HL Deb 21 February 1985 vol 460 cc697-706

4.58 p.m.

The Parliamentary Under-Secretary of State, Department of Health and Social Security (Lord Glenarthur)

My Lords, with the leave of the House, I shall now repeat a Statement being made in another place by my right honourable friend the Secretary of State for Social Services. The Statement is as follows:

"With permission, Mr. Speaker, I will make a Statement on the limited list of NHS drugs.

"I told the House on 8th November that the Government intended to introduce a system under which a selected range of drugs would be available on the National Health Service in seven categories. These were: antacids, laxatives, analgesics for mild to moderate pain, cough and cold remedies, bitters and tonics, vitamins, and tranquillisers and sedatives.

"I published at that time a provisional list of medicines which might be selected within each category. This was the basis for consultation which continued until the end of January. We made clear from the outset that our intention was to produce a list from which doctors would still be able to meet all the clinical needs of their patients. The chief medical officers of the health departments wrote to all doctors individually to seek their views on the list. I am grateful to all the many doctors who responded and I hope they will recognise that their views have been taken into account. My chief medical officer also brought together a group of independent experts practising in the relevant medical specialties, including three general practitioners and a pharmacist, to assist him. That group has now unanimously recommended a list of medicines which they believe will meet all clinical needs. I have accepted their advice in full and I am most grateful for their help in this important task.

"This extended list of medicines will contain some 100 different medicines, compared with 30 on the provisional list. Most of the medicines will be generic, or unbranded, products; but a number of proprietary medicines will be retained where the group concluded that they were necessary and where no generic preparation currently exists. I should emphasise that the quality of all the selected drugs is assured. They all conform to the very high standards we require of all medicines under the Medicines Act.

"For the purposes of the regulations which my right honourable friend the Secretary of State for Scotland and I will introduce, it is necessary to list all the products which will no longer be prescribable on the National Health Service. The regulations will also cover those products which the Advisory Committee on Borderline Substances have advised are not medicines and should not be prescribed by general practitioners. I am today publishing both the selected list of drugs and those no longer to be prescribable. Copies are available in the Vote Office.

"I shall also today be giving the representatives of the medical and pharmaceutical professions the opportunity to comment on these regulations as they affect the terms of their contracts with the health service.

"Mr. Speaker, I should like to mention three specific issues concerning the operation of the limited list which have been raised during the period of consultation.

"The first is the question of the arrangements for reviewing the list itself. This was raised by, among others, the Royal College of Physicians. We fully accept that it is essential for independent professional advice to be available after 1st April on the need for changes to the list. I do not believe that complex machinery is required but I shall be very ready to discuss with the professional bodies concerned how the arrangements which have been used to formulate the extended list should be developed for the future.

"Second, questions have been raised about the implications of the new arrangements for dispensing doctors—that is, doctors predominantly in rural areas who themselves dispense drugs to their patients. For these doctors, the regulations will in effect retain the status quo. Dispensing doctors will still be able to supply any medicine to those of their patients for whom they already dispense, although they will have to issue private prescriptions for medicines which are no longer available on the National Health Service. Concern has also been expressed about the position of retail pharmacists who now hold stocks of drugs which will no longer be available on the National Health Service. I am quite prepared to examine any relevant evidence that pharmicists may present on their stockholding of drugs.

"Third, the question has been raised whether there should be some form of appeal mechanism for individual cases in which a doctor believes it is necessary to prescribe on the National Health Service a medicine which will no longer be available. Most concern was expressed by doctors who felt that there were serious omissions in the provisional list. My unanimous medical advice is that the selected list is now comprehensive and will make it unnecessary on clinical grounds for patients to use medicines not on the list. Nevertheless, let me say this: if, after examining the complete list and in the light of experience, the medical representative organisations still wish to propose that such a mechanism should be provided, my right honourable friend and I will be ready to discuss it with them. I should make clear, however, that any mechanism would need to be very carefully controlled to ensure that it could only be used in genuinely exceptional circumstances.

"Mr Speaker, during the period of consultation a number of alternative proposals have been advanced. Yet none of these offered the same prospect of achieving sensible savings in the NHS drugs bill without either harming the interests of patients or threatening the fundamental and legitimate interests of the pharmaceutical industry. The selected list which I am publishing today is likely to produce savings in the drugs bill of some £75 million now, rising to a higher figure in due course. I am therefore convinced that the approach we have adopted remains the right one in principle. I also believe that the selected list which I am publishing today will demonstrate that in practice the health service will continue to provide all medicines required to meet the clinical needs of patients. It is by making sensible savings of this kind that we are able to provide the health authorities with the increased resources which I have announced recently".

My Lords, that concludes the Statement.

5.4 p.m.

Lord Ennals

My Lords, we thank the noble Earl for repeating his right honourable friend's long Statement made in another place. Make no mistake about it—this is an extremely important Statement. The decision taken by the Government is deeply disturbing; it fundamentally changes the relationship between the general practitioner, his patients, and the medicines he thinks are the most appropriate with which to treat his patients. The noble Lord said that eight doctors were perfectly satisfied that the list was all right. There are tens of thousands of general practitioners across the country, and every patient is different. The general practitioner knows better than any other person what is the best medicine for a particular patient.

The Statement spells the end of the clinical freedom enjoyed by the general practitioner, and it will create a two-tier system of treatment. First, there will be a limited list of drugs available on the NHS; secondly, there will be other drugs which can be paid for privately. It is therefore another step in the process of privatisation and towards undermining the basic principles upon which the National Health Service was created.

I shall not repeat today what I said last night about the effects of this development on the pharmaceutical industry in this country. If there is to be a list of safe approved drugs which can be made available on prescription, then it would be better to have a more comprehensive list than that originally published. In my view, a list of 100 drugs is quite inadequate. If there is to be both a black list and a white list, can the noble Lord say what will be the position regarding other drugs which are on neither the black list nor the white list?

Much more seriously, I have a number of questions for the noble Lord. First, can we have an assurance that this is not the thin end of the wedge; that safe approved drugs are not increasingly to be paid for by the patient? Will more drugs be added to the black list? Does the Statement affect the medical equipment needs of patients in their homes? Next, will not this list inevitably create increased costs for the elderly and disabled who are now exempt from payment, and who will now have to pay if it is the view of their GPs that the limited list does not meet the probably unlimited needs of the patients concerned?

Why have the Government taken this action? As the noble Lord understands very well, it has angered such essential professions within the health service as doctors, pharmacists and nurses, as well as the pharmaceutical industry and organisations such as Age Concern which are concerned with the needs of patients. Why have the Government rejected the recommendation of their own working party, embodied in the Greenfield Report, for generic substitution? This would have left with the doctor, ultimately, his clinical freedom.

This is an extremely important Statement, and yet none of us has seen the list published by the Secretary of State; none of us in this House is privy to it. We shall of course want to debate the Statement on the Floor of this House.

Lord Kilmarnock

My Lords, we on these Benches would also like to thank the noble Lord for repeating that Statement. But I must say that I am surprised that the noble Lord, Lord Ennals, awarded the noble Lord an Earldom on the basis of this Statement!

Lord Boyd-Carpenter

Promotion by merit!

Lord Kilmarnock

It seems to me to be a case in which primary legislation should have been used to bring in such a very important change in principle in the relationship between Government and doctors. Regulations seem to us to be quite inadequate. I start simply by saying that I regret that the Government did not accept the suggestion that I have made on two occasions that they should have kept their limited list weapon in reserve and convened a new meeting of all the interests concerned. I am sure that that was a mistake. I think that they had general agreement in the palm of their hand.

Can the noble Lord answer one or two specific questions? The Statement refers to the number of doctors who responded. Can he tell us how many of them did? He told us that the Secretary of State's unanimous advice was that all clinical needs would be covered. Clearly doctors up and down the country were not happy about this and have asked for an appeals mechanism. Can he tell us how many doctors wanted an appeals mechanism? In their increasing the original number of drugs from 30 to 100, I am glad of the Government's belated conversion to generic substances, but they have not gone about it in the way that we should have recommended.

Is it not carrying secrecy too far not to release the lists at the same time as the Statement? We are told that they are in the Vote Office but we cannot see them until this exchange has taken place. Can the noble Lord tell me whether Gaviscon is included on the permitted list, or whether Distalgesic, a very useful medium-range analgesic, is included on the list? Regarding the reviewing of the list, can the noble Lord be a little more specific about what type of body is to be set up to view new additions to the list? The Government say that they have accepted the need for independent professional advice. What kind of body do they envisage? Will it be more open than the internal departmental committee? Will it include the BMA and the Royal College of General Practitioners? Will the industry have a voice?

Finally, on the arithmetic, the number of drugs has gone up from 30 to 100. The projected savings have gone down from £100 million to £75 million. I am sure that the suggestion that I made to the noble Lord last night is much more accurate—that they will work out in the region of £40 million. How will any shortfall be treated from the point of view of the Government's commitment to 1 per cent. real growth per annum in the NHS? Will an arbitrary £75 million simply be lopped off that? How will the Government handle that in relation to their firm commitment to 1 per cent. real growth in the NHS? They will be watched very sharply on that.

5.13 p.m.

Lord Glenarthur

My Lords, I am grateful to both noble Lords for their comments and to the noble Lord, Lord Ennals, for his promotion of me, which I do not feel that I deserve.

Lord Boyd-Carpenter

It will come.

Lord Glenarthur

May I cover some of the points that have been raised? The noble Lord, Lord Ennals, accuses the Government of making a fundamental change. He knows quite well that the drugs bill has risen inexorably year on year. A total of £1,400 million is what we are talking about. That is why it is now necessary to make changes, so as to make it possible to improve other parts of the developing health service.

The noble Lord suggested that the GP knows his patients best. But I have to tell him that no fewer than three GPs were on the chief medical officer's specialist committee, and it was the unanimous view of that committee that the drugs contained in the list were sufficient to meet all clinical needs. The noble Lord, on the other hand, says it is his view that the drugs do not meet the needs of patients, but that seems to run counter to the theory which he has just advocated—that it is only doctors who really know.

May I answer the point that the noble Lord raised about other drugs, and say that of course the list with which we are concerned deals only with the categories of drugs to which I referred when I repeated the Statement. There are seven categories, and the other drugs remain as before. As I understand it, equipment will not be affected at all.

The noble Lord asked me a number of specific questions. He asked whether more drugs would be added. There are no plans to extend the list at all. We hope that it will be possible to achieve more sensible prescribing generally, and that is a theme which I think is also advocated by the noble Lord, Lord Kilmarnock, although he differs from the Government in the approach that he would make to it. But I have to say that all the signs are that more sensible prescribing generally is already happening.

The noble Lord asked about the increased costs for the elderly and disabled. It is certainly true to say that much of the publicity and fuss which has been created by a lot of people about this list has put genuine fear into the minds of the elderly and disabled—and misplaced fear at that. Although some of these drugs which have up until now been available over the counter anyway will not be available on prescription, I see no reason to believe that it will make life in the least bit difficult for those patients because their needs can quite clearly be met by the drugs which will continue to be available.

The noble Lord asked why we rejected the Greenfield proposal. We have discussed this matter before, and he knows that were we to have adopted that route we should have achieved less than half the savings to which the limited list leads us. The noble Lord can also be quite sure that, had we introduced generic substitution, that would have undermined the industry and made research not worth while, even into life-saving drugs. It would have affected all groups of drugs—advanced drugs as well. He can perhaps draw some comfort from the fact that we have not done that if he looks at the pharmaceutical industries of, for example, Australia and Canada.

Lastly, the noble Lord suggested that we should debate this. Of course the opportunity will come for that. The noble Lord, Lord Kilmarnock, suggested that what I am repeating now ought to have been done in the form of secondary legislation. The orders will be subject to the negative procedure. Regulations will be laid which will amend the National Health Service General Medical and Pharmaceutical Services Regulations 1974. That is the secondary legislation to which he refers.

To continue with some of the points raised by the noble Lord, Lord Kilmarnock, he asked how many doctors had made representations. The answer is about 1,670. I do not have the figures of how many were asking for an appeals mechanism; but I can tell him, as I said before, that the unanimous view of the committee was that the selected list met all requirements. But if the profession wishes to propose an appeal mechanism, we shall be very ready to discuss it, but it must be a carefully controlled mechanism and an exceptional one, and organisations like the BMA will have to be prepared to talk, which they have not been up till now.

The noble Lord asked about particular drugs on the list. He mentioned Gaviscon and Distalgesic Gaviscon is on the list. Distalgesic as such is not, but the procedure here is that Distalgesic is a combination of different drugs—paracetamol and dextropropoxyphene. There are three different brand names of that substance with exactly the same components. Doctors will still be free to provide the components, and they will have to write those two component names on the prescription form, not the brand name. The pharmacist will dispense one of the branded products for now but other companies will soon bring out generic versions, and that will allow genuine price competition. However, I ought to make it clear to the noble Lord—and I am sure he will be aware of this point—that Distalgesic has its own particular problems, and we hope that doctors will think carefully about when to use it. The noble Lord also asked about a reviewing list. We think that it is essential to have independent and professional advice. That independent and professional advice will consider the position of new drugs and whether there is a new suitable generic alternative to replace the branded drug.

Lastly, the noble lord challenged me on the question of savings, suggesting that the reduction from the figure of up to £100 million to £75 million was now inadequate. Of course, the consultation would always have led to a larger list and would result in less savings, but the aim now is to look for other ways of getting better value from the drugs bill through better prescribing, more competition in generic manufacturing and all that kind of thing. But the fact is that the vast majority of what is about 2,000 drugs which have come off the list lead us to a very substantial saving on the drugs bill, which can be put to other purposes in the health service which can so greatly benefit from that support.

Lord Auckland

My Lords, is my noble friend the Minister aware that his Statement is a marginal improvement on his reply in last night's debate? However, since the details of the Statement have not yet been read by us it is very difficult to comment specifically. With regard to the 1,670 replies my noble friend has had from the medical profession, can he say whether these are from general practitioners only or whether they are from the medical profession in general? Can he also say how long a period they have had in which to reply to a very important decision? Doctors are busy people. There is a feeling that the amount of time given to reply to these very far-reaching proposals may not be very long.

Lord Glenarthur

My Lords, the figure that I gave is roughly equally divisible between hospital doctors and GPs. They have had the same time as everybody else, which is three months, in which to comment on what the limited list contains.

Lord Monskwell

My Lords, can the noble Lord confirm that the financial penalties that may result for handicapped and old people as a result of these proposals will also apply to children who currently obtain free prescriptions under the National Health Service?

Lord Glenarthur

My Lords, I think the important point to bear in mind is that 72 per cent. of all prescriptions which are issued are already free and, of this particular group, 80 per cent. are free. So far as children, the young, the elderly, those on low incomes and those who require certain special medicines are concerned, they come into that percentage which I have just given the noble Lord. So far as particular drugs for children are concerned, certainly two of the more regularly used ones, that is to say calpol paediatric syrup and panadol elixir, are on the new list.

Lord Somers

My Lords, is not this decision really equivalent to saying that the doctor, who has, after all, the closest and most intimate knowledge of his patient, does not know what is best for him? The noble Lord must know that there are certain drugs which, while they are suitable for the vast majority of people, have very bad side effects on a small proportion of others and those others have to have something different. Will such people have to pay simply because they do not respond to the normal drug which is on the list?

Lord Glenarthur

My Lords, as I said earlier, the Chief Medical Officer's committee of experts have unanimously come to the conclusion, quite clearly, that all clinical needs will be met. Of course, the relationship between a doctor and his patient is important. But there is absolutely no evidence whatever to suppose that all clinical needs cannot be met by this limited range of drugs.

Lord Molloy

My Lords, is the noble Lord aware that the point raised by the noble Lord, Lord Kilmarnock, is giving grave concern to all parties on this side of the House? It seems that the Government are quickly developing the habit of first of all asking us to discuss what is really a fait accompli and reducing the role of Parliament to one that is perfunctory rather than one of debate and examination. That is a very distressing action for any Government to take.

The noble Lord said that the Government intend to invite members of the pharmaceutical organisations and industry to discuss this proposal and also to have discussions with other professional bodies. May I ask why they did not have such discussions before? The crucial point is this. Both the industry and other professional bodies may make suggestions and submit schemes which they think are superior to what the Government are doing, and can produce arguments which will be better—bearing in mind that the British Medical Association and the pharmaceutical associations constitute a few more than two or three GPs with whom the Government have had discussions.

Finally, we should bear in mind that this is really a money saving device. It has nothing to do with health. I do not think the Government really care whether any health will be injured by this act. Therefore, if there is a proposition to save money in some other way, without endangering the lives of people, should not the Government be prepared to consider it? I am sure such proposals will be made by both the industry and the BMA.

Lord Glenarthur

My Lords, I am not quite sure what particular question the noble Lord was asking. If he is spelling out the importance of the BMA in this issue, which he seems to be, perhaps he can tell me why the BMA would not come and talk to my right honourable friend the Secretary of State about it. So far as its being a money saving device is concerned, as I have stressed on several occasions from this Dispatch Box in the course of the last few weeks, the whole reason why it was necessary to produce a list was that the drugs bill was running out of control. It was becoming quite colossal. It has risen year on year quite out of proportion. It is a problem which has affected and faced, or should have faced, several Governments for many years in the past. The fact is that we now have to get to grips with it.

When the noble Lord seems to allude to the suggestion that we ought to have consulted further before we actually produced the list, I am not quite sure what he means. Does he mean that my right honourable friend should have stood up in another place and said, "I want to consult on something but I cannot tell you what it is because that would prejudge the issue. Unless anyone succeeds in identifying what it is and objects within three months, I shall go ahead"? That really is an unrealistic way to proceed.

Lord Newall

My Lords, I wonder whether among all this gloom and doom my noble friend the Minister is aware that, having taken some soundings among GPs, I have discovered that they are most happy and very satisfied with the proposed list, fully realising that there is some need for this measure. They will be very satisfied with what the Government are proposing.

Lord Glenarthur

My Lords, I am very grateful to my noble friend. I, too, have asked for the views of certain GPs, as one is bound to do under these circumstances, and I find that my views coincide precisely with my noble friend's.

Lord Ennals

My Lords, in my original intervention, it was not my wish to promote the noble Lord, nor would it be my wish to demote him, because I know that it was not his Statement; it was the Statement of his right honourable friend and it is his right honourable friend whom we must blame. May I make two points? First, the noble Lord has not really answered the question about consultation. Surely he accepts that the Greenfield Report was the kind of document that should have gone out for consultation in order that all those concerned, general practitioners, pharmacists, the pharmaceutical industry, any of us here in this House or in another place, could consult about what they thought was the best way of dealing with the problem of the drugs bill. He will understand that I do not think any Member of your Lordships' House has suggested that there does not need to be some further savings in the drugs bill. The question is one of principle. I do not think the noble Lord has answered the question of consultation.

The last point I want to make is very largely the point made by the noble Lord, Lord Somers. Nothing that has been said by the noble Lord, or in the Statement that has been made, can satisfy me about the principle concerned. No list of eight experts, or of 80 experts or of 800 experts, can replace the judgment of one doctor about a particular patient. What I believe is quite wrong in principle about this proposal is the assumption that somehow or other you can group patients together and assume that all their needs can be met by just a limited list of forms of medication. Each patient is different. Only the doctor, the GP, can properly and effectively understand what is in the best interest of the patient. That is the vital principle that is being breached by the Statement made today.

Lord Glenarthur

My Lords, on the question of consultation, I do not think that I can add to what I have already said. The fact is that my right honourable friend announced a proposed limited list. We were fully aware, of course, that the list would be amended in the light of consultations for which my right honourable friend asked. There it is. The BMA refused to come and take part. That is its fault, not my right honourable friend's.

On the question of consultation on the Greenfield Report, I would say that it was an internal report. The Government adopted nearly all the recommendations that the report contained. But they did not follow the route of generic substitution, for the reasons that I have stated on many occasions in the past.

On the question of principle, there is absolutely no reason to suppose—the noble Lord is wrong to suggest—that the clinical needs of patients will not be met by this limited list. It is a very comprehensive list. It is available for your Lordships to see; it is available now in the Library. It contains a list of about 100 drugs which cover all clinical needs. A change it may be, but it is necessary to make a change such as this if we are to contain the alarming greater growth in the drugs bill to the detriment of other parts of the health service.

Lord Kilmarnock

My Lords—

The Earl of Swinton

My Lords, we have now spent 33 minutes on the Statement. I know that it is a very important Statement. However, we have recently had two debates on this subject. We have another Statement to come. The noble Lord, Lord Kilmarnock, has had a chance to question the Government and he did so at some length. I think that we should now pass on to the next Statement.

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