Lord Newton, one thing: that is, whether he could give us the details of how insulin can now be obtained, because I believe I am right in saying that, on a single prescription for 2s., one can get both short and long-acting insulin.
§ LORD TAYLOR
I thought it was. That is one alleviation of the situation, which makes it slightly less bad than it otherwise would be. You can get both types of insulin, if the patient is on both of them, for the one 2s.
Finally, my Lords, I should like to draw your Lordships' attention to a really first-class book called, Britain's Search for Health. It came out last week, and it is by an American, Professor Paul Gemmill. Now Professor Gemmill is the Emeritus Professor of Economics at the University of Pennsylvania, and one 585 might imagine that he was very much an anti-Health Service person. I know Professor Gemmill, and he is the most honest, nice little chain you could possibly meet. He came over from America to find out what was really going on in the British Health Service, and he did it in the most intelligent way. He went and sat in doctors' surgeries for seven months. He was the last patient, so he heard all that was said. He used quietly to administer questionnaires to patients waiting in the surgeries, and then he saw the doctor and had a chat with him. He was completely unbiased, and this book is completely unbiased. It is a beautifully written book. He tells you all about what the doctors like and dislike, and what the patients like and dislike—in fact, how the thing really works. It is the best account of the Health Service that has ever been written.
Of the things patients dislike, he mentions three things: long waits—long waits in the surgery and long waits in the out-patients' departments. That was the top dislike that he found. The second dislike he mentioned was hurried surgery consultations as a result of big lists. The third thing he mentioned was these Health Service charges. The way in which the charges were mentioned (they came up spontaneously, and in those clays they were only 1s.) was almost always as a deterrent to getting things done which ought to be done—these were ordinary patients speaking—particularly people not getting the specs that they ought to get, and not getting their teeth attended to as they ought to get them attended to. He certainly mentioned that.
He also gave a very fine description of the attitude of the British public to National Assistance and to the Poor Law. He said:The British are a proud and sensitive people. They have a horror of anything that smacks of means tests or Poor Law charity. Professor Lafitte cites an example from the days of the Great Depression: ' No fewer than a million aged pensioners who had quietly refused to ask for poor relief flocked to the Assistance Board in 1940. and qualified for help, when relief was offered them outside the Poor Law under the new name of "supplementary pensions"'. A feature of the National Health Service that appeals to the patients strongly is the fact that the medical care they get comes to them as a right and not as charity.586 My Lords, I think those words are absolutely true. The point that Professor Lafitte makes about the dislike of the Poor Law atmosphere, and about people's pride, which is hard to legislate for (though it was legislated for successfully on that occasion, and again when the National Assistance Board was created), disproves the point made by the noble Lord, Lord Derwent.
Finally, there is this quotation from this book:The doctors are happy that they can now prescribe the best medicines (regardless of their cost) for even the poorest patient, knowing that a lack of funds will not prevent the prescription from being filled. This was not always the case uncle] the private-enterprise medical system of a dozen years ago. I have talked with physicians who, in pre-N.H.S. days, sometimes felt compelled to prescribe the poorer of two possible remedies, simply because they were sure that the better one, which was quite expensive, would never be purchased by the patient. Unsolicited comments from N.H.S. general practitioners indicate their satisfaction in being able to get the most effective medicines into the hands of their patients. One such comment, from a 9,700 patient partnership in Devonshire, says: 'It is gratifying to order treatment, knowing that the patient can obtain it and not be worried about the cost.' Another, from a large general practice in Lancashire: At first my partners and I were against the Service. Now we approve of it. Any treatment, however expensive, is open to everyone, no matter how poorThe quotation goes on:In the days off fee-for-service practice, a doctor who thought a follow-up home or surgery visit desirable might nevertheless hesitate to suggest it because it would mean an extra fee for him and extra cost to his patient. By dissolving the commercial link that formerly existed between doctor and patient the N.H.S. has obviated any embarrassment which this relationship may have caused in the past, and has thus made it easy for the physician to continue his treatment of a patient for as long a period as he thinks desirable. Report has it that the removal of this obstacle to seeing the job through to the end is much appreciated by doctors who … measure their success very largely in terms of the service they render.My Lords, that service is being rendered just a little less effectively as a result of these charges. It is a great pity and a great blow that that should have happened, and it is a needless blow. We know that we cannot get the Government to change their mind. There is only one thing which could do that, and that is a change of Government. And that, my Lords, is what I think will happen in due course.
§ 7.12 p.m.
§ BARONESS SUMMERSKILL
My Lords, I am sure we have listened to the noble Lord, Lord Taylor, with great interest. I followed him carefully, and I was interested to learn what should be the contents of the perfect medicine box. I wonder whether the noble Lord has examined the medicine box in another place. Over a period of twenty-three years I have treated the initial stages of every disease in that other place—with the exception of a confinement—with the drugs available. I think what we should learn from the noble Lord to-night, although he was jocular about the contents of a medicine box, is that doctors throughout the country who conduct the medical education of the people, illustrating what the doctors themselves consider are the most effective drugs, could time after time tell interested groups that the last thing a doctor would take was an antibiotic, unless he thought it absolutely necessary. It is tragic to think that this country to-day—and here I am speaking rather to the noble Lord, Lord Auckland—attaches such importance to these expensive proprietary antibiotics, when the fact is that in consequence of taking unnecessarily all the penicillin he has mentioned many people to-day are unfortunately resistant to penicillin. This is a matter on which we should have a long debate in this House, because it is fundamental not only to the health of the people but to the National Health Service.
I must apologise to the noble Lord, Lord Auckland, for interrupting him, but I was a little astonished. Here we have a progressive young man, and he was saying things which I thought really could not be acceptable in view of the information that most of us have. I told him about the Kefauver Committee. I would also direct his attention to the statement of the Auditor General, and to the Public Accounts Committee, which I think my noble friend Lord Stonham mentioned. They invited the Permanent Secretary to the Ministry of Health to give evidence on this subject, and the noble Lord will find the Report most interesting reading.
It was only three weeks ago, when I entered this House, that I made my maiden speech on this subject. I confess I thought I detected some sympathy 588 on the faces of noble Lords, not only because it was my maiden speech but because I thought a number of them were not too happy about the morality and wisdom of taxing the sick, the aged, and the children. I am sorry the noble Lord, Lord Derwent, is not here. I sat back in my seat and thought that his speech could apply to the last century, when little boys went up the chimneys. He could then have argued quite cogently that there were so few little boys, and that anyhow they did not seem to worry about it very much. However, I do hope that he will read what I have to say in Hansard. It is a fact that already these Orders have been in operation for nearly a fortnight. Although we have appealed to the Minister time after time to modify them, nevertheless he went forward, despite the fiscal and ethical consequences. I have no intention of repeating the arguments which I adduced three weeks ago, but I want once more to emphasise what the noble Lord, Lord Stonham, has already said, and that is that these new charges represent, surely, a departure from an important principle. Indeed, I feel that the Health Service is a noble edifice of the Welfare State, and that these charges tend to undermine it.
The National Health Service Act was passed on the principle that the Service should be financed so that the rich should pay relatively more for the poor. That is a fact which I think was applauded by all progressive, liberal-minded people. Surely these charges make a complete departure from that principle. Three weeks ago I said that a Minister, in a Department like the Ministry of Health, which is a highly technical Department, cannot fully appreciate the significance of imposing these charges on the sick and aged people. I also said that he cannot appreciate the repercussions on the administration. I want, quite shortly, to mention to-night some of these repercussions. If, as has been argued by some noble Lords, this imposition were insignificant, why is it that the conservative medical profession has not supported it? The medical profession has never allied itself with the Labour Party. The organised conservative medical profession and the British Medical Association have said, time after time, that no financial barrier 589 should be placed between the doctor and the patient. These are the people who know the situation. These are the people who know the whole field of medicine. These are the people who treat the sick and the aged. Why have they not echoed what the noble Lord, Lord Derwent, has said, that there is no problem here; that these shillings are easily available? The medical profession has set its face against these charges.
My noble friends behind me have said that the time has been short, that the Orders have been operating for only a short time, and perhaps it is not fair to judge the effect of them yet. But I think already the chemists have reported that many people will not be able to pay this extra charge. The noble Lord, Lord Newton, will correct me if I am wrong when I say that, in consequence of these warnings, the Minister has already had to revise the list of people who are entitled to a refund of the charges. Again, what a pity it is that the noble Lord, Lord Derwent, is not here, because he commented on what a little trouble this is. The fact is that a sick person has to fill in a form, post it and get it delivered; and then there is the operation of the relatively complex and costly administration of the National Assistance Board—and we must not forget that, when we are thinking of the cost of the refund itself.
I agree with the noble Lord, Lord Stonham, when he says that already we can see this amount of money which the Minister expects to save being whittled away. What will the doctors do? I agree with my noble and medical colleague that the doctor will, of course, often prescribe larger quantities of medicine, tablets and pills. Doctors have been invited to do so by the Minister himself. When I spoke for the Ministry of Health in another place, seven Conservative Ministers of Health faced me on successive occasions, and on two or three of those occasions they said that they invited doctors to prescribe large amounts. I ask your Lordships to glance at your own medicine cupboards and see all those half bottles of tablets and pills. And that is repeated throughout the country. The wastage of expensive medical preparations is such that I tremble to think of what is going to happen now, because the waste will be colossal. The doctors are now prescribing more, and 590 as the names of the preparations are not written on the bottles and boxes, after a time people forget what they were prescribed for and throw them away.
It seems to me that since this decision has been made the Minister has been compelled to meet the needs of the situation by expedient after expedient. I would ask the noble Lord to correct me when I say it is a fact that the Minister has been concerned in giving a directive to chemists that, in the event of a certain item similar to one on the prescription form E.C.10 being less in price than two shillings, they are now expected to tell the patient that they have in the shop something cheaper which is the equivalent in therapeutic value. If that is so—I think the Minister announced this about a fortnight ago—it is a menacing thing, because the relation between doctor and chemist so far has been a pleasantly professional one, and the chemist has been vigilant in interpreting prescriptions as accurately as he could.
§ LORD TAYLOR
My Lords, may I interrupt my noble friend on this important point? I made some inquiries about the situation this morning, and I understand that the chemist is not allowed to alter the script or to give anything other than what is in the script. If the chemist wants to tell the patient that anything is cheaper and that he ought to get a cheaper equivalent or even pay for it as an item, rather than have it on the prescription for two shillings, the only thing for that person to do is to take the prescription back to the doctor and get a new prescription which omits the item concerned. The chemist is not allowed to alter it, because he must follow the doctor's instructions, and the patient is not allowed to make any alteration, for fear of dangerous drug tricks.
§ BARONESS SUMMERSKILL
To suggest that even in that way the chemist ought to interfere with the treatment of a patient is opposed to all medical practice. It is suggested that the chemist should now look at the prescription in 591 a little crowded shop—and I ask noble Lords to envisage the average chemist shop throughout the country, full of toilet accessories, with one chemist and maybe an assistant or two, and crowds of people coming in all the time; these are the things which the Minister does not anticipate—and say to a patient, probably someone he has known for years, "You can get this more cheaply"?
§ BARONESS HORSBRUGH
My Lords, suppose something was under two shillings, would one be able to ask the chemist, "If that costs less than two shillings, I would rather pay the 1s. 10d. and not have it on the prescription."?
§ BARONESS SUMMERSKILL
The patient can ask anything he likes. If a patient goes into a chemist's shop with a prescription, nobody can gag him. He can say to a chemist, whom he has probably known all his life, "Tell me about this." And nobody can gag the chemist. The chemist can also express his views. But the point is—and perhaps the noble Lord will correct me if I am wrong, because this is a most important point—that if, as my noble friend says, the chemist is not allowed to alter a prescription and it has to be taken back to the doctor, then the arrangement is really preposterous. Doctors are paid on a capitation basis. The young doctor with a limited list, say, of 1,300, which he is desperately trying to build up, knows his patients personally, looks after them and occasionally cossets them. He suddenly discovers that it is possible for his patient to go to a chemist and be told that one item on his prescription, or its equivalent, can be supplied much more cheaply—in other words, that he has prescribed something that is cheap. Think of the psychological effect on the patient. Will a young doctor say that it is helpful to him as a practitioner, that it will establish closer relations and make his patients feel more confident in his treatment, if they learn that he has prescribed something so cheap that it is under two shillings?
I would dare to say that from this latest expedient of the Minister there may be unfortunate repercussions. Doctors, particularly young doctors, may say that in future they will not prescribe anything under 2s. There may be a temptation to excessive prescribing, be- 592 cause a doctor may be anxious not to prescribe anything which may be revealed in a crowded little shop as something cheap. Like my noble friend Lord Taylor, I attach importance to aspirin, because I know its usefulness. It is a cheap drug—
§ BARONESS SUMMERSKILL
— although I think that in this House tranquilisers might be sometimes rather useful. Here is a temptation to doctors to prescribe expensive drugs.
§ BARONESS HORSBRUGH
My Lords, I did not know that a doctor would take it as his standard that he would be popular with his patients if they thought that the drugs he put on his prescription were all expensive; and that if he put in anything that was cheap, he would not be popular. I am learning a great deal. That is why I stayed.
§ BARONESS SUMMERSKILL
My Lords, I did not know that the noble Lady was so utterly innocent and naive. Why does she think that the cost of prescriptions, which was about 2s. 6d. a few years ago, is about 7s. 3d. to-day? All these proprietary drugs are now on the market and very often pressure is brought to bear on doctors to prescribe expensive proprietary drugs. That is one reason why the cost has gone up.
I want to make only one more point. We have heard about Dr. Gemmill, the American who said that everything he learned was learned sitting in a doctor's waiting room. I saw him when he came over here. If only the Minister before he had tabled these Orders, had gone round the country (he might have emulated the Minister of Transport and his colleagues, who do their work in a most practical fashion and go round the country), sat in doctors' waiting rooms and in chemists' shops and listened to the talk there, he would have heard all this and he would have thought most carefully before he tabled these Orders.
593 My final point is about his attitude. I am afraid that he based his whole plan on the income of a highly skilled industrial worker: he failed to take into account the fact that the average wage of women in the country is approximately £7 a week, and that there are millions on small fixed incomes. He thought also, having had his education in the Treasury, that he could divert to medicine money spent on tobacco and drink. This in itself revealed his ignorance of the economy of many homes. No doubt he will learn a lesson from these failures—and I am sure there will be failures of the kind I have described—but, unhappily, it will be at the expense of the most helpless of the community.
§ 7.31 p.m.
§ LORD NEWTON
My Lords, I believe that this is the first occasion on which the noble Lady has addressed us from the Front Opposition Bench, and it is therefore my first and very pleasant task this evening to offer her congratulations. It is not a new experience for the noble Lady to speak from a Front Bench, but it is the first occasion in this House, and I think she should be congratulated. And nobody is more pleased than I that it falls to me to have that pleaseure.
We had a full-dress debate on February 13 on all the proposals which the Government announced on February 1 for reducing the net Estimates for the National Health Service. The debate we have had this afternoon is really an extension of that debate—indeed, my noble friend Lord Derwent said it was one of a series. I personally am very glad that we have had the debate. The noble Viscount the Leader of the Opposition explained the reasons for putting down this Motion, and I entirely accept those reasons. As I say, I am glad that we have had the debate, because I believe that the more the Government's proposals are discussed the better they will be understood generally in the country; and the better, I believe, too, will it be understood that they are intrinsically fair and justified in present circumstances.
The noble Viscount, in explaining why he was going to make only a short introductory speech, referred to his team of experts that he had at his disposal, and nobody is more conscious than I that 594 the noble Viscount has these experts to back him up.
§ LORD NEWTON
This Motion calls attention to five Regulations which came into operation on March 1 about charges for prescriptions in. England, Wales and Scotland, and for amenity beds in hospitals in England and Wales only. I do not think that anything has been said in this debate about the amenity beds Regulations and I hope your Lordships will forgive me if I do not say anything about those particular Regulations. But the other Regulations form only part—albeit an important part—of the Government's proposals for ensuring that the money available to the National Health Service is laid out in the best possible way.
In our debate on February 13 we had a full discussion about all these things, and I am sure your Lordships would not wish me to go over the ground again.
However, I should like to remind your Lordships (because this is the basis of the whole of this exercise) that I argued then that if the National Health Service is to expand in accordance with progress in medicine we must from time to time see what can be done to Limit the expenditure already incurred, in order to ensure that money available for the Service as a whole is spent to the best advantage on new developments. This is surely true, whatever the total size of the sum of money available for the National Health Service in this country, if only for this reason: that the resources which can be made available for this Service are not unlimited, any more than they are in the case of any other services. They never have been under any Government, and I do not imagine that they ever will be.
If I understand the noble Lord, Lord Stonham, aright, he argued that the sort of point I am now putting to your Lordships is not an argument for further erosion (as he called it) into the National Health Service. My answer to the noble Lord is that I do not regard 111 is as being further erosion into the National Health Service. And that is the whole basis of the Government's case. Therefore it seems to me that the Government of the day, whatever their political complexion, 595 have a very clear duty to see that whatever funds can be made available are spent as wisely as possible.
Again, in the debate on February 13 I picked out three main directions for future progress. I am not going to say more about them to-day; they are recorded in Hansard, if noble Lords wish to see what I said. The general aims were not disputed in that debate, and I do not think they have been disputed to-day. Therefore it seems to me that the real question before us now is whether, to help in realising those aims, we are making the right adjustments in the right places. I think that to answer this it is necessary to show that the changes which have been made satisfy two main tests. The first is that they must be adjustments which will not have an adverse effect on health, and the second that they must be administered in such a way that they do not cause hardship.
The Government believe that the adjustments which we have been debating satisfy those tests, and it is my aim to convince your Lordships that that is so. For many years prescriptions have been playing an increasing part in the National Health Service. There has been great advance in treatment, due to the development of new drugs, which have brought immense benefit to the community. They have saved lives which would have been lost; they have enabled patients to be treated at home, instead of in hospital, and they have shortened the length of sickness, both at home and in hospital. But there has also been a substantial increase, as we all know, in the cost of the drugs supplied; and this is a fact which has caused much concern to all Governments since the start of the National Health Service.
As I said in the last debate, if one considers the history of the National Health Service one is immediately struck by the very early date after its inception in July, 1948, that it was appreciated by the Government of the day that it was necessary to take powers to impose a prescription charge. I had intended to give your Lordships some details of these rises in costs to which I have been referring, but I think I had better omit them. I should like to make it clear, however, that these 596 Regulations are not, in the view of the Government, a substitute for action to ensure that we get value for money for the cost of the pharmaceutical services.
§ LORD NEWTON
I will come later to the cost of bottles in Scotland. There are two aspects of this problem—the prices of drugs and the prescribing of drugs—and we have heard quite a lot about both aspects to-day. In the view of the Government, so far as prices are concerned, the new voluntary price regulation scheme is a great improvement on its predecessor and is likely to show dividends.
One of the first results of this scheme has been a reduction in the price of an antibiotic group known as tetracyclines, and this reduction in price will represent a saving of £1 million a year to the taxpayers, which I would suggest is quite a good start. As for over-prescribing, this is a matter for the professional discretion of the doctor, and in the presence of two doctors I must be very careful what I say. I know, and I suggest that your lay-Lordships who are in the Chamber to-night know from your own personal experience, that some doctors prescribe more profusely than others. I know a very good doctor who is a most reluctant prescriber. It is almost like trying to get blood out of a stone—he is not the noble Lord, Lord Taylor. I felt that if I did not say that, when we remember what he said about the contents of the medicine cupboard, other noble Lords might think that I was making an oblique reference to him. This doctor about whom I am speaking takes the view that for most ailments, bed, a hot water bottle and a couple of aspirin tablets are the best cure. And he may well be right.
However a doctor may exercise his professional discretion, my right honourable friend recognises that it is the duty of the Government to help doctors to prescribe both well and economically, and that is why the new Prescribers' Journal is being produced. Those are the actions in the field of prices and prescribing which the Government are taking to ensure that we get full value for the money spent on the pharmaceutical service.
§ LORD NEWTON
I think towards the end of April, but I should not like to say that authoritatively, because I may be wrong.
These increased charges have been criticised as a tax on the sick, and it has been said that they will result in patients going without drugs which are necessary for their proper treatment, and that there will be serious hardship for many people. I cannot accept that, and I would say to the House that the Health Ministers have no evidence that the charges, coupled with the arrangements which have been in force since 1952, for refunds in the cases of real hardship, have deprived patients of necessary treatment. And there is no reason at all to expect that the increased charges will change this position. In another place my right honourable friend has offered to consider individual cases where it is claimed that the new charges would mean that necessary medicines would not be available without hardship.
Since these Regulations were made, many letters have been received by the Health Departments criticising the increase in the prescription charge. But while these letters have shown anxiety at the possible effect of the increase, they have so far given no evidence that individuals will, in fact, suffer. There is no reason why they should suffer in any way, provided that proper use is made—as indeed it should be—of the arrangements for the refund in cases where it will be a real hardship to a person to meet the new charge in addition to his other commitments. It is essential, of course, that the minority with small resources who might otherwise find it difficult, or indeed impossible, to meet the 2s. charge, are helped so that they can be sure of obtaining the medicine and other things that they need.
I should like very briefly to mention the various ways in which the cost of the charge can be reduced or relieved. First, there are the arrangements for the refund for a war-disabled pensioner, and for people receiving a supplement to a pension, or a regular weekly grant from the National Assistance Board. Your Lordships know that they are automatically entitled to a refund. Then there are the other people who are not in either of 598 these categories. The Minister of Pensions and National Insurance, and the Health Ministers, have given much thought to ways of making sure that people who may suffer hardship by meeting the prescription charges know the sort of circumstances which might entitle them to a refund.
The National Assistance Board are making available a new leaflet explaining these circumstances. This will shortly be available; it will be sent to their area officers, and will be available, for citizens' advice bureaux, doctors, chemists and other persons and organisations who may be concerned. The leaflet will explain that where prescriptions are regularly required at very close intervals, and refunds are payable, the Board's officers will provide on each occasion a franked envelope and a simple form, on which the patient can say whether his circumstances have changed. If they have not, he will normally be sent the refund without further formality.
§ LORD AMWELL
Upon whom do they claim? Do they have to go to the Post Office? What kind of bureaucracy is this?—making all these fiddling little claims. How is it going to be done?
§ LORD NEWTON
I think the short answer to that question is in the way in which it is being done already, and that the method which has been in operation for some years has not been affected by the fact that the charge has been increased. In addition, the prescription charge receipt form, obtainable on request from the chemist or dispensing doctor, is being altered so as to include a fuller explanation than it now does of the refund arrangements. A short indication is to be included on the National Health prescription form, as soon as new stocks are ordered, directing the patient's attention to the fact that he can obtain from the chemist information about refunds. These arrangements, together with the posters which have already been distributed to doctors and chemists, should ensure that patients who would be entitled to a refund of charges know what they should do.
May I now briefly consider some of the detailed points which have been made by your Lordships in this debate? My noble friend Lord Dement asked how many old people there may be with no relations and friends. Quite 599 obviously, we do not know how many there are, but there must be many old people in this country with children, relatives, friends and neighbours who care for them. I think it is so easy, when one is discussing these problems, to think of the old as though they live in a world of isolation. Do not let us forget, too, all the voluntary organisations, which I believe are on the increase in this country, for helping to care for the old people. They certainly exist in growing numbers in the part of the world in which I live. I expect that many of your Lordships are connected with organisations of this kind, or, if you are not, that your wives are.
The noble Lord, Lord Beveridge, in explaining to us why his name was not on the list of speakers to-day, said that the reason was that he was making a study of the aged poor in the affluent society; that he had begun it to-day, and that he is to publish his report soon after the middle of April. I am sure we shall greatly welcome this publication from the noble Lord. He also said that he was very dissatisfied with the answers which I had given him in reply to his views on the need for ensuring, more actively than is done at present, that the old and the aged should get the medical help which they need. I could not agree more with him that it is important that all, whatever their age or whatever their state of health, should get medical help when they need it. But the noble Lord has not brought forward any evidence that there are people in any large number in this category who are failing to get the help they need. I hope that if he has evidence, if he gets evidence in the course of the study he is making, he will let the Government have it.
The noble Lord, Lord Stonham, said that chemists' earnings per prescription in Scotland are more than they are in England. On the other hand, the noble Lord, Lord Taylor, said that the contents of the medicine bottle in Scotland cost less than the contents of the medicine bottle in England.
§ LORD TAYLOR
My Lords, I think my noble friend, Lord Stonham, said that the earnings on the bottle were double those in England. I said that the 600 cost of the contents in Scotland was half that in England.
§ LORD NEWTON
I am obliged to the noble Lord. So far as I know, the answer to the noble Lord, Lord Stonham, is that in Scotland there are more chemists proportionately to population than in England and Wales, and Scottish doctors tend to prescribe less frequently than English ones. I think the noble Lord made that point himself. Hence the Scots chemist would get much less in the way of dispensing fees if the fee were not made higher. The dispensing fee of 1s. 8d. in Scotland, as against 1s. 2½d. in England, is designed to produce the same income in the two countries.
The noble Lord, Lord Stonham, also raised what I thought was an extremely technical point about discounts. I think perhaps it would be in accordance with the wishes of your Lordships if I wrote to the noble Lord about that, rather than read out the rather complicated information I have succeeded in obtaining. The noble Lord, Lord Taylor, I think gave a very good answer to the point raised by my noble friend Lord Auckland; that there was a good case for exempting diabetics from the prescription charge, and I thought also that Lord Taylor's observations on my noble friend's other point, about the advantages of having a graduated prescription charge, were also most apt. The noble Lord, Lord Taylor, also said that more old age pensioners are realising they can get National Assistance as a result of this increased charge. If he is right about that—I do not know whether he is, but that is his view—all I can say is that it seems to me a most admirable thing. I personally have always been in favour of the citizen taking advantage of his rights whatever they are and not feeling that to do so is something which should not be done.
The noble Baroness developed her case against what the Government are doing, but I hope she will forgive me if I do not give a long answer to try to rebut her case; it is part of the general argument I am trying to advance now. So far as the question of the items on a prescription form having a retail price of less than 2s. is concerned, the answer 601 is this. If the retail price of an item on a prescription form is less than 2s. the chemists are encouraged to tell their customers of that fact, and if the customer then says, "Right, I will buy over the counter for the retail price", the chemist may then mark the item on the prescription "Not supplied".
§ LORD NEWTON
No; he just marks the form "Not supplied", and that is the end of the matter. I should like to think that I have persuaded all your Lordships of the strength of the Government's case.
§ BARONESS SUMMERSKILL
Perhaps I may intervene, because the point I made is so serious and the noble Lord has agreed I was right in this. Is he satisfied that the relationship between the chemist and the doctor will not suffer? Indeed, is he satisfied that, in consequence of this, the doctors I have described will not be tempted to prescribe more expensive things?
§ LORD NEWTON
My Lords, I really do not think it is for me, if I may say so, to try to act as judge in the case of the professional responsibilities of the chemist and the doctor. All I am saying is this: that if an item prescribed by the doctor would cost less than 2s. if bought at retail price—and the doctor may or may not know that—the chemist is encouraged to tell the customer, who will decide in the manner I have outlined.
May finally say this? I have greatly appreciated, if may respectfully say so, the atmosphere in which this debate has taken place, even though I may not have succeeded in convincing your Lordships of the rightness of the Government's case. I recognise, as I said at the beginning, that the Opposition feel strongly about these things and they feel sincerely. But I would ask noble Lords opposite to believe that we feel equally sincerely about these things, and that no Party enjoys a monopoly of sympathy and compassion for the sick and aged. Nothing has been said in this House 602 to-day to suggest that any Member of the House would not agree with that proposition, and on that I should like to finish.
§ LORD AUCKLAND
My Lords, before my noble friend finishes, I wonder if he would consult with his right honourable friend about the possibility of some kind of inquiry into the drug industry. There have been suggestions that the profits which are being made are over-large. I am certainly not in a position to dispute that one way or the other. On the other hand, I feel that certain points do need clearing up, and possibly some kind of inquiry could be considered. Would my noble friend consider consulting his right honourable friend on that?
§ LORD NEWTON
will certainly see that the views of my noble friend are drawn to the attention of my right honourable friend.
§ 7.57 p.m.
§ VISCOUNT ALEXANDER OF HILLSBOROUGH
My Lords, I was very glad to hear the noble Lord, Lord Auckland, emphasise the point. There was a drive, I understand, for economising on the drug bill in the other place, and it seems that there might be a saving of £400,000 on something over £65 million. It did not seem very effective to me. May I just say that I am greatly obliged to the noble Lord, Lord Newton, for the care and attention he has given to the case. I must apologise that I had to be absent for a large part of the debate because I had some urgent work to do, but I was glad to be back before he finished. I would say "Thank you" to my noble friends on both sides of the House who joined in this debate. We had, I gather, formally to put down a Motion for Papers, but on this type of thing we never divide, and although, as the noble Lord says, we still feel very strongly on the matter, I beg leave to withdraw the Motion.
§ Motion for Papers, by leave, withdrawn.
§ House adjourned at one minute before eight o'clock.