§ 8.33 p.m.
§ Lord Ennals
My Lords, I rise to move that a humble Address be presented to Her Majesty praying 480 that the Regulations (S.I. 1985 Nos. 290 and 296) be annulled [15th Report from the Joint Committee.]
At the same time, I should like to speak to my Motion to resolve, That this House, while accepting the need for further savings in the NHS drugs bill, deplores the decision of Her Majesty's Government to deny to general practitioners the right to prescribe the medicines which they think most suitable for their patients.
Before doing so, I should like to say to your Lordships that I feel it is absolutely disgraceful that an issue of this importance, making fundamental changes in the National Health Service, should be taken at this time of night in your Lordships' House. I make no reference as to who is responsible for this, but I think it is really quite shameful that the debate is starting after half-past eight in the evening.
May I first refer to the Report of the Joint Select Committee on Statutory Instruments. I should like to quote two paragraphs from that report:There were two areas of concern. The first was that there appeared to be differences between the lists of drugs on the two sets of regulations. In oral evidence, the Departments pointed out that while the England and Wales Regulations carry one alphabetically arranged list, the Scottish Regulations carry three separate alphabetical lists. There were still, however, differences between the two Regulations which were not intended and which had arisen through printing and compilation errors. The Departments admitted that, certainly in the case of S.I. 296 and possibly also in the case of S.I. 290, both Houses were being asked to consider regulations which were not accurate and whose errors would have to be amended by subsequent instruments".The second paragraph reads:These regulations, inter alia, allow a chemist or dispensing doctor to provide a branded drug, notwithstanding the fact that it is listed in the Schedule, in substitution for a non-proprietary drug. While it appears as if these provisions allow chemists or doctors to continue to provide listed drugs, the Department explained that such substitution was only to take place in the case of the chemist or doctor not being able to provide the non-proprietary drug, for instance if he were out of stock. They agreed that a difficulty could arise if the non-proprietary drug was cheaper than the proprietary drug. If the reason for the former being unavailable was that the doctor or chemist had failed to take the normal precautions to secure that he had it in stock, he would be required to meet the difference between the price of the two drugs. If, however, he was able to satisfy the Department that it was not his fault that he was unable to obtain a stock of the non-proprietary drug, the Department would secure that he was reimbursed by the National Health Service. In any event, however, the chemist or doctor would fall outside his conditions of service if he were to charge the difference in price to the patient".First, that is bureaucracy gone mad. Secondly, we are being asked to approve of two instruments, both of which it is admitted and accepted are inaccurate. Furthermore, it has been established by the noble Lord, Lord Cockfield, on behalf of the European Commission, in reply to a question from the noble Baroness, Lady Elles, that the Government's action is, according to the Commission, illegal.
But these arguments are the least of the arguments against these regulations, which introduce the concept of the limited list which for the first time since the creation of the National Health Service interferes with the clinical freedom of the doctor to prescribe what in his judgment of the patient's needs is best for the patient.
If I am going to say anything good about the Government, let me do it now, because this is the only good thing I shall say about them. The second list is at 481 least an improvement on the first. I am suspicious that the first list was introduced as a joke and that the second list was the real list that the Government intended to introduce. The first list that was introduced was a pretty sick joke. As Dr. Michael Wilson, chairman of the General Medical Service Committee of the BMA, has said:The law should not be brought into the surgery to dictate which drug should be prescribed. We have a revised limited list which will not enable us to meet all the clinical needs of our patients. Some will suffer".Mr. Kenneth Clarke, the Minister for Health, said roughly the same in a Channel 4 broadcast in 1983. He said:Experience shows that, however many similar drugs there are, some patients benefit from one rather than another".Later he said in another place, on 22nd November 1983:No, we are not convinced that such a list confining the judgment of the doctors will be in the best interests of the patient".I want to know what it is that has convinced the Minister for Health and the Secretary of State. I also have to ask what credence we are to place in future on ministerial assurances which seem so easily to be broken.
But Mr. Kenneth Clarke I believe was perfectly right. Perhaps I can give one or two examples of situations which may well be created as a result of the route that the Government have decided to take. This is the first example given by a general practitioner. He has a patient with multiple sclerosis, who is still mobile and caring for her elderly mother but who suffers pain in her legs. He tried various medicines to control this but the patient suffered gastric side effects. He found, however, that soluble Distalgesic was effective and well tolerated by the patient. Yet this presentation of the drug would, under the revised list, no longer be available under the NHS in any form.
In the same case, the mother had trouble sleeping, and this also affected the daughter. It was the doctor's clinical opinion that she needed night time sedation but he observed that most hypnotics cause undue 'hang-over' side effects. These are dangerous to the elderly. But the medicine lormetazepam is the fastest clearing benzodiazepine and especially suitable for the elderly. She was successfully introduced to this medicine, but under the limited list proposal it would not be available in any form. So the doctor's judgment on the basis of years of experience is to be thrown away.
Perhaps I may give a second example which is pretty close to home. A disabled ex-serviceman in his sixties suffers from ankylosing spondylitis, which leads to a substantial degree of constant pain in the spine and the head. It sometimes strikes at joints in the shoulders and in the arms. After a good deal of trial and error, it was found that the most effective drug for this patient was DF 118: but that drug can no longer be prescribed. That drug, my Lords, is the one I am no longer allowed to have, or, rather, is the drug for which I will have to pay after April Fool's Day.
I have not decided how best to deal with the pain involved, but I am reminded that the Secretary of State for Social Services, Mr. Norman Fowler, at a meeting 482 of the Conservative Medical Society on 1st December 1984, said that DF 118 would not be affected by the Government's limited list proposals. He repeated this on 5th December 1984, when opening Pfizer's new research facilities in Kent. As I asked before, what credence are we to place on assurances given by Ministers when, within a few weeks or a few months, they solemnly break their word?
I can give several examples of that, but I will touch on only one other issue. It is one that happens to annoy me at the moment in my capacity as patron of the National Society for Non-Smokers. It amuses me somewhat that on the eve of Non-Smoking Day, and on the very day when the Chancellor of the Exchequer has very sensibly increased tax on cigarettes at rather more than the rate of inflation, a doctor will no longer be able to supply medicines to help smokers give up their habit. How crazy can you be?
Apart from particular examples, the inability of doctors to prescribe what they and their patients know to be most effective can undermine the doctor-patient relationship. Patients, whether they have been in exempt categories or not, will be forced to pay for what they need and for what the doctor has said they need, or else take something that is less satisfactory. It is another way of pushing patients, whether or not they can afford it, into the private sector. It could be that such is the intention of the Government, and no doubt the Minister will comment on that point when he replies.
I have referred to the patients: what about the doctors? In a personal letter to me a day or two ago, Dr. Michael Wilson, whom I have already quoted, stated:The BMA joined with the Department and others in producing the Greenfield Report, published 4th February 1983. I was a member of that working party. The Report recommended that a national Limited List should not be introduced. That Report and all its recommendations, except the one relating to generic substitution, were accepted by the Government".He goes on to state:We believe"—that is, the BMA—a system of Regulatory Control would introduce a bureaucratic machine into an area where a joint approach, relying on professional action, could achieve so much more, across the whole range of prescribing, and avoid the doubts which have now been raised regarding the continued commitment of Government to a comprehensive health service. We have been saddened that, despite our contribution to the Greenfield Committee, there have been no discussions or consultations with representatives of the profession since the report was published in February 1983".I know that the Minister will say that there have been consultations with the professions about what the list should contain, but it is the principle that has never been discussed with the BMA, with the ABPI, or with any other responsible organisations.
We should be fair to the general practitioners in Britain. They have contained expenditure on drugs in this country. They are at the bottom of the spending league, per head of population, among all the developed countries. The most recent figures for the number of prescription items per capita are: in the United States, 16.6; Italy, 11.3; West Germany, 11.2; France, 10; Spain, 9.6; New Zealand, 8.5; Australia, 7.7; and the United Kingdom, 6.9.
§ Lord Ferrier
My Lords, if the noble Lord will allow me to intervene, it is not of our choosing that we find ourselves landed with this debate at this late hour. The noble Lord is speaking so fast, but so interestingly, that it may be prudent of him to let us hear more clearly what he has to say, and his quotations.
§ Lord Ennals
My Lords, I must say to the noble Lord that I am very sorry if I was speaking too quickly. It was due to the fact that there are so many others who wish to speak and I do not want to deprive them of the opportunity because I happen to be the first speaker.
I was making the point that regardless of the actual statistics, in terms of spending on health service prescriptions, Britain is at the bottom of the list. It is not as though the Government can say that there is great over-expenditure by doctors; and even that level of spending is under special circumstances.
Over the past 10 years general practitioners have had to cope with a reduction in hospital beds of 20 per cent. They have had to cope with a reduction in the average length of stay in hospitals of 25 per cent. This is a very important consideration, because it means that far more responsibility is placed on doctors in serving their patients in the community. That is good in many ways, but it inevitably places additional responsibility on the doctor, in particular in regard to what he prescribes. Also, doctors have had to cope with an increase of 25 per cent. in those aged over 75—a group which, of course, needs the most treatment and the most prescriptions. Doctors have had to respond also to a professional request to reduce the quantities on repeat prescriptions so as to reduce waste, but that means more prescriptions for smaller amounts. Finally, general practitioners have to cope with heightened expectations as a result of medical advance.
I find it very difficult to criticise the medical profession, who have sought to do their job well, and who have, as the noble Lord, Lord Kilmarnock, will point out when he speaks to his amendment, put forward themselves, as has the pharmaceutical industry, suggestions as to alternative ways in which the money could be raised.
What about the pharmaceutical industry? Each time I have spoken in your Lordships' House about the pharmaceutical industry—and I have done so on a number of occasions—I have emphasised the very damaging effect which the Government's policies are likely to have an onward investment, on jobs and on exports. Time and again, while accepting that savings can be made in the drug industry, I have congratulated The pharmaceutical industry on the contribution it makes to our balance of payments, being in the front line of innovation and of research. The warnings I have issued to the Government they seem not to have taken seriously, but they have been proved to be true.
A survey recently undertaken by the ABPI revealed that since the Government's limited lists proposals were announced in November last year investment projects to the value of £143 million in pharmaceutical production or research have been either cancelled or postponed. Some companies are naturally reluctant to make public announcements 484 about the cutbacks because of industrial relations and other considerations. However, Wyeth Laboratories, with headquarters in Maidenhead, Berkshire, have publicly announced the cancellation of a £30 million investment at Swindon—a matter which will no doubt be of great concern to the former constituents of my noble friend. Wyeth laboratories have also made 110 members of staff redundant at their plant at Havant, Hampshire.
In September last year the Secretary of State, Mr. Fowler, opened new production facilities for A. H. Robins and Company at Langhurst, West Sussex. At that opening the president of the parent company hinted quite strongly that the firm were planning to set up a major European research and development facility on that site. Mr. Fowler himself said that he looked forward to seeing "Langhurst Mark II". The chances now are that Langhurst Mark II will not emerge, as the parent company is now looking elsewhere, to other countries, for another site.
Mr. Fowler may also have sought to take comfort from the fact that he was asked to open a new plant for Pfizer in a former constituency of mine, in Kent, last year, and that he is being invited to open new research facilities established by Merck Sharpe and Dohme at Harlow in May of this year. I understand that the potential for developing the Merck Sharpe and Dohme research facilities at Harlow is now being seriously down-graded. I know that from conversations I have had with their most senior executives.
Decisions by the parent companies of these two transnational corporations to invest in the project that Mr. Fowler has been invited to open, or has already opened, were taken at least five years ago. They were taken at the time when I was Secretary of State for Social Services. It would be quite wrong for him to cite these as examples showing that his current proposals will not damage future investment. I am convinced from the many firms which have spoken to me that the proposals will be gravely damaging to the British economy and to the work situation. The ABPI estimated that there would be a loss of roughly 2,000 jobs. My own union, ASTMS, has carried out a study which puts the figure at nearer 5,000 possible redundancies in production and research. Therefore, I fear that the pharmaceutical industry and its future in this country is now very much at stake. This I deeply regret because of the role I personally played in seeking to encourage firms to invest in Britain.
In conclusion, I fully accept that there are savings to be made in our drugs bill. I say that in the Motion which stands in my name. I have always accepted the recommendations of the Greenfield Report in precisely that respect, including the right of general practitioners, if they feel it necessary, to insist that there should not be a generic substitute but that what they have prescribed should be provided. I should add that the instrument designed to contain drug profits is the PPRS. I have an interest in that, too, because I negotiated it when I was Secretary of State.
One asks, why, instead of using the method that was set up for controlling drug profits and which has worked effectively for many years since it was negotiated in 1977, the Government should now embark on what I believe is a ridiculous and dangerous 485 scheme? It is dangerous because it takes away the rights of doctors; it takes away the rights of patients; it endangers the pharmaceutical industry; and it undermines confidence in the word of Ministers. Furthermore, it gives to Ministers the power to change the list, to add more items to the black list and take actions which could further undermine the interests of the patients. I fear that everyone involved, with the possible exception of the Government, though I doubt whether they are going to achieve their savings target, will suffer as a result. That is why I have sought to move this Motion. I beg to move.
§ Moved, That an humble address be presented to her Majesty praying that the Regulations (S.I. 1985 No. 290) be annulled.—(Lord Ennals.)
§ 8.52 p.m.
§ Lord Kilmarnock had given notice of his intention to move, as an amendment to the Motion of the Lord Ennals on Drug Prescribing, To leave out all the words after ("Government") and insert ("to implement these regulations without first giving the medical profession the opportunity to put into practice their own proposals for responsible prescribing for a trial period.").
§ The noble Lord said: My Lords, I rise to speak to the amendment which stands in my name to the Motion of the noble Lord, Lord Ennals. I shall formally move my amendment at the end of the debate.
§ There are many things which the noble Lord, Lord Ennals, said, with which I agree, and I shall return to some of them. My noble friends and I felt that this resolution, as phrased, might be interpreted as an advocacy of the status quo, while we believe that there should be substantial reforms in prescribing practice in order to save money on the drugs bill for redeployment elsewhere in the National Health Service.
§ Our difference with the Government is that they have chosen control by regulation whereas we believe that they have lost a great opportunity to secure the consent of the profession to voluntary self-regulation. The list has become more acceptable since its first derisory draft, which looked as if it had been scribbled on the back of an envelope. However, even now there are severe drawbacks to the Government's chosen method. The noble Lord, Lord Ennals, instanced a number. I should like to mention the following.
§ First, the clinical cover is not as thorough as suggested. There are categories of patients who quite simply are not catered for; for example, those suffering from coeliac disease who require special foods which are banned. Also, Complan food is banned. That seems to be very petty because it is used outside hospitals largely for the debilitated and for terminally ill patients. With the banning of solfadein there is no dispersable non-aspirin analgesic. Wright's vapourising fluid for respiratory diseases of infants has also gone. I could go on.
§ That brings me to my second point. Faced with these therapeutic gaps, doctors are bound to prescribe upwards—trading up, I believe it is called—thus eliminating some of the savings that the Government imagine they are going to make.
§ That brings me to my third point. It will not always be the doctor's fault if a more expensive drug is 486 substituted for a cheaper one. The regulations themselves state in paragraph 2.6(b) that a chemist may provide a branded drug, notwithstanding the fact that it is listed in the schedule—that is to say, it is on the black list—in substitution for a non-proprietary drug; that is, a more expensive drug if the cheaper one is not available. It is a sort of generic substitution in reverse. The 15th Report of the Joint Committee on Statutory Instruments, to which the noble Lord, Lord Ennals, referred, comments adversely on this self-defeating anomaly, as it does on the discrepancies between the English and Scottish regulations, on which I shall welcome the noble Lord's comments.
§ These may be purely technical hitches which can be ironed out, but there are further serious legal queries hanging over the black list in the shape of the answer given by no less a person than the noble Lord, Lord Cockfield, to a question put by the noble Baroness, Lady Elles, to the European Commission, from which it appears that the list may be incompatible with Article 30 of the Treaty of Rome. This point was mentioned by the noble Lord, Lord Ennals. I hope we shall hear something on that from the noble Lord, Lord Glenarthur.
§ My noble friend Lord Winstanley will deal with this matter at greater length. My noble friend asked me to say that it was through an oversight that his name was not included on the list of speakers and the fact that he will be speaking in the gap does not mean that his speech is a last minute improvised intervention. I know that he has important points to make on practical, medical and administrative matters and we look forward to his intervention.
§ The fifth of my points, which may well be linked to the legal aspect, concerns an appeals mechanism to decide on the inclusion or exclusion of new drugs. The Secretary of State said that he will look sympathetically at this, but in the debate in the other place last night it emerged that no system has yet been agreed. That seems to be another reason for postponing the implementation of these regulations. The Government may care to ponder on the widom of introducing the regulation with effect from April Fool's Day. Even if an appeals mechanism is set up, it will absorb resources and time and it will further reduce any savings that are likely to be made.
§ As regards these savings—and this is my sixth point—I have already raised in a Question earlier this afternoon the difficulty of identifying and accounting for them except on a very arbitrary basis. I was told in reply to my Question that general National Health Service funding will not be affected by the regulations; that is to say, that the Government's pledge of a 1 per cent. increase in real terms for the coming year will be kept. However, it seems to me that there is likely to be an effect. It has been widely suggested that the £75 million projected by the noble Lord when he made his Statement on the regulations is not likely to be forthcoming. If there is a shortfall, we want to know where it is to come from and whether or not it is to be taken from the allocation for the hospital service.
§ I have given six drawbacks and I could go on to others. There is the withdrawal problem; there is the question of pharmacists' stocks which will be left on their shelves; and there is the confusion among elderly 487 people. There is also the Government disregard of the public response to the list as expressed through the mailbags of Members of Parliamment in the other place. There are not only people who have been, so to speak, whipped into signing petitions; there has also been a great deal of individual private correspondence in the mailbags of Members of Parliament. The Government have not paid enough attention to that.
§ However, I do not want to pursue that at the moment. I want to pause here and state categorically that opposition to the Government's list does not imply Alliance endorsement of unbridled clinical freedom. I think it is well known that we would introduce generic substitution, where feasible, by the pharmacist, unless the doctor ticked a box or underlined the brand name, specifically asking the pharmacist to dispense that brand name and only that one. We hold that this would maintain a healthy and desirable level of clinical freedom because the doctor would have the last word and there would be no need for all this cumbersome appeals procedure.
It has been calculated that, even under the Government's scheme, a major proportion of the savings will be made simply by generic substitution of benzodiazepine sedatives and tranquillisers and mild to moderate analgesics. Thus a large part of the objective of the Government could have been achieved without all this fuss and all this bad blood. Well, it is never too late to think again, so let us just look at what the profession now proposes. I do not want to go into all the accusations and counteraccusations that we have previously debated. There was undoubtedly lack of consultation, there was provocation, angry response by the BMA and so on. That is now behind us. What is now relevant is that the General Medical Services Committee of the BMA is prepared to be helpful and constructive, given the chance to do so, and so is the Royal College of General Practitioners. In an earlier debate I quoted from the BMA's letter to me of 4th February. I quote it again. These are their words:
You ask whether the GMSC could associate itself with an approach based broadly on Greenfield together with the self-monitoring proposals advanced from several quarters. The answer is yes".
In particular, I like the approach of the Royal College of General Practitioners, which always seems to me to be highly responsible. I therefore attach importance to the letter of their Chairman. Dr. Irvine, to me on 11th March, in which he wrote:
Inevitably, the broadened list has taken much heat out of the matter. Nevertheless, I remain convinced that the proposal is intrinsically unsound and likely to cause difficulties for some patients after 1st April and, if recent news reports are correct, likely to save even less than the forecast if chemists are now to have the fees they would have lost made up".
Incidentally, perhaps the noble Lord will comment on the way in which the Government propose to handle the question of chemists' fees. Returning to the proposals of the Royal College of General Practitioners for responsible prescribing, these seem to me to make much sense. I will not go into them in detail. They say that many GPs are getting to grips with the need to prescribe sparingly, working to practised formularies, listing drugs for particular conditions, prescribing generically, limiting the
quantity of drugs prescribed and being more explicit about when not to prescribe at all. The College is convinced,
that the way forward in general practice lies in refining and extending the use of the methods just described. Our approach has one particular advantage—that it covers every group of drugs"—
and that is an important one because the proposal of the Government covers only a certain number of therapeutic categories, those that appear in the black list.
The Royal College of General Practitioners also talks about the contribution that could be made by the Prescription Pricing Authority's computer to clinical performance review by individual doctors and practices. That is another important point. But I want to stress their conclusion. I am quoting again. They say:
This is a time for looking forward and for a constructive partnership between Government and profession, rather than for recrimination and conflict".
They go on to urge the Government to think strategically and to bring together all concerned with the prescription and supply of drugs in order to agree and implement a properly thought-out plan for prescribing within the National Health Service.
Before I sit down, I should like to turn to the speech of the Secretary of State last month in the other place. At col. 698 he said:
The selected list has achieved one thing—far wider recognition than ever before of the need for action on the scale and quality of prescribing. The debate that has taken place over the past few months has probably been the most extensive on prescribing in the history of the National Health Service".
One would not disagree with him here and my heart lifted a little. I thought, "My God! The chap is going to be sensible and withdraw the list, having achieved his aim, which must have been all along to get everybody to think hard about this". I eagerly read on to find that he proposes to convene a conference involving all the relevant professional interests. "Even better", I thought, until I realised that one of the objects would be to set in its proper perspective the limited list proposal. That is to say that the conference would have the list as its starting point—not its ending point, but its starting point.
§ Was there ever such an instance of doing things the wrong way round? Have your conference—great—but keep your list in reserve. The Secretary of State has people eating out of his hand. He has the profession eating out of his hand. He could make greater savings through voluntary co-operation than any that he could possibly hope to obtain from his white list and from his black list. I started and I finish by saying that the Government are losing a great opportunity if they do not withdraw these regulations and proceed on these lines.
§ The noble Lord, Lord Ennals, has indicated that he will recommend his friends to support the inclusion of my amendment in his Motion. I am grateful to him for that. If the noble Lord decides to divide the House in due course, I hope all noble Lords from all parts of the House will support the amended Motion.
§ 9.7 p.m.
§ Lord Glenarthur
My Lords, whatever the timing of this particular debate, this occasion is I think the fourth in as many months when noble Lords opposite 489 have chided the Government for choosing the method of the selected list to curtail a soaring NHS drugs bill. That bill now stands at some 1.n a year—and that is ten times what it was 15 years ago.
As least the noble Lord, Lord Ennals, the noble Lord, Lord Kilmarnock and the Government have one thing in common: we agree that a bill of that scale is far too high. From what they have said, the Opposition seem to believe that the answer lies in attacking the pharmaceutical industry. We do, however, already control the profit levels on NHS sales achieved by the drug companies through the Pharmaceutical Price Regulation Scheme, to which the noble Lord, Lord Ennals referred. That is a scheme which we review regularly. We do not undervalue the advances in research made by the pharmaceutical companies and the resulting benefits to patients. Unlike the noble Lord, Lord Ennals, certainly if he supports his party, as I believe he does, we do not regard profit as a dirty word, and we have no wish to discourage the pharmaceutical industry from continuing its vital work in research and development.
§ Lord Ennals
My Lords, I am grateful to the noble Lord for giving way. Will he withdraw that remark? I made no such suggestion at all. I made no attack on the pharmaceutical industry. I said that there are savings to be made. I did not say that profit was a dirty word. I hope that the noble Lord will withdraw allegations that are quite untrue.
§ Lord Glenarthur
My Lords, I believe that the noble Lord is speaking for his party. It has stated that it has a long-standing policy, repeated in its last manifesto, and confirmed by the shadow spokesman in the other place, as recently, I believe, as during last night's debate, in which it talked about nationalisation of the pharmaceutical industry. If that is the case and if the noble Lord is supporting his party, I assume that that is the basis on which he stands. In any case, I cannot, for one moment, see that the industry is clamouring to accept further cuts in profit levels. Another cut in their profit levels was advocated by the noble Lord across the Floor of the House only a few weeks ago. Undermining the industry therefore is not, so far as we are concerned, an option. How much more damaging it would be, I say, to that industry to be brought into public ownership, which his party seems to advocate.
The noble Lord, Lord Kilmarnock and the noble Lord, Lord Ennals enjoin us to adopt the recommendation of the Greenfield report on generic substitution. The noble Lord, Lord Kilmarnock, refers to us as generating bad blood over this whole issue. I would he the last person to discount the importance of more effective prescribing. We always encourage doctors to think generically. But we have given our reasons why we felt that to impose a requirement on doctors to accept generic substitution across the board would not be the best approach. It would, to a far greater extent than the selected list, infringe that clinical freedom which noble Lords opposite so loudly advocate. It would do far more damage to the drugs industry because it would cut across the whole range of drugs. It is plain to us also that the resulting savings would by no means match those we expect to achieve through 490 the selected list. The resources of the NHS are not limitless. The taxpayer is at present required to subsidise the production of luxury pharmaceutical items—and luxury they are, in many cases—with the result that money that would otherwise be available for further improvements to patient services is not spent to good effect. The noble Lord opposite and some of his noble friends are ceaselessly calling for such improvements. I must ask the noble Lord opposite, then, why they are standing in the way of sensible measures to achieve them.
§ Lord Glenarthur
My Lords, let me explain again why we are introducing a selected list and what drugs are affected by it. First, there are those which could be broadly described as "comfort medicines"—cough and cold remedies, laxatives, mild and moderate painkillers, indigestion remedies, vitamins and tonics. Some of these drugs are used to relieve the symptoms of chronic complaints or to offset the effects of other drugs in serious illness. But, in the main, they are used for commonplace ailments which will get better of their own accord. Most can be bought over the counter at chemists. Many have the same effect as other, cheaper, drugs. Secondly, there are the benzodiazepine tranquillisers and sedatives. In recent years, there has been a proliferation of drugs in this group. Again, many of them have exactly the same clinical use but some of them cost much more than others. Some graphic examples were given by my noble friend Lord Molson a week or two ago.
In order to get value for money, we decided to allow under the National Health Service only those drugs, of the types that I have listed, which will meet all clinical needs at the lowest possible cost. On 8th November, during the debate on the Address, my right honourable friend the Secretary of State told another place about our plans and said that we welcomed comments on a provisional list of drugs to remain prescribable. We promised that all essential drugs would continue to be available at National Health Service expense. We have kept that promise.
We received more than 10,000 letters during the consultation period. Many of these provided very helpful comments. The Chief Medical Officer set up a group of independent medical and pharmaceutical experts to consider the content of the list. This group considered all the comments received and, taking them into account, put forward a list of drugs in the groups affected which it considered would meet all clinical needs at the lowest possible cost to the National Health Service. We accepted their advice in full.
There are about 100 drugs in the categories affected which will continue to be available under the National Health Service. This compares with the provisional list of 30, which was a minimum list of essential drugs—and no joke as the noble Lord, Lord Ennals, suggested it was. It was to be the basis for detailed consultation. Nearly all the additions are for reasons of convenience; for instance, to avoid patients having to take more than one drug at a time, or for palatability, particularly for children, old people and the dying.
491 We have been criticised for introducing a provisional selected list without prior consultation. But this criticism, endlessly resorted to by the noble Lord, seems to me frankly absurd. No democratically elected Government could go about their business satisfactorily if they were impeded at every turn in the formulation of policy by a requirement to hold prior consultation with every interested party before they could settle the general principles of their legislation. In this case, we do not regard the principle as being in question. We recognised that the drugs bill was unacceptably high, that it had to be reduced, and that the most effective way of significantly reducing it was by introducing a selected list. This method is consistent with a full and proper regard for patients' needs. It cannot seriously be said to diminish the doctor's clinical freedom. We promised to consult widely on the final contents of the list, and this we have done.
Most of the drugs on the selected list are generic products, but there are a number of branded ones. This is because the Chief Medical Officer's group advised that in some cases there was no suitable generic drug available and that we should retain a branded drug, or a number of similar branded drugs, for the time being. Whenever a generic name exists the branded drugs are prescribable only by that name. This is to encourage further savings. On average, generic drugs are less than half the price of direct equivalents with brand names. By specifying the generic name any manufacturer can compete for a share of the National Health Service drugs business on the basis of price and quality: and we expect that manufacturers will soon bring on to the market equivalent generic preparations of those medicines which are at present only available under brand names.
The regulations we are debating tonight list the products which will no longer be prescribable under the National Health Service. We have also produced a list of prescribable products, which is only a list of the main products to remain available. It is issued simply for guidance and has no statutory force. We have taken the opportunity of including in the list of substances not prescribable under the National Health Service those items which the Advisory Committee on Borderline Substances has advised are not drugs in the circumstances of general practice. These non-prescribable borderline substances are mostly ordinary products, like Flora margarine and Nivea face cream, which we believe are simply not appropriate charges against the health service. They are products over which the National Health Service has no price control. I could give further examples of this. It is an abuse of public funds, and one which we believe would scandalise an unwitting taxpayer if it were more widely known.
§ The Countess of Mar
My Lords, can the noble Lord give examples of doctors who prescribe Flora margarine and Nivea face cream?
§ Lord Glenarthur
My Lords, I cannot give examples of doctors. What I can tell the noble Countess is that there are examples of drugs which are prescribed under the arrangements which I have described and 492 are referred to the Advisory Committee on Borderline Substances. I can add to the list I gave Radiol fly repellant, Elizabeth Arden and Max Factor cosmetics, Colgate and Maclean's toothpastes, and even Persil non-biological washing-up powder. I can in due course give the noble Countess the details of more.
§ Lord Glenarthur
My Lords, the regulations allow for it, and that is why we are making the changes that we are making.
§ Lord Glenarthur
My Lords, the regulations provide that, from 1st April, general medical practitioners may not prescribe and community pharmacists and dispensing doctors may not dispense at National Health Service expense the products listed in Schedule 3A to the regulations. General medical practitioners will, however, be able to issue a non-NHS prescription to NHS patients for Schedule 3A drugs to be used in the course of National Health Service treatment, if their patients wish it. They will not be able to charge a fee for such a prescription.
We are charged by the noble Lord, Lord Ennals, and others that this creates a two-tier system. We say that it does not, for, as I have repeatedly pointed out, there will be no clinical need for patients to buy drugs not available under the National Health Service. We therefore envisage that such non-NHS prescriptions will be issued very rarely. Under the regulations, doctors will not be able to sell or dispense Schedule 3A drugs; but dispensing doctors will be able to supply and charge for those drugs to patients on their dispensing lists when they are prescribed as part of the patient's NHS treatment. For dispensing doctors the regulations will therefore effectively maintain the status quo, and their dispensing patients will look to them for the supply of all prescribed medicines. The regulations also make provision for named drugs to be prescribed to certain types of patients.
I should now like to mention a number of specific issues concerning the operation of the selected list. As I explained to your Lordships on 21st February, we shall be setting up a professional committee to advise us on a continuing basis on the contents of the list. This committee will be asked to consider whether new drugs coming on to the market fall within the scope of the selected list and, if so, whether they should be available under the National Health Service. The selected list advisory committee will also regularly review the existing list. We expect to consult on the details of this new committee, including membership, as soon as possible so that there is no delay in the important task of maintaining the list.
The noble Lord, Lord Kilmarnock, asked particularly about an appeal mechanism for individual patients. As he will be aware, we have received some representations that in exceptional circumstances doctors should be allowed to prescribe drugs not on the list when they think their patients need them. Our expert advice—and it is expert advice—is that the list 493 is comprehensive as it stands. Some patients may want a drug not on the list and decide to pay for it. That, of course, is their choice, but the expenditure will in our view be unnecessary.
However, my right honourable friend the Secretary of State has said that, while he cannot consider any exceptional arrangements which would simply enable doctors to circumvent the selected list, he will be prepared to consider with the profession proposals it may have for overcoming any problems that genuinely arise for individual patients in the operation of the selected list. Indeed, my right honourable friend has already met the General Medical Services Committee of the BMA to discuss the question of an appeals mechanism.
It was agreed that any mechanism should be non-bureaucratic and should be applied locally. Its exact status remains for detailed discussion; that is, the nature of the committee proposed and under what circumstances appeals should be allowed. It is precisely to consider these kinds of question that my right honourable friend the Minister for Health will be continuing these discussions tomorrow with the BMA and representatives of the Royal College of General Practitioners. We hope that a satisfactory agreement will take effect as soon as possible after 1st April, when the regulations come into force.
I am concerned that some members of the medical profession seem to think that the Government are mounting an attack on them and their prescribing practice. I must stress that we are fully aware of the very important role played by doctors and only too willing to recognise that many of them are very careful to prescribe economically and effectively.
However, there could be further improvements. Common sense, not great medical expertise, is often all that is needed to achieve economic and effective prescribing. Bathroom cabinets throughout the country are full of half-used bottles of medicine. In order to avoid such wastage of expensive products, no more than is absolutely necessary should be prescribed; and the patent can return to see the doctor if he needs further medication.
Another area where improvements could be made is repeat prescriptions. It is obvious that repeat prescriptions over a long period can be very dangerous as well as wasteful. Patients need to see their doctors at regular intervals in order to have their medication needs reassessed. We very much hope that those doctors who are opposed to the selected list will not be so irresponsible, as some have threatened, as to demonstrate their opposition by following a policy of uneconomic prescribing. Such misuse of NHS resources would be deplorable.
As your Lordships all know, the Government greatly regret the BMA's refusal to co-operate in discussions on the selected list. We hope, however, that, once the list has been introduced, we shall be able to work together to improve prescribing practice. As my right honourable friend the Secretary of State for Social Services said yesterday, the Government intend 494 to convene a conference involving the relevant professional interests to set the agenda for further discussions on prescribing standards and costs. Indeed, the noble Lord, Lord Ennals, referred to that matter in his opening speech. I hope that this conference will be the beginning of very fruitful co-operation between the Government and the medical profession.
The Association of the British Pharmaceutical Industry (ABPI) has made some extravagant claims about the effect the prescribing restrictions will have on the industry. They have indulged in even wilder scaremongering about the effects of the list on the sick and the elderly. They have reputedly spent over £ 1 million on publicising some highly misleading claims. But the savings we expect to make from 1st April represent only about 5 per cent. of the industry's sales to the National Health Service and about 2½ per cent. of their total output. I cannot believe that such a small reduction is likely to compel many companies to stop investing, or that it will seriously affect exports or jobs. Neither should research suffer unduly. We shall continue to finance research on a very considerable scale. Last year we contributed to research and development costs to the tune of well over £200 million through the prices we pay for National Health Service medicines.
The measures—the main details of which I have once again described—have been decided upon after a great deal of careful and detailed consideration. I ask your Lordships to consider carefully the arguments that I have put before you. With your Lordships' leave, at the end of the debate I shall refer to other detailed points which are raised. However, the selected list represents a sensible way of releasing £75 million a year—and more in the longer term—for important improvements in NHS care without in any way harming patients' interests. It is with confidence in that, that I commend the regulations to your Lordships.
§ Lord Wilson of Langside
My Lords, before the noble Lord the Minister sits down, if I understood him aright, he said that he regretted the feeling that we on these Benches—and I think that he suggested that this was true of members of the medical profession too—felt that the Government were mounting an attack on the prescribing practice of the profession. If that suspicion is not justified, why did he quote these rather absurd illustrations in response to the intervention of the noble Countess?
§ Lord Glenarthur
My Lords, the fact is that the items to which I referred in the regulations are the tip of an iceberg in some respects. As far as I am aware—and I certainly was not aware of it until I looked into it myself—these particular items could be dispensed under the arrangements which I described earlier. All these things have been prescribed by doctors. They have been prescribed very recently by doctors. I find it a very strange way of practising medicine, and I honestly believe that the average taxpayer would, too. It would be not only the pharmaceutical industry that we had to contend with if the prescribing of such common or garden items 495 became widespread; we would have to deal with the grocers' lobby as well.
My Lords, the noble Lord said that all these things have been prescribed, and prescribed recently by doctors. He has not been very specific and said which things. I have authoritative 496 information that there are items on the black list which have never in fact been prescribed since the National Health Service started on 5th July 1948. In other words, they are just there as window dressing.
§ Lord Glenarthur
My Lords, we have the prescriptions and I dare say that, if necessary, I could get them and show them to the noble Lord.
§ 9.27 p.m.
§ Lord Porritt
My Lords, until I came here this afternoon I was not aware of the batting order of speakers tonight. It was only after I arrived that I learnt that I was to follow the noble Lord the Minister. This, your Lordship may be surprised to hear, I consider to be a privilege, though it is equally a very difficult task because I disagree with a great deal of what he has said. His speech was, as ever, gracious, lucid, and comprehensive, but I sympathise with him for having had to make it so many times and in so many different forms over the last three months. I could almost make it myself, but not nearly as efficiently.
To me, what the Minister has said tonight is just a new edition of what we have heard before. It amounts really to a defensive explanation of a measure which I would suggest is based on a false premise and a shattered principle. If that is true—and I firmly believe that it is true—then whatever is said to support it must be a specious argument. I hope not to deal too much with detail, but rather to expand perhaps the thoughts that this odd measure has raised over the months.
However, I should first very much like to thank the noble Lord, Lord Ennals, for raising again, as he has done tonight, what I consider to be this rather miserable business of the limited lists. On the previous occasion some six weeks ago—I think on 2nd February —we could discuss it only in the context of an Unstarred Question. At that late hour on that occasion—it seems doomed always to be late hours for this discussion—when the attendance in your Lordships' House was pretty thin, there was no doubt whatsoever that there was almost complete opposition to this measure, apart from the noble Lords on the Government Front Bench. But of course no vote was taken.
Although in the interim not very much really has happened—except for the substitution of two very dubious and contentious black and white lists for the original patently ill thought out and totally inadequate limited list—tonight's debate gives us the opportunity to express our opinion of this extraordinary maladroit proposition. It is a proposition which, despite the Minister's so-called explanations, remains generally unacceptable to both the medical profession and the pharmaceutical industry and may. I say also, remain likewise to a large number of voluntary organisations, charities and individuals. The change in form of the restricted list has already reduced the possible projected savings by 25 per cent. The implementation of the proposed regulations and the setting up of an appeal mechanism will undoubtedly lower the figure still further.
Despite all this it seems—again from what we have heard tonight—the inexorable decision of the Secretary of State to proceed with the implementation of the scheme in two weeks' time. He continues to say—and we still hear this—that the BMA refused to discuss the matter with him. This of course is not true. The BMA and its GP Committee did refuse to meet him in regard to the limited list as this denied, and still denies, the basic right of a doctor to be personally responsible for the treatment of his patient. That is what I mean by a bond, and that is what is being broken.
498 From the start when the limited list was first produced without, as we all know very well, any consultation with anyone concerned, the BMA expressed their complete willingness to bring forward and discuss other methods of reducing an admittedly over-large drug bill. But may I say incidentally that this over-large drug bill is, as has already been mentioned tonight, considerably less in the United Kingdom than it is in most other countries of the world both in relative and in real terms. It has been correctly quoted tonight that in the USA, Japan, Australia, New Zealand and a lot of European countries, it is more than it is in this country.
It is also a complete misrepresentation to say that the pharmaceutical industry has not made substantial contributions to the reduction of the NHS drug bill. This the Secretary of State has said. In 1983 the industry agreed to a 2.5 per cent. reduction in prices, and to a price freeze. In 1984 the return on their capital was statutorily reduced by almost 16 per cent. under the PPRS arrangements. This figure is almost certain to go down further still to 2 per cent. to 3 per cent. next month.
We all know that the Ministry has made a complete U-turn on the Greenfield Report. The Minister originally stated categorically that the concept of a limited list found no favour, but that generic prescribing and generic substitution should be developed. The profession was very happy to go along with generic prescribing but objected to generic substitution. I feel strongly that the difference between these two processes is much misunderstood both in this House and elsewhere.
Generic substitution leads to many difficulties and even dangers in deciding on the safety, the efficacy, and the bio-availability of certain drugs. Now we are told—and we have heard it again tonight—that as soon as a suitable substitute—and I underline "substitute"—can be found, yet more of the few branded drugs which remain on the white list will be removed. This is surely a thoughtless and a heartless cure of the health of the Treasury, and nothing to do with the cure of the patient.
What patients want is neither a white list nor a black list. What they want is a personal list selected by their own doctors, which incidentally is what both the patient and the doctor were guaranteed at the inception of the health service, and of course for many years before that in the long accepted and sacrosanct confidential doctor/patient relationship. It is this deliberate breaking of a bond that I find so distressing and so depressing.
If a doctor is going to be dictated to by a Government department as to what he does for the good of his patient then, my Lords, the vista is limitless and, to the profession, horrifying. If these regulations are brought into force it will of course mean alterations in the Medical Act, which lays down the terms of service of a general practitioner.
As I stated in our previous debate on this subject, principles and politics make very bad bedfellows. It all comes back to the basic fact, which I have commented on in this House more than once but without any effect, I may say, that whatever may be possible with 499 companies, institutions, commercial organisations and so on, you cannot nationalise a profession. Ask the lawyers, ask the Ministers of the Church, ask the engineers and the accountants. They will tell you. The ideal of a comprehensive medical service no one would deny. It is irrefutable, but the implementation of that ideal is impractical and impossible if it is to be comprehensive. In the last 50 years so many countries all over the world have proved this. The demands of a health caring service which includes an ill health curing service have no limits. The means to fund them have very definite limits and so we are forced into a quagmire of priorities. This limited list is a classical example of priorities.
When one talks about priorities one gets into the realms of moral and philosophical considerations. If these decisions are dealing with life and death, surely we are getting beyond the realm of politics. But this is not an occasion to belabour my hobbyhorse, except to say that in medicine (and, in pharmacology, the optimum use of drugs) policies take an unconscionable time to mature. Now, after 20, 30, 40 years, we are seeing our chickens come home to roost.
There are a few more pertinent, though I am sure the Minister would say impertinent, points that I should like to make. Any discussion on the details of the amended list—and, we are told, the final list—would seem to be out of place in this debate, but my much more erudite and scientific colleagues have told me already that there seem to be very obvious flaws in both the white and black lists. The noble Lord, Lord Kilmarnock, has shown some of those already tonight. What they do is to make it increasingly difficult for doctors to satisfy their patients' legitimate needs.
On the pharmaceutical industry side, I can only quote from well-informed articles published in reputable journals in the last month. I have already declared an interest, in that I am a director of a well-known pharmaceutical company. These articles show that in countries which have limited lists—and there are a number of them—the pharmaceutical industry is suffering badly and continuing to do so. Most important from our own industry's point of view, these countries will say quite frankly that they have not saved money. As the ABPI state, despite all the things that have been said about it,they impede the free and fair working of the market place and distort competition".Despite what the Minister has said tonight, I should like to quote one company which I know well. What has happened in that one company is that it has lost 25 per cent. of its profits, which amount to many millions of pounds, to say nothing of a considerable quota of its workforce, up to nearly 500, and it has had already, on the presumption that the change will take place, to cut its extremely successful research programme. This has happened, so it is impossible to say that this is having no effect. We know that it is having a definite effect on the possibility of research.
This is what is happening in the countries that already have limited lists. They have found their pharmaceutical industry slowly disappearing. No new drugs arrive and if they do arrive they take years to get 500 any recognition. A decreasing and pitiful picture is painted by the countries which already have limited lists.
This industry that is being damaged—and there is no doubt that it will be damaged further—is an industry which exports £1,200 million-worth of medicines each year. It spends more on capital investment in Britain than it makes from the profits of the NHS; £50 million more. It spends £500 million a year on research and development, which amounts to about 10 per cent. of the world figure; and as has already been pointed out tonight, it attracts a vast amount of foreign capital investment, which is already being frightened off. I do not know, but it does not seem to me that it is very good business to do the pharmaceutical industry a wrong.
There is another point that I was going to bring up, but the noble Lord, Lord Ennals, has already mentioned it. That is the question of the EEC. Perhaps your Lordships may say that that is not very important. But it is interesting, I think, that the two people concerned in the recent developments are both Members of your Lordships' House. The noble Baroness, Lady Elles, asked the question in the European Parliament, and the noble Lord, Lord Cockfield, replied on behalf of the EEC. The noble Baroness's question asked whether the criteria for setting up a limited list in this country were consistent with the rules of the EEC. The noble Lord, Lord Cockfield, in a long reply (which I have but which is too long to read to your Lordships) definitely, in essence, comes down without any doubt on the side of saying that according to Article 30 of the Treaty of Rome it will not be legal in the EEC but that it may be legal here. So this is yet another complication of this whole miserable business.
I suppose that at heart I have been conservative (with both a little "c" and a big "C") all my life, but in recent months I have really begun to wonder what this Government are up to. The process of antagonising groups of hitherto faithful supporters by introducing relatively minor and, seemingly, largely unnecessary measures from a national point of view goes on apace.
We have heard a fair amount of it in this House lately. First of all, we lose our trusty pound notes in favour of a heavy, dubiously recognisable coin. Then our cornershop post offices are threatened, the very core of rural village life and, probably more important, of community life in the conurbations. Then, as we had a long discussion about the other day, our cheerful, red telephone boxes are to be replaced by characterless erections of a colour far too reminiscent of those frightening wheel clamps that we have heard about recently. And now, on top of all that, we have the enforced removal of our favourite and well-tried medicines.
It seems to me to be so much unnecessary interference for so little purpose. At the same time as they are doing this, they are also damaging the British community's health care and endangering one of the most valuable industries that the country has. Greedy hands are chipping away at the very jewel in the crown of the welfare state, its health service; and those same hands are the hands that have been faithfully promising to create a safe and sacred repository for the health service.
501 I hope that we shall see this proposition for what it is: a hasty and ill-thought-out manoeuvre to meet Treasury demands to cut public expenditure, and nothing to do with medicine or pharmacology, or drug discovery or promotion. I trust that in your Lordships' House we shall be able to show that principles still have some value and that we shall express in no uncertain terms our profound dislike of the limited list concept, and reject it.
§ 9.45 p.m.
§ Lord Nugent of Guildford
My Lords, I have listened with interest to and, indeed, have been half-persuaded by the formidable advocacy of the needs of the pharmaceutical industry by the noble Lord, Lord Porritt. It was particularly interesting and, of course, cogent; but I have an impression, after the recent PR campaign that they have been running, that they are well able to speak for themselves—and some of their contributions were not entirely creditable. However, I much respect, indeed, much more than respect, the noble Lord who occupies such a distinguished position in the world of medicine and in many other places and who has been such a stalwart ally of mine on other campaigns. But in this particular context I am afraid that I do not agree with him.
I recognise, of course, as any layman does, that any limitation of the clinical judgment of doctors is a serious matter. Like everyone else here, I know my personal obligation to the medical profession, but I just cannot accept that no limitation is justified in any circumstances. In fact, many doctors of my own acquaintance with whom I have discussed this matter, agree in principle with a limited list and, as all of us know, although the BMA and the general practitioners were heavily against it, the Royal College of Physicians and the Royal College of Surgeons are in favour.
The Government policy for the National Health Service has been one of continuous expansion since we came into power in 1979. The last Labour Government were spending at the rate of about £7.75 billion a year in 1978. Today, we know, because the Minister has recently told us, that next year's estimate provides £17 billion for the National Health Service Vote. Even allowing for the cost of living increase over the years, that is a very substantial net increase and it really does refute what the noble Lord, Lord Porritt, rather unfairly said—that this was Treasury priority before patient priority. This Government have provided on a really splendid scale for the steady increase and expansion of the National Health Service, because we recognise that it is a sheet anchor to the life of this country. But, at the same time as they do that, my right honourable friend the Secretary of State has made it plain, as has my noble friend Lord Glenarthur, too, that they are committed to a determined drive to get good value for the taxpayers' money which is provided on this very large scale.
That brings me, my Lords, to the case for the limited list. I am not going over it in detail at this time of night. We have heard about it from my noble friend Lord Glenarthur very clearly, but I should like just to repeat three major points. First, the annual bill for drugs is now £1.5 billion. That is formidable enough, but it is 502 steadily growing in net terms at the rate of 5 per cent. per annum. Secondly, the range of medicines also grows. In the last 25 years it has doubled to a range of some 17,000 medicines. Thirdly, the number of prescriptions in the last recorded year, 1983, was 334 million—a 40 per cent. growth over the past 25 years.
In the face of this huge annual bill, plus, even more significantly, a continuous annual growth—and I address this to the noble Lord, Lord Ennals, who has been a Minister and knows all the responsibilities of that office—any Minister is bound to look at the situation; and if he does not, he should be castigated by Parliament until he does. No responsible Government could refuse to act.
The fact is that, despite the comparisons made with other countries, we in this country, all of us, have a very large appetite for medicines and pills. The habit of our people is to pour cascades of medicines down their throats. That is an observation which perhaps the younger Members of this noble House may not remember, but some of the older ones will. It was made by a great Minister of Health, Aneurin Bevan, in 1950, when the Labour Government of the day were introducing prescription charges for the first time. I am glad to see the noble Lord, Lord Ennals, noting that observation. It is a very colourful one; I could not claim to have invented it myself. It makes the point that there really is an unlimited appetite here. There is a huge expenditure and it is growing every year. The Government of the day have an absolute obligation to tackle it.
My noble friend has told us about how the limited list, which is now of roughly 100 drugs, has been compiled. There has been extensive consultation—sadly not with the BMA, but certainly throughout the profession—and the list includes some brand names where adequate generic drugs were not available. My noble friend has told us that the Secretary of State is setting up a commiteee of professional and independent advisers to review the limited list on a continuing basis, so that if new drugs occur or if mistakes are found to exist amendments can be made. Perhaps in a way even more importantly, he is already in consultation with the BMA and the general practitioners on the appeal machinery. So that the safeguards that we wish to see to give the flexibility that ought to be there, when introducing something as important as this, are there and will be made to work.
As regards the pharmaceutical industry, of course I recognise its splendid record, its splendid profit-making record for the benefit of this country and of the export trade, and its outstanding successes in its research work. But I do not believe—and my noble friend has given us the figures—that the limited list will seriously affect its profitability. The fact is that 95 per cent. of the drugs which are not on the list can be bought over the counter without a prescription, as my noble friend has told us. But as I said before, some of its PR campaign fell well below the great reputation that that industry deserves.
So this is a measure which is estimated to make a saving of £80 million per annum. Perhaps it will make rather less, but it will help towards this huge total which this Government have committed for the health 503 service next year of £17 billion—it is a very great credit to my right honourable friend the Secretary of State—to maintain the Government's policy of a continuous, expanding improvement of the service, and I feel that we should support the Government in making this modest measure of economy in a place where it can be made.
§ 9.53 p.m.
§ Lord Pitt of Hampstead
My Lords, I am really sorry that we have come to this situation. I had hoped that the Government would recognise the need to halt in their march, and would rethink and rediscuss the whole issue and come to a more sensible solution. The drugs bill is as much in need of control as any other bill. The criticism that I make is that the method selected is basically wrong and it is based on wrong premises. We are frequently being told that it meets all clinical needs. That is impossible. Not even the whole pharmacopoeia meets all clinical needs. After all, if it did we would not have so much acceptance of, and even chasing after, alternative medicine. So, of course, it cannot meet all clinical needs.
The other problem is the failure to recognise that people are individuals and individuals react differently to drugs. It is not necessarily the main ingredient of a drug to which they will be allergic or which they will find themselves unable to tolerate. It may be merely the way in which the drug is prepared. This is the rare point that this autocratic approach fails to understand. You cannot just say that certain drugs can be prescibed in certain ways for certain ailments—period. It is not true. There will be people for whom that drug ought in fact to be suitable but it is found to be unsuitable. That is why this question of doctors being able to prescribe for their patient what they think the patient needs is of the utmost importance in the treatment of sickness.
I can give an illustration. I had a patient—in fact, she came to me from somewhere else. She was on valium. I gave her Diazipan. She was upset by that. I put her back onto valium and she was happy. I decided that there was need to change her treatment altogether. I tried to take her off Diazipan and put her on to something else. The strange thing is that if the limited list is now the law of the land, I would not be able to put her on it. In fact I changed her to Frisium and she was happy. This is the point. You get that with very many patients.
The Minister has said that the limited list is mainly for guidance, but you know that is what I have been begging him from the beginning to accept—to produce a recommended list, because that makes sense. If you introduce a recommended list, most doctors will use it. That makes sense. But there will be patients for whom it is not suitable and doctors will be able to use other drugs for patients for whom it is not suitable. The Minister's list is a recommended list—that is sensible—but in the same breath he is also deciding that certain drugs should not be prescribed.
It is not only because those drugs are expensive. I must confess that my favourite cough medicine is ammonium chloride and morphine. I find it extremely 504 effective—and it is very cheap. It is not, however, very nice. Some patients do not like it and to patients who do not like it, I give something else. But I find it very effective. But it is banned according to the list. I am a great believer in rhubarb compound mixture. I find that quite useful, too. Neither of these is an expensive drug. Both are very old remedies that have stood the test of time. Whoever was advising the Minister thinks that the mixture of the expectorant and the sedative is not a good thing and he therefore advised against it. I can assure you that I use ammonium chloride mixture without morphine and it is not as effective as ammonium chloride with morphine. That is my own experience.
I find Asilone a most effective drug for flatulence. It is not more expensive than Gaviscon. Gaviscon is the comparative drug. But Gaviscon is on and Asilone is off.
I am not using these examples in their own right, because that does not matter; I am using them in an illustrative sense. They illustrate that one cannot really draw up a limited list which will not affect some patients adversely. The Minister himself has said in the past that generic drugs are half the cost of branded drugs and that he wants to see more of them used. Therefore, the Minister should be pushing for generic prescribing. In his own words, generic drugs are half the cost of brand name drugs.
§ Lord Glenarthur
My Lords, I will just say that we do encourage generic prescribing; it is generic substitution that we have not been able to adopt. The noble Lord knows the arguments for that. We have consistently recommended that doctors should adopt generic prescribing.
§ Lord Pitt of Hampstead
I know, my Lords, and generic prescribing should be encouraged. I am speaking personally. I also believe that generic substitution can be negotiated. What is required is that the doctors should be in control of that and their willingness to allow substitution should be there.
There are differences between the BMA and the Government over Greenfield and what Greenfield actually recommended. Greenfield recommended, for example, that a doctor should tick the prescription if he wanted the brand drug to be dispensed. The BMA suggested that a doctor should tick if he wanted the brand drug to be substituted. I confess that I prefer the Greenfield approach and I believe that the Greenfield approach could have been negotiated.
The Government are not doing anything about that. There have been no discussions between the profession and the Government since that time until the 8th November, when the Government indicated that they intended to introduce a limited list. The Government's whole approach to this problem has been of a draconian nature. Actually I would use different words and say that they took the attitude that they were in power, that they knew best and that they would say what should be done.
The Minister's right honourable friend in another place stated that no government would discuss issues 505 before they had indicated their intentions in Parliament. All governments since 1948 have done that. That is how the National Health Service has worked until now. The Government have always discussed with the profession what they have in mind. The profession has made suggestions as to how things can be done.
In the past, the Government and the profession have reached agreement and things have been done. That is how matters have been handled since 1948. There is now the idea that one cannot start discussing an issue of importance such as this with representatives of the very prople who have to make it work. That I consider to be arrogant nonsense.
The Government say that they are having these surveys and have seen limited lists in other countries, but the reports that we get suggest that the limited lists in other countries have not worked. In some cases they have made some savings—about half of what they thought they would—but in one particular case they found that as a result of the introduction of a limited list the cost was greater.
What has always been possible is a reasonable saving on the drugs bill through an agreement between the Government and the profession, under which there would be an extension of local formularies and a measure of generic prescribing being encouraged with a certain amount of generic substitution also being agreed to; together with an agreement for smaller quantities being prescribed at any one time. That was always possible and would save a lot more money than the imposition of a limited list. However, the Government decided that they must impose their will and therefore introduced a limited list. So here we are with this limited list.
As I said earlier, I am sorry that we have got to this. I hope that the House will pass my noble friend's Motion together with the amendment of the noble Lord. Lord Kilmarnock. Not that that will prevent the limited list from becoming law; because in accordance with the traditions of this House, it will become law. However, it will be an expression of the way in which we feel about this matter. I hope that, as a consequence of the House passing such a Motion, the Government will think again. The Secretary of State says there will be a conference. That conference should be held before and not afterwards. I invite the Government to make the conference the start of progress. This limited list is only—how shall I put it?—an irritation. It cannot be anything else but an irritant because it cannot have the effect that the Government seem to think it will. What it does is what the department said in its representations to the Greenfield Committee: it creates the maximum amount of ill-will.
§ 10.8 p.m.
§ Lord Holderness
My Lords, not surprisingly, even at this early stage of the debate, some of the compelling arguments which I had prepared for your Lordships have already been laid before you. In view of the fact that the list of speakers is still long and the hour is late I shall do my best to be unusually brief.
506 It seems to me, having had an interest in but not an immensely close connection with the National Health Service for many years, that it is the issue of complete comprehensiveness which has been at the root of all the arguments about the service in the past four decades. It is here with us again today when ignorant laymen such as myself, unlike the distinguished experts such as the noble Lord, Lord Porritt and the noble Lord, Lord Pitt, have the difficult task of trying to weigh up the alleged damage to patients with the removal of complete prescribing freedom for the doctors against, on the other side, the benefit of additional resources released for other health purposes.
It seems to me that the BMA could have given people such as myself great help and the pharmaceutical experts could have clarified a number of questions. However, there is no doubt that neither the association nor those who know most about the drugs, even when the Government's intentions to issue the list were perfectly clear, seem to have been willing to discuss possible amendments to the list. Therefore I cannot but be grateful for small mercies and grateful for the advice of the Secretary of State's own panel and for the support of the general principle of limitation from the two colleges in guiding me to what my decision should be. That still leaves me and other inexperts, as often before, without unanimous professional guidance and forced to reach a judgment on an important question on incomplete advice and partly on other grounds.
One of the other grounds is obviously the financial ground. The financial arguments are certainly very compelling. Leaving aside the astronomical cost of the health service altogether, which has already been mentioned, or even the cost of the whole pharmaceutical service, I really cannot see that any Government could neglect the expenditure on this part of the pharmaceutical service nor the vast increase in prescribing without, on the other side, unanswerable and virtually unanimous arguments in favour of the free availability of all existing drugs and the complete freedom of doctors to prescribe.
The situation we face, or I face, is certainly not that. Medical opinion does not seem unanimous, but the Government for their part can claim the support of considerable weight of expert opinion. The sector to which the regulations refer is limited and patients, even in that limited field, will not be denied free drugs for their treatment.
Further, I applaud the wisdom of my right honourable friend in being willing, after advice, to expand the original provisional list. If, as my noble friend Lord Glenarthur has suggested, he can go a step further and find a way to include certain drugs, at present proscribed, for particular and exceptional circumstances, I think that my remaining worries will be removed.
In my view the Government have significant professional backing for their proposals. The financial pressures on the pharmaceutical service are very great. The scope of the regulations is relatively small. I am convinced that my right honourable friend the 507 Secretary of State has shown—and I hope that he will show even more—sufficient flexibility to convince me that I shall be willing and able to support my noble friend tonight if it is necessary.
§ 10.13 p.m.
§ Lord Hunter of Newington
My Lords, with all the discussion that there has been in your Lordships' House about the drugs lists and the debate on the pharmaceutical industry one would have thought that there could not possibly be any new factor to consider in this situation. However, there is an important new factor. It arises because on the day following our debate on the pharmaceutical industry the Secretary of State for Health made an announcement in another place about the long list of drugs which could not be prescribed in the health service and about a recommended list of drugs which contained at least three times more drugs than the original published list—in fact 120 as against 32. There are also other very important categories of drugs which have not been mentioned here, such as antibiotics, which of course remain unrestricted.
The question we must consider is what, if any, difference the introduction of this new list, drawn up substantially by a committee of experts, chaired by the chief medical officer, makes to the situation. When the original drug list was published, many people had reservations about it. Of a substantial proportion of the medical profession who wrote to the Department of Health, 38 per cent. made it clear that they felt a drug list recommended by professional experts was something that they would support, 24 per cent. were against it and 38 per cent. were uncommitted. Again, at a Royal College of Physicians meeting to discuss this matter, only the proposer and the seconder of the amendment were not in favour of the professionally recommended drug list. It is a matter of great regret that the British Medical Association and the Royal College of General Practitioners have felt it necessary to object to the list on a point of principle and that they have not been fully involved in drawing up the finally recommended list.
In considering the resolution of the noble Lord, Lord Ennals, one must examine all the factors that influence doctors in their prescribing and then consider whether the action of the Government is to be supported or deplored. Noble Lords may remember that, in the debate on the pharmaceutical industry, the noble Lord, Lord Kilmarnock, drew attention to the amount spent by the industry on promotion. This was somewhere in the region of £180 million a year, and the whole intention was to influence doctors to use a particular company's drugs.
There are many other sources of information open to doctors. There are prescribing books like the National Formulary produced by a joint committee of the British Medical Association and the Pharmaceutical Society of Great Britain, and funded by the Department of Health and Social Security to ensure that this is sent to all prescribing doctors. There is a host of professional meetings which the Government, in the shape of the Department of Health, are willing to subsidise doctors to attend—this 508 in spite of the fact that they are contractors with the health service. So, much is done to make doctors familiar with drugs apart from the information provided by the industry. Also, most medical schools, in teaching clinical pharmacology, recommend to their students that generic drugs should be used when possible.
Now that the recommended list has been available for examination and discussion for a period of time, it is well to examine how it meets the needs of doctors in practice. The information that I have received is that, accepting doctors' present prescribing habits, somewhere around 95 per cent. of their usual prescribing habits will be met and their patients' needs may be met to about the same degree. I understand that the list has been designed to meet all clinical needs. If that is the declared objective of the Government, then the profession and their advisers should be insisting that that comes about. It is for these reasons that I do not feel able to support the resolution of the noble Lord, Lord Ennals.
There is, of course, the question of the pharmaceutical industry. Again, I agree with what the noble Lord, Lord Kilmarnock, said in the debate on the pharmaceutical industry that there is little reason to suppose that it cannot respond to the changing pattern of demand. What will have to change, I think, is the idea that in the United Kingdom all companies are research based. One would hope, however, that in the future the PPRS would distinguish between companies whose main research activities are based here and those which do a little research here but whose main research effort is elsewhere. I am saying that if the main research activity is in the United Kingdom, regardless of the fact that it is an American or a European company, this fact should be taken into account.
I also believe that it is an urgent and important matter for the Government to address themselves to the question of the patent life of drugs. Those who achieve excellence in the pharmaceutical industry should make legitimate profit from it.
Finally, I would urge that those who represent the medical practitioners—the British Medical Association and the Royal College of General Practitioners—should co-operate with the new, recommended proposals on the understanding that there is to be set up a machinery which will keep it up to date and ensure sensitivity to the needs of medical practice. It seems to me that in response to pressures—legitimate pressures—by responsible persons, largely fellows of the Royal colleges, the Government have moved very substantially over the content of this list. It seems to me to be very unwise for some professional bodies to remain apart from this important matter. They should, at least, while maintaining their objection in principle, test the Government's flexibility and good intentions over the future by co-operating in this way.
§ 10.21 p.m.
§ Lord Molson
My Lords, I think it somewhat surprising that the noble Lord, Lord Ennals, should have moved this Motion apparently questioning the 509 right and indeed the duty of the Government to take the measures that they have taken. His party, if I understand aright its philosophy, stands for the general principle that the state should exercise a general supervision over the activities of various bodies in the state. That of course applies even more in the case of the National Health Service, where the Government are obliged to pay the bill. Any suggestion that the action of the Government implies an attack upon the National Health Service seems to me to be totally unfounded. Any economy that can be made in unnecessary expenditure upon drugs can, and I do not doubt will, be spent upon the extension and improvement of other aspects of the National Health Service.
The amendment moved by the noble Lord, Lord Kilmarnock, seemed to me to be more in line with what I understand to be the philosophy of his party: that is, to take a more discriminating line and to seek reasonable co-operation between the Government and various bodies—in this case, of course, the medical profession. I think that he and also the noble Lord, Lord Porritt, perhaps stood for what I might call the complete autonomy of the medical profession. Recently, the autonomy of a number of professional bodies has had to be called in question. The solicitors have had to abandon their exclusive right to conveyancing; and that is not the only example. It seems to me to be perfectly clear that the Government are under an obligation to make certain that the clinical freedom of doctors to prescribe is contained within reasonable limits.
The noble Lord, Lord Porritt, made a remark which I did not quite understand. I think he referred to the chickens coming home to roost after 40 years. It is just about 40 years ago that the National Health Service was introduced. I hope that the noble Lord does not mean to imply that he is opposed to the principles of the National Health Service. I remember very well that at that time the attitude of the medical profession was not wholly co-operative with the Government of the day, whom I supported. I do not speak with any desire to criticise the medical profession. I am the son and the grandson of doctors, and I have received much beneficial treatment from the medical profession, which I greatly admire. But I say that a limit must be drawn to the extent of its complete freedom to prescribe drugs.
As I said on 20th February, I am wholly ignorant—or at least I was wholly ignorant—of this subject. However, partly as a result of a conversation with the noble Lord, Lord Hunter, I read a review of a book entitled The Wrong Kind of Medicine, and I bought it. It is compiled by a Dr. Andrew Herxheimer, who is the editor of Drug and Therapeutics Bulletin; a member of the World Health Organisation Expert Panel on the Selection of Essential Drugs; and, as a guarantee that he is not merely a theoretical chemist but has high standing in practical medicine, he is senior lecturer in clinical pharmacology at Charing Cross Hospital Medical School. I felt, therefore, that I could rely upon the information that I gathered from his book. I have never met him, but I have consulted him on the telephone.
510 I was so impressed by the book, that I sent it to a doctor friend of mine and I shall quote his reply. He said:The book I found most interesting and quite informative. I tend to agree with you that the medical profession has taken an unnecessarily arrogant stance with regard to listed prescribing, but they all seem quite petrified that they will be dictated to in clinical terms if they give in at this point! I can see no logical reason why a series of professors cannot concoct a list which is satisfactory to most people … I see no reason why the future doctors should find any difficulty in coping with a restricted list as projected by the Government.I invite your Lordships' attention to my friend's reference to "professors". As a busy practitioner, he knows that the opinion of academics—like the noble Lord, Lord Hunter, who is so eminent in this sphere and whose contribution to this debate has been so helpful—is the opinion of those who specialise in this arcane study in a way that is quite impossible for the ordinary general practitioner to do.
What emerges from my study of the book can be summarised in this way. Owing to the complexity of modern drugs, no ordinary practising doctor can prescribe without consulting the publications of expert bodies in this and other countries. In this country not only do we have the Government-appointed Committee on Safety of Medicines, of which the noble Lord, Lord Hunter, was such a distinguished member, but we also have the United Kingdom Joint Formulary Committee, as well as the unofficial Drug and Therapeutics Bulletin. In addition, the World Health Organisation produces a model list of some 250 essential drugs.
The numerous pharmaceutical companies compete in the wonderful research which has produced such blessings to modern man, curing us of ailments from which earlier generations suffered and died, and relieving us also of pain. Not only must we be grateful to them for what they have done, but we must do nothing to obstruct further progress in this beneficial work.
However, this beneficial work brings with it dangers and problems with which Governments must cope. The terrible thalidomide tragedy is only one example of the dangers that accompany this progress in making sophisticated drugs. There is always a price to pay for taking any medicine, varying from mere expense and inconvenience to an unpleasant or even dangerous effect.
In studying this matter I have only been able to look up drugs which have been prescribed for me. I think it was in 1979 that the Dutch registration authority suspended the production or sale of Halcion for insomnia. I think, therefore, that it was unfortunate that my doctor in Scotland prescribed that for me, because it is said that it may have serious mental effects. I hope that any incipient insanity that you detect in me will not be attributed to the short course that I had of Halcion, but I do not blame that general practitioner. How should he know the technical investigations that had been made in Holland by a specialist body? I cite this as an example of why the Government are under a responsibility to have monitoring authorities looking at the safety of drugs and their possible side effects.
If that is true with regard to the safety of drugs, why should not the same principle apply to the price of drugs? The National Health Service bill for drugs in 511 England alone is £1½ billion, and the number of drugs that can be prescribed is 17,000. How can a busy doctor evaluate precisely which branded drug, if any, to prescribe? I emphasise the word "branded". Many are virtually identical but produced by different competing companies at different prices. Many are similar or even identical to generic products sold at much lower prices. I do not hesitate to repeat what I have said on 20th February: that when I got my doctor to substitute Nitrazepam for Mogadon the cost to me each time I bought them went down from £12.02 to £1.77. Looking this up again, I find that had he prescribed Anxon—which is very much the same—the cost to me would have been ten times as much as that of Nitrazepam. My doctor was only prescribing what had been given to me by previous doctors.
Dr Herxheimer has authorised me to say that in his considered opinion the lists produced by the advisers to the Government are—without committing himself to any individual items—in general fair and reasonable. I could give further examples but at this hour of the night I will not do so. However, I am satisfied that the Government are discharging their duty in producing these two white and black lists and that on the advice of their experts—to which I hope the British Medical Association will contribute in the future—they have produced lists which are satisfactory to those in the best position to judge.
§ 10.34 p.m.
§ The Countess of Mar
My Lords, I do not hesitate to admit that there is an urgent need for action to reduce the National Health Service drugs bill. There is no doubt that there have been flagrant abuses by some doctors in prescribing unnecessary medicines; and that some patients have demanded drugs which they do not need.
However, I do not think that the introduction of these regulations is the correct way to put matters right. Ever since the original proposals were presented to Parliament in November 1984 there have been clear, loudly-voiced indications that doctors bitterly resent the inference that they are irresponsible and lack judgment. They have indicated that they are prepared to put their own house in order.
There is already in being the machinery to control frivolous prescribing, in the form of the Prescription Pricing Bureau and the family practitioner committees. Would it not have been more sensible to allow prescribing doctors to continue to use their clinical judgment in conjunction with advice and perhaps firmer vigilance from these bodies? The list itself has been variously described as "a squalid little cost-cutting measure", "an overhasty half-baked scheme" and "a rushed, ill-thought-through, damaging measure" by an Honourable Member in the other place. What do we think about it? The evidence is before us tonight if only we care to look at it.
First of all, take those drugs on the permitted list under the heading of antacids. Gastrocote and Gaviscon tablets have the same constituents. Altacite, Actal, and Lord Pitt's preference, Asilone, all of which have differing modes of action, have been omitted, while Topal tablets, which have not been available for a number of years, are included on the list.
512 The permitted list of analgesics indicates the theoretical but not the practical knowledge of its compilers. The noble Lord, Lord Pitt, put it so clearly: pain is infinitely variable, as are the human beings who suffer it. I am reliably informed that this list would compel doctors to prescribe strong painkillers for mild to moderate pain. Aspirin is rarely prescribed because of its irritant qualities. Dextropropoxyphene—I have done well in pronouncing that—plus paracetamol, dihydrocodeine, dihydrocodeine plus patacetamol and pentaocine are only available under brand names. In other parts of the list brand names are used, so why not in this section? Febrilix, Paldesic, Panaleve and Salzone are not in MIMS—to doctors that is the equivalent to the vicar's Bible—and are therefore unlikely to have been prescribed.
Under the list of substances not to be available at NHS expense from 1st April 1985—and I am going to press the noble Lord on this matter—I see Sainsbury's soluble aspirin. Not only do we have Sainsbury's soluble aspirin but Sainsbury's cold powders with blackcurrant. Sainsbury's hot lemon powders, Sainsbury's indigestion tablets, Sainsbury's junior soluble aspirin tablets, Sainsbury's paracetamol tablets, and Sainsbury's aspirin tablets.
Most of us know that Sainsbury's brand name products are only available through their own stores, and so far as I know there are not pharmacies within their stores. The noble Lord said that all the items on the black list had at some time recently been prescribed by doctors. Does the patient take his prescription to the cash desk at Sainsbury's, or does he take his prescription to the chemist, who then sends a messenger to Sainsbury's to buy the paracetamol or the aspirin or the cold cure? Does he then run back to the chemist's shop, and the chemist then presents Sainsbury's soluble aspirin to the patient? I should be grateful for an answer.
We all know how debilitating coughs and colds can be. One only needs to be in your Lordships' House when the bugs are doing their rounds. They cause numerous days lost from work. There may not yet be a cure for the common cold but the general medical practitioners are aware that patients are better able to work if their symptoms are relieved. I would not dream of going to see my doctor if I had a cold, but some people need the support of a qualified practitioner. Others may be prone to complications and early treatment may prevent these.
There are no demulcents or compounds in the list, and there is only one nasal decongestant. Actifed is considered to be so useful that it was provided for American astronauts to take to the moon, and yet that is not on the list. Karvol capsules are of great benefit as an inhalation for infants, but, as they have been blacklisted, parents, however poor, will have to pay for them.
As to other blacklisted preparations in this category, it is fatuous to suppose that doctors would have prescribed them. They would soon have been pounced upon by the Prescription Pricing Bureau. I wonder how many doctors prescribe those mysterious tablets B006 et al, or even know what they are. The permitted and not permitted lists seem to be an outstanding example of the naivety of politicians and bureaucrats 513 who believe that they know better than those who have undertaken a long and arduous training followed by years of practical experience.
Now to the financial aspects of this measure. We are told that it will produce likely savings in the drugs bill of some £75 million, rising to a higher figure in due course; that these savings are sensible and that they will not harm the interests of the patients. Out of this £75 million I understand that £28 million is to be given to the chemists as compensation for the likely underpayment resulting from a fall in the script volume and the net ingredient cost when the limited list is introduced—as reported in the Chemist and Druggist of 23rd February 1985. A further donation of £17 million, making a total of £45 million, is to be given to them because general medical practitioners wrote fewer prescriptions in 1983. Did the GPs receive any reward for writing fewer prescriptions? Of course not, and they did not expect it. Why should chemists have a handout of around £2,000 each when the poor and the elderly are having to find more money out of their already slender resources for the drugs they need?
We are also led to believe that chemists will be compensated for stock in hand which may be redundant after 1st April, but no offer has yet been made to the dispensing doctors who have stocks for which they have already paid. What are the proposals for them? Already we can see that the savings have dwindled to less than £30 million.
Lurking somewhere in the Elephant and Castle are proposals for energy conservation in hospitals which would save £80 million a year, as reported in The Times of 13th February 1985. There is tremendous scope for saving in administration costs, which were £2,314 million in 1981–82. I am told that theft from hospitals is a major charge on the National Health Service and yet little seems to have been done to curb it. The Office of Health Economics Statistics shows that the cost of doctor dispensing is £2.90 per prescription and chemist dispensing is £3.14 per prescription. If all doctors were to be allowed to dispense there would be a saving of £ 106.5 million per annum.
There is hound to have been a rise in prescription costs over and above the cost of living index. The noble Lord, Lord Ennals, gave several reasons. The population has increased. We have twice as many over 75s in the population as we had in 1948. This is a tremendous tribute to the National Health Service, but, as many of your Lordships will know, they need more sophisticated drugs to keep them going. Unemployment is responsible for a great many stress-related illnesses and the sufferers often need medication. Have the Government taken these factors into account?
Well over half the population is entitled to free prescriptions. The young, the elderly and the poor, those who need and use the National Health Service most, are to be second-class citizens in sickness as well as in so many aspects of their lives because they will not be able to afford drugs not on the limited list. This surely was not the intention of those who originally conceived the idea of a health service for all.
The sum total effect of this piece of legislation will be discontented doctors, unhappy pharmacists and 514 confused patients. The Government are dealing yet another blow in the solar plexus of our National Health Service. It opens the gates to further restrictions no matter how much the Minister may deny it, and all this for a saving equivalent to the cost of two miles of motorway!
§ 10.45 p.m.
§ Lord Ferrier
My Lords, I am a growing lad and I was just going off to bed when I was stopped in the corridor to be told that Lord Molloy and somebody else had cut out and that I should follow the noble Countess, Lady Mar. Your Lordships will have to forgive me if I am a little upset. I am reminded of the stalker who got his rifle close to a stag who was browsing towards the march. He said, "There you are, sir, tak' your time, but be quick about it!" That is what I propose to do.
The noble Baroness who has just sat down touched on a point which had not been raised previously in the debate, so far as I remember. That was the fact that an enormous amount of time and money is wasted by people who go to the doctor because they feel that they must go to the doctor. In fact, sometimes the surgery is a place where they can have a good chat. But, my Lords, a quarter of a century ago I was chairman of a group of pharmaceutical companies. I say that only to remind your Lordships of my experience and my respect for the industry which has been amply rewarded by listening to speeches such as that of the noble Lord, Lord Porritt, who really said practically all that I wanted to say—but not all.
Many a time in your Lordships' House I challenged what I called in those days—and I am talking of a quarter of a century ago—the ritual dance which was executed at that time by the critics of the pharmaceutical industry. In those days "profit" was a dirty word. It is not so today. My noble friend the Minister has made it clear that he regards the industry with respect. At the same time there is no question about it, from what your Lordships have said this evening, that there is a feeling that there might be more sacrifices to be made by the pharmaceutical industry. I do not believe that that is so. As one noble Lord pointed out, the ability to research is being restricted by the sacrifices that the industry has already made in reducing prices.
Things have, of course, changed since the days when profit was a dirty word. But the Minister, I think, is inclined to praise the industry so far as his department will let him. Nevertheless now we find the Government involved in what can well be described, and somebody has described it so, as bureaucratic lunacy. That is my view of it. Here is the paper as it applies to Scotland: 32 foolscap pages, 23,000 doctors. Really, is this particular manoeuvre going to pay? I doubt it myself.
Frankly, I do not think it makes sense, as has been pointed out in the other place. This leads me to complain bitterly—and I hope that some of your Lordships will agree with me—at this debate having been shoved off into the midnight hours when it is of such great importance. We have not really had an opportunity yet of studying the debate in the other place and what was said there. After all, Hansard cuts off at 10 o'clock.
515 I do not think that the proposals in the papers make sense, and that is why I support the amendment of the noble Lord, Lord Kilmarnock. Is it possible that those whom the gods wish to destroy they first drive mad? Can we not use this amendment to give my noble friend the Minister and his "brother officers" in the department a chance to have another hack at it before it comes into effect on what, after all, is April Fools' day. I think it is a mistake.
There are other ways in which money can be saved. The noble Countess who has just sat down has pointed out how it could be saved, how people could go to the doctor less, take a dose of salts or a spoonful of castor oil or buy an aspirin at the corner. I think that one method of saving would be the acceptance of manipulative therapy under the National Health Service in order to reduce the cost to the state of outgoings in respect of treatment, medication and even surgery which backpain involves. But that is another matter.
Is this plan practical? What is going to be the cost to the ordinary GP? It is all very well, but I have discussed it with GPs and their time is money, particularly in widespread rural areas where, as I think the honourable Member for East Kilbride said in the other place yesterday, doctors and patients cannot pick and choose where they are going to get their medicine. They may have to go 30 miles to the nearest chemist. That is really why I support the amendment of the noble Lord, Lord Kilmarnock.
Has not the time come to reduce the size of this cumbrous and obviously unmanageable department, the Department of Health and Social Security? After all, it was created only in 1968 and now it is manifestly, to the ordinary man in the street, unable to look after itself. I do not think it is fair to involve the Ministers concerned with this giant and apparently unmanageable spending organisation. The Departments of Health and of Social Security were merged in 1968. Has not the time come to separate them again and give the Ministers a chance to run the business properly?
Something of the sort was hinted at during the debate here on the 27th February. For instance, my noble friend Lord Cullen of Ashbourne, in the debate on the spectacle muddle, pointed out that we shall have to retrace our steps over that. Since the 27th February this problem we are now debating has blown up. With respect to the noble Lord, Lord Winstanley, who in his speech the other day—or was it in a press interview?—referred to the Falklands expenditure as being an outgoing of money which we could ill afford, that is another matter; that is world politics. We are talking today of our housekeeping in our homes. Let us see what proposals the medical profession will make after reading the report of this debate. If, as I hope, your Lordships carry the amendment of the noble Lord, Lord Kilmarnock, that will give us another opportunity to oversee the question of prescribing.
§ 10.54 p.m.
§ Lord Rea
My Lords, there are just a few more points that I feel should be made, but I hope not to keep your Lordships more than about five minutes. As 516 my noble friend Lord Pitt has indicated, the medical profession in this country has become acutely aware of the need to improve prescribing, not only because of considerations of cost, but also because over-prescribing is increasingly recognised as bad medicine in itself. It may actually harm patients and it certainly increases their dependence on the National Health Service.
Our drug costs, as the noble Lord, Lord Ennals, has pointed out, compare very favourably with those of other advanced countries. The National Health Service does not encourage doctors to mollycoddle their patients, as do some other health care systems. There are increasing numbers of examples of groups of doctors taking steps to improve prescribing and to cut costs. Only last week I received a bulletin from the Royal College of General Practitioners which described six such schemes. The St. Mary's study, which I mentioned in the House on 6th February, showed how the provision of detailed feedback information to general practitioners by the prescription pricing authorities about their prescriptions could, if followed throughout the country, save £63 million, which is more than the present regulations will achieve, taking into account the compensation to pharmacists which the noble Countess, Lady Mar, has mentioned.
My own experience of drawing up a limited list in the group practice to which I belong was published in the British Medical Journal of 8th February. I do not disagree with a limited list in principle. In fact, our limited list agrees rather accurately in the categories concerned with the white list which the Government have drawn up. But there is a very important difference. Our list was drawn up willingly by the doctors concerned, in association with a professor of pharmacology, Professor Laurence of University College, London, and we intend to implement the list very flexibly to start with, with frequent revisions, taking into account both doctor and patient response. We appear to have no such mechanism provided for in the regulations as they stand, and I hope that when he replies the noble Lord will give us a few more details about what is proposed.
I have still heard no satisfactory explanation as to why the report of the Greenfield Committee, which was set up by the department itself and was representative of all the interests concerned, was not implemented in full. By enlisting the co-operation of a willing profession, a much better basis for a real lasting reduction in drug costs could be achieved. These are some of the reasons why I have no hesitation in supporting both the Motion of my noble friend Lord Ennals and the amendment of the noble Lord, Lord Kilmarnock.
A final thought is that when the National Health Service was founded—and this particularly follows on from the speech of the noble Lord, Lord Porritt—the then Minister of Health, Mr. Aneurin Bevan, negotiated a tough but very honest deal with the medical profession, and one of the most crucial points in that deal was that the clinical freedom of doctors to treat patients as they thought fit should not be breached. It is a very odd twist that it is a Conservative Government that has first broken that trust, which is basic to the profession's participation in the National 517 Health Service. Up till now, GPs have mostly voted Conservative, and I think that 80 per cent. was the figure given in one survey in Pulse. But I can predict with little doubt that if these regulations come into effect the party loyalty of many of these basically conservative men and women is unlikely to be maintained.
§ 10.58 p.m.
§ Lord Colwyn
My Lords, at this stage of the debate we are about equally divided for and against in our arguments on the Motion of the noble Lord, Lord Ennals, this evening. It is my intention to support the Government, and I have to admit that I have not so far heard any argument which could make me change my mind. Much has been said about the Greenfield Report. In their evidence to the Greenfield Committee, the DHSS expressed concern for individual doctors having to take account of a patient's financial circumstances when deciding whether to continue treatment with drugs not on the limited list. Those are very admirable sentiments but they are not consistent, for we are discussing this limitation within one week of a Government announcement raising prescription charges to £2 and continued persecution—for that is what it is—of the dental profession by the increase, again, of charges for dental treatment. I am tempted tonight to digress on this subject, which I hope we shall be able to discuss in the very near future.
However, I started by saying that I support the Government—and I do—in that I agree with the principle of a selected list of medicinal products being mandatory for prescription within the National Health Service. The general practitioners are contracted and agree to work with the DHSS, and I see no reason why their list, like the National Health Service dental list, should not be limited by specific instructions as to their prescribing habits. The long list of drugs to be withdrawn was certainly interesting reading to me, although misleading; for despite having never heard of most of the products listed, a large number of them do not appear in the British National Formulary, and are therefore not available for prescription within the NHS. I am sure that most GPs were unaware until this list was published that there were so many variations of the seven categories of medicinal products that we are discussing this evening.
Although the list is long and has not been available for sufficient time for detailed examination, I was unable to find a single item which could be considered of therapeutic value that was not covered on the approved list either by a single item or by a combination of items. I cannot believe that we shall shed any tears for the loss of Bonomint chewing gum; Clarkes blood mixture; Dr. William's pink pills; Indian brandy solution; Male gland double strength supplement tablets; Nurse Sykes powders; or Scotts husky biscuits. I have read reports over the past week which say that certain drugs that are essential will not now be available. The reports include an article by Oliver Gilley in the Sunday Times in which he gave several examples of popular medicines that are to be withdrawn. Each one mentioned was clearly available on the retained list under its generic name.
518 The noble Lord, Lord Ennals, spoke this evening of the dropping of the pain killer DF 118. This is still available as dihydrocodeine. He also talked of limitations in the benzodiazepine tranquillisers. He did not mention the name, but librium, valium, ativan, mogadon and normison are all available under their generic alternatives.
As a keen advocate of the maintenance of health with a balanced diet and the treatment of disease by use and stimulation of the body's own defence mechanisms, I must support any measure which will limit the number of harmful substances that we continue to pump into ourselves, many of them on medical prescription, 350 million of which were issued last year alone. Perhaps this legislation will encourage people to look towards the use of homoeopathy and natural remedies, all of which are harmless and many of which are cheaper.
Although I consider that the Government have made a sensible cost saving decision, I was delighted to hear the Secretary of State for Social Services say in the debate in the other place last night:I am ready to consider with the profession whether in exceptional circumstances doctors should be allowed to prescribe drugs not on the list when they believe their patients need them".If he can stand by this—I have not been able to read his summing-up speech—surely the major objection to this regulation has been effectively answered. I also hope that this offer will overcome the problems for old-age pensioners and patients on supplementary benefit who may now find that a medicine they have considered essential for years is not available within the National Health Service. Perhaps the Minister can confirm that their cases will be covered by the availability of a special prescription if careful substitution and explanation by the general practitioner is not sufficient.
Unless some of the medicinal products now blacklisted have solely relied on subsidy from the National Health Service and cannot survive without it, they will continue to be available either over the counter or on private prescription, most of them at prices considerably cheaper than the present prescription charge of £1.60. I do not see the limitation regulation as an infringement of the GP's right to prescribe the medicines which he feels most suitable for his patients. I see it as a logical cost effective business measure which, in my opinion and in the opinions of many doctors whom I know, should have been introduced many years ago. My Lords, I hope that you will support the Government in the event of a Division.
§ 11.5 p.m.
§ Baroness Masham of Ilton
My Lords, I am pleased to be following a doctor and a dentist and I should like to say a few words on behalf of patients. I feel very worried that the relationships between the medical profession and the Government seem so strained. Doctors have to deal with the greatest responsibility of our society—life and death. Yet the Government are not giving doctors the chance to prove themselves in this respect, now that they realise that drugs have to be limited.
This regulation seems to have been rushed through. For many people who are struggling with sickness and 519 the difficulties of life it must be very depressing to have to try to understand the message which the Government Ministers are trying to put over—because all the Ministers are young, active males in the prime of life, with boundless energy.
I agree that everyone should accept the need to make further savings. Tonight I want to ask only three questions. First, should not this limited list regulation at least be delayed until the appeals procedure is ready? I have been telephoned by a woman whose new doctor has taken a great deal of time and trouble to wean her off the addiction of Valium by putting her on two lesser tranquillisers, which are suiting her. Those tranquillisers are now on the black list. What will happen in cases such as that? Will the doctor be able to prescribe what suits his patient, or will she have to go back to using something stronger?
Secondly, can the Minister give me a good reason why Actifed cough mixture has been taken off the prescribing list? This mixture is cheap, popular, easy to take, and very effective in cases of croup in children. In fact, for patients who do not enjoy exemption from charges, it is cheaper to buy Actifed over the counter. But I am concerned about those who are exempt from charges: children, the elderly, the chronically sick, and those of social security.
Finally, will the list be kept under regular review? I look forward to hearing the Minister's answers.
§ 11.8 p.m.
§ Lord Mottistone
My Lords, we have heard many speeches, and I shall not be long. One consistent feature of this debate has been that even those noble Lords who are against this measure, with the possible exception of the noble Lord, Lord Porritt, recognise that there have to be economies made in the National Health Service. I believe we would all agree with that. Indeed, I have said before in your Lordships' House that if economies are not made in the National Health Service, it will gradually price itself out of existence, as has happened with other Government bodies.
That is a very important point, and it is sad that those noble Lords who say they agree that there should be economies then go on to say, "But not in this area".
§ Lord Mottistone
That is what people always say, my Lords. I come from what was one of the oldest nationalised industries in this country—the Royal Navy. I suspect that in the days of Samuel Pepys, when he was introduced to create just such economies in that service, my predecessors in the Royal Navy were saying the same kind of thing as the opponents of this measure are saying now; that is, "Yes, we must have economies, but not in our area, not in this area". That is the problem.
There needs to be economy; and the noble Lord, Lord Rea, said, yes, we must have this sort of economy provided we do it ourselves. But I suspect that that is not something which can readily be applied, otherwise the Government would have resorted to that. Indeed, I believe my noble friend said that they had considered it. That fact is, we have reached the stage—and the 520 figures given by my noble friend the Minister made this clear—that with the increase in drugs and the vast increase in cost there has to be a regulatory principle.
I am able to say that my own GP, who raised the subject with me—I happened to be visiting him—rather than my asking him, said that he agreed very much with this. The only aspect he questioned was whether the positive list was right. He questioned whether the right sort of people had been on the committees advising the Government. I suspect from what I have heard tonight that the reason the right people were not there is that they did not want to be there. It is perhaps their fault that they were not. In any case, my GP said that he thought that such changes that he would make, if given the chance, were minimal. He thought that the principle was right, as the noble Lord, Lord Rea, thinks it is right.
If one feels that I cannot see how one can possibly support the noble Lord, Lord Ennals, or the noble Lord, Lord Kilmarnock. It must surely be the case that we must have some sort of control. It seems to me that noble Lords who have spoken who know much more than I about these things, like the noble Lord, Lord Hunter, and my noble friend Lord Colwyn, are saying that there is nothing very much wrong provided that the Government—and I think the Government have already said they will—review the list and keep it up to date. That must be the right sort of principle. One should not grumble about whether the pharmaceutical companies will suffer. As my noble friend the Minister said, the pharmaceutical companies have been very well considered in this whole operation. Therefore, if we do have to take this to a Division—and I very much hope we do not because that would be inappropriate under the circumstances—I hope that the Government will receive all the support they deserve.
§ 11.13 p.m.
My Lords, the noble Lord, Lord Mottistone, said that those who support the Motion of the noble Lord, Lord Ennals, as amended by the amendment of my noble friend Lord Kilmarnock, believe that there should be economies but not in this area. We believe no such thing. We believe very positively, and have said over and over again in this House and elsewhere, that there should be economies in this very area but not in this way—which is a very different thing indeed.
Most speakers in the past hour or so have said that the hour is late. The hour is late, but I must say that it is not our fault that it is so late. Frankly, I agree with other noble Lords that it is outrageous that your Lordships' House should be required to debate a matter of this importance in this way at this time. Noble Lords will recollect that originally this was the main business of the day. It warrants being the main business of the day. It is extremely important business. It is the kind of business which demands the full attendance of your Lordships' House with a full and thoughtful and, at the end of the debate, a clear and carefully taken decision. But the Government, for reasons of their own, at the last minute interpolated other business. If any noble Lord tells me that the Chief Whip expected the other business, in which the speakers were mainly to be Her Majesty's judges, 521 would go through quickly, he must think again. The Government's purpose in interpolating the other business was to make absolutely sure that this matter would not be ventilated in the kind of way that this House would have done, had it been given the opportunity to do so with a full House.
I am bound to say, as many noble Lords have said, that the Government should think again. I think that the Motion, as amended, would give the Government an opportunity, if they accept it—and I know that they are not going to—not only to think again but to use the period while they are thinking again for something which could bring benefits far greater than those which could emerge from these regulations. In other words, as envisaged in the amendment of my noble friend, we would be trying another method of achieving vast savings, possibly much greater savings than can be achieved by this particular method.
In the next few minutes I should like to say why I believe the Government should now think again. First, I think they should think again because the whole legality of the exercise upon which we are embarked is open to question. I honestly believe that if this order arrives on the statute book and comes into force on 1st April it will ultimately be challenged in the courts. If it is challenged in the courts I believe it will be successfully challenged. I should like to explain why.
First I shall refer to the document which has already been referred to by the noble Lord, Lord Ennals, and others. That is the Fifteenth Report of the Joint Committee on Statutory Instruments which has looked at the order. The noble Lord, Lord Ennals, quoted at length from that report. I shall quote a little more briefly. However, because some time has passed since it was previously referred to, I shall just remind noble Lords that the report says this:The Department admitted that, certainly in the case of [Statutory Instrument] 296 and possibly also in the case of S.I.290, both Houses were being asked to consider regulations which were not accurate and whose errors would have to be amended by subsequent instruments".It really is intolerable that we should be asked to give automatic assent to orders which are erroneous and faulty, and which require further orders to be made—further orders about which we have as yet heard nothing. That is the first ground upon which I think that maybe the whole provision is ultra vires.
The second point is this. This, too, has been quoted. In response to the Question put by the noble Baroness, Lady Elles, in her capacity as a member of the European Parliament, we had the answer of the noble Lord, Lord Cockfield. I have it all here. He has said with the utmost clarity and made it quite clear that if we go ahead in this particular way we shall be in breach of Article 30 of the European treaty.
I am prepared for Britain from time to time to be in breach of the European treaty. Indeed, we have been. In matters in which we have been in breach for very many years we have taken a very long time to put ourselves right. But that is a very different matter from knowingly going into breach of the treaty. We have been told that what we are about to do will put us in breach of Article 30. So that is the second reason why I think the whole procedure might find itself in difficulty in the courts.
522 There is a third and rather odd reason which is perhaps a little more remote. But I should say this. It is interesting that when the Act to which these regulations refer is amended in the way in which the regulations will apply different groups of people will be treated differently. That concept is known as hybridity, as noble Lords know. In regard to a Bill, of course, it results in somewhat lengthy proceedings before it can actually be done.
However, let me explain what I mean. We have this list. Let us take the English list, never mind the Scottish list. Noble Lords know that we have different lists in the hospitals—totally different lists—which will be approved. That is an interesting point. Let me digress for a moment. What will happen? The noble Lord, Lord Ennals, has told us that for his complaint, about which we all sympathise with him, he has to take a particular drug, and a very valuable one, these tablets DF118. They are available on most of the hospital lists but they are not available on this particular list.
Let us suppose that a patient in hospital is on a particular drug which is perfectly permitted on the hospital list. Then that patient is discharged. In the fullness of time the hospital consultant writes to the general practitioner and says, "This patient is on such-and-such a drug". The general practitioner says, "Oh, well, I cannot prescribe that because it is on the black list". What is to be the situation? Must the patient then go to the hospital pharmacy. If he does go to the hospital pharmacy and expects the dispensing to be done there, I should think he will get a rather strange answer.
But what I am more concerned with is the fact that certain people who are more or less resident in hospital institutions will be able to get a certain drug, while other people who are not resident in those institutions, who are outside, but who suffer from the same condition will not be able to obtain that particular drug. In other words, we have different groups of people being treated differently under a statute.
Then there is a fourth matter which I think raises grave doubt about the whole proceedings. It has already been referred to by other speakers. That is the whole question of the possibility of an appeals mechanism. As already stated in another place yesterday, the Secretary of State acknowledged that he felt there was a need for an appeals procedure and that he would be entering into negotiations to devise an acceptable procedure and to introduce it. When asked by Mr. Michael Meadowcroft why he should not introduce the appeals procedure before the regulations were implemented, the Secretary of State, Mr. Fowler, said, in a rather unusual reply, at column 697:I cannot take the responsibility for the delay, which was entirely the fault of the General Medical Services Committee, not the Government".If an appeals procedure is necessary in connection with these regulations, then an appeals mechanism is necessary: it does not matter tuppence who is responsible for the delay. I accept that the Secretary of State is probably right and that the British Medical Association—not the General Medical Services Committee, which is a slightly different body—has some responsibility for the delay. Be that so or not, the fact remains that if these regulations require an 523 appeals procedure then they require an appeals procedure; we should know about it before the regulations come into force.
We are talking about an appeals procedure that could possibly allow an individual doctor to override the blacklist in certain specific circumstances. But there are other needs for flexibility, for appeals and for changes. I shall come to them. First, however, there is the general matter. If these regulations come into force in the manner that is threatened and likely, I have no doubt that, if they are subsequently challenged in the courts, the challenge will be successful.
I should like now to refer to other bureaucratic muddles which will indicate, I believe, the need for further thought. They are bureaucratic muddles that will be the inevitable consequence of the procedure upon which we are now embarked. I should first like to remind the noble Lord, Lord Glenarthur—I know that he is aware of this—that many modern group general practices, on the advice of his department and sometimes with the help of public funds, have computerised their operations, including their whole repeat-prescription systems. This is quite an important mechanism. It makes for economies. Repeat prescriptions are necessary for certain people—those suffering from epilepsy, diabetes or other conditions for which they require continuous therapy. By computerising repeat prescriptions, one can ensure that they get the right drug in the right amounts at the right interval, and also that they are recalled for a review of their prescription at the right intervals so that it can be reconsidered.
The average general practitioner received the list only a week last Monday. Many did not receive it until the Tuesday or the Wednesday. In other words, the noble Lord and his colleagues are giving those general practitioners a matter of days in which to reprogram their computers—an enormous undertaking that will be a heavy burden for the doctors themselves and for those who work in their practices.
I move to the consequences of the uncertainty about what is to happen to articles which chemists and dispensing doctors are left with—this was mentioned by the noble Baroness, Lady Masham—and which they will never be able to get rid of. It is interesting to find that this is already happening. I do not say this in any way as being to the credit of my profession. It is, however, obvious that dispensing doctors are now prescribing those particular items with a quite extraordinary rapidity to make sure that their shelves are empty of them by 1st April.
The noble Lord, Lord Ennals, asked what he was to do about his DF 118 tablets. I can tell him one thing that he can do. He can come to me and I can give him a prescription, a bulk prescription, which will carry him far beyond 1st April. For some time I have been prescribing a substance—quite a valuable therapeutic substance, though, I agree, not an essential one—for two noble Lords, one who sits on the Government Benches and one who sits on the Labour Benches, which is now on the blacklist. What have I done? I have given both those noble Lords bulk prescriptions which will carry them far beyond 1st April.
524 I am merely suggesting to the noble Lord that what he will find, and what I am already finding, is that pharmacists are going to general practitioners they believe to be co-operative and saying, "Look, I'm going to have an awful lot of this or that left on my hands. Haven't you got any patients you might help?" This is not a very creditable kind of exercise, but I think it is right to warn the noble Lord that he will find that the drug bill initially is not going to go down; it is going to go up. It is going to go up for that particular reason.
Now let us move to another uncertainty. I want to say—
§ Lord Kinnaird
My Lords, if I may be excused for interrupting, before the noble Lord has to prescribe any more drugs can we not get on and vote?
My Lords, it is not my fault that we are here at this hour, and the noble Lord should use his undoubted influence with those who manage Government business. I intend to say what I have to say, and I hope that other noble Lords will listen. If the noble Lord who has intervened does not wish to listen, I think that possibly we could do without him when the vote comes.
Let me now refer to the consequences of the uncertainty about an appeals mechanism and flexibility with regard to the list. This is a matter which has been referred to by many noble Lords in the course of the debate. It is a matter of the utmost importance, particularly to the pharmaceutical industry. If a list system is to work effectively, we must have a mechanism, an understandable mechanism, whereby new drugs, if they are valuable and useful and economic, can be added to the list, and old drugs which have become obsolete can be removed from it. We have heard nothing yet about that mechanism. Indeed, that is partly why there is grave anxiety in the pharmaceutical industry. As certain noble Lords have said, it is threatening the whole question of investment in the pharmaceutical industry in this country. One noble Lord mentioned Robbins, who have opened a new place. I had the honour of hosting a reception for them on that occasion. Unless we hear what is to be the mechanism for adding new things to this list—if we are to have a list—I am very doubtful whether the noble Lord will find that as many new things do in fact arrive as have been arriving in the past.
I have been talking in the main about the white list. I should like to come for a moment to one or two items on the black list. I do not want to have an argument about it, but, as the noble Lord will recollect, I intervened and we talked about things such as Flora margarine. My recollection of the actual situation is that there are some substances which in certain limited circumstances can be prescribed if it is held that in regard to those cases in which they are prescribed they are in fact a drug rather than a food; or, as in the case of the other item which was mentioned—Nivea cream—they are a drug rather than a cosmetic preparation. To hear some people talking about the freedom with which some of these things have been prescribed you would think that there have never been any constraints at all on what a general practitioner can prescribe. Of course there have been constraints.
525 The noble Lord, Lord Glenarthur, in response to my intervention, when I said that I doubted very much whether certain of these substances had been prescribed at all since the National Health Service started, said he would show me the prescriptions. I should be delighted to see them. When I see the prescriptions I shall ask him what on earth his department has been doing to allow those prescriptions to go through. There is a mechanism, and the mechanism that has existed in the past is as follows. If a doctor's prescribing habits are extravagant, if there is excessive prescribing or extravagant prescribing, he is called to account. The general practitioner receives twice yearly an analysis of his prescribing costs—how much per patient, how much per prescription, how that relates to and compares with prescriptions, and the cost per head for other doctors in comparable areas. If his prescribing costs exceed substantially those of other doctors, he is called to account. That has been the system. If he was found to have been prescribing extravagantly, the excess could be, and often was, deducted from his remuneration.
If the noble Lord, Lord Glenarthur, tells me that doctors have been prescribing almost everything from rice pudding onwards, I would ask, "What on earth has the department been doing?" I have made inquiries about these matters and I am told that there have been two cases—two only—in which Flora was held, in the particular circumstances in which it was prescribed, to be a drug in those cases and therefore it was allowed by a medical services sub-committee when a hearing was held. Does it mean that it can be prescribed by anybody for anything? I think that the same applies to Nivea. Therefore, it seems to me that there are items on the black list which have never really been prescribed and I can only assume that they have been put on that list as a kind of window dressing to show how necessary it was to intervene to stop doctors prescribing in this extravagant way.
I must repeat once again that those of us who support this Motion, as amended, believe—and believe very deeply—that there should be major economies in the drug bill. We believe that there could be major economies in the drug bill, but we do not believe that any of those economies will be achieved by this particular route.
This is almost the last possible occasion on which to ask the Government to think again. I really do wish that they would do so. They are making a grave mistake. I do not think that they will achieve the results for which they hope. I believe that they will find that the drug bill will go up rather than down, that there will be all kinds of administrative muddles, and that the exercise will prove to be costly, rather than the reverse.
However, I am quite sure that, if the Government were prepared to proceed by another route, they could save not the small amount which they are proposing to save, but at least £200 million a year on the drug bill without detriment to the patient and without doctors having to forfeit their clinical rights in any serious way at all. I support very strongly the Motion of the noble Lord, Lord Ennals, as amended by the amendment of my noble friend Lord Kilmarnock.
§ 11.32 p.m.
§ Lord Wilson of Langside
My Lords, my task in winding up this debate from these Benches has been rendered much the easier by the speech just made by my noble friend Lord Winstanley. As I listened to the debate I made up my mind that I would not shake—indeed, was incapable of shaking—the conviction of the noble Lord, Lord Colwyn, but it occurred to me that perhaps my noble friend's speech had given the noble Lord at least some food for thought.
It would be unforgivable at this time of night, even with the noble Lord, Lord Kinnaird, gone, to repeat what has already been said so effectively. However, at the risk of transgressing in that connection, let me say that we were surely indebted to the noble Lord, Lord Ferrier, for expressing his outrage at the timing and placing of this debate. It really is quite outrageous, as I think both he and my noble friend Lord Winstanley said (and I apologise for repeating it), that we should be placed in this position without the opportunity to consider in particular the legality of the implications of what was said in the debate yesterday in the other place and what is said in the Fifteenth Report of the Joint Committee on Statutory Instruments, and the implications also of the provisions of Article 30 of the Treaty of Rome. It is a great pity that we were not able to give more mature consideration to those matters in this debate. I hope that the Minister in his reply will be able to reassure us on these matters.
Turning to the debate, I should like very briefly to deal with some of the matters which have been raised. I was puzzled by some of the comments which the Minister made in opening. I was puzzled in particular when he objected to the criticisms relating to the lack of consultation on the part of the Government. I can understand the circumstances, because I do not like corporatism myself—I always associate it with Benito Mussolini. I can understand the Government feeling that there are some matters upon which they must make up their own mind. However, when we look at the history of this matter—certainly the recent history, because of course the history of the expenditure on drugs or the drugs bill is longer than that—it seems quite absurd to complain.
The recent history begins with the Greenfield Report. If you examine this, you find that, having accepted this report, the Government suddenly did a U-turn on it without any consultation. And, after all, the report had commented on the circumstances: that the committee had had to work from a timetable; they had not been able to look in depth at all the topics which arose in discussion; and they expressed a willingness to continue their work if the Government wished them to do so. But, without any adequate consultation, the Government did, in effect, a U-turn. In the face of that situation, to criticise us for complaining of the lack of consultation I should have thought was quite unfounded. I have been throughout puzzled at the apparent indifference of the Government to the criticism of Members of this House such as the noble Lord, Lord Porritt. They cannot answer it. They simply appear to ignore it.
Might I deal with two comments that were made by two of your Lordships who have spoken in the debate. 527 The first on which I would touch was that of the noble Lord, Lord Holderness. Like myself, he said that he spoke from the position of an ignorant layman—and I do too. I could understand the reasonableness of his approach to the whole matter. One could not quarrel with that. But I was puzzled as to the grounds on which he reached the conclusion that, in the face of the professional opinions which had been expressed, no Government could ignore the expenditure implications of the matter. We are not suggesting from here that any Government should ignore the expenditure implications of this matter. Surely the gravamen of our attack is the competence of the Government's handling of the whole matter, because of course the whole matter started with the storm which arose within the medical profession from the Government's first list, which, on any view now, is seen to have been quite a dotty one.
The noble Lord, Lord Nugent of Guildford, said that, while acknowledging that the limitation of the clinical judgment of a doctor was a serious matter, he could not accept that no limitation would be acceptable in all conceivable circumstances. I do not think that any one would necessarily quarrel with that. But here again the point surely is that in the known circumstances the problem of excessive expenditure on drugs could be dealt with without limitation on the clinical judgment of the doctor. In other words, with all respect to Lord Nugent of Guildford, the point which he made was not a valid point. Of course, with expenditure running at £11½2 billion a year no responsible Government could refuse to act, we would agree. It is the way that they have acted that we are complaining about, and that surely has been made clear in this debate.
The noble Lord, Lord Molson, who also contributed thoughtfully as he always does, referred to the autonomy of the medical profession and said that the Government were simply discharging their duty in a way which he thought would be satisfactory to all concerned. That appears to ignore entirely the letter from the chairman of the General Medical Services Committee, which was referred to in detail—and I shall not repeat it—by the noble Lord, Lord Ennals, in opening the debate.
That is all I have to say on what was said in the course of the debate. It does not seem to have got through to the Government that what we are attacking is the competence with which they have handled this matter, and the unnecessary upset it has caused within the medical profession, without whose co-operation the success of the National Health Service will be less than it would be otherwise. I would commend to the House the amendment of the noble Lord, Lord Kilmarnock.
§ 11.41 p.m.
§ Lord Glenarthur
My Lords, with the leave of the House, perhaps I may say that we have covered a lot of ground in this debate in which many expert and eminent Members of your Lordships' House have taken part. I am grateful for the many helpful remarks which have been made on this side of the House which have led to a balanced discussion. Perhaps I may try to answer some of the points which have been raised 528 tonight. There are rather a number of them, but I shall do my best to cover as many as I can.
Before I do so perhaps I ought to say a word or two about the timing of the debate tonight. I am sure that the noble Lord. Lord Ennals, the noble Lord, Lord Winstanley, and the noble and learned Lord, Lord Wilson of Langside, will understand that this subject is a matter for the usual channels. It was agreed through them that today's order of business would be what it was, and that is a matter for them and not for me.
The next point which concerned your Lordships was the report of the Joint Committee on Statutory Instruments raised by the noble Lords. Lord Ennals, Lord Kilmarnock and Lord Winstanley, and the differences between the English and Welsh and Scottish schedules. I am the first to admit that there have been typing errors and errors of omission here. There are only three minor differences. I need not go into the details now. My right honourable friend has already announced in another place that these trivial errors will be corrected in amending legislation.
As for the question of legality, which the noble and learned Lord, Lord Wilson of Langside, raised I have to tell him that so far as the Joint Committee on Statutory Instruments are concerned they have not queried the legality of the regulations, and indeed the Deputy Speaker in another place ruled only yesterday that the differences between the English and Scottish schedules did not affect their legality. I quote what he said at col. 684:I have looked at the 15th report, and I must tell him that there is nothing that invalidates the regulations before the House".The noble Lord, Lord Porritt, was one of several of your Lordships who raised the matter of the answer to a question in the European Parliament and suggested that the recent European answer was to the effect that the selected list is illegal under the Treaty of Rome. Lest anyone should misunderstand perhaps I ought to say that that particular answer set out certain criteria for such schemes and confirmed that the European Commission would try to ensure that national schemes met these criteria. There was no suggestion that the selected list is illegal in European law, and the Government are satisfied that it meets our obligations under the Treaty of Rome. Those who raised that will be aware that it is a matter for the lawyers, and I am not one, but nevertheless we are confident that what we are doing is perfectly legal.
So far as substitution in reverse is concerned, which was a point raised by the noble Lord, Lord Kilmarnock, I can tell him that the joint committee commented on the arrangements for reimbursing a pharmacist who dispenses a proprietary product when a generic one is not available. These are long-standing arrangements which have nothing to do with the selected list, and the joint committee's fears that they could lead to disputes between pharmacists and their FPCs have not in practice been borne out over the years.
Earlier in the debate the noble Lord, Lord Ennals, produced a couple of quotations. Perhaps the most recent and the most important was the quotation from my right honourable friend the Minister of State for Health which suggested that he had rejected the selected list in November 1983. What my right 529 honourable friend rejected then was an across-the-board selected list, and that the Government continue to reject.
Perhaps I may assure the noble Lord—and my noble friend Lord Colwyn made this point for me—that he can find DF118 on the list as dihydrocodeine tablets BP; so he need not get a monthly, yearly or 10-yearly supply of drugs from the noble Lord, Lord Winstanley.
A point raised by the noble Lord, Lord Ennals, and by the noble Lord, Lord Porritt, concerned the United Kingdom's position in the spending league. They quoted examples of countries with higher prescribing rates than the United Kingdom, but they conveniently ignored those with lower rates, such as Holland, Canada and the Scandinavian countries with their so-called model health care systems. Spending leagues are largely beside the point when all Western Governments agree that they spend too much on drugs. Even the BMA accepts that economies are possible. We have heard nearly everybody tonight agree that economies are possible and so I do not understand the defence that is made in relation to other countries.
I am the first to acknowledge the involvement of the noble Lord, Lord Porritt, in the pharmaceutical industry and his very great experience. The savings expected through the selected list account for less than 5 per cent. of NHS sales of 21½2 per cent. of total sales of the pharmaceutical industry. The United Kingdom is only 4 per cent. of the world drugs market. We are talking about a tiny fraction of 1 per cent. of world trade in drugs. I do not believe that that effect will be enough to bankrupt a successful industry.
My noble friend Lord Nugent pointed to a steady increase in National Health Service funding. He referred to the National Health Service as the sheet anchor of the life of this country and also pointed to the enormous growth recently in the number of prescriptions—a 40 per cent. growth. He quoted Aneurin Bevan and what he said about the cascades of drugs. I am grateful to him for his remarks. He highlighted many points that I have endeavoured to make from this Dispatch Box over the months which have indicated quite clearly that in funding the NHS this Government are committed to its best interests and we stand by everything we have said.
The noble Lord, Lord Pitt, in his remarks spoke of clinical need. He spoke about a recommended list. He felt that a recommended list was the best way to proceed and not the selected list that we have discussed. I have to tell him that the point about that is that it would not guarantee the savings which we require in these circumstances. He spoke about opting in. He preferred the Greenfield recommendations. I know that the noble Lord has a keen involvement and will shortly have a keener involvement in the British Medical Association, but the BMA rejected the Greenfield proposals.
§ Lord Pitt of Hampstead
My Lords, the noble Lord the Minister really must not persist in that. The BMA did not reject the Greenfield proposals. What the BMA recommended is what I said in my speech. Greenfield proposed that unless the doctor ticked the 530 prescription, there should be generic substitution. What the BMA recommended was that the doctors should tick the prescription when they agreed to generic substitution. To say merely that the BMA rejected Greenfield is unfair.
§ Lord Glenarthur
My Lords, the fact is that the BMA did not accept the recommendations in the totality which came out of the Greenfield report, whatever the noble Lord says.
He went on to describe the process of consultation and said that it was quite wrong of us to have adopted this particular mechanism without discussion. He said that it was important in principle that with all changes of this sort there should be full prior discussion. I cannot agree that that is a sensible or practical way and I do not think that the noble Lord, Lord Ennals, would think so either; because if he is going to go down that road, I can only say this. When faced with the sort of cuts which had to be made as a result of the IMF loans in, I think, 1978, when substantial cuts had to be made, for example, in capital spending in the National Health Service, the Government were faced with a situation that would lead to just the sort of discussions which the noble Lord is now advocating in the case of the selected lists.
As for the remarks of the noble Lord, Lord Pitt, about general prescribing, can I say that we accepted the advice of independent experts that the drugs on the selected list should be generic whenever possible. I am very glad that the noble Lord, Lord Pitt, agrees with me on this. Where branded products such as Maalox and Gaviscon are on the list, it is because the advice was that there was currently no suitable generic equivalent. We shall be encouraging the manufacture of suitable generics to replace them. I might add, in part answer at least to the noble Countess, Lady Mar, that in the case of antacids the experts did not think that any of the branded products were ideal, either. They are retained temporarily because they are a bit nearer to the ideal than available generic drugs but will be replaced in due course.
My noble friend Lord Holderness applauded the appeals procedure which I described in my early remarks, and for that I am grateful. He called for flexibility from my right honourable friend the Secretary of State. I am quite sure that my right honourable friend will note his remarks and, indeed, I can assure him that my right honourable friend is always flexible in matters like this. It is important in this case that the procedures which we have set up are brought into effect soon in order to achieve the savings for other parts of the health service which are needed. I am grateful to him for making those points.
The noble Lord, Lord Hunter, set in context the views of the medical profession and their support for the list. I, too, am tempted to quote the many doctors I have spoken to, who have just as sincere views about clinical freedom as has the noble Lord, Lord Pitt, and the noble Lord, Lord Porritt, but who support the Government's proposals. He made one or two other remarks about patent life. That is a complex area and one that I shall have to write to him about. I would not dream of tackling a subject like that without the noble Lord, Lord Lloyd of Kilgerran, being here. I see that he was here earlier. Perhaps that was an even better 531 reason for not going down that particular road. The noble Lord, Lord Molson, said that claims that savings would not be made were quite wrong. He said that that view was quite unfounded. I have to agree with him entirely on that. He thought we had only scratched the surface, quoting drugs affecting him. He quoted particular drugs that he knows well and he also quoted some stunning examples of possible cost savings.
The noble Countess, Lady Mar, asked particularly about Sainsbury's products. The fact is that they are prescribable as things stand at the moment. If we do not list them, doctors who wish to be awkward will start doing so. It would then be the pharmacist who would have to run round to Sainsbury's to get them, and not the patient. Not all the products in the black list have been prescribed recently. Those I have specifically mentioned have been. The noble Countess is sure that no doctor would ever prescribe most of the items in the black list. What possible objection can she have to the Government saying that it is not permissible to do so? What restriction on judgment or clinical freedom is it to tell a doctor that he cannot do something that, according to the noble Countess, he would never dream of doing anyway?
The noble Countess went on to talk about the naivety of the politicians and bureaucrats in producing a list. That is not the case. The lists were drawn up by eminent doctors and pharmacists and later on, if time permits, I may go into more details on that. She spoke about other savings that could possibly meet the needs of the health service in raising finance. Of course, she will be well aware that we have established a general management function within the health service, have set about cost improvement programmes, and have set about Rayner scrutinies, all of which together have produced so far something like a 1 per cent. saving which can be applied elsewhere in the health service; so it is wrong to suggest that in pursuing this particular means we are not going to add to that already significant improvement.
We have been into the details of the Greenfield proposals, which the noble Lord, Lord Rea, also raised. It was a question of clinical freedom that worried the BMA in the first place; and that is what I was trying to allude to when I referred to Lord Pitt's remarks. It is a fact that doctors under those circumstances would not have had all the clinical freedom that I think the noble Lord, Lord Rea, would like them to have.
My noble friend Lord Colwyn made a robust and helpful speech. He referred, particularly latterly, to the appeals procedure but he thought that many major objections to the scheme had been answered. I also believe that many objections have been answered.
The noble Baroness, Lady Masham, asked me a number of questions. I shall try to answer two: in particular why Actifed was removed from prescription. The fact here is that expert advice is that there is no clinical need for compound cough mixtures such as Actifed. The British National Formulary says that they have no scientific basis and no place in the treatment of respiratory diseases. I quote:Such preparations are to be deprecated not only as irrational but also for administering a large number of drugs to patients in inapproprate dosage and in excess of their needs.532 I believe that this very clear and cogent expert opinion is more than adequate explanation for our decision to accept the advice of our experts that Actifed should not be available.
So far as weaning people off Valium is concerned, the fact is that no benzodiazepines should be used for long-term treatment and questions of relative strength, as such, do not really arise. There are real difficulties over reducing dependency, not always soluble by substituting one variety of tranquilliser for another. The ultimate goal, of course, is to avoid the prescription of these drugs in the first place. As to the noble Baroness's question about the review, I can assure her that we are setting it up and I referred to the details in my earlier speech. My noble friend Lord Mottistone referred to the committee, which I mentioned just now, and I can let him have the details which show quite clearly that all the people on it were experts in their field. I am grateful to my noble friend for his helpful remarks.
I must say that I am a little surprised, and to some extent sad, that the noble Lord, Lord Ennals, and others opposite have chosen to oppose measures which are designed to produce significant and sensible savings by sensible means. I am surprised that they have chosen to pitch their tents on what I think is rather shaky ground. I often wonder about the noble Lord, Lord Ennals', view and I often think of the noble Lord as an apostle in search of a creed. But I am not sure—and I suspect that this is his problem too—that he knows just which followers he is seeking to recruit. I have answered his charges and those of other noble Lords opposite several times during the last few weeks, and I have to say that the force of their arguments, in my view, has diminished rather than increased, as the beneficial nature of our proposals and the unsatisfactory present situation have become more widely understood. Their advocacy has certainly become more strident, but in that I think it has become less convincing. They have not been able to marshal really sound reasons for their opposition to the measures: nor have they presented credible alternative policies for limiting an astronomical NHS drugs bill without harming doctors', patients' or taxpayers' interests.
The principal features of the selected list are that it will meet all clinical needs; it will help to encourage the prescribing of generic preparations rather than more costly brand-name equivalents without seriously diminishing the doctor's clinical freedom; it will have only minimal effect on the overall profitability of the pharmaceutical industry; and, above all, it will release additional resources for further improvements in patient care in the National Health Service.
By contrast, the noble Lord and others opposite—who are, I think, anything but united in their total approach to this problem and have no credible policies to advance—have put forward proposals which range from simple support for generic substitution to wholesale nationalisation of the pharmaceutical companies. My Lords, the noble Lord says he has not said a word, but it is the stated policy of his party. If he wants to stand up now and refute it, then I shall be all too willing to listen to him. Enforced generic substitution in itself would only tinker with the edges of the problem: it would not produce the savings 533 needed for further improvements in our health service and it would infringe doctors' liberty to a far greater extent than the selected list.
I respect the sincerity with which the noble Lord, Lord Kilmarnock, holds the views he has put forward, but I hope he will agree that what I have said tonight makes more sense than he previously understood, and, I hope and believe, good sense at that. Our final selected list is the result of enormously wide consultation and consideration. I am convinced that our proposals are the right ones. They are the only ones which avoid the dangers that I have described and achieve results leading to the improvements we need. That is why I ask your Lordships to reject decisively the Motion before the House tonight.
§ Lord Shaughnessy
My Lords, before the noble Lord the Minister sits down, he commented on one of the parts of the 15th Report of the Joint Committee on Statutory Instruments, but he neglected to say anything about the second point raised in that report. I wondered whether he would care to comment on it now.
§ Lord Glenarthur
My Lords, without referring to all the notes that I have before me, I could not possibly find out which point that was. But I will certainly look at it and let the noble Lord know.
§ 12 midnight
§ Lord Ennals
My Lords, I am sorry to rise at precisely midnight, but it certainly was not my fault that the debate started as late as it did or that so many noble Lords took such an interest in it. I want briefly to thank those who have supported my Motion, as amended by the noble Lord, Lord Kilmarnock, and indeed others who have spoken in the debate.
The Government may conceivably win in the Lobby tonight, but I believe that they are on very shaky ground for reasons that have been given, which I will certainly not repeat. The noble Lord, Lord Glenarthur, said that I had become increasingly strident, but if anyone has become increasingly strident it is the noble Lord the Minister himself, who made extraordinary statements as if he was quoting me about things that I have never said at all.
I want to make just three points in relation to his remarks and then only two in relation to those of other speakers. First, on consultation, he really gave no satisfactory explanation at all for the failure to consult in either a discussion document or a Green Paper. In fact, he went so far as to say that that is not how Governments work. Maybe that is not how this Government work, but it is how most Governments in the past have worked. When we came to the PPRS, which he will recognise as the principal means of controlling prices and profits within the pharmaceutical industry, there was a consultation period of well over a year before we finally reached agreement with the pharmaceutical industry, though, of course, we had to compromise. One has to compromise in everything that one does.
It was said that the Government had no alternative. Of course there were alternatives. It was simply that they chose the wrong one. Why did Ministers who, in 534 statements that have been quite clearly quoted and that are known to the whole House, had turned down the limited list, do a U-turn? Ministers who said that the idea was wrong now say that this is the only way to do it. It is incomprehensible how they could have done so.
The Minister totally failed to justify his suggestion that GPs have been playing dirty, in a sense, in prescribing Flora margarine, make-up and all this utter nonsense. I do not think it helps the Minister's case, or the Government's relationship with the pharmaceutical industry, or with the doctors, openly to attack doctors and the pharmaceutical industry in the way that he has done. If he suggests that I have been making an attack upon those industries, he knows perfectly well that that is not true. I just want to raise two points that were mentioned in the debate—
§ Lord Brougham and Vaux
My Lords, will the noble Lord answer my noble friend's question about the Opposition's nationalisation plans?
§ Lord Ennals
My Lords, I will make it absolutely clear. When I was Secretary of State for Social Services, I made it plain that it was not the policy of the Government to nationalise the pharmaceutical industry. Had I not done so, it would have been impossible to attract into this country the new investment as a result of which the present Secretary of State is having the pleasure of opening research laboratories for which I made provision as Secretary of State.
I said I wanted to make two comments in relation to other speeches. I thought that the noble Lord, Lord Porritt, made a remarkable speech. The noble Lord is one of our most distinguished doctors, and his reputation stands head and shoulders above most of those in the profession. When he said that this was a breach of a bond, this, I believe, was the most important statement that was made in this debate. I want to say to the noble Lords, Lord Nugent and Lord Mottistone, that of course I do not believe that there is anyone who is criticising the Government at this stage who does not accept that we have to make cuts in drug costs. Let me make that quite clear. It is not the argument as to whether there should be cuts in drug costs. After all, it was I who introduced the PPRS in the first place. I should make it clear that what is at issue in this debate is whether the method the Government have chosen, quite contrary to the views of their own advisory groups and without consultation with the professions, is the best way to do it.
My noble friends, those on the Alliance Benches and many on the Cross-Benches have indicated quite clearly that they do not believe that the Government are going about it in the right way and do not believe that the proposals that are before the House are acceptable. I therefore withdraw the Prayer but I stand by the Motion that is standing in my name. I indicate in advance that I will accept the amendment which 535 will be formally moved by the noble Lord, Lord Kilmarnock, and ask all those who are critical of the Government to think again.
Motion for annulment, by leave, withdrawn.
§ Lord Ennals had given notice of his intention to move that an humble address be presented to Her Majesty praying that the Regulations (S.I. 1985 No. 296) be annulled. [15th Report from the Joint Committee.]
§ The noble Lord said: My Lords, I do not wish to move this Motion.