Pharmacy: Nuffield Foundation Report

HL Deb 04 June 1986 vol 475 cc1026-57

6.19 p.m.

Lord Hunter of Newington rose to call attention to the Nuffield Foundation report on Pharmacy; and to move for Papers.

The noble Lord said: My Lords, this report, I believe, is of great importance and significance to everyone. Do your Lordships remember years ago the first time they entered a pharmacy, sometimes called a druggist or apothecary? The shop had a distinctive, unusual smell. There were rows of bottles, all with Latin names, and perhaps a jar or two of leeches. Medicines were prepared and compounded at the rear of the shop. The pharmacist was a friendly, helpful person, and if one felt unwell but had no prescription, then he was prepared to advise.

History tells us that the apothecaries stayed in London during the Great Plague when many of the physicians fled. Whatever the truth of that, their connection with human illness goes back many hundreds of years, and doctors and pharmacists have frequently worked together for the benefit of sick people. The schools of pharmacy in this country have achieved high professional standing in relation to retail pharmacy, the pharmaceutical industry, and the field of medical research. It is mainly about the first of those that I should like to speak to your Lordships.

There are about 10,000 pharmacies in England and Wales dispensing 350 million prescriptions ever year. That costs the National Health Service more than £1.7 billion. There is no control or restriction over who may open a pharmacy or where, but there must be a qualified pharmacist in control whenever a pharmacy is open.

The situation is different in many European countries and in the United States of America. We have all heard of and seen the drug store in the United States, which does so many things other than dispense doctors' prescriptions. On the other hand, in France or Austria a pharmacy only dispenses drugs and it does not sell other goods. In the United Kingdom we have the big multiple chemists that also sell many items, and the small pharmacist who very often has a modest shop as well. His income comes substantially from National Health Service dispensing of prescriptions, but to make his livelihood he may have to earn 30 per cent. of his income or more from other commercial interests.

However, there are problems. There are economies of scale in dispensing National Health Service prescriptions. The more prescriptions that are dispensed in a pharmacy, the less that each of them costs, because overheads are spread more thinly and chemists obtain discounts if they run large organisations and buy drugs in large quantities. So the larger the number of prescriptions, the more profitable is dispensing and the greater is the saving of public money.

It is therefore not good for the taxpayer if there are many small pharmacies open near one another. A balance obviously needs to be struck between the size of the pharmacy and ensuring that sick people do not have to travel too far to obtain their medicines. The report tells us that there are too many pharmacies in towns and cities and not enough of them in rural areas. What the report does not mention is what relationship it thinks pharmacists should have with dispensing doctors in rural areas.

There is another set of problems related to developments in the pharmaceutical industry and to the modern technology of packaging and presentation. In contrast to 50 years ago, when the pharmacist compounded his medicines, the modern pharmacist does very little preparation and dispensing. He buys from the manufacturer drugs that are ready for use by the patient, often packed in special containers and accompanied by instructions clearly presented for use. Those containers include the childproof bottles that the noble Baroness was telling the House about at Question Time the other day. I did not dare rise to tell her that the person who taught me how to open one of those bottles was my granddaughter aged five.

Should the pharmacist, as a drug expert, have a different relationship with the family doctor, as many hospital pharmacists have with the medical staff, and ought something to be done to discourage the development of small pharmacies where there are already enough of them? Should there be that new role for pharmacists? What asssistance can be given by new communications technology, perhaps with substantial savings in costs?

In hospitals, nurses have begun to play a wider role in drug treatment, particularly in respect of complex cancer therapy. What sort of people are pharmacists? They are one of the best qualified, in a professional sense, of the professions allied to medicine. They are graduates, and the standards of their professional education are rigorously maintained by the Pharmaceutical Society. That training has begun to recognise what is called clinical pharmacy, which is designed to achieve maximum efficiency and to minimise toxicity in the giving of drugs to individual patients.

Should the pharmacists be remunerated, as in the past, in relation to the number of prescriptions that they dispense, or should they be remunerated differently, as highly qualified professional people giving a different type of service? It was against that background that the Nuffield Foundation set up an inquiry into pharmacy. The chairman, Sir Kenneth Clucas, expressed the optimism of the report when he stated: The pharmaceutical profession has a distinctive and indispensable contribution to make to health care that is capable of still further developments". The report deals in the main with community pharmacy, or general practice pharmacy as it is sometimes known. It recommends that pharmacists and general medical practitioners should co-operate on a more systematic basis to increase the effectiveness and reduce the costs of prescribing. Their co-operation should include regular discussion on appropriate medication, drug interactions, and adverse drug effects.

There is, however, the difficulty that the pharmacist is running a business as well as dispensing and he must make a reasonable living. There tends to be a clash between the requirements of running a business and professional duties and responsibilities. The Nuffield Report suggests that payment under the National Health Service contract should be reduced and that separate payments be made for other professional activities. Other noble Lords will be discussing that point.

When one considers the modern scene, with massive drug taking and drug abuse, one begins to wonder whether there is an even wider role for pharmacists in health education, with perhaps expert input into police drug squads. Such highly qualified people could surely be of inestimable value in such situations. Do they have a role, for example, in relation to the complex use of medicines in homes for the elderly and perhaps in assisting in the rational prescribing that is so important for the third world? I believe that a number of noble Lords will be dealing with facets of that problem. The Nuffield Foundation has done a service to the pharmacist and to the public by commissioning this inquiry. I beg to move for Papers.

6.28 p.m.

Baroness Gardner of Parkes

My Lords, I thank the noble Lord, Lord Hunter of Newington, for bringing this very interesting debate before the House today. It concerns a subject in which I have a great interest. As a general dental practitioner, I have always felt an affinity with the pharmacists with whom I have served on many health committees. Indeed, most of my remarks will be about the community pharmacist.

The noble Lord, Lord Hunter, mentioned the smell of an old pharmacy. I have in my own home a cupboard that I have owned for about 20 years, which was an old pharmacy cupboard. It still has that smell, and it is very pleasant and certainly nostalgic when one opens it.

I must also explain to the House that I shall not be able to stay for the whole of the debate. I explained that fact to the noble Lord, Lord Hunter, when he kindly invited me to speak. His debate was put down at short notice and I have a long-standing engagement. However, the noble Lord persuaded me to speak and I am glad that he did so.

In speaking about the Nuffield report it is also interesting to note that the DHSS discussion paper on primary health care has a large section on the community pharmacist which obviously has been related to work done by the Nuffield committee, as there seems to be quite a parallel. There are definitely changing patterns for the community pharmacist. When I was on the executive council of the health service in inner London in the 1970s, before the first reorganisation of the health service, many small pharmacists were suffering badly. They simply could not make ends meet and small pharmacists were greatly disadvantaged. There was enormous pressure then to do something to help the small pharmacies to stay in business.

That action was taken and was very effective, to the extent where the front loading for the small pharmacist is now making him quite a lot better off than the equivalent pharmacist in the larger concerns. This means that the community pharmacist is now asking for action to be taken to counteract the previous action that was taken. It is interesting to note that there is in the other place the National Health Service (Amendment) Bill which will be coming to us and which deals with many of these points concerning the community pharmacist.

Without doubt, as in dentistry, there is a need for a more rational distribution of pharmacists. The dentists and the pharmacists have over the years resisted any attempts to set up a committee which would determine where and how they should practise. They like a completely open, free market. But the situation has changed. I believe that dentists too are reaching a point where they would welcome a committee along the lines of the Medical Practices Committee which has always, in medicine, determined where doctors were needed.

In the days when dentists and pharmacists happily set up anywhere and everywhere it was because there was plenty of work for them. Now there is a considerable fall-off in the amount of work for them. In dental practice the reasons are different, but in pharmacy many of the lines that were standard for the chemist only to sell are now readily available in the supermarkets. That is definitely affecting the income of community pharmacists. A number of pharmacists now find themselves locked into small practices which they cannot sell. No one wants to buy simply because they are not profitable enough.

These pharmacists will, I am sure, be delighted at the provision which I understand will be included in the Government's Bill—it has been agreed by the Pharmaceutical Services Negotiating Committee and the DHSS—to provide early retirement with benefits as high as £22,000 according to a formula, the length of time and the business of the pharmacist. I welcome that and I hope the same will happen in dentistry.

There is a suggestion in the Nuffield report that patients should be able to register with a particular pharmacist. That proposal, while not being harmful, will have only a limited role. However, there are some elderly people who benefit from an attachment to one place and there is no harm in that. It is a good idea to encourage pharmacists to play a greater advisory role in health matters. I am at present an elected member of the General Dental Council. We have considered this matter in relation to our own profession. We think that it is excellent for pharmacists to be better informed and able to help people who go to them, as the public tend to do. Many more people will pop into a chemist shop for a little help or relief than will go to the bother of arranging a medical appointment.

It is important that in the case of both medicine and dentistry pharmacists must be trained to recognise which conditions need referral to a doctor or a dentist. Many simple complaints can be dealt with and that would remove a burden from doctors and dentists, but there are other more serious conditions which must not be left unrecognised, because that could prove harmful.

Many people are merely looking for some comfort and understanding. I remember, when I first came to England, going to a general practitioner's waiting room where there was an elderly lady sitting in front of the fire. When her turn to see the doctor came up she said to the others waiting "You go ahead of me." It transpired that she only went to the waiting room because she liked the warmth of the fire and the company of the people in the waiting room.

In this country we suffer from too much legislation. We certainly also suffer from too many prescriptions. Those matters are clear-cut. Throughout the whole country we have had, and continue to have, what are called "dump" campaigns. Under these dump campaigns, hundreds of thousands of tablets, potions, pills and lotions are delivered to chemists but eventually thrown away. Those hundreds of thousands of prescriptions must represent a considerable waste of money. There may be many reasons why prescriptions are not taken. I remember a patient many years ago who had some trouble after oral surgery and I gave him a prescription for antibiotics. His wife returned 48 hours later and told me that he was no better and, in fact, was getting worse. I said, "Really, but those tablets should be having an effect." She said, "But he has not been taking any of them." I asked why not and she replied, "The prescription states that they should be taken after meals and he has not felt up to eating." That is a true story and it is typical.

Some people like to be given a prescription by the doctor but have no intention of taking whatever is prescribed. Others take a few tablets and are not sure whether they like them or whether the tablets disagree with them. Indeed, there are many drugs for which it is important to make clear to patients that the) must take the whole course of treatment or they could be harmful.

Shortly after the election of the Conservative Government in 1979 the BMA and the Pharmaceutical Service Negotiating Committee put forward a suggestion which they considered would save money. It was for the use of three-tier repeat prescriptions. This involved the use of what I believe is called a no-carbon-required pad in triplicate on which the patient's name and address is written. Each of the three sheets represents one-third of the prescription, so that the patient can collect one-third of the prescription and if more is wanted the second and third parts can be collected and treated as a continuation of the same prescription. I understand that although the BMA and the PSNC were much in favour of the proposal and the Minister of Health was considering that it might be good, eventually, the Minister was persuaded against the idea because the officials said that the cost of the no-carbon sets was known but the cost of the saving was unknown. Therefore they did not think it was worth trying.

Under present conditions, 70 per cent. of national health prescriptions are dispensed free of charge to patients. Only 30 per cent. are paid for at £2.20 per item. In some cases that is because the item is less expensive than the £2.20. I know that if I go into my chemist and ask for some Piriton for hay fever and present an NHS prescription he will tell me not to bother because the prescription price is £2.20 whereas the product can be purchased for less than half that price. It is clear, therefore, that the people who are using national health prescriptions all the time are those people who do not have to pay even half price but are receiving completely free treatment. I find that there is a considerable gulf beginning to occur in both dentistry and pharmacy where some people get everything totally free and others have to meet the total costs. Of course, I think that the gap is much greater in dentistry than it is in pharmacy.

There are a lot of new things that we are planning to do and we are asking a lot of the pharmacists. We are asking them to be skilled businessmen, and I should point out that under their new contract, which has already been agreed, they still have a cost-plus basis. As a dentist, I have prayed all my life for a cost-plus basis but dentists have never achieved it. Under the cost-plus basis those pharmacists practising in more expensive areas have direct help with their rent and rates. This is not the case in dentistry, where the dentist working in an expensive area is that much worse off than his colleagues elsewhere, because for dentists the system is worked out on an averaging basis.

As I say, we are asking a lot of the pharmacists. We want them to be skilled business people and we want them to be ethical professionals—and I have no doubt that they are—and we want them to be a mainstay of the community in caring for people. I have no doubt that they will respond. I have a very high regard for the members of the pharmaceutical profession and I believe that they will respond to these demands.

However, I say to the noble Lord the Minister and other noble Lords who are present today that we must not regard anything that has been decided in the Bill that is to come before us as being an end to the matter. My own experience in the health service has shown me that when ever a solution to a problem is found it subsequently creates a new problem of its own, and a few years later the question has to be looked at again and the next step has to be considered. Let us now press on with the Bill that is at present going through in another place and welcome it when it arrives in this House; and let us remember that it is just another stage in the long, continuing health story.

6.41 p.m.

Lord Rea

My Lords, I think that we should all be grateful to the noble Lord, Lord Hunter of Newington, for bringing forward for discussion this important document, which, as he says, affects us all. At some time in our lives we all make use of the services of pharmacists. I am personally grateful to him because it is not the first time that he has actually encouraged me to read properly an important report such at this, instead of just skimping the reading which I would otherwise have done. It is a very welcome addition to the discussion on primary care which is much in the news at the moment with the Government's recent publication of their long awaited Green Paper (actually it is now a Blue Paper) entitled An Agenda for Discussion.

In fact, that report in the section on pharmacy services refers to the Nuffield report and largely welcomes it. This evening I shall concentrate my remarks on the relationship between the community pharmacists and general practitioners which are both branches of the family practitioner service and in one of which I happen to work. Since I started in general practice, which is about a generation ago, I have been singularly fortunate in having very good relationships with the pharmacists in my area. In fact I can say that I and my colleagues have had a special relationship with the pharmacists who are working nearest to our practice. We have found them courteous, helpful and tolerant of the occasional inaccuracy in our prescriptions.

They have also been a very useful source of information: for instance, when a patient has needed an unusual drug or if it has been difficult for us to identify a preparation or drug that has been prescribed elsewhere and which a patient has produced and wants to have repeated. More than that, the helpful advice of a pharmacist on a number of prescribing problems has always been available and has been useful. Unfortunately it seems that this is not always the case and throughout the country sometimes not very good relationships are found with overt or covert conflict between two helping professions which should be co-operating.

The British Medical Association, while welcoming the report in general, has been a little lukewarm about it. I quote: The General Medical Services Committee supports the need for a greater clinical pharmacological input into patient treatment but is not convinced of the wisdom of persons with no formal clinical training or experience becoming involved in diagnosis or intruding into patient therapy without consultation with the doctor in charge". In my view that is rather a defensive statement but it reflects the feelings of the consumers association that advice given by chemists is not always good and is too often given by unqualified assistants rather than by the pharmacist himself—or herself, because it is more likely to be a woman, as women are in the majority now in the schools of pharmacy.

The British Medical Association discourages the idea of home visits by pharmacists or the registration of patients with pharmacists which was put forward in the Nuffield Report as a possibly helpful arrangement for old people who have complicated drug regimes and who may need guidance and reminders as to how to take their treatment. To my mind this is something which perhaps could be done rather better by a pharmacist than by the doctor. Certainly there could be greater collaboration in this area than is sometimes the case.

The noble Lord, Lord Hunter, has explained why this review—the report of the pharmacy profession—was necessary. A pharmacist's work has indeed changed over the past decade or two and though the potency of drugs has increased and there is greater need for care in overseeing that the drugs dispensed are correct, there is in fact far less work for the pharmacist to do which involves making up complex products in the pharmacy. Theoretically, this should allow the pharmacist rather more time to concentrate on professional activities other than physically preparing drugs for dispensing, and the report suggests a number of ways in which this extra time could be used.

But it faces squarely one of the problems of the community pharmacist, which is that his income is largely dependent on the amount of prescriptions which he dispenses. So an increase of the time in which he advises clients or patients may not seem to the pharmacist to be well spent if it results in advice against the use of a drug, though this may well be to the benefit of the patient and at the same time reduce the cost of drugs to the National Health Service.

In fact, the report says: It is very difficult to ask any professional to act continuously against his or her own economic interests. A serious criticism of the way in which the community pharmacist is at present remunerated is that it acts counter to rather than in support of the exercise of a professional role. This criticism we would stress is a reflection on the system and not on the individual pharmacist. It is the system that needs to be changed". I find the proposals for change in the Nuffield Report very well thought out. They suggest greater delegation of some of the routine activities of dispensing to assistants working under supervision and under careful rules, perhaps with the aid of more electronic equipment to reduce the incidence of errors and improve their detection. Suggestions are made about how such assistants should be trained.

With regard to remuneration, the report points out that payment systems influence behaviour, as I have mentioned, and it suggest that the linking of pay so closely to dispensing is one of the reasons why community pharmacists involve themselves personally in dispensing rather than delegating it to assistants. The present system does not encourage the individual pharmacist to collaborate with his general practitioner colleagues to reduce the level of prescribing or the cost of individual prescriptions, because that could lead to a reduction in the pharmacist's own income. I quote again from the report: The trouble about the existing remuneration structure is that it fails to support and reinforce the objectives that we think the Government and the profession should now pursue. It acts as a serious handicap to development instead of acting as a powerful force for change. The objective of changing the type of work that a pharmacist does in the community is not served by a system which requires that the whole of a pharmacist's own costs are to be met and the whole of his professional fee is to be paid by reference to prescriptions dispensed. Later the report recommends, that some of the amounts under either or both these headings should cease to be paid by reference to prescriptions dispensed and that the money so saved together with the basic practice allowance should be used to enable other professional activities to be separately and specifically remunerated. Then it goes on to list which work they feel should be encouraged, and it includes, first, work done in collaboration with doctors to improve the effectiveness and reduce the cost of prescribing, including work done as a member of a drug or therapeutics committee; and then, perhaps most contentious, advice to patients on response to symptoms which may or may not lead to the sale of a medicine. They admit that there are difficulties here and suggest that there is a variety of ways in which it would be possible to define the work for which payment is to be made and to monitor whether it has been done. One suggestion here is that pharmacists should provide a room where consultations can be held in private. This is in line with a suggestion of the consumers' association, but it is viewed with some alarm by the pharmacists themselves who are chary of possible medico-legal problems which might arise. It would seem here that the pharmacists are more afraid of intimate contact with their clients than vice versa.

They also suggest that there should be more services provided to individual patients on long-term or complicated medication. Here the controversial suggestion is made of a capitation fee for patients opting to register with a single pharmacy, to which the British Medical Association takes some exception. They suggest that pharmacists should be responsible for the supply of pharmaceutical services to residential establishments—old people's homes, for instance—and finally that they should be involved in health education and that all these activities should be recognised as meriting remuneration.

The report suggests that the number of pharmacy outlets should perhaps be reduced while retaining pharmacists in outlying districts who might not be able to operate on an economic basis without some special payment. But here there is scope for discussion with the representatives of general practitioners who provide dispensing services themselves. The report argues that there is still a role for pharmacists in remote districts but that this is rather a delicate area and will need some carefully conducted discussions between the two professions. I am sure the noble Lord, Lord Winstanley, will have something to say here. Dispensing general practitioners wish to retain their rights to dispense and argue that it is not economic to encourage small pharmacies to develop in such areas, and that their function can be perfectly well carried out by doctors, to whom the additional dispensing fees act as an inducement for them to work in such remote areas.

It is gratifying to see that the Government's agenda for discussion which I have mentioned takes up many of the suggestions put forward in the Nuffield Report, but it seems to me that they dodge the issue of exactly how to alter the contract and the system of remuneration so as to encourage, in financial terms, the expanded range of activities which they welcome and advocate for pharmacists.

Both the Nuffield Report and the agenda for discussion look at the education of pharmacists and point out that it is necessary for the rather rigid laboratory-based curriculum to be expanded and include aspects of the behavioural sciences which might be helpful to the community pharmacists in their wider role. There is already considerable criticism that pharmacy degree courses do not prepare graduates for the kind of work that they are going to meet when out in the field and where they are often very isolated from their professional colleagues. Several useful suggestions as to how this problem should be overcome are made in the Nuffield Report, some of which I think would make uncomfortable reading for the academics in certain pharmacy schools, but many of the suggestions will be welcomed by the more forward-looking members of staff in those schools.

Some of the same problems that face community pharmacists also face hospital pharmacists, particularly the dispensing of ready packaged preparations rather than the formulation of medicines in the pharmacy itself. The expanded role of hospital pharmacists into clinical pharmacy which the noble Lord, Lord Hunter, mentioned leads to them becoming much more involved in the actual ward care of patients in hospitals. It is recognised in the report as an important and desirable development. Where this is working well, it is much welcomed both by the doctors and the pharmacists, who found it a mutually very rewarding method of collaboration between the two professions. It means that more of the routine work in hospital pharmacies should be done by technicians and less by trained staff, in the same way as is suggested for community pharmacy. This has training implications for the junior personnel involved.

A sensible suggestion is that it should be possible for such technicians doing that work to enter the profession of pharmacy itself by enabling them to gain qualifications, if they have the ability, by the provision of part-time courses and perhaps the reduction or elimination of the required pre-registration year.

My Lords, I hope that the Government will be guided by the sensible recommendations which this report makes. The fact that they have already adopted a number of its recommendations in the Green Paper on primary care is a welcome indication that this is likely to be the case. Altogether, I think this is a sensible, forward-looking document which indicates how the profession should advance and change to adapt to present and future developments. If the recommendations are followed, I think that the profession of pharmacy will become more satisfying for pharmacists themselves, and it will also give a better service to the other branches of the health service and the public.

6.58 p.m.

Lord Winstanley

My Lords, bearing in mind the forthcoming debates in your Lordships' House on the National Health Service (Amendment) Bill, to which reference has already been made by the noble Baroness, Lady Gardner of Parkes, I think that this is a very timely debate indeed. Therefore, I would say that the noble Lord, Lord Hunter of Newington, has earned our thanks for introducing the debate at this time. It gives us, if I may say so, a first bite at a number of cherries which we shall be chewing over very carefully later on. I will leave that Bill for the moment, save to say that certain of the matters dealt with in it are dealt with comprehensively in this report.

Unlike the report we were discussing a little while ago to do with legionnaires' disease, which we had only just received, this report is one which I have read from cover to cover and therefore I feel perhaps I can comment on it without the same inhibitions as I had in the case of the other one. It is a very all-embracing and widespread report which seems to me to cover almost everything in the field of pharmacy. Therefore it allows us to stray very widely indeed in discussing this topic without finding ourselves outside the rules of order. In general I should like to give the report a very sincere welcome. I welcome the majority, if not all, of its recommendations, and in particular I welcome what it has to say about the relationship between the pharmacist and the general practitioner.

Turning to part of the report, I should like to quote one or two of the things said in the section on page 28, at the top: Doctors are increasingly recognising the value of a pharmacist's advice before reaching decisions on prescribing. Co-operation of this kind is much more rarely to be seen between the GP and the community pharmacist. I am not wholly sure that that is true, but that at least is what the report says.

It goes on on the same page to say: What is needed is a working relationship between GP and pharmacist in which prescribing and dispensing are discussed regularly and naturally between them, and not just as the consequence of a query on an individual prescription that has been made". I underline and echo those sentiments very warmly indeed. I have noticed that such things are beginning to happen.

Page 29, paragraph 3.44 in that section of the report, states: We think that there is a need for more systematic, though not necessarily more formal, arrangements to enable community pharmacists to co-operate with GPs in order to increase the effectiveness with which medicines are used and to reduce the overall cost of prescribing". To that too I say a fairly loud "Hear, hear".

I think it is right to say that there have always been—and I do not think that this is referred to anywhere in the report, and I have read it all—certain ethical difficulties with regard to the close working of the general practitioner with the pharmacist. Indeed, it has been regarded as ethically improper for a general practitioner to have any kind of commercial interest in a pharmacy business or indeed to be operating directly in partnership with a pharmacist. That impediment was overcome in my earlier days by the simple measures of a young doctor marrying a pharmacist, or, to show that there is no discrimination, occasionally a pharmacist taking the sensible decision of marrying a young doctor who was in general practice. I had many experiences of those unions operating happily and to the great benefit of the doctor and the pharmacist and indeed to the considerable benefit of their patients, but I have no doubt to the intense chagrin of other pharmacists who I think looked at such arrangements with grave distrust. That has been one of the problems.

When I worked in a group practice not all that long ago we had a pharmacist next door. We worked closely with him. Indeed, we had an extension telephone line to him. I could pick up the 'phone and say, "Look, which is the cheapest of these?" or "What is the dose of so and so?" or "What have you in stock?". It was very helpful. I do not think that the other pharmacists in the district altogether cared for it. But there is no doubt that that close association between the general practitioner and the pharmacist was immensely beneficial to me as a general practitioner. I am quite sure that it was therefore very beneficial to my patients. I hope we can arrive at arrangements whereby that can happen more readily and easily than it does now.

I note that the report refers to the fact that only in 150 health centres—I do not know how many there are in Great Britain—is there a pharmacy. Why is there not a pharmacy in them all? In part the difficulty relates to the matter to which I have just referred. Here I am treading on rather dangerous ground so far as some of my noble friends on these Benches are concerned; but some noble Lords will recollect that when we had the doctors' charter—I think that it was at the time when Mr. Kenneth Robinson was the Minister—there was a recommendation that we should have some kind of experimentation with a salaried service.

I am not crossing to the Benches next to me to say that I am wholly wedded to a salaried system, but it was recommended at the time of the charter that we should have an experiment with the possibility of a salaried service, not just for GPs but for pharmacists as well, in certain areas. If that were to happen it would be very easy indeed in a particular area to have a GP with a salaried pharmacist working in the same health centre. I accept that that is dangerous ground. I do not want to see us move to a salaried system, but I should like to see impediments to such a working partnership removed, and there are impediments.

The report lays considerable emphasis on the fact that the pharmacist is often the first port of call in time of health trouble. Indeed, we all know that to be true. It is to the pharmacist that the patient first goes. Here I should like to say a little about my experience in this field. In 1960, I think it was—I cannot be absolutely sure—I wrote an article in the Manchester Guardian on the subject. It had struck me at the time—and I had friends who were studying pharmacy and becoming pharmacists—that a great deal of that exacting and lengthy course (it is very lengthy indeed; almost as long as the course to qualify in medicine) was taken up with students learning to do things which, frankly, were no longer necessary. They learnt how to make pills, how to compound mixtures, how to make ointments and things of that kind. In other words, they were learning how to dispense in that sense.

In reality we now know that dispensing is not making pills or compounding mixtures. It is reaching on to a shelf, picking the right bottle of tablets, putting the right label on to them and passing them to the patient. If less of the time of trainee pharmacists or pharmacy students was spent in learning skills that were no longer required and some of that time could be used to train the pharmacist in the diagnosis and treatment of minor maladies, that would be to the advantage of all.

I was astonished at the time to get letters of rebuke—and one appeared in the Guardian from the secretary of the pharmacy society—asking what business it was of mine as a doctor to ask pharmacists to do my job. How times have changed! Now that is the job which many pharmacists are asking to do. It is the job too that the report for the Nuffield Foundation is asking them to do. That shows how times have changed.

If we are to change in that way and to recognise that the pharmacist is the first port of call, it could be helpful to the patient and the general practitioner by removing some of the workload if the pharmacist had a bit more training in the diagnosis of minor maladies and their treatment. That could be very valuable. But there would be other changes. If the pharmacist was so trained, we should have to make certain other changes. We should have to ensure that the pharmacist was remunerated directly for that professional service and that he was not required merely to finance that service by the sale of possibly unnecessary remedies.

That matter has already been referred to by the noble Baroness, Lady Gardner. It has always seemed to me in general practice that we too as general practitioners have encouraged the national reliance on remedies; that every symptom must have a remedy. It was my experience in practice that it may take only one minute to dish out a bottle of inert medicine, but it may take half an hour to persuade the patient that he did not need treatment.

If we are to take steps to train the pharmacist and to encourage him to be the first port of call and to treat minor maladies, we ought to remunerate him so that he does not find it necessary to subsidise that part of his work by selling the patient unnecessary remedies. If we did that we should be in a similar situation to the recent one with opticians, where there was a division between two jobs, one which was a commercial one of selling spectacles and the other a professional one of testing eyes. If we move in that direction with the pharmacists, I hope that we shall see to it that they are properly remunerated for the professional task of being the first port of call and being, as it were, a sieve that could reduce the workload of the general practitioner regarding dealing with minor maladies.

I was particularly interested that in the report totally separate sections are devoted to hospital and community pharmacy services. I should like to come at once to some of the recommendations and to point in particular to one with which I do not wholly agree. It is recommendation 40 on page 134. That states: Serious consideration should be given to the transfer of outpatient dispensing to the community sector, without reducing the number of pharmacists employed in hospitals". That is the recommendation, but it is a long section in the report on the hospital pharmacy service. It does not seem to me that that says enough about the recruitment of hospital pharmacists, which is a difficulty at the moment. But it comes with that recommendation. I notice that elsewhere in the report there is the possible suggestion that a community pharmacist might take over the work of the hospital pharmacist. In other words, it would still be a hospital pharmacy but it would be sited with the community pharmacist rather than the suggestion that appears to be implied in this recommendation No. 40 that hospital outpatients should almost invariably go to GPs for their prescriptions. That is a matter that I have pursued in your Lordships' House for a very long time indeed.

The noble Lord, Lord Ennals, will recollect that when he was Secretary of State a note of guidance was sent to hospitals which pointed out that where a hospital consultant retained clinical responsibility for a patient he retained with that clinical responsibility the responsibility for prescribing drugs and seeing to it that those drugs were dispensed in the hospital pharmacy.

I have in mind people who were on anti-coagulant therapy and things of that type and who had to go weekly to the hospital for blood tests. The consultant then adjusted the dosage. If he did not give the patient the prescription or the patient did not have it made up in the hospital pharmacy, the patient had to trudge round and make an appointment to see me as a general practitioner. By that time I should not have received a note from the consultant, and I would have to ring up the hospital to find out what the drugs were and what change had been made in the dosage. The patient had been put to a great deal of inconvenience and it had all probably cost a lot of money.

The noble Baroness will recollect that I have recently asked Questions, to which she has replied, about the comparative costs of prescribing and dispensing drugs by the hospital pharmacy and by a pharmacy under contract to a family practitioner committee. The noble Baroness has not been able to give me the exact costs. I have referred to the letter of guidance sent by the previous Government. I later asked Questions which established that the same policy was adopted by the present Government and is still adopted by them. I asked a Question which was answered by the noble Baroness's predecessor, the noble Lord, Lord Glenarthur. I asked: whether they will take steps to ensure that patients attending hospital out-patient clinics and who are under the continuous clinical care of a hospital consultant, and require drugs prescribed by that consultant, can have their prescriptions dispensed by the hospital pharmacy rather than have to pay an unnecessary visit to their general practitioner, who will not, by the time of the patient's visit, have received notification of the nature of the prescription". The answer which I received way back on 7th February 1984 was from the noble Lord, Lord Glenarthur, who said: Long-standing guidance to health authorities makes it clear that when a hospital consultant needs to retain clinical responsibility for the treatment of an out-patient, he should also retain responsibility for prescribing. The Department of Health will continue to follow up individual cases of non-compliance with the guidance".— [Official Report, 7/2/84; col. 1135.] I have given the department innumerable cases of non-compliance, but I now find that in the present situation, when hospitals are forced to try to save money, many of them no longer have a hospital pharmacist and in certain hospitals all out-patients are being referred for their drugs to general practitioners. First, it causes the patients a great deal of inconvenience and sometimes distress if they are not well and have to pay a special visit to the general practitioner. Secondly, it causes the general practitioner unnecessary work; and, thirdly, though it may save the hospital some money I suspect that it probably costs public funds a great deal more. That it is without quantifying the general practitioner's time or the patient's inconvenience.

When last I raised this matter in your Lordships' House I received innumerable letters from consultants. I have many of them here. One states: I am required to send all my patients away"— that is, all hospital outpatients— and to refer patients to the general practitioner for their drugs in order to save money for the hospital". The consultant points out that that probably does not save money.

Another consultant states: We have, during the last part of the last financial year, been asked not to prescribe drugs if at all possible but to return patients to their GP to get their prescriptions. This is undoubtedly more expensive to the public purse". That consultant rheumatologist with the Greenwich Health Authority further states: I would estimate that it would be as much as 50 per cent. to 75 per cent. more expensive. It is a most useful way of saving hospital money especially as our pharmacy budget at Queen Mary's has been markedly overspent". I hope that the noble Baroness will be able to answer that question at the end of the debate.

I have referred to Recommendation No. 40. I have no objection to the idea suggested in the report of a community physician taking over the role of a hospital pharmacist. But among the many letters that I have received from consultants since ventilating the matter, I have had one from a senior pharmacist with the hospital service who asks whether I realise that patients are sent to their general practitioner of necessity because the hospital cannot recruit pharmacists. He confesses that they cannot recruit hospital pharmacists because they do not pay them adequately and people will not seek the jobs.

I should like to ask the noble Baroness one or two specific questions. I should like her to tell us, if she possibly can, what is the present position with regard to the recruitment of hospital pharmacists. If it is impossible to get any, we need to know the reasons for that. Secondly, what can she tell us about the comparative costs to public funds of a patient having had to be sent unnecessarily to the general practitioner for his drugs, rather than those drugs being prescribed at the hospital by the doctor who sees him there?

If I receive answers to those questions, I shall be deeply grateful to the noble Lord, Lord Hunter of Newington, for introducing the debate, because they are questions which I have been asking over and over again for many years.

Lord Rea

My Lords, before the noble Lord sits down, I should like to back up his request to have those questions answered at the end of the debate; and if they are not, perhaps the noble Baroness will pass them on to the Minister.

7.15 p.m.

Baroness McFarlane of Llandaff

My Lords, I should like to thank the noble Lord, Lord Hunter of Newington, for giving your Lordships' House an opportunity to debate the Nuffield Foundation report on Pharmacy, and to congratulate the foundation on its initiative and the quality of its report. I also welcome the statement put out in the discussion paper on primary health care that the department will give the report serious and positive consideration.

The Royal Commission on the National Health Service which reported in 1979, of which I was a member, had an opportunity to look in broad perspective at the different professions within the health service and their relationship to one another. In that discussion I came to recognise the critical role played by the pharmacist. Two aspects of pharmacy concerned us. One was access to pharmaceutical services, especially in rural areas, and the effect they could have on access for the aged. Our deliberations were greatly helped by the OPCS survey on access to primary health care, which was published as a research paper allied to the commission's work.

The second point about which we were concerned was the evolving role of the pharmacist. We pointed out its increasing role in health education advice to patients, and the implications that that could have for economies within the service and also for advice to the health care professions.

Both those aspects of the subject have been covered well and in great depth by the Nuffield Foundation report. I am grateful for the way that it highlights the excellence of the background and education of pharmaceutical sciences, firmly built on physical and biological sciences, and the unique mix of the knowledge that they bring to the health service, which embraces the nature of the properties of drugs, the appropriate formulation of medicines, their actions and their interactions. The effective use of modern drugs is a prime consideration and hence the value of the advice that the pharmacist can give to the cognate professions.

I should like to take up the function of pharmacy in respect of my profession of nursing. Over the years, there has been a great deal of variation in the customary practice in respect of the administration of medicine and the scope of professional judgment accorded to nurses. When I trained as a nurse, almost 40 years ago now, on admission every patient was prescribed a limited list of medicaments, such as laxatives and simple analgesics which could be given as required by the nurse. In that, the nurse used her professional judgment. On leaving my training hospital I was surprised to find that that practice was not universal. I believe that in the intervening years defensive practices have been developed by many health authorities which have eroded the nurse's ability to use professional judgment in the use of medicines. That kind of restriction can militate against the rehabilitation of the patient.

I have been to geriatric wards and seen equipment installed, designed to help elderly people become adapted to self-administration of drugs before they are discharged home, but the equipment is left unused because of the legal implications associated with it. There are, however, some more positive developments, I believe, within the nursing service. I was on Monday at the nursing development unit at Oxford where patients are admitted directly for nursing care. There is at the unit a limited formulary of 60 items which a nurse may administer. Here, increasingly, the nurse is able to use her professional judgment. However, in other situations, a great deal of nursing time is wasted and patient treatment delayed, so that there is unnecessary suffering. A nurse may have to wait for a prescription from a doctor. I have witnessed this in the work of district nurses who may be delayed in getting dressings, ointments, aperients, and so on, that are well within their professional competence to prescribe.

We have then a whole area, already referred to, of more complex management of pain and management of patients on chemotherapy undertaken by the nurse. I rehearse these instances to underline the importance of the recommendations made in the Cumberlege report, Neighbourhood Nursing, and taken up in the discussion paper, Primary Health Care, that nurses should have the power to prescribe a limited list of items and simple agents as part of their nursing care programme and that the DHSS should issue guidelines to enable nurses to control drug dosage in well-defined circumstances.

The implications for pharmacy are, first, in the educational preparation of the nurse. I believe that nurses, to carry out this role, need a far greater depth of preparation. The pharmacist is the person to whom we should be looking for education in pharmacology. It is essential, I believe, that nurses should understand the action and the reaction and be aware of the contraindications in the use of certain medicines. Certainly, my own students in their undergraduate programme in the University of Manchester have a year's course in pharmacology together with a year's course in pathology. I am confident that with that kind of preparation they have a far more effective awareness of the action of drugs than they might otherwise have.

We should be looking to the pharmacist for help in the education of nurses. A colleague relationship with the pharmacist should be fostered and developed. I am excited, too, at the reference to the use of information technology on pharmacy and all that this could hold for cognate professions such as nursing and medicine.

As someone involved in higher education, I should like to turn now to the implications of the report for education. As a member of the University Grants Committee panel on subjects allied to medicine, which includes pharmacy, pharmacology, nursing and allied subjects, I have been greatly impressed with the scientific excellence achieved in many schools of pharmacy. This has been underlined when I have joined visits by the panel to the schools of pharmacy. It has also been underlined in our recent resource allocation exercise in which schools of pharmacy have figured very well and also by their ability to attract new blood posts in the universities. I recognise the value of the knowledge fed into the health care system by this discipline. Yet, as the report says, its relevance to practice has to be made apparent. The report suggests that practice or practice research units should be set up in the universities. These will have implications, I believe, for staff-student ratios and obvious resource implications for the universities.

In addition the report rightly stresses the importance of continuing education for the changes of role of the pharmacist. It is also suggested that continuing education should be made a condition of re-registration for practice. One would support that, having seen it happen in other health service professions. The Department of Education and Science has encouraged those of us in the university world to invest far more in continuing education. Unfortunately, no resources have been made available through the UGC. I believe therefore that the resource implications of the role in education and continuing education of pharmacists and allied professions such as medicine and nursing need to be addressed. This is, I believe, a responsibility of the department if it is to have an efficient heath manpower force.

Associated with the educational needs of the profession is the dilemma of attracting and retaining good scientists in the universities. There is the lure of industry. Pharmacists and scientists certainly have a contribution to make to industry. While university salaries remain at their present inadequate level, one has the dilemma of attracting and keeping pharmacists in the university sector.

I should like, in conclusion, to welcome the report and what it has to say about the enhanced role of the pharmacist, particularly in public education and advice to professions such as my own. I would, however, ask the Government to consider related suggestions—for instance, what the Cumberlege report says about the role of nurses in a limited formulary—and that the resource implications for the suggestions in education and continuing education should be taken into account.

7.27 p.m.

Lord Ardwick

My Lords, I believe that I am the only lay person to speak from the Back-Benches. I cannot therefore follow the arguments of the noble Baroness, Lady McFarlane of Llandaff. I have nevertheless a special interest in the subject. Twenty-five years ago I was reaching the end of a five-year term as assistant director of the Nuffield Foundation. I am delighted that thanks to the noble Lord, Lord Hunter of Newington, we are debating a report sponsored by that splendid institution. Indeed, the noble Lord, Lord McGregor of Durris, himself a foundation grantee, has reminded me that our previous debate this afternoon was very much in the Nuffield domain. In the early 1970s, the foundation set aside £250,000 after the Lord Chancellor's legal aid advisory committee had reported. The foundation set up a legal and research unit to study unmet legal need. As a result, the legal action group was established that created the radical atmosphere in which law centres proliferated and led to the Benson Royal Commission on legal aid.

This is, I believe, the first time that the House has used a Nuffield report as the basis for one of our free-ranging Wednesday debates. Yet this House has had close links with the foundation almost since it began. For as long as I can remember, such noble Lords as the noble Lord, Lord Todd, and the noble Lord, Lord Flowers—people of that high calibre—have served as managing trustees, for example.

The very first Wednesday debate that I attended 16 years ago was on ageing and the aged, and I fully expected noble Lords to deploy the conclusions reached by the studies the Nuffield Foundation had sponsored over a long period. Those studies dealt with psychological, sociological and physiological problems, but I am afraid that they had not made the slightest impression on the noble Lords of that generation.

Nor did we debate even the famous Nuffield studies undertaken by Members of this House. I am thinking of the long-term investigation into hospital functions and design led by the late Lord Llewelyn-Davies: or the work of the noble Baroness, Lady Wootton, on social science and social pathology; or Lord Taylor's work on good general practice.

My experience at the foundation was that the problem of communicating with the inner ring of decision makers was simple; yet it was always difficult to make an impact upon wider audiences and so produce a head of democratic steam behind proposals for reform. Therefore, I very much welcome the bringing of a Nuffield Foundation report into this wider area this afternoon. I hope that the two reports which they now have in the pipeline on town and country planning and the learning of languages in higher education will find their way some day into our discussions.

So far as this report is concerned, I speak only as a customer. Like some other noble Lords present in the Chamber, my experience goes back long before the National Health Act to when you could ask the local chemist—and no layman ever talks about a "pharmacist"—to relieve you of the symptoms of some minor ailment, the kind of ailment in respect of which you were reluctant to consult your doctor because it would be putting him to unnecessary trouble and yourself to unnecessary inconvenience and unnecessary expense.

In my district of Ardwick there was a chemist who had greater reputation, greater respect and who was held in greater affection than any of the doctors. I do not know what he put in his medicines but they were taken with great pleasure.

As an earlier speaker was saying, the great advantage of the chemist's shop was that it was a walk-in service. The great disadvantage was that you could not be sure of privacy and it was embarrassing to mention in the presence of other customers symptoms which could not be discussed in polite society in those inhibited days. Therefore, it is a very good idea that there should be a place in a chemist's shop where you can speak confidentially to the pharmacist. I can understand the objections to a closed room, but perhaps one could go round a corner and talk to him.

It is years since I asked an English chemist for advice. I am tempted to say that after the age of 40 every man is a fool or is his own pharmacist. However, that cannot be true, because if it were I might be asking for valerian or belladonna or some of the recipes of my youth.

On several occasions when in France I have consulted the pharmacien, who has, I think, a rather higher status than his opposite number here. I think that he undergoes a longer training of five years. I approached those people rather than tackle the difficulties of going to an unknown French doctor. Twice I had to seek help late at night. It seems that the French chemists accept an obligation that from time to time they must be available on duty for 24 hours or for a whole weekend. I often think of this service de garde when I see in the chemist's window in England a notice saying that they will open late until 7 p.m., or for an hour on Sunday morning.

I can see that there are great difficulties these days. Even if we could persuade the chemists to adopt the system of the French chemists, in these days of drug abuse and of violent assault, the idea of somebody being required to give a service at any hour of the night presents difficulties. Yet I should have thought that if chemists are to have a wider function, particularly a wider function of giving advice, they should be open longer than they are at present. They seem to close very early—at about 5.30 or 6 o'clock at night.

The report points out that on the Continent the pharmacists do not diversify into cosmetics or, to use an utterly vile word, toiletries. Yet that does not make them ethically superior to our chemists. Last week I was in France and each French pharmacy that I saw had a big window display for a slimming cream which the Advertising Standards Authority in this country would instantly reject as misleading.

They do not order everything better on the Continent. I once accompanied the noble Lord, Lord Bruce of Donington, as interpreter when he went to a hospital in Brussels in the hope that they would syringe his ears which had been made painful by the wearing of headphones all day. They said that they could not help him, because they did not have an ear specialist on duty. I was reminded of the famous Fleet Street chemist who many years ago on the morning of the resumption of Parliament had a busy time syringing the ears of the Press Gallery reporters!

I note with relief that the law should continue to require pharmacies to be under the personal control of a pharmacist, but that the requirement should be satisfied if, while absent on other professional work, he can be contacted. My mind went back to the famous Bardell/Pickwick trial, where, you will remember, a chemist was pressed into service on a special jury. He resisted on the ground that he had no assistant. The judge insisted that he should be sworn, but the chemist interrupted again. The chemist said, "There'll be murder before this trial's over". The judge was unimpressed. The chemist said, "I merely wanted to observe, my Lord, that I've left nobody but an errand boy in my shop. He is a very nice boy, but he is not much acquainted with drugs. I know that the prevailing impression on his mind is that Epsom salts means oxalic acid, and spirit of Senna, Laudanum". With that, said Dickens, the chemist composed himself into a comfortable attitude, and assuming a pleasant expression of countenance appeared to have prepared himself for the worst. I shall emulate the chemist.

7.38 p.m.

The Countess of Mar

My Lords, perhaps it will be some consolation to the noble Lord, Lord Ardwick, to know that he is not the only lay person on the Back Benches. I am patron of the Dispensing Doctors Association and that is where my interest in the debate comes from.

The Nuffield report on Pharmacy has very effectively brought into the public arena a situation which has been developing over a number of years. I too am most grateful to the noble Lord, Lord Hunter of Newington, for bringing the contents of the report before your Lordships for debate. As we have heard other speakers say, technology has radically changed the role of the high street chemist since the inception of the National Health Service. It is hardly surprising that qualified pharmacists are seeking to extend their role, albeit in an advisory capacity, into the field of general health care. The rewards in terms of job satisfaction cannot be many for the modern pharmacist within the community.

Before I embark upon consideration of some of the recommendations in the report, it is important that I point out that what we are discussing is the future of the profession of pharmacists and not the National Health Service pharmaceutical provision. All registered medical practitioners are qualified and licensed to dispense medicines and over 3 million of our population receive the National Health Service provision from some 3,000 National Health Service general practitioners. I have said before in your Lordships' House that all patients should have the right to choose whether their medicines are dispensed by a doctor or a pharmacist, and obviously it is practical that doctors practising in rural areas should also dispense. Any new contractual arrangements for pharmacists should not interfere with the integrity of the rural dispensing regulations which ensure a cost-effective and comprehensive provision, and have been agreed mutually after long debate between the two professions.

We need also to remember that doctors carry the burden of responsibility in law for patient care, and that they can never abrogate their own responsibility. Collaboration between GPs and pharmacists can only be beneficial, and should be encouraged. However, I am concerned that people with no formal medical qualification or experience should become involved in diagnosis, or should intrude into patients' therapy without consultation with the doctor—the noble Lord, Lord Rea, mentioned this, and I think he tends not to agree—who is ultimately responsible.

Many of the suggestions made in the report for the extension of the role of the pharmacist would duplicate systems already made available by doctors, nurses and health visitors as part of their long-accepted duties. Home visiting beyond the provision of oxygen is known by health care professionals to be costly, and under the current financial restraints I cannot see that the proposals in the Nuffield report are feasible. A peripatetic pharmacist would also be taken away from his major responsibility, his pharmacy The pharmacists' professional organisation has made much of their role in supervising dispensing of prescriptions and discovering and rectifying mistakes made by doctors. Now this report suggest that they can leave this work to unqualified staff while they make domiciliary visits.

All those involved in health service provision hear a responsibility for health education, and it is laudable that pharmacists should want to utilise their skills and their premises in furtherance of better provision, but they must receive a comprehensive training. The report of the Consumer Association survey on advice given by pharmacists published in the Which? magazine of August 1985 highlighted some serious flaws in the advice given by some pharmacists, or permitted by them to be given by their assistants.

To offer advice without the necessary qualifications would seem to be asking for payment under false pretences. Not all pharmacists surveyed followed the guidance of the Pharmaceutical Society when dealing with patients asking for advice, and in almost all cases medicines were sold whether or not their need was indicated. It is inevitable that there will be conflict between their commercial and advisory selves, and the commitment to reduce drug consumption when they derive the bulk of their income from the provision and sale of drugs is clearly unlikely to materialise.

I fully understand the desire of pharmacists to find a more rewarding professional role, but few of the proposals in the report could be implemented without cost to the NHS; and in some cases a quite considerable cost in altering premises and that kind of thing, for example, and home visiting. In view of the financial restrictions currently imposed on the health service it could well be said that some of the proposals are untimely. There is a good deal pharmacists can do to help themselves, their counterparts in other disciplines in the health service and their customers, without demanding payment; but maybe I am being too altruistic.

That they should collaborate with doctors and other health workers goes without saying. Many do this very effectively now. Advice to patients on minor ailments has been a traditional part of the service they offer. Patients will soon know which pharmacists provide sound advice and which merely want to sell them nostrums of limited therapeutic value.

If doctors, nurses and health visitors are not currently providing the services for which they have contracted, family practitioner committees have the power and the duty to see that they do provide them. I can see no need for yet another professional group taking on these responsibilities. I also have a feeling that there would be a great many confused patients, and sick elderly patients do not take much confusing—for that matter, sick young ones do not either. The NHS was created for the benefit of patients, and we really must ensure that their interests are paramount. Their freedom to choose must be defended, and we have a duty to ensure that the service gives value for money.

7.44 p.m.

Lord Ennals

My Lords, we are greatly in the debt of the noble Lord, Lord Hunter, for having introduced this important debate, and I want to thank him. At one stage he was wondering whether there would be adequate response to the subject that he had chosen. When I realised that he had attracted a former assistant director of the Nuffield Foundation, a professor of nursing, two general practitioners, a dentist, and two old politicians, if I may say so, I began to ask myself, "Is there a pharmacist in the House?" We have not actually got a pharmacist but we have got the patron of the dispensing doctors association, so we have done the next best thing.

I recognise that this is the first comprehensive report on pharmacies in very many years. I also thank the noble Lord for adding to my reading in the Recess. Not only the Nuffield report, but comments I had made in speeches when Secretary of State, and in articles subsequently written about the crucial role of pharmacists in the community, in hospitals and in industry. I found the report refreshing. I am certainly not going to get into the argument as between dispensing doctors and pharmacists.

It has long been my view that pharmacists have a range of expertise and experience which should be more widely available in society, and that pharmacists should be enabled to take on a wider role with greater responsibilities. That is the real lesson and message of the report, for which we are also grateful to Sir Kenneth Clucas as chairman of the review team.

It is a view also held by the Pharmaceutical Society, and in their evidence to the Nuffield inquiry they demonstrated not only the essential service that the profession, in all its branches, provided for the public but also the unused potential that could be, and ought to be, tapped in the public interest. The Nuffield report endorses those views, and in so doing has improved tremendously the chances of developing the pharmacists' full potential.

This broad view was fully endorsed by the Nuffield report, and also by a leading article in the Pharmaceutical Journal on 22nd March which said: The publication of the Nuffield report has been awaited with hope, but with some trepidation. In the event, the report not only places a high value on pharmacy, but on pharmacists themselves. There was a fear at one time that arguments that pharmacists were over educated for their tasks and that they could be replaced by lesser qualified individuals, might have found favour with the inquiry. On the contrary, the report says that there can be no question of the educational qualifications for community pharmacists being reduced. I agree with that, and the more so when I read the Consumer Association's report referred to by the noble Countess, Lady Mar. Perhaps I may just draw a little from the study they made. They showed that it was easier in 1984 compared with 1974 to consult the pharmacist in person when a specific request was made. But when no such request was made a large number of inquiries were either still handled by assistants without reference to the pharmacist, and they asked fewer relevant questions.

A significant minority of pharmacists, one in four, were still selling medicines for potentially serious symptoms without asking further relevant questions, or advising the need to see a doctor. Of the four out of five pharmacists who sold medicines for serious symptoms, almost two thirds failed to check whether any other medicine was being obtained. I learnt from that that it was of great importance that the standards of education and training of pharmacists should be increased, and certainly not decreased.

There is a demand for good, qualified pharmacists, and adequate training is a virtual guarantee of employment. The Government's own Green Paper on higher education showed that in 1983 unemployment in associated disciplines was as follows: of those trained in chemistry, 29 per cent. of graduates were unemployed; in biochemistry, 33 per cent. were not in employment; biology, 39 per cent. When I say were not in employment, I mean that they were not using their skills for the benefit of society, for which they had been trained. These are horrifying figures which tell the sad tale of Britain's decline in economic performance. But in contrast pharmacy had a nil percentage of unemployed because of the demand for pharmacists. The section in the report on remuneration for community pharmacists is a crucial part of the report and very relevant to the profession itself. The committee wants a shift away, as has been said, from payments based on prescriptions throughout to a system based on services provided. It proposes some new services such as a state remunerated advice service to patients and an advisory service to doctors—not necessarily the rather incestuous relationship that I thought the noble Lord, Lord Winstanley, at one stage seemed to suggest—nevertheless an advisory service to doctors the latter funded in part with money currently allowed as legitimate expenditure on medical representatives by pharmaceutical companies.

Pharmacies providing an advisory service for patients should have facilities for confidential discussion. This is an important point which was touched on by the noble Lord, Lord Winstanley. If I return to the Consumers' Association report it showed that four out of five conversations with pharmacists could be overheard and that may be a possible source of embarrassment to customers who may wish to discuss an ordinary common complaint such as diarrhoea or what-have-you. If one is to consult a pharmacist I think there ought to be circumstances in which it can be done privately. The Consumers' Association concluded that while it might be more convenient to visit the local chemist's shop to obtain a medicine for a minor ailment than to have to book an appointment to see the doctor, not all pharmacists were following Pharmaceutical Society guidance when giving advice, and large numbers of inquiries were handled by other staff in the chemist's shop. Overall, it was thought that the situation could be improved but there was concern over the lack of privacy in the average chemist's shop.

The report also wants part of premises devoted to NHS pharmacy services to be "visually distinguishable" from the rest, although it does not feel that the professionalism of pharmacy need be compromised by a commercial environment—I agree with this. It is critical of retail establishments engaging in pharmacy simply to enhance their image. One can think of examples in this respect. The report backs the new contract in overall terms, but criticises the absence of a national appeals procedure in relation to contract limitation. It is against pharmacists having any say in the local sub-committees deciding in the first instance whether a new contractor would be necessary or desirable. I think that is a very important point. I do not know whether the noble Baroness, before the Bill is brought before the House, will have time to consider this. If she does not, clearly there will have to be consideration in this House about precisely that question. It will possibly be an issue to which we shall return.

A number of points were raised in the Nuffield report which would positively require the Government to look again at some aspects of the contract negotiated by the Pharmaceutical Services Negotiating Committee and the DHSS. Perhaps I may pick on three. In a sense this is pointing towards some of the issues that will certainly arise when the health services Bill comes before us.

First, there is the ability that has been demonstrated over the past eight years to influence numbers through the price mechanism which it is said should be fully utilised. I think that is right. If the differential between different sizes of NHS contractors is not producing the desired results, it should be adjusted, says the report. The more accurate the tuning of the differentials, the fewer the applications that will need to be considered by the family practitioner committees.

Secondly, the report thinks it is wrong that pharmacists should play so large a part, as is proposed, in deciding whether or not new applications should be granted; a point that I have already touched upon. Thirdly, the report states that there should be an appeal against decisions of the sub-committee to the Secretary of State and not as at presently proposed to a neighbouring family practitioner committee. In that respect the report is absolutely right and this is a further point which we shall need to come back to when the Bill comes before us.

There is one quotation from the report which I should like to give. It states: There is one element in the new agreement with which we do not agree, and that is the decision, as a consequence of abolishing the basic practice allowance, to load the NHS remuneration even more heavily on to the number of prescriptions dispensed. For the reasons we have given, we regard that as a thoroughly retrograde step". I think we have to consider that very carefully. When I, as Secretary of State, introduced the system of loading NHS remuneration on the basis of the numbers of prescriptions dispensed, it was at a time when there was a serious decline in the number of pharmacies across the country. That loading certainly stopped what was a very serious slippage in the number of available pharmacists. That slippage was to the detriment of the customer as well as to the small pharmacies, and we were seeing small pharmacies going out of business. Many of the small pharmacies do not want to see simply a reversal to the previous situation just because there is now, as it is argued, a surfeit of pharmacies or an adequacy of pharmacies, or whatever we may say.

My own local pharmacist Mr. Michael Franks (from whom I quote every time I touch upon the subject in this House) as far as I am concerned is, like my general practitioner, a fount of wisdom and a wise counsellor. I consult him frequently.

Baroness Trumpington

My Lords, the noble Lord will send him a free copy of Hansard.

Lord Ennals

My Lords, I am not paid for it, if that was the suggestion.

Baroness Trumpington

My Lords, I merely said that I expect that gentleman will get a free copy of Hansard tomorrow.

Lord Ennals

My Lords, I promised him that if I were to refer to him I would give him a free copy of Hansard so he gets paid. I thought for one horrid moment that the noble Baroness was suggesting that I was not declaring an interest.

I am quoting my pharmacist and he said: I trust you will push for your Robin Hood scheme to be retained". Two of his arguments as a small pharmacist tire: Small contractors are useful to the community"— so say all of us, including the Nuffield Committee. He says: Nobody in the pharmacy gains from the scheme to any great extent—but smaller contractors lose out to a great extent I certainly do not want to see introduced into our country a system which squeezes out the small corner-of-the-street pharmacies who often are vital members of the community and to whom, because they are better known, and not just a little corner of a big pharmacy, is someone to whom one goes for consultation.

I turn briefly to hospital pharmacists on which this time I must declare an interest as the editorial adviser to the new publication Pharmacy Management, which brought out a special supplement on hospital pharmacy in April this year. The past 20 years have seen two highly significant developments in the nature and conduct of pharmaceutical services in hospitals. It has been noticeable in this debate that we have talked almost entirely about community services. I think that this is quite right because three-quarters of the pharmacists are working in the community. I said there have been two highly significant developments. The first has been acceptance of the principle of specialisation within hospital pharmacy. Among these two key areas are quality assurance and drug information. The second even more critical development was what has been described as the move of the pharmacist out of the pharmacy and onto the ward. The potential consequences of this development raise by far the most important issues in considering the future role of the hospital pharmacist.

There was a whole section in the Nuffield report of great significance to hospital pharmacists, touching on pay and a variety of other issues that I am not going to go into but which I hope the Government will study because we shall want to go into them eventually. I do not think that we can expect from the noble Baroness a reaction to every one of the 42 recommendations, or however many there were, in her speech tonight. It would otherwise be a very long speech.

If I may quote from Pharmacy Management: Hospital pharmacy over the last 10–15 years has been leading the profession in many professional aspects and the potential to continue on this path is certainly present. However, the most overwhelming problems caused by the acute shortage of junior hospital pharmacy personnel are such that not only is the extending role threatened but the very basis of hospital pharmacy is in jeopardy and unable to follow the Nuffield pathway". I think we must take this very seriously. When I said that it was very good that there are virtually no pharmacists who have had their training and education who are not now putting it at the disposal of the community, the situation actually was much worse than that because there is a serious shortage of pharmacists operating within the hospital system. I think we must try to remedy that.

As I have said, the report has 22 recommendations on hospital pharmacy alone, so that its total number of recommendations must be more like 80 or so. I want to come to my conclusion, but there is a third section that we have not talked about. That is the industrial section. This is an issue which has not been touched upon here and it concerns only a small proportion, relatively, of the pharmacists who are involved in industry. If I may quote a report about Professor Peston, the professor of economics at Queen Mary College, University of London, and a member of the Nuffield inquiry, he said that he had no doubts about the professionalism of hospital pharmacists, who were perhaps the most impressive people he had met on the inquiry, and not many doubts about the professionalism of industrial pharmacists. The real problem, he said, concerned community pharmacists.

That really takes us back to where we started. The bulk of pharmacists in this country are working in the community; and all of us, I think, would echo the basic recommendations of the report that they should not only be trained to the maximum degree; they should not only be enabled to use the skills that they have for our benefit and the benefit of the country; but they should be an integrated and integral part of the community health team which we shall no doubt discuss when the White Paper which introduced a Green Paper which introduced a Blue Paper introduced by the Government comes up for debate in this House.

8.3 p.m.

Baroness Trumpington

My Lords, may I first of all add my thanks to those who have already praised the noble Lord, Lord Hunter of Newington, for giving us this opportunity to debate the report of the Nuffield inquiry into pharmacy. The timing of this debate can be looked at by me in two ways. The various exchanges of views we have been listening to will certainly be noted by my colleagues in another place who are presently discussing the National Health Service (Amendment) Bill. Those same views will most certainly be valued in the context of the Government's discussion document on primary health care. However, these two factors leave me little choice but to say that the Government are examining carefully the recommendations of the Nuffield report and are consulting interested parties about the way forward. I would not want to say anything today to pre-empt or prejudice the consultations that lie ahead on these important issues.

The Government wish to see discussion on the important issues of how to make the best use of nursing skills and clinical expertise. Views are being sought on five main issues contained in the report. One of these is that, as part of the nursing care programmes, nurses should be able to prescribe a limited list of items and that they should be able to use their professional judgment on matters such as the timing and dosage of drugs prescribed by doctors for pain relief. Ministers will be holding a series of meetings with representatives of the professions, or consumer organisations and other bodies. But they will also want to hear from local bodies and individuals, those engaged in providing care, those receiving it and others with an interest. So, until all the consultations are completed, it would be premature for me to make any statement on this issue. I am sorry to keep on saying that I am not going to say anything—and boy, am I going to take a long time to say nothing!

The noble Baroness, Lady McFarlane, described the nurses in the Cumberlege report. The Government will be very interested to have the views of all interested parties on the proposals in the Cumberlege report that nurses should be able to prescribe a limited list of items and a varied dosage of drugs. Any legal or statutory implications arising from whatever changes are recommended will be considered at the end of the consultation period when all comments have been examined and analysed. These would obviously be new training requirements, if changes were proposed, and these would be brought to the attention of the nurse education and training bodies.

What I would wish to say immediately is how much the Government welcome the establishment of the committee of inquiry by the Nuffield Foundation and we are pleased to note the publication of this detailed and thorough report. Let me illustrate just how thorough the committee was. It met 29 times, received over 200 submissions, held 12 sessions for oral evidence and made a number of visits to working pharmacies. We congratulate the committee for its work. The report represents an important contribution to an important debate.

The Nuffield report covers all aspects of pharmacy: in the community, in the hospital, in industry, and in education and training. The aspect of pharmacy with which the public most often comes into contact is community pharmacy—the local chemist about whom we heard so much this evening. Public interest in medicines and health has always been evident. Nowadays, however, although patients need a prompt and efficient service, they quite rightly want more information given to them. They want to know more about their treatment; more about any potential side-effects of their medication; and they are more willing to accept greater responsibility for their own health.

At the same time, there has been a shift of emphasis in the role of the community pharmacist. He still has the task of providing an accessible and responsible source of advice about the treatment of minor ailments, over-the-counter medicines and counselling patients on the use of prescription medicines. However, as the noble Lord, Lord Hunter, said, community pharmacists are now rarely called upon to make up a medicine from different ingredients. Now, most medicines are supplied already prepared in a form allowing direct supply to the patient. These are the so-called original packs. But, while the pharmacist's expertise on the manufacture of medicines is now not so important, other areas of the pharmacist's knowledge are increasing in importance. The limitations of medicines, their possible side-effects, interactions between different medicines and foods: these are all areas in which the patient relies on his local pharmacist to complete his proper and efficient treatment.

It is our belief that these developments create a need for, and provide an opportunity for, the skills of community pharmacists to be put to better use. The Government are committed to using the skilled resources of pharmacy as effectively as possible. The Nuffield report makes a number of recommendations about the development of a wider role for pharmacists. There may well be; I should like to say to the noble Lord, Lord Hunter, a role for pharmacists in the fight against drug abuse. I am sure that this will be one of the topics which will be aired when we discuss the possible wider role of pharmacists and I shall be very pleased to hear the view of the profession itself on this subject.

The second stage of our policy is to develop the role of the pharmacist in allowing the profession to make a greater contribution to patient care. With the agreement of the profession, we have embarked on a two-stage process to achieve our joint aim, which is better pharmaceutical services for patients. Stage 1 is the introduction of a new form of contract, a better arrangement for pharmacists that is less complex, more efficient and more conducive to a more effective distribution of pharmacies. Stage 2 (the development of a wider role for pharmacists), will have a firm basis, provided by the new contract for pharmacists.

In 1985, after more than a year of negotiations between the pharmacists' negotiating body, the Pharmaceutical Services Negotiating Committee, agreement on a new NHS contract for pharmacists was reached. It was approved by the then Minister for Health and by a conference of the local pharmaceutical committees. Both sides agreed on the desirability of early implementation. However, in the light of subsequent legal advice it was reluctantly decided to delay the introduction of the new contract to allow the Government to confirm their powers to make the new arrangements for the allocation of NHS contracts. The National Health Service (Amendment) Bill, which is currently being considered in another place, contains the necessary powers.

The new arrangements would not exercise any control over non-NHS retail pharmacy. Failure to obtain an NHS contract does not stop a pharmacist from setting up a dispensing pharmacy, if the market can bear it. The Government would not wish to interfere with private enterprise and we are not doing so now. The issue here is about contracts to provide a public service and how to avoid the cost of excessive provision.

To follow up a point which was put by the noble Lord, Lord Hunter, in rural areas, whether the dispensing is done by doctors or pharmacists or both is determined by the rural dispensing committee. We believe these arrangements command the support of both professions and we have no plans to change them. They will exist alongside the new provisions.

I am very pleased to note the Nuffield report's general support for the new contract. However, I should point out that the report makes three suggestions to temper the powers proposed for family practitioner committees. They are: that the use of the price mechanism should be fully utilised and that the role of pharmacists in deciding when a new contract should be awarded should be looked at again, as should the proposed appeals mechanism. We are considering these suggestions carefully, in the context of the new contract, the report as a whole, and the debate in another place on the National Health Service (Amendment) Bill. However, those reservations should not divert us from the report's general endorsement of the new contract arrangements, which the report considers are basically well conceived.

Moving on to stage 2, the committee of inquiry stated that it was anxious to ensure that its recommendations would be both realistic and cost-effective while, so far as is possible, reflecting consumer choice. Also, it said that the recommendations were directed towards improving the use of existing resources rather than increasing them. This shows a realistic and sensible approach which I commend. The Government will examine carefully what further contribution pharmacists might make to primary health care services. This will include how such services might be paid for and monitored to ensure quality of service and value for money.

We agree with the general principle that the remuneration system should support and encourage the activities we want pharmacists to provide under the National Health Service. That was a point raised, I think, by my noble friend Lady Gardner and by the noble Lord, Lord Rea. It has long been our position that we are prepared to introduce a system of payments which will reward good professional practice. We have made this point to the pharmacists' negotiators at many meetings. The great barrier hitherto to such a system has been the absence of a generally agreed body of standards within the NHS contract. Now that discussions with the Pharmaceutical Society are going forward, that barrier appears to have been passed.

Another factor we shall have to take into account is that community pharmacy in this country has developed in a way that has required the pharmacist also to be a shopkeeper. When looking at the requirements of fulfilling customer demand through a public health service, I think there is no conflict between the successful businessman's need to provide a decent service for customers and the ethics of public service. I intend in no way to belittle the obvious importance of other pharmacists when I say that combining business motivation with public service is a great strength of the pharmacy profession in this country. It should be borne in mind that the average NHS pharmacist spends 95 per cent. of his time on dealing with NHS pharmaceutical services rather than his other business interests.

The noble Lord, Lord Rea, asked about the number of prescriptions going down, and so on. If the number of prescriptions goes down, the pharmacy profession does not suffer. The fees are set at a level which distributes all the money to the profession. If the number of prescriptions goes down, each fee goes up and the same amount of money is spent.

Let me now turn to hospital pharmacy. I know that the hospital pharmacists, like other professional groups employed by the NHS, are concerned about their role, management responsibilities and accountability in the new management arrangements in the health authorities. I hope they will see this change as an opportunity to develop ideas and formulate policies in the interests of all involved: patients, the taxpayer and the community as a whole. The essential message of the Griffiths proposals and the Government's policy is to ensure that the NHS delivers the goods to its customers as imaginatively, efficiently and effectively as possible.

The noble Lord, Lord Winstanley, practically issued a "dare" to me; but with regard to out-patient prescribing I rather fear the noble Lord may not like my answer very much. A distinction has to be made between prescribing and dispensing. Our policy, about which the noble Lord, Lord Winstanley, has talked, is very clear. Prescribing is the responsibility of the clinician with clinical responsibility for the patient. Once the patient has a prescription it can be dispensed either in the hospital or in the community by the pharmacist. The hospital doctor does not send the patient back to the GP to prescribe. That is why I said I did not think the noble Lord would like my reply. I repeat, as my predecessor, my noble friend Lord Glenarthur, said, that we shall follow up all cases that are brought to our attention; and we would welcome the details the noble Lord has.

The health authorities should be perfectly aware of our policy about prescribing for hospital out-patients. The doctor who is clinically responsible for the patient's care should prescribe any necessary drugs. The decision as to which doctor has clinical responsibility is for the doctors concerned. Health authorities should not attempt to transfer prescribing responsibility to GPs in order to make savings: nor on the grounds that a GP has a continuing responsibility for his patients. Such measures are not legitimate contributions to cost-improvement programmes and can add to the total cost of the NHS; nor are they in the best interests of patients. As the noble Lord, Lord Winstanley, said, they can put them to unnecessary inconvenience. My department follows up cases brought to its attention where health authorities appear not to be following this policy. As I said before, we shall gladly look into any specific cases which are brought to our attention.

Lord Winstanley

My Lords, will the noble Baroness give way? I was most interested to hear what the noble Baroness has said. I know, of course, that her words are very carefully followed by health authorities. I wonder whether on this occasion she could take special steps to make sure that the words she has just spoken in answer to the point. I raised are brought specifically to the attention of health authorities; because I am bound to tell her that many health authorities are acting in a manner quite contrary to that advice.

Baroness Trumpington

My Lords, I would not want to go to the extra expense of sending out a blanket notice, but I will see that my words are brought to the notice of the health authorities. For instance, we have a review process, and that is one of the questions which it would be very good to ask them—

Lord Ennals

Send them a copy of Hansard.

Baroness Trumpington

That would also be extra expense. The pharmacists' main concern on Griffiths has been that its implementation could fragment the current grouping of pharmaceutical services. These arrangements, which were implemented in the early 1970s, followed the recommendations of the Noel Hall report. If any authority contemplated action which would be detrimental to the provision of pharmaceutical services for hospital patients, I am sure that pharmaceutical officers would not be slow to offer the necessary advice. I am equally sure that the principles of wise management, which must prevail in the NHS, will ensure that the advice will be heeded, provided it is seen to be in the interests of patients.

Since we have decided that it is for each health authority to determine its own arrangements, it is inevitable that there will be different decisions and detailed structures from district to district: there can be no ready-made solution dictated from the centre, if the meeting of local needs is to predominate. However, we should not forget that pharmaceutical chief officers will, of course, be accountable to their general manager for day-to-day management functions. But they will remain directly accountable and have direct access to their health authority on the presentation and quality of professional care.

The staff side have not yet accepted the management side's offer and have asked for a meeting to discuss some aspects of it in greater detail. I say that in reply to the noble Lord, Lord Winstanley, about the Nuffield report not saying enough about the recruitment problems in hospital pharmacies. This meeting is being arranged and it would not be right for me to speculate on the outcome while negotiations are in progress. No claim for salary increases in respect of 1986–87 has yet been received.

I am confident that all pharmaceutical officers will be able to bring new thinking, new energy and a wider, more flexible view of their service demands in order to produce the more efficient NHS which we all recognise to be so necessary.

I was teasing the noble Lord, Lord Ennals, at an earlier stage, but, of course, I share his admiration for the wisdom and hard work of pharmacists in general. I can out-do the noble Lord and tell him that I am acting as a sponsor to my ex-pharmacist for a scholarship to an American university, but I fear that she will not get a copy of Hansard.

Pharmacists, in whatever sector they work—the community, the hospital, education and training or industry—are facing a period of change. I am confident that it will be change for the better; an exciting period rather than an uncertain one, which pharmacists will find challenging rather than frustrating, but, above all, a period when the pharmacist's role will expand rather than contract.

Lord Hunter of Newington

My Lords, I think we shall all want to thank the noble Baroness for her vigorous reply, and, in spite of many cautions, the light of hope was strongly shining through her statement, which, I think, was welcomed by everybody here. May I also thank all noble Lords and Baronesses who have taken part in this debate. I beg leave to withdraw my Motion.

Motion for Papers, by leave, withdrawn.