§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Mather.]12.25 am
§ Mr. Thomas Torney (Bradford, South)
When Nye Bevan introduced our National Health Service, he had to fight on two fronts. One was the doctors who were apprehensive about becoming civil servants and so possibly becoming subject to the dictates of some Government. The other was the Tory party. While the doctors finally agreed to become perhaps reluctant partners, they are now enthusiastic supporters of what was the finest Health Service in the world. They now believe that the welfare of patients counts before savings for the Treasury, whereas the Tory party against which in those days Nye Bevan was battling to establish this great service — from these very Benches — was opposing its establishment. It fought our Health Service every inch of the way.
The Tories have not changed. They believe now, as they did then, that only those who can afford to be sick should be allowed to be sick.
Restricting prescription strikes at the heart of our Health Service. To tell a doctor that he must take into account the patient's ability to pay before he decides what the patient needs is criminal and makes a mockery of the Prime Minister's statement:The Health Service is safe with us.The National Health Service was founded by the Labour party upon the principle that the best health services should be available to all and that money should not be the passport to better or quicker treatment. The Government seek to undermine those unimpeachable principles by stealth.
I have a serious constituency problem created by those proposals. The city of Bradford has a serious unemployment problem. It has well over the national average of unemployment. Those unemployed people could never afford to pay the full price for the drugs at the chemists.
Bradford has an aging population. With the help of many of the drugs that the Government now propose to ban, people are living longer. The forecasters say that Bradford will have even more older people in the years ahead.
Those elderly folk are more likely to fall sick, often with serious and painful maladies. Many are pensioners on supplementary benefit who could never afford to purchase the drugs now prescribed for them under the National Health Service.
I have received hundreds of handwritten letters from constituents. I will quote from just a few. I apologise for any mispronunciation of chemical names as I am not a doctor. One constituent writes:I collected my prescription for Fybogel and was informed that the Government propose that it will be on private prescription only, from the 1st of April.It is the only product I can have for my condition as everything else including pain killers give me a horrible itchy rash from top to toe. I am a pensioner aged sixty eight".She complains that the cost would be too much for her to pay.
Another writes:I am very concerned regarding Propain tabletswhich the doctor gives her for arthritisas I suffer mostly in my knees and joints.1227 That constituent, aged 77, also complains about the high cost which she could never afford.
Another objects to the Government withdrawing the drug Gaviscon from the prescription list as he suffers from a hiatus hernia and has been told that it isimperative that I be treated with Gaviscon or a similar drug." He, too, is afraid that he will no longer be able to get the drug.Another pathetic letter begins:To look at me now you would not tell I am arthritic, but I have suffered from Arthritis for 33 years. In that space of time I have progressed from being crippled to quite active, but believe me at times the pain is excruciating. Obviously after coping for so long I only take painkillers when really necessary.I am only 35 yrs. old now, so if we take the average life-span I have another 35 yrs. of life left, with the distinct possibility that my Arthritis will worsen. I have faced this gruesome thought in the past, with confidence, as I have known if necessary I can take Distalgesic tablets when the pain is bad, but how can I and thousands of others now face the future, when we are given to understand we will no longer be able to obtain Distalgesic tablets on prescription?Many people who attend my regular surgeries tell me that their doctors have said that there is no generic alternative to the antacids asilone and mucaine, the analgesics distalgesic and equagesic or the laxative dobinex.
Branded drugs are made by reputable companies to the highest standards, backed by years of research at very high cost. Generic drugs may not be made by reputable companies. They may be produced in the far east or in eastern European countries. They may be sold cheaply without the Government safeguards and inspections that we have here. Will the National Health Service compensate patients if something goes wrong?
Another example of lack of consideration by the Department is the fact that only one benzodiazepine has been left in the Government formula — diazepam, otherwise known as valium.
I have it on the best authority that medical opinion is very concerned about the effects of the continued use of valium over a prolonged period. There are newer, more effective and less harmful drugs that could be used, but the Government have taken them off the list.
I have had letters galore from doctors, health authorities, community health councils and, above all, the BMA, all condemning the Government's pernicious scheme.
§ Mr. Tim Yeo (Suffolk, South)
Is not valium some 14 times more expensive than a clinically identical substitute? Does the hon. Gentleman seriously suggest that the Government should, by including valium on the list, waste resources that could be used elsewhere in the NHS?
§ Mr. Torney
The hon. Gentleman cannot have listened to what I said. I said that valium is one of the few drugs that has been left on the list, although there are newer—
§ Mr. Torney
That is my information. [Interruption.] Conservative Members may scream as much as they like, but I have it on good medical authority that valium is on the list, although there are newer and better drugs. The medical profession does not like valium because of the danger to the patients if it is used for a long time.
In 1982, the informal working group on effective prescribing reported to the Secretary of State for Social Services. According to the report, 1228There are in the region of 6,500 preparations available for prescribing at NHS expense and the new BNF lists some 4,500 of these. In comparison, the average prescriber is said to use a range of 200–300 drugs. A number of schemes for the introduction of a national Limited List of drugs has been proposed at various times by different people. We have considered these, but it is our view that a limitation on prescribing at NHS expense would be interpreted by some doctors as an attempt to curtail their clinical freedom. Since we have not seen any convincing evidence that suggested financial benefits would outweigh the administrative problems in, drawing-up and maintaining the list, we have concluded that such a move would not be justified and we do not recommend any measures to introduce nationwide a Limited List.On 9 January 1985, a resolution of the BMA council stated thatThe Government's intention to limit by Regulation the range of drugs available for prescription on the NHS from 1 April 1985 is in our opinion contrary to the spirit of the NHS Act The Act lays a duty on the Secretary of State to provide a comprehensive health service, including the supply of proper and sufficient medicines ordered by a medical practitioner, free of charge except in so far as charges (e.g. prescription charges) are made under any enactment.Between 8 December 1983 and 8 November 1984, there was a complete reversal of Government policy. There were no discussions or consultations, and no evidence was produced to explain the reversal of policy. The objections raised by the Department to the introduction of a limited list are still valid and the controversy that followed the announcement on 8 November 1984 proved the accuracy of the conclusion in the departmental paper that the introduction of a limited list would cast doubt on the Government's intentions towards the standard of provision of general medical services in the NHS.
Last but not least, the list makes for double standards in the Health Service. Those who can afford it can have the best that the drug industry can offer, but people who, like most of my constituents in Bradford, are poor, members of a low income group, dependent on pensions or benefits are condemned to suffer pain and hardship for the rest of their lives, and perhaps early death, simply because they cannot afford to pay for the drugs that are available and so that the Tory Government can save money, perhaps to give tax cuts to the better off.
§ The Minister for Health (Mr. Kenneth Clarke)
I congratulate the hon. Member for Bradford, South (Mr. Torney) on his good fortune in the ballot, but I cannot say that I believe that he has made constructive use of it. With respect, his speech on our limited list proposals, on which we are still consulting, comprised an amazing amount of cant and nonsense.
The hon. Gentleman gave his version of the origins of the National Health Service and claimed that we are trying to change it into a service in which treatment is dependent on a patient's means, or ability to afford better treatment. Most of the objections to our proposals come from commercial and professional lobbies, which have obviously spent some of their time briefing the hon. Gentleman. They are perfectly entitled to lobby. The professional interests involved are extremely respectable people such as the British Medical Association. Whatever reasons might be raised against our proposals, I hope to persuade the hon. Gentleman, and anyone else who shares his feelings, that the argument that we face a two-tier service or that the poor and the elderly are threatened with suffering is misplaced.
1229 To illustrate his point that elderly patients are at risk, the hon. Gentleman drew heavily on many letters that he has received from patients citing the drugs that they are using. It is obvious that they are not altogether spontaneous letters, because they are written in terms about the drugs that would not ordinarily come immediately to elderly patients. They cite the drugs that they are taking, and most patients do not know the professional name of drugs. Some of the names were given inaccurately, as though a layman was doing his best to give the name. It is quite obvious that, within the hon. Gentleman's constituency, there are some doctors who have been carrying out what I regard as an unethical and unscrupulous campaign by alarming their patients and telling them to lobby their Member of Parliament because they face the risk of pain and suffering because the Government are threatening to withdraw a drug.
A doctor is quite entitled to campaign against any part of the Government's proposals for the NHS if he wants to. We have invited every doctor to make his professional views known to the chief medical officer if he criticises the list that the Government have proposed. It is not right for doctors to alarm patients, such as those who have been writing letters in Bradford, by combining political campaigning with medical advice, thus inspiring patients to write what I accept are heart-rending letters in the hope that the Government will be pressurised into change.
I hope that, faced with these problems, the hon. Gentleman will show his usual concern for his constituents by trying to reassure them and by telling doctors that this is no way in which to conduct a sensible political debate. The hon. Gentleman should tell doctors in his area to respond to the request that they have had. If they are worried about the effect on patients of any changes in the drugs available, they should give their considered opinion, as forcefully as they like, to Ministers and the chief medical officer—our adviser.
The hon. Gentleman has obviously leapt on the opportunity that is provided by the letters to stoke up fears and alarm among the elderly and the poor in his constituency. He is lending himself to an unscrupulous campaign. I strongly regret that he and some of the doctors in his constituency have set about things in that way. If he will not reassure people in Bradford, it is obviously my duty to do so. The Government have no intention of debarring any of the poor or elderly from the treatment, free if necessary, under the NHS that they require. We have every intention that under the NHS it should be possible for doctors and patients to have access to a complete list of preparations, which is sufficient to cope with all the clinical and medical needs of the service.
§ Mr. Torney
When the right hon. and learned Gentleman said that my constituents would not know the names of their drugs, is he aware that when a doctor gives a patient a presciption to take to the chemist, in 99 out of 100 cases the chemist will write the name of the drug on the bottle for the patient to read? Some old people have been taking a drug for so long that they are well aware of the name of it. How does the Minister account for the fact that the BMA is opposed to the list—surely he does not doubt its bona fides?
§ Mr. Clarke
The BMA is opposed to the list for a variety of reasons. Some sections of the BMA are advising 1230 doctors to campaign in the way that has clearly taken place in Bradford. In some parts of the country pre-prepared letters are presented to patients when they visit their doctor, on which the name of the drug is written by the doctor so that the patient can send it to his Member of Parliament.
§ Mr. Clarke
Those are obviously all hand-written letters, but, if the hon. Gentleman explores further, he will discover that one, or probably more than one, practice in Bradford has been inspiring patients in a subtle and varied way to write to him complaining about the proposals. I am not saying that such doctors are bad. All doctors have been asked to give their considered professional opinion, if they wish, to the chief medical officer about a proposal to limit the range of drugs in certain therapeutic categories that will be prescribable on the NHS. Doctors would have been better advised to give their professional opinion and to reserve judgment until they see the final proposals that will be published shortly. It was not right of doctors to campaign in such a way as to cause alarm and anxiety — the hon. Gentleman admitted that — to many frightened elderly patients who had visited the surgery for treatment, reassurance and help.
§ Mrs. Edwina Currie (Derbyshire, South)
Is it not a fact that the total number of letters received by the DHSS from our doctors in practice amounts to no more than 2 per cent. of doctors and that 1,800 of them either mention a particular commodity or make warm comments about the proposals?
§ Mr. Clarke
I am not sure of the precise percentage, but I accept that my hon. Friend may well be right. Certainly we have had 1,800 letters from doctors giving constructive comments on the contents of the list and saying which preparations they would like to see on the list, as it was suggested all those concerned should do.
We have not issued a final and definitive list, but a proposal that in certain therapeutic categories it would be wise for the service to restrict the total number of products available because at present the NHS provides a large number of similar, and sometimes identical, products at varying prices. We saw the possibility of making substantial savings for the NHS by restricting that range to the full list that is required to deal with all patients' clinical needs. We therefore issued a list for discussion, and have received the 1,800 responses that I mentioned, and many others from pharmacists and companies in the pharmaceutical industry. The chief medical officer and a panel of distinguished outside experts from all the specialties and areas affected by the proposals are considering what the final list should be. Nothing has yet been taken from the list. Any patient who is told, as the hon. Gentleman was told, that his drug will definitely not be available after 1 April has been misled, because no decisions have been taken about what drugs will be available on 1 April. Anyone who discovers when the final list emerges that the brand of product to which he is used is not available will also discover that the alternative is an equally effective drug, which will do the medical job required at somewhat less cost to the National Health Service.
I cannot emphasise too much the fact that there is no motive to introduce a two-tier service, thus driving 1231 patients to buy their health care, or any of the bizarre theories advanced by the hon. Gentleman. What we are doing here is what we are doing throughout the Health Service — seeking sensible economies that do not adversely affect patient care. We are seeking better value for money for the resources that we put into the National Health Service. We are increasingly trying to maximise the patient care that we obtain for the money that we spend. If we can save up to £100 million on the drugs bill without damaging patients, that will enable us to sustain the increased expenditure on the Health Service that we are planning for next year and the two years beyond that.
The subject of cutting drug costs has been examined for some time, including, in 1982, by the expert committee that produced the report cited by the hon. Gentleman, which is usually known as the Greenfield report. In all the discussions that we have had about drugs costs, one thing unites the Government, the BMA, the vast bulk of the medical profession and the pharmacists: everyone is agreed that it is legitimate to consider ways of reducing the drugs bill. Anyone who is interested in the NHS appreciates that it is undesirable that our drugs bill has continued to increase at the rate that it has. It is increasing by more than 5 per cent. above the general rate of inflation each year, and is now £1,400 million in total. The number of preparations and prescriptions is increasing, as is the cost per prescription. If that money continues to be drawn into an ever-increasing drugs bill, it will be more difficult for the Health Service to maintain other services. Everyone has co-operated in searching for ways to reduce drugs costs.
The Greenfield committee considered various methods, and recommended the system known as generic substitution. I will not burden the House with the details of that tonight, because it is not the issue raised by the hon. Member for Bradford, South. The Government rejected it because of the immense damage that it would have done to the British pharmaceutical industry, and because it was opposed by the British Medical Association. The BMA believed that it would create considerable difficulties if a doctor prescribed one drug and the pharmacist dispensed another. It was worried about instances of a doctor prescribing a drug and never knowing what the pharmacist eventually dispensed to the patient as the cheapest generic equivalent.
It is true, as the hon. Gentleman said, that the Greenfield report mentioned a limited list, and he fairly and accurately quoted the terms, saying that the committee was aware of it. It believed that some doctors would argue that their clinical freedom would be threatened if such a list were introduced. However, only some would do so, because it is extending the concept of clinical freedom a little far to say that it means that not only should doctors have the full ability to treat all the clinical needs of their patients, but that they should be able to prescribe any product on the market at any price, even though a cheaper alternative may be available.
The Greenfield report rejected a limited list because there was no evidence that financial savings could be 1232 made. Since 1982, we have done substantially more work on that aspect. We have considered experience here and abroad, and international experience is very enlightening. We realised that the paucity of evidence could be remedied. When one considers the experience abroad, it is plain that, although no country has exactly the same provisions for drugs as Britain does—every country has variants in drug pricing and policies—but every one of the Western developed countries has some element of selection of products and some element of listing of drugs in its health care policy.
More to the point, we are certainly the only country with our present system whereby every product that obtains a licence can come on to the market at a price determined by the manufacturing company and is immediately available for prescription by any doctor in the National Health Service, paid for by the taxpayer without question. The number of products available under the NHS has gone up to 18,000 and doctors can select any one of those.
I believe that the list we are producing will eventually be seen by doctors as useful guidance, based on the work of an expert panel which has sifted through all the advice we have received from the professions and set out a full list that will allow doctors to deal with all needs in these limited categories of drugs. Two thirds of the drugs we are talking about can be bought over the chemist's counter without a doctor's prescription, anyway. The prescription-only drugs are largely the tranquillisers, which are often criticised — the benzodiazepines, many people have argued, are over-prescribed in this country and not always prescribed carefully. Valium is a criticised drug and is not on our provisional list, contrary to what the hon. Gentleman asserts.
We will look at all the drugs and select those which are essential to patients out of the very wide range of very similar tranquillisers available on the Health Service at the moment, and similarly with sedatives and some sleeping pills. But we have very carefully confined the categories of drugs we are dealing with. We have not touched the life-saving drugs; we have not touched many of the more advanced areas. We believe that we can safely introduce a system within this section of the drugs Bill that does not adversely affect patients and saves money for the Health Service.
We are the real friends of the Health Service, by improving its efficiency and its cost-effectiveness, and making sure that its resources are devoted to patient care. The hon. Gentleman is rehearsing old arguments, old prejudices. He has not got any ground for rehearsing them on this occasion. He has been misled by a commercial campaign and the rather odd behaviour of some of his doctors into believing that there is a cause to be pursued here, which I believe, when he thinks about it more carefully, he will realise should not have been pursued on this particular ground.
§ Question put and agreed to.
§ Adjourned accordingly at five minutes to One o'clock.