HL Deb 28 April 1993 vol 545 cc349-82

3.9 p.m.

Lord Hunter of Newington rose to call attention to the role of the pharmaceutical industry in relation to the interests of both doctors and patients in the National Health Service; and to move for Papers.

The noble Lord said: My Lords, I have already referred in a recent debate to the cost of prescribing in the National Health Service. In relation to the London scene I suggested the creation of large group practices with additional facilities or secondary care centres. I also suggested that a pharmacist should be readily available to the group and able to offer advice to doctors and patients and to collaborate in the making up of local pharmacopoeias.

The position is complicated. There are many pharmaceutical preparations which are available without prescription which a doctor may suggest a patient takes or which patients themselves may decide to take, having received advice from a practice nurse or pharmacist.

In Great Britain in the past the Government control scheme has been the prescription pricing regulation scheme, a voluntary agreement between the industry and the Government which agreed profitability on National Health Service provision of drugs. From the beginning an element in that pricing has been the research-based nature of the company. It would be useful if at some stage the Minister would tell us what is the present position concerning that arrangement, which has worked so well for the past 40 years. It has supported the development of a research-based industry in this country which has been enormously advantageous from the point of view of profitability. The exports of those companies make up a substantial proportion of total UK exports.

However, the family health service authorities and their professional advisers are charged with the challenging task of: improving the quality and cost effectiveness of prescribing". Their role and effectiveness is well worthy of examination. Perhaps the Minister would like to comment on that issue.

The limited list is a scheme whereby particular medicines may not be prescribed under the National Health Service. The scheme was introduced in April 1985 and included seven categories: indigestion remedies, laxatives, analgesics, cough and cold remedies, vitamins, tonics and benzodiazepine sedatives and tranquillisers.

However, the position is changing. The Government, in their wisdom, have made a number of decisions in relation to the National Health Service, introducing the concept of providers and purchasers of materials and services. The Government's argument in support of their White Paper Working for Patients relied partly on the lack of strategy for reform.

The White Paper was built on a number of fundamental assumptions. First, it assumed that pricing in medical care effectively reflects value and that trading in internal markets would therefore increase efficiency. There is no substantial evidence to support that view. Managers lack the information to purchase value for money because the data do not allow any measurement of the effectiveness of care. Secondly, the White Paper also assumes that patient throughput effectively measures care performance, despite the complete absence of measures of patient outcome.

There was a need for the development of an applied research agency in the National Health Service, supported by a clinical database, and the direct results of such a policy should lead to change. In fact, that is a concept which the Science and Technology Committee of this House had in mind when it proposed research and development changes. There is now for the first time effective machinery to begin to study the results of change in treatment or management.

The procedures for the examination of new drugs must be understood and accepted by the pharmaceutical industry, the medical profession and the National Health Service Policy Board. The existence of the new machinery developed by the Director of Research and Development makes all that possible.

There is a new aspect to this issue with the introduction of an element of competition into the service. It is being suggested in the pharmaceutical industry, as it has been in the United States of America, that there is a case for the industry to be in direct contact with patients.

In the past representatives of industrial companies were in contact with doctors, but recent studies have shown that that is totally inadequate from the point of view of prescribing habits in practice and that substantial savings can be made by close collaboration between doctors on the one hand and between doctors and pharmacists on the other.

Hospitals are given large discounts on drugs. Such discounts could mean that the price of a branded drug is lower than the price of a generic drug, but consultants may be unaware of the price being charged or the price at which the drugs are sold in the community. However, one good business outcome of that policy of hospital consultants and the pharmaceutical industry in relation to hospitals is evident from a recent survey in which four out of five general practitioners claimed to follow the hospital prescription on patient discharge. The influence of the industry is evident.

The situation in general practice is quite different. Drugs are expensive in primary care, not only because of the unit costs but because many patients continue to take them for years. The remedy for that is in the hands of doctors. Generic substitution of drugs is common in hospitals but in primary care only two out of five prescriptions are written generically. In the United Kingdom an incentive could be a reduction in prescription charges if the patient accepted the generic option.

In the United States the pharmaceutical industry is increasingly providing advice direct to patients. As I have said, the question has been raised indirectly here by the Government in their support for the system of providers and purchasers. In that regard the views of Jerry Avorn, associate professor of medicine at Harvard Medical School, are pertinent. He said: A nation that puts health care into the market-place as if it were any other commodity should not be surprised when manufacturers of drugs begin to utilize market-driven strategies".

The advent of the Tomlinson inquiry drew attention to the need to strike a balance between market-led and planned approaches to health care delivery. That is important not only for hospital rationalisation but also for the preservation and development of services.

Specialised services which include new pharmaceutical preparations are often in the forefront of improving standards of care and the introduction of new developments. However, in the internal market for health care provision created by the 1990 NHS reforms more flexible and sensitive mechanisms are required to provide stability for specialised services while at the same time enabling the benefits of purchaser choice and provider competition to be realised. The Government must define their policy more clearly.

There is also the important issue of the limited list, which is at present the subject of consultation. Many aspects of the issue were dealt with eloquently in the debate of the noble Lord, Lord Hacking, on 14th April. I should like to quote something said by the noble Lord, Lord Jenkin of Roding, in that debate which is relevant to our discussions: However, the more I have studied the effect of introducing the selected list at that time and how it has worked in practice the more I have come to doubt whether it is a sensible measure".—[Official Report, 14/4/93; col. 1153.] Everything that is decided about the limited list is of vital importance to industry. It is an industry which has brought great wealth to this country. Whatever the decisions about the final list, the whole trend will encourage industry to advertise drugs directly to patients. Is that the Government's view and purpose? My Lords, I beg to move for Papers.

3.21 p.m.

Lord Hacking

My Lords, two years before I did so, my noble friend Lord Jenkin of Roding—alas he is not present in your Lordships' House today—addressed the European Federation of Pharmaceutical Industries in Paris. He introduced a rather intriguing statistic. He told those who attended that conference in Paris that in 1951 when Her Majesty the Queen ascended the throne she sent out in the first year of her reign 270 telegrams to those who had achieved their 100th birthday. He then cited that four years ago—I anticipate the number of telegrams would now be more—Her Majesty was sending out annually 2,700 telegrams to those who had achieved their 100th birthday. Within my time in your Lordships' House there has been at least one Member of your Lordships' House who has received such a telegram. That is welcome news.

That is welcome news, too, because it represents a demographic change in our community and indeed in the communities of all the countries in the world. We are living longer. For one who is in the latter days of his youth, like many other noble Lords, this is good news. The spread of those figures is happily across the world. For example, in the period from 1960 to 1982 the rate of population growth in France was about 17 per cent. But the rate of those who have lived over 65 years increased in the same period by 28 per cent.; and those who lived over the age of 85 years increased by the splendid figure of 50 per cent.

The impact of those welcome developments on health costs is most significant. I do not wish to plunge your Lordships into a series of statistics but I shall give a few more because I believe that they will be of assistance to your Lordships in the debate. They are official figures. In 1970 the total cost of the National Health Service came to £2.04 billion. In 1980 our health cost had risen to the level of £11.9 billion. In 1990 it rose to £28.5 billion. These figures can be projected fairly accurately—they have been produced to me by the Office of Health Economics. The estimated figure for 1992 is £36.1 billion. For 1995 it is estimated to be £42.7 billion. By the year 2000 by the same projected figures—they may be underestimates—the figure is £54.5 billion. Therefore in the 25-year period between 1970 and 1995 we are witnessing an inflation of over 2,000 per cent.—an inflation which would dazzle even some of the economies of South America.

We can reach only one conclusion: that under the present structure of the health and welfare of responsibilities of our Government (and indeed of governments of any Western country which take on responsibilities for the health and welfare of their peoples) there is a burden placed on the working population which is unsustainable. Therefore the only long-term solution, I suggest, does not lie in readjustment with the pharmaceutical industry or other readjustments within the National Health Service. It means a radical rethink. That is not to burn the effigy of Nye Bevan, but to recognise that times have changed, and changed so significantly that a radical reappraisal has to take place.

This Government quite rightly approach cost cutting exercises and look at where costs can be saved in the National Health Service. The feeling in the pharmaceutical industry is that the Government look first at their industry. It is an easy target. The difficulty is that, first, the Government are the upholders of British industry. That includes the pharmaceutical industry. But at the same time the Government are the regulator and the monopoly buyer of the goods of the pharmaceutical industry. It is that conflict which the Government face when they seek adjustments with the industry.

In a notable speech which the President of the Association of the British Pharmaceutical Industry made in London a few days ago—I am happy to tell your Lordships that he has come to listen to your Lordships' debate—he quoted some of the figures of the pharmaceutical industry's success as a British industry. He quoted the figure of £750 million in 1980 and £2.25 million exports in 1990. He cited further statistics to show what is now well established: that the pharmaceutical industry is a major and most important industry.

I have argued before in your Lordships' House—I repeat the argument in this debate—that what is needed is co-operation between that great and successful industry and the British Government. That industry achieves enormous savings in National Health Service costs. One example is anaesthetics to enable day surgery to take place which involves enormous savings in hospital bed costs. Two drugs have been developed in the United Kingdom for gastric ulcers, one by a United Kingdom and another by an American company. Those drugs have saved the National Health Service industry enormous costs. As the noble Lord, Lord Jenkin of Roding, quoted in the debate that I introduced on 14th April, while the cost of medicines may have increased—that is, the use of those particular drugs—by 66 times, and there are statistics to support that figure, the overall savings on the treatment of patients was of the level of 70 per cent.

It is therefore saddening that the Government's short-term response to the need for looking at cuts is to cut back on the patent term protection, introduce the selected list scheme and so forth. Those can only cause damage to a successful industry, and an industry that is highly supportive of the National Health Service.

One can go on citing examples concerning the selected list scheme. I do not intend to reiterate the argument that was placed before your Lordships on 14th April. However, I am waiting for the Minister to give a more measured response to the argument that was presented in that debate than she was able to do at the time.

Mention has already been made of the speech in that debate of my noble friend Lord Jenkin of Roding. Let me cite one example of the treatment of skin disease. A Written Answer in another place stated that there are 1,770 potential drugs to be placed on the new extended selected list scheme. Of those, 900 are drugs not requiring a product licence. They include such things as sun creams. The net saving to the National Health Service of taking all those drugs off the selected list scheme would be £60,000. However, the bureaucratic cost of their removal from the selected list scheme will be in the region of £½ million. I merely cite that as another example which has come to my attention.

Lord Rea

My Lords, I thank the noble Lord for giving way. I wonder whether he meant that. Did he mean £60 million or £60,000 saving in costs?

Lord Hacking

My Lords, I am grateful to the noble Lord, Lord Rea. If I said £60 million it was a slip of the tongue, the savings would be £60,000. That is against the figure of £½ million in increased costs for carrying out the exercise. From the sad relationship between the Government and the industry that exists at the moment—it is too much a relationship of confrontation—it is good to record that there are developments in co-operation. There is the strategic working group set up by my noble friend's department, the Department of Health. There has also been the initiative of the Department of Trade and Industry in setting up the chemicals and pharmaceuticals section. Thus, there are developing areas of co-operation. However, let us have the right adjustments in the right way and at the right time.

3.32 p.m.

Lord Rea

My Lords, I wish to thank my noble friend for moving this Motion. It is useful to take a wider view of the pharmaceutical industry than we did two weeks ago when we concentrated on the proposed limited list. This is only one way in which drug costs can be curbed; I hope to describe others.

As the noble Lord, Lord Hacking, and others have pointed out, the pharmaceutical industry is one of the United Kingdom's most successful manufacturing sectors, with a healthy contribution to our export earnings. Its success, however, is in part due to the stability of the internal market offered by its historical relationship to the National Health Service. The pharmaceutical price regulating scheme, negotiated with the industry initially by my noble friend Lord Ennals, takes into account the need for a high research and development expenditure by the industry. The profits allowed are in large measure related to the investment of the industry in the United Kingdom, which is therefore encouraged—a wise move by my noble friend in setting up the scheme.

I am sure that a Labour Administration would like to see the industry's success continue, but, like the present Government, we would be forced to explore ways of controlling the upward spiral of costs so well described by the noble Lord, Lord Hacking. They run at nearly twice the rate of inflation. I know that there are many reasons for that, including the ones which he put forward: the demographic changes in the population—the greater number of older people with greater health care needs and of course also increasing technical sophistication, with its inherent high costs.

However, following the debate two weeks ago, my noble friend Lord Desai came under subsequent criticism from the ABPI because he differed in some measure from the views of the Opposition health team in another place by giving qualified support to the Government in their limited list proposals. I have to say that the campaign of the ABPI against those proposals has borne fruit in that some people who should possibly have been wiser have been persuaded of the total wickedness of the proposals, even before we know what drugs will be put on the list.

I have made a list of the drugs which I prescribe. As the noble Baroness, Lady Cumberlege, said during that debate two weeks ago, I am probably the only Member of your Lordships' House who has the right to use a National Health Service prescription pad. I have made a list of the drugs which I prescribe and frankly I doubt whether many of them will be affected. If one or two are, I shall look at alternatives which will still be available, and still on the list.

This time round, the Government have been careful to include a wide range of professional interests on their advisory committee to decide on the drugs to be put on the list. If they insist on eliminating irreplaceable essential drugs of importance, I shall be the first to protest, particularly in the field of the newer oral contraceptives—the "lipid-friendly" progestogens—which are more expensive. I have it on some authority that at least some of these will be on the permitted list. In fact, I think that all important drugs with proven clinical benefit will still be available. Many general practices and hospitals already have their own limited lists or formularies of drugs, consisting of about 300 drugs out of the many thousand available right across the board, not merely in the proposed categories, which will be limited. Not only does that help to control costs, but it also leads to rational drug treatment with benefits to patients.

It is far better for doctors to become familiar with, say, six drugs in each category than to jump into prescribing the latest preparation as soon as it comes on the market. That is usually twice or three times, or even more expensive, than the one it replaces. The industry, of course, points out that doctors in the United Kingdom are already slower than other countries to prescribe new products. That is because our prescribing habits are more rational than those of other countries; it is not that we are dragging our feet particularly. Although, regrettably, doctors and general practitioners in particular receive their most persistent postgraduate pharmaceutical education from drug reps and drug lunches—as we know, there is no such thing as a free lunch—despite that, they retain a healthy scepticism. Perhaps not enough, in my view, but enough to make our prescribing habits more economical than those of France, Germany and many other countries, as the advertising campaign of the ABPI, for example, in the House Magazine week by week clearly points out.

The remarks of the noble Lord, Lord Jenkin, have already been quoted from the debate two weeks ago. He made a good case against the limited list which was produced in 1985 by the Government. But in so doing, I think he made a good case—perhaps without meaning to—for generic substitution, which is another cost containing method. When a proprietary or trade name drug is prescribed, the pharmacist is then permitted to dispense a generic equivalent of the drug manufactured by any firm when the patent period of that drug has expired. That will usually be cheaper. It is the method of cost reduction which was recommended by the Department of Health's Greenfield Committee in 1983 but which the Government were persuaded by the industry to reject.

Since all hospitals in the National Health Service substitute generically, as do the United States and Germany, there is no real objection to this, especially if when prescribing the doctor may insist on the proprietary drug if there is a special indication for it. But that is quite rare.

A disincentive to prescribing generically is that the names are far longer and more difficult to write—a problem when a doctor is seeing many patients. I am told that the pharmaceutical industry dominates the naming committee for generics. For example, Ponstan, which is quite a well-known analgesic and anti-inflammatory, is Mefenamic acid in generic terms (13 letters to write instead of seven) and Co-amilofruse is the generic term for Frumil (12 letters as against six).

There are several other methods for cutting costs. One method which the Government have introduced but have not yet fully capitalised upon is the PACT scheme (prescribing analysis and costs) under which all GPs get details every quarter of all the drugs they have prescribed and the costs. I do not think that that excellent educative tool has yet been sufficiently exploited. Teachers of pharmacology in medical schools should be allowed greater access to this mass of data. At present it is highly confidential. No names need to be given, but it could be made use of for research and teaching. My own family health service authority has, however, introduced "prescribing fora" in which groups of GPs discuss their PACT returns in groups with the pharmaceutical advisers of the FHSA. I attended the initial series of meetings and found them very helpful.

Other possible ways of reducing costs include toughening up or expanding the requirements for licensing new drugs. At present, safety, efficacy and quality are the only considerations. I consider that perhaps cost-effectiveness in comparison with existing drugs should be included. Such a comparison is much more complex than it might seem since it includes calculations on savings which the drug might achieve, such as those mentioned by the noble Lord, Lord Hacking, in avoiding hospital admissions or extending what are known as QUALYS (quality-adjusted life years). The industry is naturally opposed to such a move. It emphasises the difficulties of such assessments and the length of time that the calculations would take—hence putting off the time when the drug could be marketed. There are many other ways in which cost containment could be considered.

The PPRS (the pharmaceutical price regulating scheme) is a useful mechanism. It recognises the need for the industry to make extra profit to go into its high research and development costs: But I think that the Government need to field a pretty tough team in their negotiations in the next round of the PPRS. The industry is very skilled in putting its case. I am sure that the noble Baroness knows that.

Research in the pharmaceutical field is vitally necessary. But is it so necessary that the drug industry needs to invest £1.2 billion in research, which is more than comes from all other sources of medical research—the universities, the Medical Research Council and the medical charities combined. It has been said, with some justification, that the high pay and status given to research scientists in the pharmaceutical industry attract good scientists away from other important tasks—those relating, for example, to the prevention of disease rather than the treatment, perhaps too late, of established disease.

I want to see, as we all do, a healthy pharmaceutical industry. But fitness and long life are associated with leanness, not with running to fat. I believe that the Government should encourage the industry to lose a little excess weight and accept the need for cost limitation. Otherwise, it will become a parasite on the very body on which it lives; namely, the National Health Service, which it will debilitate and even possibly destroy.

3.44 p.m.

Lord Brightman

My Lords, I intervene in the debate in my capacity as an occasional consumer of the products of the pharmaceutical industry. I have no medical or scientific training, and inevitably my contribution will consist of questions rather than answers.

Three aspects of the drug industry are important to me as a potential patient: first, the quality of the drug which is administered to me; secondly, the potential of that drug for serious side-effects, particularly side-effects which are irreversible; and thirdly, the adequacy of the research which is carried out into the improvement of existing drugs and the production of new ones.

To refer first to the quality of a drug, I was a little alarmed when I learnt that doctors are now encouraged—or it may be that they are directed—where it is possible and cheaper to prescribe a drug by a general description rather than by a particular brand name; in other words, a so-called generic drug in preference to a well-known and well tried brand name.

I am aware of the Government's problem. The noble Lord, Lord Hacking, has given impressive statistics. Perhaps I may add one more. The annual cost to the National Health Service of the dispensation of drugs has risen from £54 million in 1960 to no less than, and possibly more than, £3,400 million today. In other words, we now spend 63 times more money on drugs than we did in 1960. So I know that savings must be made. But a drug prescribed by a doctor without a particular brand name may turn out to have been manufactured in any of some 14 or more countries.

When a drug is prescribed by a generic name the prescription is taken to the pharmacist, who then hands over a drug of any manufacture which fulfils that generic description. The choice in the case of a generic drug rests with the pharmacist. The drug may come from any country which manufactures that drug, provided that it can lawfully be marketed in this country.

My question is this. When so-called generic drugs come onto the market from so many different sources, are the Government satisfied with the measures in place to control their quality and to ensure their efficacy and purity? Is it correct, as is suggested in some quarters, that there can be a significant variation in the clinical performance of some drugs purporting to meet the same description? Would it be better to leave it to the judgment of the doctor to decide whether to prescribe a drug by a particular brand name in which he has confidence rather than leaving it to the chemist to hand over a drug of any authorised manufacture that he chooses?

I leave the quality of drugs and turn now to the important question of side effects. My concern here is with a drug that may have a potential for serious and possibly irreversible side effects if by mischance the administration of the drug is not adequately controlled or monitored. The question that concerns me is whether the drug company gives as much prominence to the drug's potential for serious side effects as it gives to its curative properties.

So far as a new drug is concerned, the major sources of information available to doctors are, I understand, professional journals on the one hand and publications issued or meetings sponsored by the drug company on the other hand. Professional journals are likely to be wholly impartial. But reading professional journals is time-consuming for the doctor. In consequence, I am told, meetings and discussions with representatives of drug companies are a common way in which doctors keep themselves up to date. However, it is difficult to suppose that such meetings and discussions will always be wholly impartial. The representative of a drug company, who will not be a medically qualified person, is bound to be sympathetic toward the drug which he seeks to sell.

I should like to feel that a drug company, in promoting such meetings and discussions, will recognise that it is under a duty to give as much emphasis to a drug's potential for serious side effects, if any, as to its curative properties. My question is: are the potentially serious side effects of a drug sufficiently publicised by the drug company to the medical profession and of course by the doctor to the patient?

Lastly, I turn to the subject of research. The aim of a pharmaceutical company, like that of any other trading company, is to generate profits which will cover its expenses and reward the shareholders who have risked their money. In the case of a new drug which will be used to treat some common disorder, it is relatively easy for the drug company to recover its outlay and to have money to spare for research, because the drug will inevitably be prescribed by a large number of doctors during the life of the patent.

But what about drugs needed to treat the less common or rare diseases? Where is the money to develop and test those drugs? I am told that it may cost £150 million to develop and test a new drug. Therefore, some drug companies—perhaps all drug companies—have a policy not to seek to develop a drug unless they can be assured that there will be sales of £x million during the effective life of the patent. One can understand that approach. The same problem arises in the case of tropical diseases. Governments of countries in which such diseases are endemic may not have the financial resources to import such drugs in significant quantities. So the drug company's target of £x million would not be met if successful research led to the discovery of the needed drug. I ask therefore to what extent the pharmaceutical industry is in a position to finance research into drugs which will not yield the large profits that are needed to offset the costs of discovery.

Those are my questions. What is clear is that only a strong pharmaceutical industry is likely to have the resources needed to develop new drugs and improve existing drugs. I very much hope that a strong pharmaceutical industry will prosper in this country and not be overtaken by the pharmaceutical industries of other countries.

In conclusion, I am grateful to my noble friend Lord Hunter of Newington for having introduced this thought-provoking debate and for giving us the opportunity to discuss important issues.

3.56 p.m.

Lord Lyell

My Lords, first, I should like to thank the noble Lord, Lord Hunter of Newington, for giving us the chance to hear some remarkable speeches. It is also an opportunity to develop our scientific knowledge. Like my noble friend Lord Hacking, I have no scientific knowledge—at least, I presume that he has more scientific knowledge than I do. I do not have even one O-level in science. This afternoon I shall receive a free course in pharmaceutical science and in law. The noble Earl, Lord Halsbury, whom I saw in his place a few moments ago, and other noble Lords may remember that 16 years ago this House discussed the reform and updating of the law of patents. From that day my interest in the law of patents and allied subjects, such as pharmaceutical science, was ignited.

We have heard from the noble Lord, Lord Hunter, and my noble friend Lord Hacking that the pharmaceutical industry is very successful. I stress that it has been by far the most successful industry in the United Kingdom since the end of the Second World War. Perhaps I may pass on to the House some figures that have come to my knowledge.

Each year the industry obtains a surplus on the balance of trade of £1 billion sterling. It employs upward of 90,000 people. A further 18,000 people are employed in research and development. In his comments the noble Lord, Lord Rea, did not begrudge the tremendous effort and work done by the industry. I suspect that much of what those 18,000 people employed in research and development are doing spills over into areas other than pharmaceutical science and into lines other than the ones they are immediately pursuing. Another figure shows that United Kingdom research and development in pharmaceutical products represents upward of 10 per cent. of pharmaceutical inventions each year. That goes to prove that the industry is remarkably successful.

As noble Lords have stressed—especially the noble Lord, Lord Hunter—all that effort has to be targeted. Let me take the example of the United States of America, where the health care budget, I understand, is over 800 billion dollars a year. Roughly, 7 per cent. of that budget, which represents upward of 50 billion dollars a year, is spent on ethical medicines and prescription drugs. In the United Kingdom the latest figure is 10 per cent. However, that figure is probably not far out of line with the United States, as the cost of the health care budget of the United States might vary in some ways.

Indeed, the Centre for Medicines Research in the United Kingdom, which has considerable knowledge of the pharmaceutical industry, has produced figures estimating that the total global amount spent on research and development on medicines and pharmaceutical products rose from 15.3 billion dollars in 1988 to nearly 27 billion dollars in 1992.

In the European Community and on the continent of Europe generally, the cost of bringing one compound—a compound is the base for any of the pharmaceutical medicines that the noble and learned Lord, Lord Brightman, or I might obtain in the shop or which may be prescribed by the noble Lord, Lord Rea to the market in the late 1960s, when I was struggling with chartered accountant examinations (from 1957 to 1970), was 50 million dollars. Twenty years later, to bring a similar compound to the market—science and technology have changed as well—the cost was between 250 million to 300 million dollars. Of course those figures would have to include the costs of parallel scientific research carried out by the pharmaceutical industry which might have some bearing on the compound being brought to the market. But it shows that in 20 years inflation as well as technological change have contributed to the increase in the figures.

I believe that there are four points that the pharmaceutical industry would consider relevant to the Motion moved by the noble Lord, Lord Hunter. The industry is concerned both with doctors who are trying to understand and prescribe the medicines and with patients who are perhaps consuming them.

First, on what areas does the pharmaceutical industry concentrate its effort? I suspect, and the industry may agree, that there are known and agreed areas of research. Through scientific knowledge and the pursuit of patents each company will have a good idea of the specific areas, products and aspects of human health that its rivals, both large and small, are pursuing. Occasionally a company can strike what I may call "lucky"; by chance and by tolerance a company can achieve an enormous breakthrough.

In Basle a company called Sandoz allowed one of its scientists in the late 1970s, in his own time, to pursue a project that had virtually been abandoned. The project went under the name of Cyclosporin A, the trade name of Sandimmun —naturally from Sandoz in Basle—and I understand (my noble friend on the Front Bench was inquiring about my scientific knowledge) that it will suppress the immune reactions to transplanted organs. It was a complete chance effort but it showed that there was tolerance and benevolence from the members of the company who did not push the scientist and tell him to abandon his work.

Secondly, another aspect that the pharmaceutical industry would like to look at are the specific aspects and products that are innovative. I understand that there have been enormous efforts made in the United Kingdom—I hope that they will be successful—to bring the European Bioinformatics Institute to Cambridge. That would provide a European, if not a world, centre for gene technology. We may have an opportunity to discuss that at a later date. Gene technology is in the process of trying to discover and decode upwards of 100,000 different genes which it is estimated are present in the human body, and to discover what scientists call the "handbook of man".

The third aspect of today's debate that may interest the pharmaceutical industry and which has been mentioned by every speaker, including my noble friend Lord Hacking, is the speed with which companies can bring their product to the market. I have seen it quoted in much of the research presented to me that one day's delay—between today Wednesday and tomorrow Thursday—in bringing a specific compound or product to the market can cost a company up to 1 million dollars a day. Of course, the product may or may not be marketed or the company may be beaten by a rival. Even when the product has been brought to the market I understand that there is a requirement to make £50 million by the third year of its launch. That information comes from a British company. A Swiss company working along the same lines would be looking for a return of 300 million Swiss francs in the fifth year of marketing the compound.

With regard to the speed of bringing products to the market place I looked at one specific example and was somewhat startled to find that a company in San Diego which produced the concept and film "Star Wars", which many noble Lords may have seen, have developed a new technique called "virtual reality". It gives the illusion of going through an electronic screen and being surrounded by molecules. Indeed, there is something called a "virtual reality helmet" —I hope my noble friends on the Front Bench do not wear them when they are listening to a Wednesday debate—which can take one into another world.

The concept gives the scientists the chance to be in what one would call a molecular superstore where one can pick and choose molecules and put them together. I am advised that it is producing remarkable strides in the speed with which products can be brought to the market. That specific company is involved in cancer research.

The fourth consideration is the management of human resources. We must have computers in pharmaceutical research, but the systems must be devised and tested by humans. Motivation was mentioned by the noble Lord, Lord Rea. I still believe that it is not difficult to bring research and development in science into the main-stream of a company's activities in the pharmaceutical industry. One then comes to the information, the marketing and selling of the product, especially for small companies.

In the pharmaceutical market in the United Kingdom there are 30,000 general practitioners, 6,500 consultants, 5,000 registrars and around 10,000 pharmacists who need to be apprised of specific products which may be available from a company. I understand that a company launching a product will not get much change from £2 million. I hope that the Government will take that on board.

But what the pharmaceutical industry may really be concerned about is the price restraint scheme. I believe that it works well. I hope that the Government will be able to fine tune it, keep their nerve and, above all, that my right honourable friend the Secretary of State will be able to justify the figures that she quoted when she said that the drugs bill would grow by 12 per cent. every year and starter costs in the health service were going up by only 1.5 per cent. If my noble friend on the Front Bench could clarify that information I should be grateful.

In regard to the extension of the selected list there are three items which my noble friend may be able to explain. One is the appetite suppressants and another is contraceptives. Are they clinically necessary? The third relates to—yesterday my noble friend might have said "How would I know?"—female complaints. But I wonder whether some of the products are clinically necessary. I can only presume that they are.

Finally, I thank the noble Lord, Lord Hunter, and hope that my noble friend will be able to give us some answers this afternoon.

4.8 p.m.

Lord Ashley of Stoke

My Lords, I add my thanks to the noble Lord, Lord Hunter, for initiating the debate and I congratulate him on his fine speech. I intend to strike a different note from that of all the speakers in the debate.

Notwithstanding the pharmaceutical industry's fine record of innovation, which has saved millions of lives throughout the world, and which has transformed many fatal diseases into minor ones, I intend to highlight grave misgivings—particularly grave misgivings—in regard to the surveillance of drugs to ensure safety. Some of the doctors concerned, and some practices, are in danger of jeopardising the health of patients and even imperilling their lives. That is a scandalous situation which calls for urgent action by the Government, the medical profession and the pharmaceutical industry.

We have seen many disasters, from thalidomide onwards, and we must all do what we can to avoid any more. I am indebted for much of my information to Professor Bill Inman, who was the pioneer of the yellow card reporting system on adverse reactions and the originator of prescription event monitoring, which monitors the whole medical condition of a person taking a drug for a specific ailment. This system is supported by four-fifths of Britain's GPs, many of whom do a great deal of work without payment. It is effective for identifying reactions. Professor Inman's work has been invaluable.

However, another drugs surveillance system, far from adding to patient safety, actually endangers it. Some companies are carrying out their own drug surveillance, an idea put forward some eight years ago by a working party, and which at first sight seems very reasonable. What is wrong with people carrying out their own drugs surveillance? But what is unreasonable is the hidden objectives of some companies and, consequently, the way some schemes are carried out.

The first urgent danger signals should be flying when we learn that patients taking part in these commercial trials do not have to be fully informed volunteers giving their written consent after careful explanation. This is what always happens in pre-marketing clinical trials and it should happen in all post-marketing trials. So, incredibly, patients can be unwitting guinea pigs.

Why should some doctors participate in such potential malpractice? It is because they are offered inducements to take part in these commercial trials. I am told that the inducements include pocket computers costing more than £100, valuable equipment for the surgery and cash payments for each patient enrolled.

I have read the latest newsletter of the Integrated Network for Computer Administration. It reports a survey showing that GPs can earn £70 for half-an-hour's work by using a computer programme, designed by INCA, to complete 10 three-minute reports on their patients' progress after taking the drug under surveillance. The newsletter is a blatant encouragement to doctors to supplement their incomes in this way.

We all know that most doctors are honourable professional men and women, but there are obvious inducements to indulge in excessive patient registration. Professor Inman has described one case of a doctor who prescribed a new drug, which the Committee on the Safety of Medicines had determined should be used only for rheumatoid arthritis. He prescribed the drug to no fewer than 235 patients in six months. The average number would be about five or six patients suffering actively from this complaint in a practice of 2,000 patients. It is understood that the doctor received between £100 and £200 per patient. So some 230 patients were prescribed a drug which in many cases was not relevant to their illness, but which made money for their GP.

Professor Inman, because of his own system of monitoring, has been able to monitor GPs' involvement in the drug companies' activities. In almost all of his studies the "top 1 per cent."—the heaviest—prescribers accounted for about 10 per cent. of the early market for new drugs, while the top 10 per cent. accounted for about 50 per cent. of the market, often prescribing for dozens or even hundreds of patients at a time when simple common sense would indicate that perhaps one or two per month, carefully observed and monitored, would be a more reasonable number. Professor Inman says that in the groups of high prescribing doctors, more than 90 per cent. are male and more than 40 per cent. gained their first degrees overseas. Clearly, some doctors are responding to the inducements by prescribing promoted drugs to an excessive number of their patients.

If the patient does not have the complaint for which the drug is intended—and it seems that this is happening—it is outrageous to prescribe an unnecessary drug with the inevitable risk of side effects. If the patient does have the complaint, his or her current drugs should be changed only for good medical reasons and not for the benefit of the drug company or indeed the doctor.

These company trials mock scientific practice. They are uncontrolled. The numbers involved relate mainly to the strength of the company inducements and to the willingness of GPs to be induced to participate. And equally important, the results are kept confidential by the drug companies concerned. They are deemed to be commercially sensitive, a highly convenient phrase to be used by the companies. The truth is that these drug trials are little more than drug company promotions, providing generous rewards for doctors in return for prescriptions for their patients. The trials are an outrage which should be stopped by the Government and by the medical profession. Patients' informed consent must be made compulsory and the number of patients any one doctor can include in a trial should be limited. Unless strong and urgent action is taken, this medical malpractice will continue to the detriment of people's health and it will be a danger to their lives.

I want to conclude with this thought. In an earlier speech the noble Lord, Lord Hacking, said that the pharmaceutical industry is a great and successful industry. He was quite right: it is. We all want to support it and give it all the help we can because it really has many fine accomplishments to its credit. But it is these few companies Which are bringing the industry into disrepute. I hope that the Minister will be able to give a full and comprehensive answer to these points. If she cannot, I will fully understand that, but I would appreciate it if she could write to me later if she is unable to answer them today.

4.18 p.m.

Earl Baldwin of Bewdley

My Lords, I note with interest that much of our debate so far has been about costs. My perspective in this debate is a little different again, and I think I ought briefly to explain why.

I speak largely as a patient, as did my noble and learned friend Lord Brightman, most of whose concerns I share. Having, over many years, exhausted the resources of mainstream medicine, I was compelled, as many are, to turn to the world of the unconventional therapies. As a result, I have developed a profound respect for much that goes on there. I found myself serving for a while on the Research Council for Complementary Medicine, and I am currently chairman of the British Acupuncture Accreditation Board and also (jointly) of the Parliamentary Group for Alternative and Complementary Medicine.

Quite early on I became intrigued by one particular question, and it is this. If there is so much of value in acupuncture, homoeopathy, chiropractic, healing, massage, nutritional and herbal and environmental medicine, why are we not all aware of it? Many surveys, which I have quoted on other occasions, demonstrate that millions of people are benefiting, so it cannot just be a matter of my own experience. Here we come to the subject of the present debate.

Like other speakers, I would want to take nothing away from the great benefits that mankind has received from a wide range of therapeutic drugs, even if more is sometimes attributed to them in the eradication of disease than the evidence will bear. But it is my belief—and not just mine—that the immense financial power of the pharmaceutical industry is now distorting our whole perception of medicine to a degree that is positively unhealthy. This happens in a number of ways, some of them even more fundamental, I believe, than those referred to by the noble Lord, Lord Ashley, whose speech I listened to with great interest.

The influence of the drugs companies, with their multi-billion pound turnover, now reaches into almost every corner of mainstream medicine. They have been involved for years in the funding of medical schools, of journals, of conferences. It is not possible that so much money should be put in and that outcomes should not, however subtly, be influenced. I am not talking here about sinister motives—merely of the unavoidable influencing of attitudes and priorities. The majority of the members of the Committee on Safety of Medicines have links to the pharmaceutical industry. The Medicines Control Agency is wholly funded by fees from product licences. And then there is research. Without the drugs companies, whole areas of research would simply not be covered. But it is product-orientated research: it has to be, because these companies are not in it for their health. And other kinds of research are being squeezed out.

Drugs company money has gone into Health-Watch, the body that has set itself up to expose unacceptable practice in medicine (but unacceptable, one may ask, according to whose agenda?). In the world of AIDS, nearly all the voluntary groups are substantially funded by pharmaceutical companies, and AIDS patients have been almost exclusively snapped up and recruited into trials of the drug AZT. Even the All-Party Parliamentary Group on AIDS receives a five-figure sum from the drugs industry.

The chief implication of this is that we suffer the dangers of a virtual monoculture. And one of the principal dangers of a monoculture is that you are not even aware that you are in it. It is easy, for example, to fool ourselves that AZT, or something like it, is the only worthwhile approach to AIDS. If we believe this, it is more likely because AZT is virtually all that we have been presented with. Whenever there is a medical problem, the cry goes up, "We must find a drug!" or, "We must find a vaccine!" The agenda is severely distorted when only one view is being heard. And it is heard everywhere because of the overwhelming power of one of the players.

I know of examples where highly promising lines of research into complementary medicine are being stifled by the influence of drugs company funding of the department concerned. In another area of medicine, Linus Pauling, the Nobel Prize-winning scientist, has told of the difficulty of getting good research on the benefits of vitamin C published in medical journals, because of the editors' fear of losing drugs company advertising. Vitamins and minerals cannot be patented—nor can foods—which explains why so little research effort is put into these areas.

In yet another field, I know of a distinguished scientist who took a lone stance on a medical issue, and was questioned by a friend of mine as to how he could be the only scientist to oppose the general view. "Oh", he said, "I'm not the only one at all. I know eight other senior scientists who believe as I do. But I am the only one who is free of financial attachment. None of the others is in a position to speak out because of the strings attached to them".

If we are to see and judge clearly, it is crucial that we should be aware of the power of financial attachments. You do not need to be a conspiracy theorist to have serious questions about the large commercial interests in the field of healthcare policy.

I want to tell briefly of a research project in the AIDS field published in 1992. It was conducted by the Bastyr College of Natural Health Sciences in Seattle, Washington. It was a one-year open trial of 16 men with AIDS-related complex on a regime that comprised dietary and lifestyle counselling, nutritional supplementation, psychotherapy and hydrotherapy, with the alternative of homoeopathic or herbal treatment. The results, with no patients progressing to AIDS, no patients dying, and in fact some clinical improvement observed, compared more than favourably with anything that had been achieved in the orthodox, pharmaceutical field. It was not in any way a tightly controlled trial, and the numbers were small. But does anyone imagine that if the agent involved had been a drug it would not, in the present climate, have been pursued by pharmaceutical money for all it was worth? Leads have been followed up on far less when the incentives were there. So far as I am aware, the Bastyr College is still looking for funds to proceed to Stage 2.

In the field of cancer, I am aware of a number of approaches that have yielded good, not to say dramatic, results in some cases. The US Congress Office of Technology Assessment has listed no fewer than five in its detailed report two and a half years' ago on unconventional cancer treatments: behavioural/ psychological; herbal; dietary; biologic/ pharmacologic; and immuno-augmentative. So far as I know, there are no major trials underway on any of these. For the most part they are not money-spinners. They are not even part of the medical agenda. In the field of heart disease, the position is not much different.

At a deeper level still, the grip of the pharmaceutical view exerts an equally unfortunate influence. There are two doctrines which I believe will eventually come to be seen as unhelpful in medicine, if not actually pernicious. The first is the doctrine of specific aetiology, which arises from the germ theory of disease and leads to the mirage of the magic bullet, and, incidentally, to the view that HIV equals AIDS—a hypothesis, as one distinguished critic has remarked, that has yet to save a single life. Drugs seldom get at the root cause of disease, in any case.

The second is the notion, so firmly entrenched in the medical mind and so laughable to the practitioner of natural medicine, that you cannot have benefit without risk. This has led, among other things, to the easy acceptance of a situation where some 10 per cent. to 15 per cent. of hospital beds are occupied by people who, among their other complaints, have been injured by their treatment—not all pharmaceutical, but mostly so. The dominance of the drugs-based approach to medicine helps to underpin both these doctrines.

I have said enough to show why I believe that the role of the pharmaceutical industry does not always serve the best interests of patients. But I should like to take the case briefly one step further and beyond what I might term the intrinsic consequences of an over-concentration of power in the therapeutic field.

I spoke the other day to a man who was the inventor of a device which was proving very successful with migraine. In a search for funding, he was visited by a senior manager in a major drugs firm who flew over to inspect the device. This man said, in front of witnesses, that he believed that approach had a major future in medicine, and that his firm were going to do everything in their power to ensure that it did not see the light of day for 50 years. There was an interesting sequel to this. Some time later a merchant bank offered to back the device. After protracted negotiations, my contact was on the point of signing a not very favourable agreement when a director of the bank rang him strictly off the record and said that he thought he ought to know that behind the deal was the self-same drugs company, whose plan it was to buy up the rights to the device from the bank and suppress it. There are some who see a pattern in events of this kind. I do not know about that; but I have heard of other examples.

Having said as much, I ought to say that it is the inherent dangers of the monocultural view that worry me the more. A conscious abuse of power is serious; indeed, criminal. The unconscious distortion of the whole way a society sees its system of medicine is much worse, not least, as I said earlier, because it may lie too deep to be seen. Unless you step outside the system, even if only in imagination, I do not believe you will get it in perspective. There are two maxims which can stand as a summary of what I have been trying to say, and I think that we ignore them at our peril if we wish to get things in proper focus: power tends to corrupt; and he who pays the piper calls the tune.

4.29 p.m.

Lord Auckland

My Lords, not for the first time the noble Lord, Lord Hunter of Newington, has enabled your Lordships' House to debate a very important subject aligned to medicine, and, as usual, he has graced the House with a very eloquent speech.

I have to tell the House that I never learned science at school; I learned languages instead. My interest in this subject came via the Medicines Bill and a very respected friend of your Lordships' House, the late and lamented Lord Lloyd of Kilgerran, when I was asked to support him on a matter concerning patent law, on which he was the acknowledged expert in your Lordships' House—not only in his time but, I should think, in the future also. How I dreaded the experience, but I learned a certain amount from it.

There are clearly two parts to this Motion—one concerning the doctor (and the general practitioner in particular) and the other concerning the patient. The noble Earl, Lord Baldwin of Bewdley, made an interesting contribution about complementary medicine. I believe that complementary medicine, particularly homoeopathy, has a part to play in the health of the nation, especially for what one might call "non-malignant diseases". Even with all the research carried out by the pharmaceutical industry in this country and elsewhere over the years, conditions such as the common cold, the common cough, dyspepsia and other illnesses can be cured more effectively by old-fashioned remedies, such as perhaps cinnamon, by other remedies which are obtainable over the chemist's counter and, indeed, by homoeopathy, which I have tried on occasions myself.

General practitioners today work under a great deal of constraint, especially in rural practices. One of the problems which he or she faces is the enormous amount of literature which is piled upon him or her about new drug products which, of course, the general practitioner must study. I hope that more is being done by the sales managers of the drugs companies to ensure that they use an appointment system with general practitioners. This is an important point. That practice should be carried out to a much greater extent because it is much more important that general practitioners treat and heal their patients than that they spend their time during working hours dealing with matters of this kind.

Speaking from the patient's point of view, I recall suffering from a mastoid problem in 1941 following a very virulent attack of measles. This was before the discovery of Sir Alexander Fleming's great invention of penicillin—and it was not a pleasant experience. Since then, much progress has been made and although conditions such as mastoid are still serious—I have a nephew who suffers from it—developments within the pharmaceutical industry have been considerable.

It is interesting to note from the government White Paper, The Health of the Nation, that the life expectancy of girls is now 79 and that of boys is 72. I think that it is fair to say that the pharmaceutical industry can claim at least some credit for that. I would certainly not be rash enough to say that it can claim all of it, but it is important to get this matter into perspective.

What is important is that research and development is kept under reasonable control. It is essential that the leading pharmaceutical companies, which are members of the Association of the British Pharmaceutical Industry (the ABPI), should develop their ways instead of what one might call some of the "outside" companies which are not necessarily registered. It is at least possible that this is why the pharmaceutical industry has come under a certain amount of fire.

I have seen research carried out into such dreaded diseases as Alzheimer's disease. A particularly dear friend of my parents—and in later years of myself—who was the matron of St. George's Hospital when it was at Hyde Park Corner (my father served on the board) died at the age of 64 of that terrible disease when she was Chief Nursing Officer for Scotland. Ever since then, the need for urgent research into this dire and tragic complaint has been brought home, to me at least.

Mention has been made of migraine, into which a good deal of research is taking place. Again, homoeopathy has a part to play. I know one or two people who suffer from migraine and who get certain benefits from homoeopathy. I believe that there is a case for some kind of liaison between alternative medicine and the pharmaceutical industry. As I mentioned earlier, non-malignant and curable complaints can be dealt with in that way. It is in relation to the long-standing complaints, such as that awful complaint of cystic fibrosis which affects children—how sad it is—that we look to the pharmaceutical industry for research and development.

We have been given an opportunity this afternoon to discuss a subject which will always be controversial. This country's pharmaceutical industry has not only done a great deal for our exports, but employs people at all grades who work very hard and in a dedicated manner. With all the reservations that there may be, long may the industry continue.

4.37 p.m.

Lord Colwyn

My Lords, I must apologise to the noble Lord, Lord Hunter of Newington, for not being present to hear his speech at the beginning of the debate and to other noble Lords whose contributions I missed. I look forward to reading them in Hansard tomorrow. I should like to thank my noble friend the Chief Whip for finding me a position towards the end of the list of speakers. It is very difficult for me to get away from my practice as early as three o'clock.

I have given some thought as to whether it would be sensible for me to take part in this debate as I have very strong feelings about the pharmaceutical industry and two brothers-in-law who fundamentally disagree with everything I say. One is an eye surgeon in Salisbury and the other is a very senior research chemist with Glaxo. However, before I make a very brief contribution, I must declare an interest as President of the Natural Medicines Society and an association with other organisations which believe that our health and medical treatment should in most circumstances be maintained and treated by the promotion and reinforcement of the inherent biological systems within us which maintain health and eradicate disease. Your Lordships will be aware of my interest and belief in the effects of natural medicine and fundamental disapproval of the continued reliance on synthetic drugs to allay symptoms rather than treat the cause of the problem.

The assumption that greater availability of medical services, the increased recruitment of doctors and other health-related personnel, the construction of more hospitals and clinics, or the development and distribution of a wider range of drugs or surgical techniques will inevitably lead to improvements in health, increased longevity or the eradication of disease is ill-founded yet widespread, even among well-educated sections of the population. It is an assumption that has been challenged repeatedly for more than a generation by an articulate, well-qualified and careful body or researchers and commentators, yet it has been almost totally ignored by policy-makers and by the public at large.

The best interests of doctors and patients in the NHS has not been served by the failure on the part of governments and public bodies to control the almost uninhibited growth of medical technology and synthetic drugs and inability to rationalise the style and content of treatments on offer. It is ironic that, in a period when the accountability of industry for environmental damage has become a major priority on the political agenda at home and overseas, the undoubtedly damaging effects of much orthodox medicine continue to provoke little more than temporary scandals.

In 1986 the World Health Organisation launched its first Health Promotion Charter in Ottawa. In describing the nature of health promotion, it emphasised how it ran throughout most, if not all, the activities of society. The charter states: Health cannot be separated from other goals … and health promotion goes beyond health care. It puts health on the agenda of policy makers in all sectors and at all levels, directing them to be aware of the health consequences of their decisions and to accept their responsibilities for health". This is an approach which is now called holistic medicine; a concept which looks at the individual as a whole rather than just at the symptoms which present themselves at the physical level. It is, above all, a recognition that detectable symptoms are but a hint that there is some underlying cause of the patient's disorder and that it is this cause or causes which must ultimately be treated if the patient is to become healthy.

It is not my intention to suggest that all would be well if only current procedures of orthodox medicine were replaced by alternative methods. I pay tribute to the good and caring doctors, dedicated nurses, effective drugs and life-saving treatments. Natural medicine is no panacea for all human ills, any more than orthodox medicine has proved to be. The simple replacement of one set of therapeutic modalities with another would still leave untouched the issues of improvement in preventive medicine, social organisation and community care which, taken together, are bound to have the greatest impact on public health as they did in the last century. Nevertheless, it is obvious that something radical has to be done and that the careful intelligent introduction of what may broadly be termed holistic health care may, in a fresh context, lead to significant improvements on several levels.

Criticism of the current state of medicine ought not to be deflected by promises of reform and assurances from the pharmaceutical industry that there are yet more wonder drugs to come. I am reluctant to remind my noble friend of my advice to the Government six or seven years ago when I asked them seriously to consider the wisdom of allocating funds towards research for a "magic bullet drug" to combat AIDS. I think that I have been proved correct and can say that it is now generally believed that "lifestyle" and the maintenance of a competent immune system are far more relevant. It is, as was said by the noble Earl, Lord Baldwin, virtually impossible to achieve any funding for something as simple as that. In fact, I would go so far as to say that the almost total refusal of the scientific establishment to fund and undertake research into at least the better-established alternatives—or aspects of them—is in poor keeping with the spirit of independent scientific inquiry.

It is time for reappraisal. There are adequate studies on which to draw, competent critics to whom to turn and numerous avenues to explore. Should we turn in the right direction the future for human health on this planet may well be bright. If we fail to turn at all the 20th century will have produced no greater ecological disaster than that now being manufactured within human beings themselves.

4.45 p.m.

Baroness Robson of Kiddington

My Lords, I too thank the noble Lord, Lord Hunter, for introducing the debate. When one reaches this point in the list of speakers many of the comments which one was going to make have already been made. However, I shall risk repeating some of them. I was fascinated to listen to the speeches, in particular those made by the noble Earl, Lord Baldwin, and the noble Lord, Lord Colwyn. I am certain that there is more in what they say than most of us are aware of. On the other hand, today we are discussing the contributions of the pharmaceutical industry to our healthcare system. I also enjoyed the non-scientific explanations of the noble Lord, Lord Lyell, which blinded me with science. I could not understand some of the scientific terminology which he used.

I wish to apply myself to the role of the pharmaceutical industry in relation to the interests of doctors and patients. I believe that everyone connected with healthcare —whether doctors, nurses, ancillary staff or those who supply the NHS—have a common goal; that is, to improve the health of the patient. The success or failure of our healthcare system and of its suppliers, such as the pharmaceutical industry, should be judged against how far it achieves health gain for patients.

The role of the pharmaceutical industry is obviously to provide good quality, effective and safe medicines for patients. Indeed, the industry is probably one of our most successful. I was therefore sad to be told that in the preparation of The Health of the Nation White Paper there was little co-operation with the pharmaceutical industry. The noble Lord, Lord Hacking, mentioned the importance of the existence of such co-operation. In preparing the White Paper the department did not draw on the resources of the pharmaceutical industry. Yet, within each of the five key areas, the industry possesses knowledge and is engaged in ongoing research and development to find a cure and, perhaps more importantly, the prevention of disease.

If the test of success is making patients better it may be helpful to examine recent developments in the UK pharmaceutical market, particularly as the NHS drugs bill has risen markedly in recent years. Department of Health policy has been to shift the balance of healthcare from hospital provision to treatment by GPs in the primary sector, of which we all approve. This has been happening for some time. That means that medicines will use a higher proportion of total NHS resources, since the main treatment option available to GPs is to prescribe medicines.

An example of this shift to primary care was the introduction of the new GP contract in April 1990, which encouraged GPs to hold clinics in conditions such as asthma which can be life-threatening if not diagnosed early. This has led to an increase in the total cost of medicines used by GPs in asthma treatment. That has obviously been for the good but there is also evidence that it has reduced emergency hospital admission for asthmatics. The contract also specified targets for the immunisation of children, which were reached by May 1991. In that year for the first time ever there were no infant deaths from whooping cough or measles.

Indeed, GPs are also now able to carry out minor surgery rather than send patients to hospitals. In the first year of the contract, GPs carried out 850 minor surgical operations. In the same year, GPs' use of wound healing preparations and antibiotics showed a marked increase. Therefore, in part it is health policy which has increased the drugs bill.

We all believe that that treatment in the primary sector is not only cheaper, although I doubt that, but it also implies that it gives patients a better quality of life. It is important that we keep that in mind.

There is evidence that the use of pharmaceutical medicines is a very cost-effective use of scarce health resources. Classic examples are—and these are always mentioned in debates—the receptor blocking agents such as Zantac and Tagamet which have greatly reduced the number of patients requiring surgery for gastric ulcers. One survey shows that these medicines increased the "drugs" element of treatment costs for ulcer patients sixfold, but reduced total treatment costs by 66 per cent. These medicines, both of which were discovered and developed in the UK and are manufactured by British companies, save the NHS millions of pounds a year and make a valuable contribution to the economy of the country.

A recent calculation by the Office of Health Economics shows that the annual savings from seven groups of diseases as a result of the reduction in hospital bed days (using 1957 as a baseline) amounted to £4 billion in 1991. By contrast, the cost of all medicines prescribed in general practice for all diseases in the same year was £3.3 billion. Therefore, there is a direct benefit to the NHS.

Cancer is identified as one of the target areas in the Health of the Nation. In 1988 an article in the Lancet showed that the use of carboplatin in place of the cheaper cisplatin for the treatment of cancer can prove less expensive in the long term because it is not so toxic, is easier to administer and improves the quality of life of cancer patients. It allows out-patient therapy to replace costly in-patient treatment. Carboplatin costs £205.71 against £17.90 for cisplatin, but the total treatment costs are reduced from £347.90 to £228.77. Therefore, there is a direct saving to the NHS by using an expensive medicine.

Of course, new medicines do not come free. Pharmaceutical research and development is a costly and risky business. It takes an average of 12 years and £150 million to develop a new medicine, and only one in 10,000 compounds researched actually reached the market. Scientists who work in that field are some of the most patient people in society. But if a higher value medicine reduces overall treatment costs or enhances the quality of life for patients, then it is cheap.

Because of its reputation in the pharmaceutical industry, the United Kingdom attracts a disproportionately high share of research investment in the EC because of its innovative track record. Three of the major drug discoveries, which are the best selling drugs in the world in recent years, have their origins in British research laboratories.

The drugs bill is not rising because of price increases. Price increases are already less than the rate of inflation. The drugs bill is rising because more patients are receiving treatment and because new and more effective treatments have been made available by the pharmaceutical industry.

Much has also been said today about the pharmaceutical industry's economic and financial standing in the country. It has been mentioned that it produces a trade surplus of over £1 billion and the UK's export of pharmaceuticals reached almost £3 billion in 1992. I believe that the noble Lord, Lord Auckland, mentioned also that it employs 87,000 people of whom 18,000 are research scientists, but he failed to add that an additional 250,000 people are indirectly employed.

In my view, the industry has an outstanding record of investment in research and development, capital equipment and training. Six out of 20 of the world's top selling medicines were discovered and developed in the UK.

In summary, therefore, the pharmaceutical industry has contributed to the ability of doctors in the NHS to treat more patients, both more effectively in terms of the quality of life of individuals and more efficiently in terms of the use of resources. That this has led to an increase in the NHS drugs bill should be no surprise. The rise of the NHS drugs bill is a symptom of the success of the NHS in achieving health gain for the population and providing high quality care for those who need it. At the same time, the pharmaceutical industry has made an enormous contribution to the economy and to the creation of wealth which allows health care to be funded in the first place. The pharmaceutical industry's role in relation to doctors and patients in the NHS is an important one, and one of which the industry can rightly be proud.

4.57 p.m.

Lord Desai

My Lords, we have had an excellent and radical debate on the subject introduced by the noble Lord, Lord Hunter of Newington, to whom we all owe a vote of thanks. At the beginning of the debate this afternoon I did not expect that we should cover such new and radical ground as has been covered in the speeches by the noble Earl, Lord Baldwin of Bewdley, the noble Lord, Lord Colwyn, and my noble friends Lord Ashley and Lord Rea. We have covered a wide ranging set of issues.

At one stage we were in danger of repeating the debate which we had two weeks ago on the narrow question of the selected list and the Government's policy about the drugs bill. I am unrepentant as regards what I said on that occasion. We broadly support the Government on that issue. We have reservations about certain items on the list but by and large it is the correct way to go forward. So long as they are effective and safe, we should pursue the path of generic prescriptions; that is the way forward. I have no reservations about that.

Lord Hacking

My Lords, I am aware that time is limited but I am troubled by what the noble Lord said about reiterating his position and the position of his party, as I understand it.

Lord Desai

My Lords, I said "my position".

Lord Hacking

My Lords, perhaps the noble Lord will help us about this. In another place his party has condemned the selected list scheme.

Lord Desai

My Lords, I thank the noble Lord for his intervention. I have nothing to add to what I have said. I said that I broadly support the position but have two reservations which I have already mentioned. They are the reservations put forward by my honourable friends in another place who signed the Early-Day Motion.

We should not make this a debate about the interests of the pharmaceutical industry and the role of doctors and patients in furthering them, but rather about the pharmaceutical industry furthering the interests of doctors and patients. I am somewhat puzzled that people simultaneously argue—I was not going to get into this argument, and I am sorry about it—that the selected list will be ineffective and will not save much money, but yet will do untold damage to the pharmaceutical industry. We are led to believe that the pharmaceutical industry is successful, innovative and dynamic—something which I believe to be true. It is a profitable industry. At the same time the mere announcement by the Government of broad topics to be discussed, even before the medicines have been listed and decided upon—consultations are continuing—results in us being told that should the policy be carried out untold damage will be done to the pharmaceutical industry and the NHS.

I advise the friends of the pharmaceutical industry to be more subtle and restrained in their analysis. I agree that research and development in this area is important. I shall come to the cogent and radical speeches of the noble Earl, Lord Baldwin of Bewdley, and the noble Lord, Lord Colwyn. The industry spends nearly 15 per cent. of its total revenue on research and development. At the same time the way to encourage research and development spending is not just to leave the generic prescription case out of consideration. There are other ways in which the Treasury can encourage research and development not just in the pharmaceutical industry but elsewhere. I do not believe that the selected list will be that damaging. It would have to be proved that the previous selected list was damaging, if that were to be the case.

We have reservations about who is being consulted, and whether there have been consultations with patients. We have reservations about contraceptive drugs and dermatology, but by and large the idea is good and it is one that we should pursue.

Two issues have been raised upon which I wish to comment. First, I greatly welcome what the noble Lord, Lord Hunter, said towards the end of his speech, that given the new purchaser/provider culture being introduced into the NHS we should think about the variety of flexible ways in which doctors can respond to the opportunities available to them with respect to prescriptions or the alternatives by which they can save money. I shall read his speech carefully and learn much from it. There is clearly a case for thinking further about that matter.

The subject of alternative medicine was eloquently raised by the noble Earl, Lord Baldwin, and the noble Lord, Lord Colwyn. I had the good fortune to grow up not in a mono culture but in a pluriculture with respect to medicine. In as much as the UK is now a multiracial society, access to alternative medical systems should be available. Such systems should perhaps be considered as a matter of official policy. We should see whether we can satisfy consumer choice. If consumers want such alternative medical systems, we should consider whether there are ways of satisfying that choice. We should not believe that there is only one truthful way, because there are many alternative ways. So I welcome that suggestion.

I was impressed by the observations of my noble friend Lord Ashley about the safety of medicines. There is anxiety about the testing for new drugs which may not be ethical, but is not quite unethical, and the way in which new drugs are pushed at doctors. The newspapers recently reported a case relating to Wellcome, the well-known pharmaceutical company, and the side effects of a drug used for immunising against whooping cough. Such anxieties are genuine, we should remember them although we should not exaggerate them. Moreover, issues regarding the broader responsibilities of the pharmaceutical industry towards patients should not be forgotten.

In general, I agree with the many noble Lords who have said that the pharmaceutical industry has made a tremendous contribution towards improving the health of patients. I also agree with the noble Lord, Lord Colwyn, that medicines do not provide the only way to good health and that in some cases they may be an obstacle to it. Many noble Lords commented upon how much more money we are now spending on the NHS. I would argue against that. The numbers naturally seem large but when we compare our expenditure on health internationally, the UK spends a smaller proportion of its GDP on health and receives good results. One reason for that is that governments of different political hues have jealously controlled costs within the NHS. That should continue to be the case.

5.6 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Baroness Cumberlege)

My Lords, I too should like to thank the noble Lord, Lord Hunter of Newington, for initiating this debate. It is a matter of great importance to the prosperity of this country and to the well-being of its people. There can be no person better fitted to the task, and I am sure that your Lordships will agree that the noble Lord has given us a clear and concise exposition of the issues involved. I am grateful to the noble Lord for that, and to your Lordships who have taken part, for this is a confused and complicated area. In fact the Government are in a delicate position.

The Government's first duty is to patients, but they are also the purchaser of drugs supplied buy the pharmaceutical industry, and as a result our relationship with the industry is immensely complicated. The Government pay the entire NHS drugs bill. My noble friend Lord Hacking and the noble and learned Lord, Lord Brightman, highlighted graphically the meteoric rise of the drugs bill and the forecast figures which, if unchecked, are breathtaking. Of course money spent on drugs is money not spent elsewhere in the NHS, so it is natural that the Government should try to ensure that spending on drugs is as effective and economic as possible —seeking value for money for both patients and taxpayers.

But the Government, although paying the bill, do not generate the expenditure. It is doctors who prescribe according to clinical need. So again it is natural that the Government should look to ways of encouraging more rational prescribing. It is equally reasonable for the Government to make every effort to keep the population healthy, thereby reducing the drugs that they might otherwise require.

Although anxious to contain costs, the Government recognise the very positive contribution which drugs can make to people's lives. Astonishing progress has been made since Alexander Fleming's discovery of penicillin in 1928. Whether in mental health, transplant surgery or treatment for ulcers, innovative drugs have allowed people not only to live longer but also to overcome disabling conditions and to lead healthier and happier lives. To continue to bring those benefits and to research and develop new and more effective drugs, the industry has to generate profits from sales of existing products. The costs of research and development are of course immense and the timescale long. I should like to pick up the issue of research a little later. So the skill of the Government is to hold this balance between conflicting pressures.

I believe that we all start from the premise that all the parties involved are genuinely aiming to serve the people and the Government's role is to ensure maximum co-operation in order to achieve maximum benefits. It is also essential that the Government are active in their support for science-based industries. None of them is free-standing; they are all interdependent. The fact that our pharmaceutical industry is successful is in itself important because pharmacology is closely linked to other sciences which are vital to the practice of modern medicine. It is therefore of great importance that pharmacology does take a leading role.

Just as the pharmaceutical industry is essential to our science-based industry, so research emanating from NHS hospitals and universities is vital to the industry. The NHS is a necessary adjunct for trials and statistical data and the industry is responsible for sponsoring a good deal of research. This interdependence and co-operation are critical in maintaining an active industry and a progressive health service.

My noble friend Lord Auckland raised the question of the industry's approaches to GPs. The noble Lord, Lord Rea, voiced a mild rebuke at the way the industry employs representatives to sell its products to GPs and consultants, sometimes in a fairly lavish way. Of course eventually many of these marketing costs are reflected in the price that the NHS pays for the product.

The level of costs is of course indirectly regulated, but we also have to assess the cost against the benefit which it brings. We want a vibrant industry which is active in marketing its products, and when considering world markets we recognise that there is no place for complacency. But we also need to be careful that we do not assume that drugs are always the best solution to ill-health.

Sir William Osler, the distinguished physician, made two good points. First, he said, the desire to take medicine is perhaps the greatest feature which distinguishes man from animals", and, secondly, that, one of the first duties of the physician is to educate the masses not to take medicine". On the first maxim, the relentless work of the pharmaceutical industry's public relations, marketing and advertising departments plays on people's tendency to take medicines as a first, rather than a last, resort. The rise of sales of non-prescription drugs is a tribute to the success of those departments.

The second Osler maxim is not yet perhaps as effective a counterbalance as it should be. It will take time to educate the public and perhaps for some doctors to accept that consultations need not conclude with a prescription, although most patients expect one. Many doctors too see this as the accepted way of closing an appointment. We need to disabuse people of this expectation and to dissuade doctors from this habit. In the meantime the drugs bill increases remorselessly—by 11 to 12 per cent. per annum. Set against inflation of 1.9 per cent., and at a time when health service pay is pegged at 1.5 per cent., this rise is both disturbing and unacceptable.

My noble friend Lord Lyell asked why the drugs bill had increased by 12 per cent. per annum and how that was calculated. Between 1986–87 and 1991–92 the family health service drugs bill has risen at an average rate of 11 per cent. in cash terms. Indeed in 1992–93 the FHSA drugs bill for England rose by almost 40 per cent. Undoubtedly some of the rise in the dugs bill is due to changes in demography but much more important, as the noble Baroness, Lady Robson of Kiddington, pointed out, is the fact that doctors have been writing more prescriptions per head of the population and those prescriptions have become more and more expensive. However, the bulk of the rise in the average cost of prescriptions, some 6 per cent., is accounted for by what one can best describe as the product mix; that is to say, changes in the medicines which are being prescribed.

The Government therefore have a multi-pronged policy for containing the drugs bill. Our first priority is to maintain health, and the Health of the Nation strategy, which brings people from all walks of life together in a co-operative drive against avoidable illness, makes an important contribution on this front. But when health breaks down and drugs are necessary, the Government seek to achieve value for money, first, by encouraging the prescribing of generic drugs, which are generally cheaper, as advocated by the noble Lords, Lord Hunter of Newington and Lord Rea. The noble and learned Lord, Lord Brightman, asked whether the Government were satisfied that generic drugs are truly safe and pure and whether doctors should be able to prescribe brand names. The noble Lord, Lord Ashley of Stoke, asked whether the Government should do more to ensure the safety of drugs generally.

Doctors are already able to prescribe a brand name if they so choose. The advice that is given to them is not mandatory. They are free to reject or accept it as they wish. However, all drugs, including generic drugs, go through the same rigorous licensing tests by the Medicines Control Agency. The noble and learned Lord, Lord Brightman, and the noble Lord, Lord Ashley, can rest assured that every new drug in this country is as safe as we can make it. Those drugs undergo the most scrupulous scrutiny. Existing products on the market are carefully monitored.

Clearly every drug though has the potential to do harm and clinical trials must run a minute element of risk. However, I do not recognise the picture painted by the noble Lord, Lord Ashley of Stoke. The noble Lord has asked for a very full reply this afternoon. I am unable to give that, but I am willing to discuss with the noble Lord on another occasion the views that he has.

Lord Ashley of Stoke

My Lords, the noble Baroness says that she does not recognise the picture that I have presented. Has she taken the trouble to read the material presented by Professor Inman to whom I have referred? If she has not done so, she is in no position to be able to identify or not identify the picture I have presented.

Baroness Cumberlege

My Lords, I am well acquainted with the yellow card scheme. I have seen it work very effectively on most occasions. I am prepared to accept the noble Lord's view that it is not working on all occasions. I am happy to discuss that with him on a later occasion and to discuss the report that he mentions. I do not know it in detail and therefore I think that that is something we should explore together on another occasion.

A further measure that has been introduced by the Government is the selected list scheme which was well and thoroughly debated two weeks ago. I really do not want to go into that in detail this afternoon; but I am grateful to the noble Lord, Lord Desai, for yet again so forcefully supporting the Government's initiative, albeit with some reservations. The noble Lord, Lord Hunter of Newington, posed the question whether the selected list scheme will encourage pharmaceutical companies to advertise directly to the public. The availability of drugs for sale to the public is determined by the licence indicators of the product. These decisions are made by the Medicines Control Agency whose work is entirely independent of the advisory committee which is advising the Secretary of State on the selected list scheme. I think we shall have to wait and see what happens. I take the point made by the noble Lord as regards what is happening in the United States. Perhaps that is something we should look at.

The noble Lord, Lord Jenkin of Roding, took part in the debate a fortnight ago. As was said by your Lordships this afternoon, he was critical of the selected list. I wish to take this opportunity to stress first of all that the original list saved the NHS £75 million in the first year alone, and that the approach which the Government are now taking to extend the list to more categories is altogether different. We are more cautious. We have involved the industry as never before, and our advisory committee of highly respected professionals has been expanded in number and in experience to take into account some of the previous criticisms. We are giving it an entirely free hand, and if that committee comes to the conclusion that not a single drug should be put onto the selected list, the Secretary of State will, of course, want to take account of those views.

I was grateful to the noble Lord, Lord Rea, as the only Member of your Lordships' House in possession of a prescription pad, for his measured approach and support for the Government's proposals.

My noble friend Lord Lyell asked why the 10 selected list categories were included. He mentioned contraceptives and appetite suppressants. I am not sure whether he saw a link between the two. The 10 new categories were chosen because they cover a range of products, at varying price levels, which offer scope for savings while enabling all real clinical needs to be met.

The third measure introduced by the Government in their attempts to contain costs is the indicative prescribing scheme which guides doctors in their prescribing decisions. I was very interested in the view of the noble Lord, Lord Rea, that we have not yet made full use of that scheme. My right honourable friend the Secretary of State and her Ministers will wish to take away those thoughts and capitalise on them.

The Government have also given GP fundholders real incentives to prescribe economically. That initiative has been particularly successful, for GP fundholders' prescribing costs are not only 10 per cent. lower than those of their non-fundholding colleagues but are rising more slowly. There are lessons there for other GPs. Indeed, my right honourable friend the Minister for Health has recently announced an initiative to extend those benefits to all non-fundholding practices.

A major but indirect tool in containing costs has been the pharmaceutical price regulation scheme, which was highlighted by a number of noble Lords this afternoon, particularly the noble Lord, Lord Hunter of Newington. I suspect that he knows more about the scheme than most of us as I believe that he was one of the architects of the original scheme. It is a voluntary agreement which is negotiated between the department and the pharmaceutical industry. The scheme regulates the profits which companies make from the sale of drugs to the NHS and has proved to be more successful than the alternative schemes adopted by our European neighbours. However, the present scheme, agreed in 1986, is now being renegotiated with the Association of the British Pharmaceutical Industry, as your Lordships are aware. A fair price for the NHS and a fair profit for the industry underpin the scheme.

The Government take care not to intervene between doctor and patient, but they have a duty to collect data and to use them to assess effective treatments. The noble Lord, Lord Hunter of Newington, and the noble and learned Lord, Lord Brightman, expressed concern that effectiveness is not sufficiently taken into consideration. The Government are aware of that. Therefore, we have recently established the Medicines Resource Centre which issues monthly bulletins to all GPs on the comparative effectiveness of competing drugs. We also fund the distribution of the drugs and therapeutics bulletin which is published by the Consumer's Association.

Those are some of the national initiatives. Locally we have encouraged family health service authorities to appoint medical advisers, and in many cases pharmacists, who work directly with GPs giving them professional advice as to the most effective drugs available.

I should like to pick up a few other points raised by noble Lords. The noble and learned Lord, Lord Brightman, raised the question of information to GPs concerning the side effects of drugs. The Government sponsor a number of publications, some of which I have just mentioned, which are provided free to GPs and offer independent guidance about the drugs available. The most respected of these is the British National Formulary, which I understand is the GP's bible. That publication is updated every six months and contains the indications for each drug as well as its known side effects and interactions. Contained at the back of the publication is the adverse reaction card, which has already been mentioned this afternoon. A GP fills in a card when a patient notifies a side effect. The GP then sends the card directly to the Committee on the Safety of Medicines.

The noble and learned Lord also asked how the research costs of low selling drugs can be met. Under the PPRS scheme the Government provide substantial help with the research and development costs of drug companies. It is for the companies to decide where to spend that money. We do not interfere in those decisions. That must be a matter for the commercial judgment of the company. Further, in Britain companies have the freedom to set an appropriate price for a new drug.

My noble friend Lord Lyell raised the question of the need for companies to bring new products on to the market quickly. We fully agree that new products should be placed on the market quickly and I am happy to tell your Lordships that we have now made the Medicines Control Agency the swiftest licensing authority in the world. Unlike some European countries, there is no impediment of direct price control by the Government in this country.

I share the views of the noble Baroness, Lady Robson of Kiddington, and the noble Lord, Lord Desai, that the contributions of my noble friend Lord Colwyn and the noble Earl, Lord Baldwin of Bewdley, were full of interest and were challenging to some of our mainstream thinking. Perhaps I may do a little thinking on the subject and come back to the noble Lords in due course.

I am also grateful to the noble Baroness for pointing out that the pharmaceutical industry has an enormous contribution to make in the five key Health of the Nation target areas.

The noble Earl, Lord Baldwin of Bewdley, raised the effects of the power of the drug industry and the monoculture which results. Although the noble Earl's speech was full of interest, I do not believe that he did full justice to the industry. Many of its products have made a huge difference to the quality of life of many patients. My noble friend Lord Auckland gave just one example, of mastoiditis, which is rarely seen nowadays because of the advent of antibiotics. The noble Baroness pointed out that drugs can not only be life saving but good value for money.

In conclusion, as my noble friends Lord Hacking and Lord Lyell, pointed out, the pharmaceutical industry creates great wealth for Britain. In 1991 there was a positive trade balance of almost £1.2 billion. The UK pharmaceutical industry exported over £2.5 billion. Four of the top 10 best-selling drugs in the world were researched in Britain. The industry employs more than 87,000 people in the UK. That is an achievement which we should all applaud.

Efficient and effective use of resources is an integral part of our commitment to meeting the needs of patients. It is a reflection of our concern for them. Every pound and penny which is wasted or misspent is a loss to the health service, to the country and so to the patient. We must ensure that when the NHS buys drugs it buys wisely, when it prescribes it does so effectively and when dispensing it does so efficiently.

Medical science, the pharmaceutical industry, people's expectations, doctor's practices and NHS management methods are constantly moving forward and changing. This Government have clearly demonstrated their ability and willingness to change and adapt to new circumstances. The role of pharmaceuticals, although central in the delivery of health care, will also change, but it is clear that the NHS needs the industry, the industry needs the NHS and patients need them both.

5.28 p.m.

Lord Hacking

My Lords, perhaps my noble friend will be kind enough to allow me to intervene. We have six or seven minutes left.

Noble Lords


Lord Hacking

My Lords, we have six or seven minutes to go and I rise on a point of correction. I am entitled to do so. My noble friend referred to my having spoken of the escalation in the cost of drugs. I spoke not of the escalation in the cost of drugs but of the escalation in total national health costs. The only reference I made to increased drugs costs was when I referred to a 66 per cent. increase in a drugs' costs which was set against a 70 per cent. saving for that drug in total health costs. This is an important area of co-operation and that is why I am asking my noble friend whether the Government will co-operate with the pharmaceutical industry in relation to drugs which save National Health Service costs.

Baroness Cumberlege

My Lords, with the leave of the House, perhaps I may say this. I apologise to my noble friend if I misunderstood him. However, I believe that both the cost of drugs as well as expenditure on the National Health Service are escalating at a very alarming rate.

Lord Hunter of Newington

My Lords, I believe that the whole House unanimously would wish me first to thank the Minister for a stimulating and wide-ranging reply. I wish to thank everyone who has taken part in the debate and contributed substantially to the topic. I beg leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.