§ 9.13 p.m.
§ Lord Kilmarnock rose to ask Her Majesty's Government whether, in view of their answer to Lord Kilmarnock's Question on 15th January (cols. 867–870), and of the widespread professional support for the Greenfield Report on Effective Prescribing, they will now seek to obtain general agreement to revised proposals, taking into account the recommendations of that report.
§ The noble Lord said: My Lords, in rising to ask the Question standing in my name I want first to thank all noble Baronesses and noble Lords who have stayed here so late in order to participate in this debate. I think I am right in saying that not a single person has "scratched", which seems to me to be very creditable. This Question stems from the Starred Question I asked on 15th January. I asked whether, in view of the widespread opposition to their proposed limited list for National Health Service drugs, the Government would reconsider generic substitution by pharmacists 1158 with the consent of the doctor, as proposed by the department's own internal committee chaired by Dr. Greenfield.
§ The noble Lord, Lord Glenarthur, replied "No" to that question. But he seemed to recognise later that day, at column 870, that the list would have to be substantially amended. It is also common knowledge that the Government invited submissions from interested parties to the new internal committee chaired by Dr. Acheson. January 31 was the deadline, and the committee is presumably sifting the responses now. It is therefore my hope, indeed my aim, that what is said here this evening will play some part in that process. This Question is less tightly drawn than my earlier one because it is not intended to box the Government into a corner. It invites them to make a constructive response to the many criticisms that their plan has attracted.
§ We on these Benches are in favour of reducing the drugs bill as a proportion of National Health Service expenditure to release resources for other pressing needs in the service. We made this quite plain in a policy document we issued in 1982. But we are not in favour of the Government's way of going about this, and their friends on this issue seem to be few and far between. In 1982 we advocated generic substitution where feasible, unless there was an express wish from the GP to the contrary. We also thought that new drugs should only be adopted by the NHS if they were safer, cheaper or more effective than the drugs already available—a form of limited list, if you like, which would discourage the "me-too-ism", as I believe it is popularly called, and would encourage genuinely innovative products whose patent life we thought should be extended.
§ But what are we presented with? We are presented with a draft list of breathtaking incompetence. When doctors came into the National Health Service as independent contractors, preservation of their clinical judgment was part of the basic understanding. If they were state employees the Government might be in a stronger position to give them orders, but even in that situation it is to be doubted whether a wise Government would try to impose such an amateurish list with so little technical rationale. Even if the Government were only flying a kite this would be disturbing.
§ Let us take a few items from the list. Benzodiazepine prescribing is already on the decrease, and yet we are to be restricted to three out of over fifty. Two of these are long acting and one slightly shorter, but the spectrum of pharmacological possibilities is not remotely covered by this selection. There is no provision for someone who needs a short-acting sedative to "get off".
§ Let us take the case of laxatives. None is allowed that is effective for cancer patients whose medication induces severe constipation. Let us take aspirin. No enteric-coated aspirin is to be allowed, yet this is essential in the treatment of rheumatoid arthritis as normal aspirin in the required quantities would damage the stomach lining. If it is suggested that such patients should get their supplies from hospitals, they will have to be taken to the hospitals by ambulance for many of them are crippled, involving far greater expense than anything saved by banning enteric- 1159 coated aspirin from the GP's list. Hospitals are now required to restrict the drugs they issue to patients in the community, so where is the rationale, where is the sense of all this?
§ We have to recognise that there are a number of interests in this rather complex field. First, and most importantly, we have the patients, by whom I mean the vast majority in this country who are NHS patients. It is obvious that their interests are not best served by limiting their doctors' ability to treat them adequately or even competently. This would bear with especial harshness on the exempt categories—the elderly, the young and the poor—whose prescriptions are now exempt from charges and who would have to pay the full price, not for only the over-the-counter products but for the many painkillers, laxatives and so forth that suit them—or go without.
§ This is to introduce first, and second or third class medicine with a vengeance. Some say it would be tampering with the foundations of the National Health Service. It will undoubtedly encourage a drift back to private medicine by those who can afford it, thus diminishing the general support across class and income barriers which the NHS enjoys and upon which it depends. This could be seen as a break-up of the GP's side of the National Health Service by the back door. If that is what the Government intend they should say as much.
People recall the Prime Minister's pledge that the National Health Service is "safe in our hands". They are frankly bewildered, and that is why they sign petitions such as the one I hold in my hand from 300 people who live in Barnsley which says:
We the undersigned petition against this Government's National Health cutbacks on medicines and tablets".
I believe that 300 good citizens of Barnsley all signed in one afternoon.
§ That is the case for the patients. Now we come to the doctors, to whom the patients' interests must also be paramount. They are understandably furious over the lack of consultation. The Greenfield Report lay on the Government's table from 1982 and on the public table from 1983. On 8th December 1983 the Government said that they accepted the Greenfield Report other than paragraph 24 on generic substitution, which presumably meant that they accepted the recommendation in paragraph 25 against a limited list. There was no further discussion of the matter with the profession or the BMA before the announcement on 8th November 1984 of a limited list. Perhaps the BMA were ill advised to take such umbridge as they did at this U-turn, but it is understandable. Now, they again have offered positive collaboration with the department on policies for rational and effective prescribing, which should of course be accepted by the Minister.
Not all doctors, the Government may say, speak with one voice. Of course, there are different degrees of tone, emphasis and volume in which one can express concern. The Royal College of Physicians supports the principle of limited prescribing, but subject to important safeguards set out by Sir Raymond Hoffenburg in his letter to The Times on 15th January, in which he stresses that drugs must be available,
to meet the full range of desired therapeutic activity",
and calls for an appeals mechanism and regular reviews of the list. These are important qualifications to the Government's present proposals, and would all cost money.
The Royal College of General Practitioners have usually spoken in gentler tones than the BMA, but on this occasion they, too, condemned the Government's proposals as not well founded" and "clinically inept". I think that their letter to the Chief Medical Officer is particularly well balanced.
some well recognised anomalies in the supply and payment for drugs available through the National Health Service which are inequitable and should be removed. It is therefore time for all concerned to adopt a purposeful and constructive approach in order to establish a comprehensive strategic policy.".
Then they go on to describe their own approach to responsible prescribing on the basis of local practice formularies, generic prescribing and limiting the quantities of drugs supplied. In a letter to me on 29th January their chairman. Dr. Irvine, wrote:
We are firmly committed to the broad lines of Greenfield underpinned and reinforced by clinical performance review.".
In this the Royal College of General Practitioners is encouragingly at one with the BMA, whose information manager, Pamela Taylor, has also written to me—I have the letter here—saying:
You ask whether the GMSC could associate itself with an approach based broadly on Greenfield, together with the self-monitoring proposals advanced from several quarters. The answer is, Yes".
My Lords, who else is involved?—obviously, the community pharmacists, represented by the Pharmaceutical Services Negotiating Committee. They say that they,
support a limited prescribing list which ensures value for money"—
Wait for it!—
provided that a sufficient range of drugs continues to be available to meet the full range of clinical needs".
They would accept,
the introduction of generic substitution where the proprietary medicine has exceeded the patent protection period and where the therapeutic effect and availability of the generic drug are assured".
They have some other useful suggestions on the role of the pharmacist and for reducing waste by triple prescriptions and dose-related quantities, and things of that nature.
§ That leaves us with the pharmaceutical industry, which has mounted a very high-profile campaign against the limited list. I do not underestimate the contribution of the industry to research and to exports, but, frankly, I think they went a bit over the top—and I told them so when I addressed a symposium that they recently held in the Barbican. After all, the National Health Service represents only 4 per cent. of the world's drug market and research done in the United Kingdom is reflected in world-wide sales. I do not believe that a great industry could not absorb some change, notably in promotional expenditure. The "complete dismay"—to use Dr. Griffin's words—with which they regard generic substitution seems to me to be somewhat exaggerated. I do not see why they could not manufacture high quality generics over here.1161
Yet, my Lords, the industry certainly has some valid points on parallel importing, quality control and patent protection. Also, the Government's total change of course between late 1983, when a limited list was absolutely "out", to late 1984, when it was suddenly and pugnaciously "in"—with no intervening discussion or consultation whatsoever—has obviously taken some companies by surprise and could have serious investment and job implications. Fortunately, we shall have the opportunity to discuss these rather complex matters in the debate of the noble Lord, Lord Hunter, on the pharmaceutical industry on 20th February, and so I shall not pursue them here. The important thing for the moment is that the industry, according to the latest APBI News, which I have here, would be,
happy to join in a working party with the department and the medical profession to discuss possible economies in a fair and constructive way".
§ So, my Lords, that is the field, excluding of course the Government. If there is not total consensus on what ought to be done, there is certainly convergence of all parties other than the Government. There are differences of emphasis, but I do not believe they are so great as to make impossible an agreed solution if—and this is a big "if"—the Government have the political will to bring it about.
§ Let us now be very realistic. The Government aim at £100 million, knowing they will not achieve that. As they have already said, their list is negotiable and it is presumably being negotiated at this moment, or tomorrow. The more it becomes a workable and clinically adequate list, the less it will save. Perhaps a more realistic figure would have been £50 million. My proposals (broadly those supported by both the BMA and the Royal College of General Practitioners), involving some degree of generic prescribing, some generic substitution, local formularies and searching self-audit, along with some of the pharmacists' ideas, would easily build up to an equivalent figure and beyond, with the added advantage of wide support and a fair wind in their sails.
§ There is another important consideration. The encouragement of good practice involves no additional bureaucracy. Have the Government thought through the administrative nightmare of their scheme?—assessors, new applications, an appeals tribunal, monitoring, policing, to say nothing of the threat of legal action, which I understand to be a distinct possibility. No, my Lords, that is not the right way. A rigid statutory list can only diminish a doctor's personal sense of responsibility. Indeed, faced with a therapeutic gap, he may simply prescribe upwards: for example, an antibiotic for a linctus or a knock-out sedative for a mild one. He may be forced into expensive overkill. The Government are keen on voluntarism and self-regulation in other walks of life: indeed it is the core of their philosophy. Why do they deny it to the medical profession? The threat of a limited list can always be held in reserve if the measures I suggest fail to deliver the goods.
§ Finally, I genuinely want to get the Government off the hook of bringing unpopular and unworkable regulations to Parliament, for there will be further storms if they do. I therefore want to ask the Government seriously to consider taking the following 1162 five steps. First, to defer the introduction of a statutory limited list for, say, two years; secondly, to widen out Dr. Acheson's committee to include representation from all those bodies which have now publicly indicated a readiness to reach a sensible and workable agreement; thirdly, to facilitate and encourage the adoption of the various measures supported by the Royal College of General Practitioners and the British Medical Association, along with the anti-waste proposals of the pharmacists; fourthly, to set target savings in real terms, against which progress can be monitored by the expanded DHSS committee in the noble Lord's department; and, fifthly, if the experience is good, to stick to this course. If it is disappointing, the limited list weapon is always ready to hand, always there in the armoury.
This, I believe, is a solution which should appeal to all people of good sense and goodwill, in and out of the Alliance—for this is not a party matter. I repeat that this is not a party matter and it is in this spirit that I offer it to the Government. I realise that the noble Lord cannot say "yea" or "nay" from the Dispatch Box tonight, but will he commend it to his right honourable and honourable friends? And, in so doing, will he hear in mind that we are not talking only about the various professional and commercial interests involved—important and legitimate though they may be—but above all about patients' interests? And will he also hear in mind that the Government's actions will ultimately be judged against the Prime Minister's pledge that.
The National Health Service is safe in our hands"?
§ 9.29 p.m.
§ Lord Ennals
My Lords, I think we are all grateful to the noble Lord, Lord Kilmarnock, for introducing this dicussion and for the way in which he did it. I must say that I agreed with almost all that he had to say. I think that perhaps to ask the Government to delay for two years may be going too far, but I would certainly join in his plea that the present method which is proposed should not be proceeded with and that there should be effective consultation.
In April 1981, shortly before the DHSS established the Greenfield working group, my successor as Secretary of State for Social Services, Patrick Jenkin, said:In Britain, in contrast with many other countries … we have resisted any system of limiting the freedom of a doctor to prescribe whatever he thinks his patient needs. Not for us are such devices as limited lists, black lists … We talk about the doctor's freedom to prescribe, but what we should really talk about is the patient's freedom to be treated as his doctor recommends".I thought that that was a very good statement. I thought that it was pretty clear. I thought that it stated absolutely without peradventure that the Government were not about to do, and were not considering, what they have now said they are going to do.
I accepted, and I think that the professions and those who were interested in this subject accepted, the assurance given by the Minister that he meant what he said. If he did not, what did he mean? This is what we are talking about tonight—the right of patients to obtain medication regardless of their financial situation. I am glad that the noble Lord, Lord Kilmarnock, touched upon this, because those who 1163 would suffer most as a result of the first proposed limited list would undoubtedly be the elderly, the disabled and those suffering from arthritis, etc.
All right, my Lords, maybe the list will be much improved in the course of consultation, but the proposals which were announced by the Secretary of State in November 1984 were, in my view, quite contrary to the whole spirit of the National Health Service expressed in the principles repeated by successive Governments: first, that the patient's interests must come first—clearly, that is ignored in this proposal; secondly, that there is no restriction on the doctor's clinical freedom—that I believe successive Governments have stood by and I think that they should stand by it; and, thirdly, that we do not create a two-tier National Health Service, one for those who can pay and an alternative for those who cannot.
Let us get it quite clear that, if the Government have their way, whenever a doctor prescribes a medicine from one of the therapeutic groups that are listed, patients will have to pay the full cost of the medicine prescribed whatever their personal circumstances, unless the medicine happens to be on the limited list. There will be no exemptions. Inevitably, the ability to pay will determine the patient's treatment, prescribing patterns will be distorted and effective prescribing made more difficult.
The proposal, whatever the contents of the limited list, however much it is revised in the present consultations, runs directly contrary to the principle of the National Health Service that the individual's ability to pay determines his tax, but not his medical treatment. Once the principle of a limited list is conceded, a two-tier system of care within the National Health Service's general practice is established and the way is open for further restrictions whenever political expediency demands. I believe that these proposals open the door to things that could be even more dangerous.
What I have just said are not my views alone. They are the views of Dr. Michael Wilson, the chairman of the General Medical Services Committee of the BMA. It is interesting also that the Government's own advisory committee dismissed the present proposals—I will not say out of hand, but after careful consideration.
Perhaps I may refer very briefly to the Greenfield Report and to what they had to say. I am quoting from paragraph 25, when they said:it is our view that a limitation on prescribing at NHS expense would be interpreted by some doctors as an attempt to curtail their freedom".I think it will be interpreted by all doctors as an attempt to restrict their clinical freedom. It goes on:Since we have not received 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".It is because of that statement that I was staggered when the noble Lord, Lord Glenarthur, said in answer to a question from the noble Lord, Lord Hunter, that the proposals that were before the House, before the Government and before the country were proposals that sprang from discussions ever since 1981. We 1164 knew what the Minister had said in 1981 and we know what the Greenfield Committee concluded when it reported in 1982. The department's own evidence to the Greenfield working party opposed the introduction of a limited list.
What sort of consultation has there been? Virtually none. There is consultation about what is on the list, but there has been no consultation about the method devised; namely, a limited list. The Government put forward their plan without prior consultation with the medical of pharmaceutical professions, with patient representatives or the pharmaceutical industry. Their goal is simply to cut public expenditure on health care by £100 million, not to reallocate spending within the NHS.
The Government's proposals have been condemned by most of the royal colleges, by the BMA, by the Government's own Standing Medical Advisory Committee, by the Pharmaceutical Society of Great Britain, by patient groups, by charities such as Age Concern and Help the Aged, and by many individual experts. But somehow or other Ministers remain intransigent. Although they will probably permit some extension to their limited list of NHS medicines on the basis of the consultation that is now going on, they apparently intend to stand by their original, arbitrary and unfair intention to withdraw a large number of NHS medicines. I do not want at this stage to go into the particular medicines that are on the list. One could have a long debate about this, but I shall not do so in what will be a short contribution.
I have had a very careful discussion with doctors, with pharmacists and with the pharmaceutical industry, and all agree that the Government believe that it is in the interests of the National Health Service to save £100 million on drugs. I agree that there are savings to be made in the drugs bill. I am not saying that the Government are wrong to seek to make a saving in the drugs bill. All of those whom I have consulted have said that they are prepared to consider with the Government alternative ways of doing this, and that includes the pharmaceutical profession, the British Medical Association and the pharmacists.
The pharmacists' charter, which was published last summer, made a series of proposals which they thought would lead to a saving in drug costs of well over £100 million out of a total drugs bill of more than £1 billion. Among the things they proposed were the introduction of generic substitution where the proprietary medicine exceeded the patent protection period and where the therapeutic effect and availability of the generic drug were assured. I agree with the noble Lord. I am in favour of generic substitution provided only that the GP has the opportunity to say, "It must be what I have put on the prescription sheet". I would not interfere with clinical judgments as the Government now propose to do.
The pharmacists' charter also recommended advice to GPs on the choice of drugs, on the encouragement of generic prescribing, and on the introduction of triple prescriptions so that a patient would receive three prescriptions each for one month rather than three months' supply, thus saving excessive supplies of drugs for patients who do not need to be treated for so long. It recommended the introduction of dose-related 1165 quantities, eliminating the wastage of repeat prescriptions for high dosage pills when low dosage pills are still available. In my view this is a very good agenda for consultation. But for the life of me I do not understand why the Government have not been prepared to sit down with these organisations, all of which are essential to the good operation of the health service, and consult with them.
As the noble Lord, Lord Kilmarnock, has said, this is not an occasion to go into any detail on the problems of the pharmaceutical industry, but I think it is perfectly fair to say to the noble Lord that a qualified firm of accountants has studied the likely effects of the limited list proposal. They consulted more than 20 leading pharmaceutical companies operating in Britain. Some of those companies were British and some were foreign. Some were multinational firms and some were entirely British-based. That study related to the value of investment plans deferred or cancelled as a result of the Government's limited list proposal. It estimated that such deferment and cancellation could be valued at 138.2 million. That is a very large sum of money. It also accounts for a very large number of jobs—some 2,000—if that estimate is correct; although I cannot say whether or not it is correct.
At this stage I urge the Government to think again. I believe that they have created a great deal of anger because of their failure to consult. The opening paragraph of an article by David Fletcher in yesterday's Daily Telegraph stated (and I quote):The row with the Government over its plan for a limited list of drugs has brought relations between doctors and Ministers to their lowest ebb for years".Later it states:Ministers admit privately that they had not intended or expected to stir up such a hornets' nest of controversy. Why all the fuss?".I put the same question. Why did the Government enter into this without some form of consultation?
I will conclude by putting two questions to the Minister. First, will he urge his right honourable friends to think again?—to postpone the 1st April date to enable there to be effective consultation? Secondly, will he comment on the article which appeared in the Guardian today, which suggested that there should be both a black list and a white list and that pharmaceutical companies not only would have to apply to the Committee on the Safety of Medicines but would then have to apply to another committee to ensure that their drugs were available on the National Health Service. This is a very serious allegation and I hope that the Minister will answer both questions when he replies.
§ 9.42 p.m.
§ Lord Porritt
My Lords, when first I saw the Question put down by the noble Lord, Lord Kilmarnock, I wondered whether he planned to discuss only generic drugs. But when I examined the Question more closely and saw its reference to the Greenfield report, it became quite obvious that the discussion this evening would be more general and would deal with the different methods by which money could be saved in the prescribing of drugs in the National Health Service; in other words, a comparison of other methods with the limited list—a matter in which I personally am more interested.
1166 I must declare a double interest. First, I am an ex-medical man, albeit a surgeon. But as noble Lords will know, today anaesthetics (which are drugs) and preoperative and post-operative drugs are taking an infinitely greater part in surgery than they did a few years ago. Secondly, I am a director (although, quite frankly, very much a non-executive director) of a well-known pharmaceutical company.
Having made that declaration, I want to say first and foremost that I greatly regret the limited list concept because it destroys an ideal. That ideal existed long before the NHS came into existence but in fact was vital to its inception: the right of a doctor to treat his patients as he thought best for that patient; and, perhaps even more importantly, the right of a patient to expect that treatment from his doctor. This is a point which the noble Lord, Lord Ennals, has already made but I wish to repeat it because we are discussing here an important primary principle.
Some noble Lords with long memories will be able to recall the beginning of the National Health Service. In itself, surely, it was an ideal—even if it has proved rather expensive and impractical in the many years since. Nevertheless, when that service started, GPs refused en masse to follow Aneurin Bevan's ideal. Until he gave them the status of an independent contractor they were determined not to join his National Health Service. This status of independent contractor they still hold today, as your Lordships know: at least, they hold it until the limited list comes on the map and that is where we come to the death of an ideal; The institution of the "black list", as the profession prefers to call it. It is a suggestion which has been so bitterly and unnecessarily antagonistic to so many people.
The list has already been mentioned by the noble Lord, Lord Ennals, but I want to refer to it again because I think that we should realise the enormous antipathy to this idea. Many of the people against it are very good friends of this Government: not only the medical profession, the pharmaceutical industry and the Pharmaceutical Society but also practically all the Royal Colleges and their Faculties and specialist associations have all lined up against it. As has already been said by the noble Lord, Lord Ennals, the DHSS's own Medical Advisory Committee has come out against it, to say nothing of a mass of ordinary people; by which I mean patients and charities, which groups will include, I imagine, a number of MPs and, I hope, a number of people in this, your Lordships' House. Surely that is a formidable opposition to create and I think that it merits serious rethinking.
Personally, I never thought that I should live to see the day when a Government department undertakes the treatment of a patient. That is putting into simple terms what is being done. I think that probably most people would agree that a saving on the National Health Service drugs bill is a very good thing. There is no harm in that. That is practical politics. It is, however, very relevant to say that our expenditure on drugs in this country is lower per capita than for most of our European neighbours, and is considerably lower than that of Japan and America. So it is not as outrageous as people say. It may be a heavy bill for us, but nevertheless it is not as excessive as peope like to make out.
1167 There is the question of the much-maligned profits of drug companies. They have not, as is frequently stated in the press and in the media (and seemingly, judging by the financial raids made on it by the Government), increased very much in the past 10 years: in fact very little more than that which can be accounted for by ordinary inflation. By far the greatest part of those profits goes back into developing the industry, into research and development, and into the making of new drugs for patients.
It was stated by the noble Lord, Lord Glenarthur, in answer to a Question a week or two ago, that circumstances had changed since the publication of the Greenfield Report in 1981. No one would deny that, but let us remember that that report (as the noble Lord, Lord Ennals, said) came down firmly at that time against any form of limited list; so this is a major change. At that time he said that a study of the whole subject of prescribing medicines, in great depth, had taken place—hence, the present project of a limited list.
But what study is involved? Who took part in it? Certainly not the BMA, the ABPI or any pharmaceutical society. Who drew up the painfully inadequate list of prescribable drugs—the very exclusive "white list", as it is described? All this was not disclosed. It is a radical change without any reason at all. This project has nothing to do with medicine or pharmacy. It is entirely political and financial—the DHSS's seemingly blinkered response to the Treasury's request—or, should I say, demand?—for savings of £100 million. That is putting it crudely, but that is what it seems to all of us who are thinking straight. It is a classic example of the dictum that principles and politics make very uncomfortable bedfellows.
The so-called consultations that have taken place—more or less at the point of the gun—since the publication of the limited list have clearly shown that there are many alternative ways of saving this kind of sum. Both the BMA and the ABPI, while very reasonably refusing to discuss a totally inadequate list of which they had had no warning whatsoever, have brought forward a number of alternative constructive propositions, and they have done that without jeopardising the basic principle of clinical practice and without doing irreparable damage to the flourishing British pharmaceutical industry.
Where does this kind of restrictive practice end up? I was told on the highest authority, which I am not permitted to quote, that if the list as originally set out had to be modified after consultation, the Government would expand the scope—that is to say, the number of categories to which limitation applied—until sufficient drugs were proscribable (as against prescribable) to produce the required savings in departmental expenditure. That is where we are going.
What is to prevent the further spread of this limitation-by-diktat policy? Are we to see only "Elephant and Castle" instruments used in operating theatres; only "Fowler" pacemakers supplied to heart patients; only "Kenneth Clarke" prostheses used for hip replacements? This may seem a joke, but it is 1168 extremely serious. That is the policy. If we start doing that sort of thing in one part of the country, it will spread all over the country. It is a risk that is too great to take. The whole idea is so contrary to British medical practice that it merits one description only—sinister.
This is probably not the time or the occasion to enter into details, but I would say just this. The "Black List" is a negative approach to the problem, it is a therapeutially inadequate measure and an inflexible way to cope with an essential part of medical practice—the treatment of the individual patient and the individual disease.
That brings me finally to say a few words on the other side of the picture—the dangerous situation into which the British pharmaceutical industry will be forced as a result of this short-sighted plan. As I said originally, my personal knowledge of the industry dates back a mere 10 years or so, but I have been increasingly impressed by the results that it has achieved and the way in which it has achieved those results.
My view—and I can assure your Lordships that it is not a biased view; I came to it from nowhere at all, I just learnt like any kindergarten pupil, and it has been a very interesting education—is quite unbiased. Of course, one knows that in every industry, in every business and even, one can say, in every profession, there is an odd bad apple in the basket. I do not think that anybody would deny that there is probably an odd bad apple in the pharmaceutical basket. But I would suggest that they are few and far between. I have never been able to understand why Governments, and especially this Government, do not give more active and positive support to what must surely in their book in many ways be an ideal set up.
Here is an industry whose prime purpose is to produce substances to prevent and to treat the ills of the country's population and to reduce and to ameliorate its discomfort and distress. It is an industry employing 70,000 people with minimal industrial disruption—almost negligible. It is an industry earning more than £12 million a year in exports, and, at the same time, attracting very considerable foreign investment. It is an innovative industry responsible for at least 10 per cent. of all the research work done in the world, and probably respected to a far greater extent than that percentage indicates.
Why does it not receive more support from this Government and the backing of the media and the public? It seems extraordinary to me. It has done nothing but good—good medically, good financially, good nationally. The limited list would do irreparable harm to the industry that I have just described. It is so discriminating and so inequitable that, while some companies would lose 50 to 75 per cent. of their profits because their drugs were on the black list, others would be completely untouched by the list as it stands. This is the arbitrary selection of drugs without sufficient knowledge. There is no doubt it would severely restrict research. What self-respecting company will spend thousands of pounds and waste thousands of hours of its highly-skilled scientific staff to produce a new drug which may not achieve the bogus popularity of the white list?
1169 Already the Treasury has, from 1983, through the PPRS scheme, cut the industry's profits to the tune of £100 million. It is now apparently engaged in the process of imposing another major cut. This would seem a classic example of the "goose and golden egg" scenario. Taking all this into consideration, can we not 1170 persuade the Government, as the noble Lord, Lord Ennals, has said, seriously to think again? This is an ill-thought-out scheme and, to many people, an offensive scheme. One hopes that the Government will see these matters as sufficiently important to have another thought on the subject.
§ 9.57 p.m.
§ Lord Perry of Walton
My Lords, I start by apologising in advance to the House because I have to leave before the end of the debate. This is because I have to catch a train. May I also say that I have listened to my noble friend Lord Kilmarnock, to the noble Lord, Lord Ennals, and to the noble Lord, Lord Porritt, and I have agreed with every single word that they have said, from beginning to end. I do not want to say it all over again, probably much less well than they have already said it; but there are one or two aspects of generic substitution about which I want to say a word because I can claim to speak with a little authority.
The first reason I say that is because I spent 15 years as a member of the British Pharmacopoeia Commission. I well remember, month after month, agonising over lists of approved names for new drugs. There were certain conventions that had to be followed. One did not give a name that described the action of the drug because a little later another action might be found which was much more useful. One did try to give an indication, in the official name, of the chemical structure of the compound. It was quite extraordinarily difficult to satisfy these conventions and to find a name that was euphonious and tripped readily off the tongue.
We were up against branded names which did not have to obey any of these conventions, and which were chosen solely because they were memorable. I understand that some of them were even trademarked before a drug had been invented for the name. If I give your Lordships one or two examples, I am not at all denigrating these particular compounds. If we take librium, the name is a very easy name. It conjures up liberation from tension and stress. We found that the best name we could give it was chlordiazepoxide. It has six syllables compared with three. Going back a few years before that, a very common barbiturate went under the brand name of Soneryl. I do not know what that conjured up, whether it was somnolence or someone who snores, but it was certainly easier to describe than butobarbitone.
I would remind your Lordships that unless there had been the First World War, we would not be able to prescribe aspirin as the official name. It cannot be done in Germany. It would have to be prescribed as acetylsalicylic acid because it is a Bayer trade mark. That is bad enough. However, when one comes to drugs which are mixtures to two active ingredients, some are all right, but most that I used to teach are wrong. One example is given in the blacklist put out by the ABPI. That is distalgesic. To give distalgesic its proper name means writing down paracetamol and dextropropoxyphene. That is a pretty big mouthful. My point is that it is very difficult to get official names that will be remembered.
The second point on which I claim to speak with some authority is that I taught pharmacology in Edinburgh to medical students for 10 long years. I tried hard to persuade them to prescribe using the official names of drugs in order that there should be generic prescribing. I have to confess to total failure. Within a year of leaving my tender hands, they had 1172 learned what all the consultants in the wards did. That was to use the brand name. While that is all right in hospital because the consultants can agree with the hospital pharmacy to dispense the generic form, it is not all right when they go out into practice.
I am saying all this because many statements have been made in various papers over the last few weeks indicating that doctors should be educated to use generic prescribing. It is hopeless to expect that to happen. Official names are too difficult to remember. Even if one does remember them, they are too long to write down even if one can spell, which not all doctors can. Even if the official form of the drug is prescribed, it is still perfectly open to the pharmacist to dispense the very much more expensive brand equivalent. So it works that way round to the cost of the taxpayer. It does not work the other. That seems very odd. If we want to save money on the drugs bill, the answer was, I think, given in Greenfield. It is not generic prescribing. It is generic dispensing. It is certainly not, as everyone has said, in the limited list.
Greenfield's proposals and those that have come forward since suggest a box on the National Health Service prescription form which the doctor would tick if he wanted to allow the generic form. I do not like ticks in boxes. One never knows whether one is opting in or out unless one reads the small print. I believe that nearly all doctors, when prescribing brand names, do it for the reasons that I have outlined. They are easier to remember and quicker to write. They do not care a two penny toss whether the brand drug is prescribed or whether the generic form is prescribed. I believe that if they want the brand form they should be asked not to tick anything but to underline the name twice. Some people underline it once. If they underline it twice it will mean "I want this and nothing else". It would not cost anything. It would save far more than any limited list could possibly save.
In addition to what the noble Lord, Lord Porritt, said, I should like to refer to damage to the drug industry. The limited list will certainly damage the drug industry indiscriminately and unfairly penalising some firms. There is no doubt that generic dispensing could also damage the drug industry unless steps were taken to prevent that. But steps can much more easily be taken to protect the British drug industry, which I agree does a good job on the whole, for instance by extending the patent life of a drug before the generic form becomes available.
I should like to end simply by adding my small voice to those of noble Lords who have already spoken and pleading with the Government to think again. I believe that a generic dispensing proposal would receive general approbation if the safeguard to the industry were taken from every single branch of the professions engaged in medicine, and from the general public; but I think the limited list is being received with general odium.
§ 10.6 p.m.
My Lords, after so much medical expertise I am shaking with fright at the thought of speaking at all; I really think I need valium! I am not 1173 altogether opposed to generic prescribing, provided that the drugs used come from a reputable manufacturer or supplier who can be identified and against whom an action could be brought for any damage to the patient caused by that drug. The Greenfield Report mentions this in paragraph 21. It does not seem that the present situation is entirely satisfactory, even within the EEC; and what about outwith the EEC? I find this slightly disquieting.
My principal anxiety is about the limited list. I understand that it is being reconsidered in consultation with the professions—medical, I presume—and the pharmaceutical industry. I am very glad to hear this because it really is far too restricted. People are not all the same, and a drug or remedy which may suit one person and be effective may be quite useless or even counter-productive for another. To many of us that does not matter, because if what is available on National Health Service prescription does not suit us we ask for something else, and in many cases we go out and buy it at the chemist without ever going near the doctor; and often it is cheaper than the prescription charge.
But what about those who are exempt from the prescription charges—children, pensioners and some of the disabled? It is certainly not cheaper for them to go and buy what they need, even if it costs less than the prescription charge; and most of them really cannot afford it. I am truly concerned that they will suffer unless either the list is considerably extended or some arrangement can be made by which the limited list would not apply to people who are exempted from prescription charges. I know how important it is to cut out wasteful prescribing—and I know there is a lot of wasteful prescribing—but, please, not at the expense of children, pensioners or the disabled.
§ 10.8 p.m.
§ Lord Rea
My Lords, I had intended to start with a few rude remarks about the Government's action, using such phrases as, "Elected dictatorship" or, "Democracy isn't a ballot-box exercise to be indulged in once every four or five years"; but I think that might he regarded as party political, and I think also that the noble Lord the Minister who is to reply has already had quite enough criticism on that front.
I merely want to say that the medical profession is as concerned as anyone with the problems of prescribing; this has been alluded to by all speakers so far. Cost is only one of the problems of prescribing. We have had much responsible opinion that there is far too great a reliance on drugs—a pill for every ill, if you like. Doctors are under great pressure to prescribe. Limited time, and sometimes an unwillingness to listen, or inadequate training in getting to the bottom of patients' problems, may result in a prescription being given instead of the explanation and advice that is needed. As the Greenfield Report says:In our view a little extra time spent listening and talking to patients on their first visit will usually benefit both patient and doctor in the longer term".Unfortunately, the prescription sometimes becomes the symbol for the fuller doctor-patient transaction 1174 that did not take place. But with the best will in the world, it is not always possible to change people's expectations. Sometimes patients will say to me, after I have listened to their problems at some length, "Well, I feel very much better now. Thank you for listening to me. By the way, before I go can I have my valium?"
Changes in attitudes take place, and I can understand the Government's reluctance to wait the decade or so that it might take before better medical practice and changed public attitudes have a measurable effect. We fully accept that more urgent measures are necessary now. But that is exactly why the Greenfield working group was set up. It consisted of representatives of all the major branches of the medical profession and the DHSS. There were five GPs, three consultants, and four DHSS officials on the informal working group. They recommended not only generic substitution, which would have had an immediate cost-cutting effect, but also much longer-term measures whose effects will increase with time. The Government say that they have accepted these other recommendations, but so far there has been very little evidence of that.
One of the most important recommendations was the provision of detailed prescribing information to general practitioners. They said:General practitioners should have available to them frequent detailed analyses of their own prescribing for self-audit purposes. These should form part of a continuous educational process and research is needed into the method and style of presentation".A very important piece of research on the effect of this kind of approach is described in Prescribing: A Suitable Case for Treatment—some might say a well-chosen title—suggesting that "prescribing" is in a bad way and needs attention. But I wonder whether amputation is the right method of treatment. This report was produced by a team from St. Mary's Hospital and is published by the Royal College of General Practitioners. Here a group of 28 general practitioners in North London were given detailed computerised analyses of their prescriptions over a period of a single month on four occasions separated by six-month intervals. Each month's analysis was followed up by detailed discussions of the findings, at which groups of doctors met a clinical pharmacologist.
At the end of a two-year period it was found that the proportion of generic preparations had risen from 16 to 23 per cent. and relative costs had fallen by 12 per cent. compared with a controlled group who did not have the benefits of this information and discussion. If these results were extrapolated nationally £61 million could have been saved. This saving was partly made up of the change from proprietary to generic products and partly by better prescribing, often using cheaper alternatives of equal efficacy. It is interesting to note that this saving was achieved with only a small shift towards generic prescribing. Considerably greater savings could have been achieved with full generic substitution.
Noble Lords might be interested in another example of self-audit; this time an example from my own group general practice. As a development of an inquiry into antibiotic prescribing we decided to look at all the 1175 drugs we prescribed over a five-week period. There were 523 different preparations; of these, generic preparations made up 29 per cent. of the total, which your Lordships may note is already considerably higher than the national average. We thought that it would be useful to try to develop our own limited list or "practice formulary" of drugs which we would try to stay within, both for economy and good clinical practice. After several meetings, much redrafting and discussion with an eminent clinical pharmacologist we reduced our list to some 280 drugs, of which 80 per cent were generic preparations.
As the noble Lord, Lord Perry, has said, to discipline oneself to write out the generic title of every drug requires some effort. The list was chosen to the exclusion of brand name products. Noble Lords will be interested to know that we have described this exercise in a paper which will be published in this week's edition of the British Medical Journal. The article is entitled "Prescribing: The Power to Set Limits". This is not the first effort of this kind; several similar articles in the journals have been published over the past few years, and hospitals have for many years used their own formularies which have been drawn up and agreed by the doctors and pharmacists working in the hospital. These lists are flexible; the effects of limited drug lists depends on how and by whom they are compiled, and how the doctors' compliance is maintained. Compliance is most likely if the prescribing doctors have been actively involved in constructing the list, and this is where the Government have gone completely wrong.
Quite apart from creating the two-class system and undermining the basic philosophy of the National Health Service as the noble Lord, Lord Porritt, has pointed out, doctors are going to feel profoundly annoyed at having their judgment overruled without consultation. Some, as has been mentioned, may even consciously or subconsciously sabotage the Government's intentions to save money by, for instance, prescribing a more expensive drug from a different category which is not on the restricted list. An example might be to prescribe Tagamen, which costs £14 for a hundred tablets, instead of Asilone or Gaviscon, which cost £4 per 100 tablets. All three are useful for acid indigestion but Tagamet alone can heal a duodenal ulcer. It can also have unpleasant side effects: a healed ulcer is worth the risk, but the cost and the risk are certainly not worth it if there is no ulcer.
Changes in prescribing will profoundly affect patients and the process of constructing a formulary, or limited list, needs to be linked with the provision of information and advice to patients about the changes in prescribing that are going to take place, and should include a method of incorporating patients' response. In our practice we plan to ask our Centre Users' Group—this is a consumer group composed of patients—to consider the formulary and in their routine surveys of patients' views of the service to inquire about their views on the use of this limited list of drugs. These views will have been taken into account when the formulary is revised, and we intend to do this from time to time.
Finally I should like to give your Lordships the concluding paragraph of the evidence given by the 1176 Department of Health and Social Security to the Greenfield Committee when commenting on whether a limited list would be useful.It is almost impossible to establish whether the introduction of a limited list of drugs will in itself produce any financial saving for the NHS. What does seem apparent is that any attempt so to do is likely to arouse hostility, result in higher administrative costs, affect the pricing of drugs and the industry, generate unwelcome pressures for GPs and pharmacists, and possibly cast some doubt on the Government's intentions towards the standard of provision of general medical services in the NHS.Some of these powerful comments have already been shown to be true, and it is highly likely that time would show the other objections to be equally valid. I do most earnestly ask the Government to reconsider their mistaken step in suggesting this list. I am sure—and other medical Peers have pointed this out—that the profession will readily agree to the introduction of all the measures suggested in the Greenfield Report, and more, which will preserve a greater freedom of action and eventually lead to greater savings and more responsible prescribing if the Government will stay their hand on the limited list as all noble Lords who have spoken have requested.
§ 10.19 p.m.
Baroness Darcy (de Knayth)
My Lords, I should like to thank the noble Lord, Lord Kilmarnock, for enabling us to debate an issue which has caused concern right down the line. I should also like to apologise to him for not being in the Chamber to hear what he said, but I look forward to reading it tomorrow.
I welcome any attempt to avoid waste, and it certainly seems that the area of drug prescription is one where there is waste and in which savings can be made; but it must not be to the detriment of the consumer. As the noble Lady, Lady Saltoun, has already said, among the most worried consumers are the terminally ill, the elderly, the chronically sick and the disabled, many of whom need regular drugs and are on pensions or low wages. I am going to concentrate on the needs of people with spinal cord injury, paraplegics and tetraplegics, and this will also include people with, for example, spina bifida and, to a certain degree, people with multiple sclerosis.
People with other disabilities also have essential needs which must be met, but their problems are rather different. Here I should like to ask the Minister whether he can assure me that Brompton mixture, which is diamorphine and cocaine, will still be available on an ordinary National Health Service prescrition as it is invaluable for treating severe terminal breathing problems. I believe he has already had a letter on this from the noble Baroness, Lady Lane-Fox.
I welcome the news that the limited list is to be enlarged with regard to laxatives and pain killers, which are two of the three groups of drugs which are vital to paraplegics, the third being the benzodiazepine group. Neverthless, I am still worried, and the Spinal Injuries Association—the SIA, of which my noble friend is the president—is worried. The Scottish Council on Disability and many individual paraplegics and tetraplegics are worried, and I should like to explain why.
1177 First, laxatives. Paraplegics have no control over their bowels, and therefore it is extremely important, if they want to get around and lead normal lives, that they get the bowels right. The SIA, in its response to the proposed limitations, give some examples (but I should like to stress that they are only some) of the drugs used. I quote:Many members must use Dulcolax, Deogex or other products such as Dulcolax Rectal solution, perhaps combined with oral laxatives, because their paralysed bowel will not work without additional drug action. The balance between good bowel action, constipation or accidents during the day requires fine tuning for each individual often by the daily use of oral laxatives such as Senokot, Syrup of Figs, Dorbanex, Regulan or Fybogel in addition to suppositories".During the exchanges on the Starred Question asked by the noble Lord, Lord Kilmarnock, on 15th January, the noble Baroness, Lady Lane-Fox, said that she had had letters from people who were extremely worried by the exclusion of Dorbanex from the list. The individual person's needs vary enormously, and in the case of paraplegics they really need access to the whole range of available laxatives. It is no good suggesting that paraplegics change their diet or their lifestyle, take exercise and do without laxatives, like many able-bodied people, because their system has been impaired. I am lucky and, like the right reverend Prelate the Bishop of Norwich, I get by on bran, but most do not.
I should like to read an extract fron a letter which a very worried and otherwise healthy and active paraplegic wrote to her Member of Parliament. She said:I personally am a 'health food' believer, but my bran-and-fruit-juice breakfast is not sufficient and my digestive system cannot cope with quantities of raw vegetables or nuts. I have spent 5 weeks in hospital during the last year in an attempt to clear and regulate my digestive system and bowels. Laxatives are essential. They always have been. The laxatives which my GP now prescribes for me have restored my health. 'Laxoberyl' and 'Fybogel' (or 'Regulan') are essential for the maintenance of my good health and my paralysed body. I cannot live without them. I cannot afford to buy them. They are on the 'hit list' and there is no generic substitute".Before I move from this area of the anatomy I should like to ask the Minister about disposagloves, which I presume are not in a group subject to limitation; but the SIA and my noble friend fought long and hard to get them on prescription because the standard issue of glove could and did damage the bowel during manual evacuation. I would welcome assurance from the Minister on that point. In her quest to try to get disposagloves accepted on the list, I believe my noble friend waved a glove in this Chamber at the noble Lord, Lord Wells-Pestell, who was then the Minister. Anyway, she succeeded.
I now move to analgesics. The SIA states:Pain is the single most debilitating side effect of paraplegia for many members. Aspirin and Paracetamol tablets are usually ineffective with chronic pain and the hard-core of members who suffer intractable pain may need Distalgesics or a combination of powerful analgesics to make life barely tolerable".I very much hope that a wider range will be made available to control pain that may occur every day in the life of a person with spinal cord injury.
Finally, the benzodiazepine sedatives and tranquillisers. These are used by paraplegics and tetraplegics (the latter have broken their necks and so are paralysed 1178 in all four limbs) to lessen muscle spasm, which can be a severe problem. One can have a severe spasm of the muscles in the legs, the back, the bowels and in the stomach, and even, in the case of tetraplegics, in the arms and in the neck. These can be so severe in the case of a tetraplegic that they can throw you out of bed or out of your chair. Some people even have to be strapped in. A spasm can prevent you from driving a car because your legs may spasm up under the steering wheel. You can burn yourself drinking a cup of coffee because you have a sudden jerking spasm and you throw the boiling coffee all over your legs.
I had, with great reluctance, because it had adverse other effects, an operation to lessen spasm because mine became so strong that I used almost to fall out of the chair when I was getting dressed and I had great difficulty in transferring and I really thought that I might lose my independence. So I felt that it was worth having this operation.
The Spinal Injuries Association say that while Diazepam (which is on the list) is suitable for some members, the newer benzodiazepines can often offer better control with fewer side effects. As with laxatives, the individual paraplegic will find one particular drug that suits him and he really needs to be able to choose from the whole range.
Personally, I would prefer that there was no limited list. I believe that great savings could be made by generic prescribing, as suggested in paragraph 24 of the Greenfield Report, and I am even more convinced now, having heard the noble Lord, Lord Rea, who I thought made a very interesting speech. I think that to a lesser extent you could cut costs a lot by limiting the quantities of drugs prescribed for long-term treatments to one month's supply, as suggested in paragraph 27. When people are encouraged by chemists to return unused and unwanted drugs some bring back supplies worth hundreds of pounds. I believe that there was a case in a south coast town where someone brought back unwanted drugs worth between £2,000 and £3,000. I am also worried that if a limited list is introduced, it could be extended to other groups at some time in the future. I am worried even more so now, having heard what the noble Lord, Lord Porritt, said.
I very much hope that the Government will reconsider their decision to introduce a limited list, but if we are to be stuck with it, we must see that the various disability groups in general, and those with spinal cord injury in particular, get what they need. The SIA submit that the revised list must initially include all drugs required by its members and must be reviewed regularly, so that new drugs can be added and that, furthermore, consultants should be able to authorise a special free prescription for an essential drug excluded from the list. A consultant in spinal injuries at Stoke Mandeville Hospital says that he thinks that paraplegics should have free access to the whole range of laxatives and all the drugs to treat spasm because the treatment of spinal cord injury is so specialised that one needs the whole variety to choose from.
Whichever way it is done, my Lords, I think that all the drugs necessary to treat the consequences of spinal cord injury should be freely available for they clearly 1179 are not being used to treat minor or self-limiting ailments. We are not talking about very expensive drugs, but they are in many cases needed daily and for the rest of the paraplegic's life, which may well be for 20 or 30 years, and could be more. Most paraplegics are exempt from prescription charges. Many more are on low wages or pensions or are unemployed and so it would cause hardship to have to pay for these drugs.
Nor do I think that those who can afford it should have to pay this additional cost of disability. British paraplegics are treated in National Health Service hospitals, not as private patients, because it is in the NHS hospitals that the best treatment is available. The management of paraplegia is, in fact, one of the great success stories of the National Health Service and it would be inappropriate to have to pay for the consequences of paraplegia.
§ 10.29 p.m.
§ Lord Wilson of Langside
My Lords, it will be a serious reflection on the wisdom of the Government if we do not have a significant response to the appeals which have been made in this debate by the noble Lord, Lord Kilmarnock, himself, and by the noble Lords, Lord Ennals, Lord Porritt, and the others, up to and including the noble Baroness, Lady Darcy (de Knayth). It will be a serious reflection if we do not have a significantly positive response from the Government—perhaps not tonight, since that might be too much to expect, but certainly before the matter is finalised.
It is customary courtesy of this House to express appreciation to those who initiate these debates; but it is no mere courtesy to my noble friend Lord Kilmarnock tonight, because but for his success in obtaining this debate no opportunity might have presented itself at all. It seems to me a very great pity indeed that a debate on a matter of such great public importance should take place starting some time after 9 o'clock and finishing around 11 o'clock. There are a dozen or two of us on this side of the House—and when I say "on this side of the House" I mean on these Alliance Benches, on the Labour Benches and on the Cross Benches. There is not a single, solitary soul that I can see on the other side of the House, apart from the two Members of the Government; and I think that is altogether regrettable.
Are the Government going to brush aside and pay no attention to what the noble Lord, Lord Porritt, said? For example, he talked of the destruction of an ideal. Are they going to laugh that off and smile about it, and think it does not really mean anything, coming from Lord Porritt, with no political axe to grind—as they might accuse me, or the noble Lord, Lord Kilmarnock, of wanting to do?
The noble Lord, Lord Porritt, also said that the thing was so contrary to British medical practice that it merited the description "sinister"; and he was right. It was very much the same as the view expressed by my own general practitioner—a view expressed to me in somewhat blunter and more graphic language. Here we are dealing with it tonight. Are the Government going to respond or not?
1180 It is a great pity that we should deal with it tonight, because of course no one will hear about this. I do not suppose the media will repeat what the noble Lords, Lord Kilmarnock and Lord Porritt, have said about this matter. And the great British public, who will be affected by this as much as by almost any other single domestic issue that we have discussed in this Parliament since I have been a Member of it, will hear nothing about it. I think it is a great pity that the Government should get away with this. But governments, of course, of all parties—and I have been a member of one that got away with more than it deserved to get away with—nowadays seem to get away with an enormous number of sins, at least in this way.
Of course, no sensible person would deny the importance of keeping public expenditure, including expenditure on the National Health Service drugs bill, under control and of avoiding waste. But, surely, when they reflect seriously upon it, many will share my feeling that there is something absurdly but profoundly pathetic in this attempt—which will no doubt prove as ill-fated as have other attempts of this Government before it—to bring public expenditure under control by denying the elderly and aged poor their Dorbanex under the National Health Service. This feeling will be all the more acute if you share my view that the competence of successive Labour and Conservative Governments over these last two decades or so in avoiding wasteful or unnecessary expenditure has scarcely been exemplary.
However, away back in the 1930s there was a popular song whose refrain was.It ain't what you do, it's the way that you do it".I remember it because I was interested in those matters in those days myself. The way in which this Government handle a wide range of the nation's affairs reminds me from time to time, with increasing frequency, of the words of that old song. There is, however, a problem—and I speak of this of course purely as a layman—relating to the achievement of effective, including cost-effective, prescribing.
To me as a layman—because I do not fully appreciate some of the more technical aspects of the matter—it is the way in which the Government have approached this problem that is open to serious criticism. Indeed they have been thoroughly incompetent. So far as the Greenfield Report itself is concerned, it is not just that in paragraph 25 the committee came out against a limited list. In the face of that alone, I could understand the Minister saying, as he did on 15th January at Question Time at col. 867 of Hansard:Times have moved on since then.But that is not good enough, for in his covering letter presenting his report to the then Minister, Dr. Greenfield said, as your Lordships will remember,Because of having to work to a tight time-table we have not been able to look in depth at all the topics which arose in discussion. In the last paragragh of our report we therefore express a willingness to continue our work if you wish us so to do.What should a competent Government have done? The noble Lord, Lord Ennals, will forgive me for touching on this aspect, because he dealt with it himself very fully. But I think it is worth re-emphasising that, in the concluding paragraph, 1181 paragraph 39, of the report, Dr. Greenfield, in effect, invited the Government to come back to them and ask them to look at it further and explore the whole situation in depth. Why on earth, may I ask the Minister, were these offers not taken up? A competent Government would have followed them up.
Is it the case, as I understand it to be, that the Government accepted the report and, having accepted it, took no action, as stated in various publications by the British Medical Association? And, worse than that, having let matters rest on the Greenfield report, out of the blue comes the Secretary of State's Statement in another place on 8th November, which so upset the British Medical Association and everyone that I know in the medical profession, including my own practitioner. Is it true that the decision to issue this list was taken within the department, without any preliminary discussion or consultation with the profession? If that is so, I think it is unanswerable. The Government are damned for incompetence. If that is so, we can only assume that the responsible Minister is sadly lacking in an appreciation of the importance of having the active co-operation of the profession in this context.
I do not believe that Aneurin Bevan would have treated the profession like this. He had his differences with them but they were resolved, and the noble Lord, Lord Porritt, touched on this. I do not believe that Aneurin Bevan would have treated them with such contempt, but if he had I will bet that the Benches opposite would not have been empty. You would have heard the howl going up about it and the Government, in the face of that howl, I should hope, would have shown some humility, some understanding, of the serious mistake which they had made.
It would be a great thing if the Government were to take a leaf in this matter out of the book of the late H. L. Mencken, the American journalist about whom some of your Lordships may have heard Alistair Cooke's story the other day. He was a terrible unbeliever and he was asked what he would say if, when he died, he went to Heaven, and there were the Lord of Hosts and all the angels and disciples waiting to pass judgment on him. What would he have done? He said:I would have said, Gentlemen, I have made a mistake and I have made a serious one.I think that that is what the Government should do in this context.
§ 10.39 p.m.
§ Lord Greenhill of Harrow
My Lords, it is very late and I shall speak for only a very few minutes. I do not want to anticipate the debate that the noble Lord, Lord Hunter, will provoke later this month but I must, perforce, repeat some of the points that have been made this evening although, no doubt, I shall do so far less eloquently than the speakers who have already had their time.
Like the noble Lord, Lord Porritt, I must declare an interest. I am not a physician or a surgeon but like him I have for the past 10 years been a director of a research-based British pharmaceutical company. This 1182 company, in addition to its plants in this country, has a manufacturing capacity worldwide in developed and developing countries. It has a research and development budget of more than £100 million per annum and in the United Kingdom employs 2,000 persons in this particular function. These are people with high qualifications whom we would wish to retain in this country.
The company exports from this country more than £.150 million-worth of goods. It has one other unique characteristic; its sole shareholder is a charitable trust which supports medical research only in a wide variety of fields to the tune of about £17 million per year; and this at a time when the Medical Research Council has failed to get even a small advance in additional funds from the Government.
I draw attention to these matters not for the purpose of advertisement but as one example from the industry and to remind the House that it is one of several enterprises which should be supported and applauded rather than impeded. And at a time when we have an unprecedented deficit on our manufacturing trade, we cannot afford unnecessarily to put obstacles in the way of those who are contributing so much. We should in no way degrade industries in which we excel.
That the Secretary of State should seek to reduce the size of the NHS drugs bill is understandable. He has a clear duty to try, if only in the interests of good administration. No doubt it is a very attractive step politically; and I do not blame him for pursuing it. But leaving aside for the moment the interests of the patients, to which we must all attach the highest importance, are the savings which he is claiming to make going to be as significant as he said? Indeed, are there savings at all? If, by cutting the NHS drugs bill by x million pounds, he creates unemployment not only on the shop floor but in the laboratory for which other parts of the Government have to pay, what has been achieved? If he damages an industry which is successful not only financially but often more importantly scientifically, the wisdom of the Secretary of State's action must be further called in question.
The budget of the NHS is only one part of the equation. It is surely doubtful, even in terms of Government expenditure, whether the proposed cuts make sense; and it is even more doubtful if it is looked at as a balance struck overall in the national interest. When we come to the interests of the patients, the views of the medical and associated professions must be given appropriate and, indeed, overriding weight. Is the Minister satisfied that there has been adequate consultation with those best fitted to advise? I know that the medical profession does not always speak with one voice, but what profession does? It is to my mind hard to avoid the conclusion, which other Members of the House have drawn tonight, that the department has in this instance acted hastily and is now rather belatedly seeking further consultation. On the relative merits of the limited list and the alternative proposal in the Greenfield Report there is obviously urgent need for further thought.
The original limited list is, I believe, a mistake; certainly for the patients, possibly for the doctors, and certainly for the industry. Many authoritative people have rubbed in that point tonight. I understand that 1183 the list is already undergoing significant modification. It is clear that if it is modified and retained, it will require an expensive review and appeal system, with additional expensive bureaucracy.
On the Greenfield proposal, I would agree with the noble Lord, Lord Kilmarnock, and many others who have spoken tonight; further consideration is necessary, taking full account of the report which is indeed the work of qualified people. My recommendation, which is the same as others', is that the Minister should hold his hand until further discussion has taken place, and then come forward with a new, well thought out proposal which suits patients, doctors, and an important industry.
§ 10.46 p.m.
§ Lord Pitt of Hampstead
My Lords the hour is late but the Minister, when he replies tonight, has an important and difficult job to do. First, he will have to explain why the Government are prepared to ignore the recommendations of the Greenfield Report. The Greenfield Committee consisted of six members of the DHSS, four GPs, one consultant physician, one consultant anaesthetist, one clinical pharmacologist, and one official of the BMA who was a former GP. Therefore, we had the Government and the profession together.
The committee made certain recommendations as to how we should achieve effective prescribing. Several were positive and one was negative. The recommendation that was negative was that for the limited list. The Government have not implemetned the positive proposals; they have gone straight for the negative one. I believe it is necessary for the Minister tonight to explain to the House why the Government preferred to overturn the negative proposal rather that act on the several positive proposals.
The negative proposal was soundly based. There are many problems involved in having a limited list. There will need to be a central bureaucracy to keep the list up to date and ensure that it is not to be frozen at today's level of drugs. Also, new drugs are regularly being produced and there must be machinery for making them part of that limited list.
In addition, and as has been said before, the limited list will introduce a double service; a service which is unlimited for people who can afford to pay for the drugs they need, and a service which is limited in the case of people who are too poor to pay for the drugs they need. Now, automatically, you have that. As the noble Lord, Lord Porritt, pointed out, we do not know where it will end. You start with controlling laxatives and tonics, and so on, but what you move on to next is a different matter. Therefore, it is necessary for the Government to explain to the House tonight why they chose that particular course.
I want to say one or two things about that. I spend a lot of my time debating the issue of socialised medicine with people who are opposed to it. One of the things they invariably say is that if you have socialised medicine the Government determine what you should do and how you should treat your patients. Up till now my reply has always been the same: "It is not true. In Britain we have a comprehensive health 1184 service in which the doctor treats the patient as the patient needs; and the advantage of that service over yours is that he does not have to take into account what the patient can afford". That has always been my answer.
I do not know how I can face my friends in the United States after this. They will say to me, "We have always told you so. Once you accepted socialised medicine you gave up clinical freedom. You have accepted that a bureaucracy can tell you how to treat your patients and you jolly well will have to conform because you have accepted being part of that system". That is what they will tell me because that is what they have been challenging me with every time I have had discussions with them.
Therefore, I want the Government to take very seriously the consequences of what they are doing. It may well be—and, frankly, I do not put it beyond them—that the Government want two services and that they see this as the way that they can get the two services. They start by undermining the National Health Service, by encouraging people and making it possible for them to go in for paying for their services, and the Government will get their two services. That may well be what they want. I do not imagine that the Government will tell us in those words that that is what they want. I hope it is not. I rather suspect it is not what they want, but that they thought they were doing something which would enable them to save money and they have done it clumsily and foolishly. I hope that they will accept that they have made a mistake and will withdraw.
I hope that the Minister listened to the noble Baroness and that he is in a position to answer her. That is a serious issue: whether or not people who are handicapped will be restricted in the sort of treatment that they can have. Every patient does not respond in the same way to every drug. There is a difference. I hope that the Minister, and the Government, will understand that there is a difference between local formularies. There is a difference between what I call a recommended list and an enforced limited list.
When I have had discussions with people who try to defend limited lists they have often come forward with the fact that hospitals have local formularies. The local formularies are really recommended lists. If a doctor in the hospital wants to prescribe something else, he does it. He will have to explain himself to his colleagues when they next meet, but he can do it. That is not what the Government are recommending. If the Government recommend a limited list, and there is no way that a patient of mine can benefit from anything on that list and I prescribe something else, the patient will have to pay for it out of his or her pocket; or, frankly, I should have to give the patient the money to pay for it because that would be the only way that he or she could get it.
I hope that the Government will think about this issue. The form of generic dispensing—and I like the way in which the noble Lord, Lord Perry, put it—recommended by Greenfield is practical. If we combined that with local formulary, we should be well away. There is no need for this draconian action that the Government are taking.
1185 I hope that the Government will think again and study what has been said tonight; in particular what has been said by the noble Baroness, Lady Darcy (de Knayth). I do not really believe that they want to harm patients, and because I believe that, at this stage I am prepared merely to appeal to them to recognise the error of their ways and withdraw the proposal.
§ 10.56 p.m.
§ Lord Winterbottom
My Lords, I am not in a position to speak with the professional expertise of the noble Lord, Lord Pitt, or from personal experience as did the noble Baroness, Lady Darcy (de Knayth), but I want to make one point which I do not think has been stressed this evening and which I believe is of importance in simple terms of administration. I have been encouraged to speak tonight by a friend of mine who is a doctor in a four-member group practice in a remote part of England. It provides an admirable service, looking after many people spread over a wide area, even extending into Wales. Because they work over a very large area, they have their own dispensing facilities. The medicine is provided in such a way that the patient drops in one day and gets his medicines the next.
I believe that such practices are banded together in an organisation called the Dispensing Doctors' Association, in which there are 3,225 members. That group of doctors will be inhibited under the present proposals from providing drugs which are not on the approved list, or rather they could provide them but they would not be allowed to sell them. That will be a great problem in such a remote area.
I have been gathering information from two articles in The Doctor. It has done a small survey of the problems of people in such areas. If the dispensing facilities of the medical group are not available, such people will have to travel eight or 10 miles to obtain the medicines which they would have to buy, because the doctors in the group will not be able to sell them these medicines. The small study shows that no fewer than 48 per cent. of patients who came to the small sample of doctors cannot afford to pay for their medicines.
I wish that the Government could give undertakings that the inhibitions which would be placed upon dispensing doctors will be removed, so that somehow or other they can supply people who cannot afford to pay or to travel 10 miles to get the medicines that they require. Those patients could then continue to be served in the way that they are at the moment by an excellent organisation, conducted by competent people. I believe that that is of very great importance.
For that reason, I should be grateful to the Minister if when he winds up he can, first of all, tell us whether the Dispensing Doctors' Association has been consulted, and, if not, why not? If it has been consulted, what action will be taken by the Government to ensure that people are able to obtain products that are not on the approved list from these small dispensaries scattered throughout the country, such as the one that I have mentioned, where I live?
§ 11 p.m.
§ Baroness Masham of Ilton
My Lords, I thank the noble Lord, Lord Kilmarnock, for giving us this opportunity tonight to debate the recommendations of the Greenfield Report. As the report did not recommend a limited list of drugs, this is my reason for taking part. Also I have had many letters from GP doctors and consultants and I should like to bring some of their comments to the notice of your Lordships. I applaud the recommendations in the report that there should be greater emphasis on the teaching of therapeutics, the science and art of healing and the treatment of disease, and the education of patients.
Some countries, including the United States of America, are far ahead of us in the education in health through schools, TV and the media. The report states:The role of the doctor as educator of his patients is paramount".How many doctors are good counsellors? I do know a few. The good doctor should look after the whole patient. Here, I should like to stress how important are the correct diet and finding out from patients what are the real problems. So often it is easier and quicker for the doctor to put the patient on a tranquilliser and leave it at that.
The food in hospitals varies considerably. Some health authorities do not have a food policy. If more thought was given to correct, healthy food being given to patients in hospital, I am sure the drugs bill would be less expensive. The patients would be educated as to what was good for them and would get better sooner and keep fitter longer. The waste of food in some hospitals is appalling. Large plates of heavy, unappetising food are put in front of patients who often cannot bear to look at it. It is then thrown away. I wish the Government would look at diet as vigorously as they have looked at drugs. Maybe the members of the Greenfield Committee were not thinking of diet but I am sure it has a great deal to do with therapeutics.
When the noble Lord, Lord Kilmarnock, asked a Question on 15th January, I asked a supplementary question, asking the Government to look sympathetically at the special needs of disabled people in relation to the limited prescribing of drugs. I do hope the Minister will be able to give some assurance tonight that their needs will be carefully examined and that the views of specialising doctors will be heeded.
The Minister, the noble Lord, Lord Glenarthur, visited the Southport Spinal Unit during the Summer Recess. His visit was greatly appreciated. Because of that visit he will understand the kind of patients about whom I shall now speak. I should like to quote from a few of the letters received. The first is from a consultant in spinal injuries from the north of England. He says:With regard to the limitation of drugs proposed, paraplegics are rather a special category. The vast majority have their bowels regulated using Senakot, Phenolphthalein and paraffin emulsion and Bisacodyl tablets, rectal solution and suppositories. It would upset the whole management of their bowel care if such drugs were not available on prescription to them and I would urge the Government to allow these drugs for paraplegics after April".From another letter I quote:I have read in some detail your Memorandum CMO (84) 13 sent out on the 14th December, 1984. As a consultant urological surgeon 1187 working in the spinal injuries unit, I am extremely worried by the implications of this document both for our prescribing within the hospital and for our patients when they leave hospital.Ninety per cent. of my patients are neurologically disabled. This applies both to their locomotive system, bladder and bowel. Many also have a pain problem. In a list of drugs which would be available for prescription, there are three groups which, if limited in the way described, would cause severe upset to our patients. Laxatives: A variety of suppositories are now used, with recently Dulcolax rectal solution and laxatives, which are taken orally. There is only one type of suppository on the proposed list".In regard to analgesics, I quote only part of what he says:There is a considerable variation in the response of patients to analgesics. Many of the compound tablets may suit some patients better than others".Many doctors have told me that if the middle group is not allowed, they might have to put patients on to a stronger analgesic, which would be unnecessary.
In regard to Benzodiazepines, many neurological patients suffer with severe somatic muscle spasms and although Diazepam is suitable for many patients to help control such spasm, many find the newer Benzodiazepine tablets are better for their spasm than the simple Diazepam; for example, Ketazolam (Anxon) is of considerable benefit if given to the patient at night, getting rid of spasm at night and during the following day, with the maximum sedative effect being present only during the night, leaving them wide awake during the following day.
The surgeon concludes:I firmly believe that such a limited list of drugs would be a complete disaster for the management of the neurologically disabled patient and that, if such a list is necessary, then it be radically changed to take into consideration the problems that I have mentioned".As my noble friend Lady Darcy (de Knayth) has stated, the Spinal Injuries Association is also alarmed for the sake of some of its members whose lives can be full of worries and insecurities. The National Health Service is a life-line for many.
From a GP in Essex, I received a letter which says:If laxatives, for example, Lactulose and Dorbanex, are withdrawn, the elderly and disabled who cannot afford to buy them will need far more enemas from the nursing staff".He says about Diazepam that if it is the only minor tranquilliser which will be available on prescription, patients can become addicted to it more easily than other minor tranquillisers which they will have to buy. Also, Diazepam interferes with the reaction time more than other tranquillisers. So there will be more road accidents if Diazepam is the only one available.
I have also been told that cough linctuses, which are potentially addictive, have been included on the proposed list. If limited, this could be a problem as one in every three people are at risk of being addicted to something. Think for a moment, my Lords, of a child with an anal fissure. It can be so agonising that they do everything to stop opening their bowels, with dangerous results. I hope very much that a stool softener for all who need it—and this includes cancer patients—will be included.
I do not expect that the Government will retract, but I hope that they will look again at the advice of doctors now practising with patients. Patients with long-term illnesses and disabilities need protection and the greatest sympathetic consideration; otherwise, their 1188 quality of life, which may not be very good, could be made unbearable. I realise how expensive everything is; and the message is getting through. However, with patients leaving hospital early and the pressures of modern society being what they are, if patients vary in their reaction to drugs—and some have complicated allergies—the correct prescription can be a case of a stitch in time saving nine.
Some years ago the health district in which I live did a collection of unused drugs. It was a revelation to many as sacks of drugs of all sorts were collected. In these days when there is a need to be economical such waste is shocking. Careful prescribing is necessary, and, above all, education is necessary so that the patient finishes his treatment, as long as it suits him.
I hope the Government will augment their list to make it more acceptable to doctors and their patients. Perhaps there could also he a different coloured prescribing pad so that the doctor has total freedom to prescribe a drug which is not on the limited list for patients who have allergies, reactions or particular needs; and he would have to justify this action. I look forward with hope to the Minister's reply.
I end by saying that there is a growth industry in alternatives to medicine. All sorts of weird and ineffective potions might start appearing on the market. Some might even be dangerous. I also thought the Conservative Government stood for freedom of choice. Are they not going against their own principles? If patients cannot afford the unlimited drugs they will lose their doctors' freedom to choose what is best for them.
§ 11.11 p.m.
My Lords, at this time of night none of us is in need of any of the benzodiazepines, whether on the restricted list or off it; though I note that my noble friends seem already to have taken their mogadon and retired to bed. I hasten to say that mogadon of course reveals my age. I am one of those doctors referred to by the noble Lord, Lord Perry, who can speak only in brand names; but it is of course true that the generic equivalent of mogadon is still on the permitted list. I am of the generation of doctor who find it a bit easier to talk about Cetab rather than cetyl-trimethyl ammonium bromide, which is of course its generic equivalent. I hope that the new generation of doctors will learn to prescribe in a bit more effective terms than I have done for some 30 or 40 years. I also hope noble Lords will stay awake long enough for me to make a few short points.
It falls to me to try to draw together the various threads of what has been a fascinating discussion on a most important topic, so admirably introduced to the House by my noble friend Lord Kilmarnock. I have no wish to go over old ground or retread paths already covered by other noble Lords. I shall try merely to focus attention on what seem to me to be crucial points which have emerged from speeches of noble Lords and noble Baronesses, and to put a number of specific questions to the noble Lord who is to reply, in the hope that in due course I shall receive some specific answers.
My noble friend Lord Kilmarnock said a great deal about the inadequacy of consultations before the so-called restricted list was made public; and that indeed 1189 has been a matter which has appeared prominently in the press and has been mentioned by other noble Lords. I do not entirely disagree, and I think that perhaps one might have seen better consultations before the so-called restricted list was finally leaked and before everybody suddenly got upset about it. I do not yet know whether or not there were consultations. I personally suspect that perhaps the British Medical Association did have opportunities to play a more constructive part in the formulation of the present policy than it actually has done. But we do not yet know; no doubt the Minister will tell me when he comes to reply.
I have spent many years in your Lordships' House, in another place, in medical practice, and, as the British Medical Association's press officer in the North Region, trying to persuade doctors that it was perfectly possible to make very substantial savings in the nation's drug bill. Here let me digress for a moment to say that I entirely agree with the noble Lord, Lord Porritt, who reminded us that in relation to other countries we do not spend overmuch on drugs. Indeed, I think the last time the World Health Organistion did an analysis of the expenditure per head of population throughout developed nations we came about nineteenth.
How nice it was to hear the noble Lord, Lord Porritt, speaking. As a student, when I took my finals in medicine, I had to study the noble Lord's textbook on surgery. It was an excellent book, but I had to study it because the noble Lord happened to be the external examiner at my university, so it was very important indeed to be entirely familiar with his book. I shall return to some of the noble Lord's points in a moment.
I merely make the point that it is my view, and has been for very many years, that it should be perfectly possible to make very considerable savings in the nation's drug bill without detriment to the patient and without doctors having to sacrifice their clinical freedom in any unacceptable manner. I have been saying that for a very long time, and were I to be the Minister of Health—which I accept now seems unlikely, although I must hasten to say that, should the appointment be offered, I would not necessarily reject it—I would be looking for savings far in excess off £100 million. I believe that they could be made without detriment to the patient and without doctors forfeiting their clinical freedom.
However, those savings can be made only with the full co-operation of the medical profession, and I am not entirely satisfied that every possible effort has been made at the appropriate time—and the noble Lord will tell us this in due course—to obtain that co-operation. I think that if the profession has withheld that co-operation, then the profession itself should indeed be criticised, because all doctors know that it is possible to make savings and, indeed, we ought to be making these savings. I want to ask the noble Lord—and this point has been raised in a number of speeches—where on earth we are in this long-running saga. We have heard all sorts of rumours about restricted lists. I think that the back page of today's edition of the Guardian talks about "new white lists" instead of "black lists". Which are we to have—a white list, a black list, or both? From the admirable speech of the noble Baroness, Lady Darcy (de 1190 Knayth), it has been made utterly clear to us all that, if we are to satisfy patients and fulfil our responsibilities to patients, we must have an almost unlimited number of lists. We cannot treat individual patients with a list; we want a lot of different lists in order to treat different circumstances.
The noble Lord the Minister, and indeed his right honourable and honourable friends dealing with this matter in another place, have been told over and over again, and have said, that the hospitals have had restricted lists for many years. They have all had different restricted lists, and for perfectly good reasons. They have required different restricted lists in order to cope with different conditions in different areas and with different patients. A single restricted list is no way in which to practise medicine effectively.
I should like to know precisely where we are in the present discussions. With whom are the Government negotiating at the moment? When the so-called restricted list first appeared I seem to remember that the British Medical Association said that they would not talk about it. They had to talk about it, and I hope that they are now talking about it. I know that the General Medical Services Committee, which is often referred to as a BMA committee—it is not, of course; it is a so-called autonomous body of the British Medical Association which is elected and appointed by all general practitioners working in the National Health Service, whether or not they are members of the British Medical Association—has been having discussions, and I hope that the British Medical Association is now having discussions. I also hope that the Royal College of General Practitioners, which I think has made some very sensible remarks on this whole matter, is having discussions with the Minister at the moment. However, I should like to know from the noble Lord the Minister what is the present situation, precisely what is happening?
I think that I am right in saying that we all believe that an acceptable solution could be found, a solution which, first, would save money; secondly, would not be to the detriment of patients; and, thirdly, would be acceptable to the doctors. But we shall not find that solution unless effective consultations are taking place at the moment. I hope that when the noble Lord replies, he will be able to tell us precisely what is the present state of play, what is being discussed, whether we are to have a black list, a white list, two lists, or several different lists. I should like to know with whom consultations are taking place.
On this point, the noble Lord, Lord Porritt, in his very interesting speech asked: where does this kind of thing end? Do we finish up with the Government telling surgeons which instruments they should use? I am not saying for a moment that the Government should start telling surgeons which instruments they should use. But I am bound to say to the noble Lord, Lord Porritt, that from my personal experience there have been elderly and somewhat irascible surgeons who have sometimes persisted in using instruments which have long since been superseded merely because somehow they feel they must have that particular kind rather than another kind.
I am sure that there could be substantial savings for the National Health Service from a variety of 1191 reductions in fields other than that of drugs, but I am saying that those savings must be made by the doctors themselves. I believe that the time has long since passed when people in all branches of the profession should have got down to this job. On drugs in particular it has always seemed to me ludicrous that a pharmacist should have to stock on his shelves 120 different anti-histamine tablets and hundreds of different varieties of iron tablets because conservative and irascible old doctors go on prescribing things which have long since become superseded.
On that question let me return to the list. Who has drawn it up? It is an extraordinary list which has on it, as permitted, things which nobody in his right mind ought to be prescribing nowadays, and which has omitted many things which any sensible and responsible doctor would be prescribing every day of the week. Where did this list spring from? If we are to have a list, let us hear more about it and where it came from.
The noble Lord, Lord Ennals, made an admirable speech, and as a former Secretary of State he is clearly aware of all the circumstances here. He reminded us that since the National Health Service started on 5th July 1948 the general principle has always been that there were no restrictions on what a doctor could prescribe.The noble Lord will forgive me if I say there always were restrictions. Doctors could always prescribe whatever they wished and the chemist had to dispense it; but if it was later found that the substance prescribed was not a drug within the meaning of the Act, then the cost of that prescription was surcharged to the doctor who had made the prescription.
As the noble Lord, Lord Ennals, knows, the procedure was that where a prescription was intercepted by the then Executive Council, now the Family Practitioner Committee, then the doctor was required to justify his prescribing to a medical services sub-committee. Where the medical services sub-committee held that the substance prescribed was not a drug, and therefore the doctor had to pay rather than the patient, then the doctor was entitled to appeal. Many doctors did appeal, and they appealed to a succession of Secretaries of State.
What is the position of substances which are not now on the list but which have been prescribed by doctors, have been questioned by the Family Practitioner Committee, have been considered by a medical service sub-committee and then on appeal have gone to the present Secretary of State, Mr. Fowler, who has said, "Yes, this is acceptable, and a proper substance to have prescribed"? Surely all those substances which have gone through that procedure and which have finally been approved as being drugs within the circumstances in which they were prescribed must be on the list. Otherwise, somehow, one is undoing a whole judicial process which has been gone into in the case of a whole number of drugs over many years.
As the noble Baroness, Lady Darcy (de Knayth), made clear, what is an essential drug for one patient may not be essential for another. This matter has occurred with many conditions; for example, with children who have to have a gluten-free diet, or whatever. The question has arisen: is this substance 1192 which has been prescribed a drug or is it a food, or whatever?—and a final decision has had to be made by the then Secretary of State. When the present Secretary of State has made the decision on appeal in relation to a number of substances, are we to assume that all those substances will at some stage be added to the list?
All noble Lords in this House, and certainly all those noble Lords still here tonight, believe that our pharmaceutical industry is of vital importance to our nation's economy. It is one of our most important exporters. At a time when our balance of payments situation is not a very satisfactory one, none of us would like to see actions which might in any way imperil the pharmaceutical industry.
I am bound to say that I was not unhappy when the Government decided to take certain steps which reduced the amount of expenditure on promotional activities, sending literature to individual doctors and so on. I supported that, though I regret the fact that a number of important educational magazines, which were supported by the pharmaceutical industry, have gone to the wall. That has been a disadvantage for postgraduate medical education. If further difficulties were placed in the way, such as VAT on typescript and print, that would have a further effect on postgraduate medical education.
In a Written Question, which the noble Lord, Lord Glenarthur, answered, I asked whether the Government would ensure that generic equivalents of named drugs were, wherever possible, available from British manufactured sources. The noble Lady, Lady Saltoun, raised the question of satisfactory generic substitution. I must make it clear that I wholly support my noble friends on these Benches in believing that we should have adopted the Greenfield Report and gone for generic substitution. I wholly support what the noble Lady said about our need to know whether the generic substitute is entirely satisfactory.
I should also like to know whether the generic substitute has been manufactured in this country. The answer I was given was somewhat emollient. It said that everything was all right and that most of the drugs were available. But the fact remains that for many commonly-used named drugs the generic substitute is available only from foreign sources. I hope that, as we are moving towards generic substitution, which we shall have in the end, the Government will do what they can to try to assist the pharmaceutical industry to ensure that British firms manufacture generic substitutes for commonly-prescribed named drugs. That is certainly not always the case.
In many ways this raises the question of patents. I am going on for longer than I meant to, but many of the discoveries of new and very valuable drugs are made by accident—not all, but many. It necessarily follows that the company which has discovered the new and very valuable pharmaceutical substance is not always the best possible company to manufacture and market that product. I hope that some day we shall find the means of enabling companies that have discovered new and valuable therapeutic substances to recoup their research and development costs without necessarily having to manufacture and market the drug, while other people who are in a better position to manufacture and market it are enabled to do so.
1193 I wish to come to a final question that I regard as of the utmost importance. I hope that in his reply the noble Lord will tell us, if the Government are to proceed along the present path—with possible modifications in the light of discussions with various bodies—with lists, whether they be white lists, blacks lists or any other sort of lists, what kind of parliamentary procedures will be required to make that possible?
It is clear that the terms of service of general practitioners do not enable them, do not permit them, to issue private prescriptions for certain drugs. It seems to me that probably we shall have to have some primary legislation. I should like to know whether all this is to be done by orders subject only to the negative procedure, with the faint hope of a Prayer against them, or whether, in both Houses of Parliament, it will be possible to discuss these matters in more depth before the necessary legislation is finally passed so that the Government can take these various steps.
Finally—and this really is finally—if the Government are able to arrive at an agreed solution with the medical profession whereby we can move over to generic prescribing and make substantial changes in our prescribing costs so that we can cut the size of the drug bill without detriment to patients, the Government will have the fullest possible support from noble Lords on these Benches. But if they are to persist in a scheme which will in some ways reduce still further the provision for the elderly and the sick so that they have to pay for things which they may need, then we shall not support them along that road.
§ 11.30 p.m.
§ The Parliamentary Under-Secretary of State, Department of Health and Social Security (Lord Glenarthur)
My Lords, I join with others who have thanked the noble Lord, Lord Kilmarnock, for raising this important issue tonight. It has certainly been an interesting debate and it warrants a full reply. There has been a great deal of misplaced anxiety about the Government's proposals to limit from 1st April the range of some types of drugs available for prescription on the National Health Service, much of it rehearsed again this evening, so that I welcome the opportunity to dispel some of the myths that have arisen and set out once more the realities of the subject.
Matters have not been helped by the pharmaceutical companies' advertising campaign. I hope that many of your Lordships would join me in condemning what amounts to little more than a crude attempt to frighten the poor and the elderly into believing they will be denied essential medicine. This is simply not true. And, if that was not its intention, it certainly has been its effect. The noble Lord, Lord Kilmarnock, called it a "high-profile campaign". He can certainly say that again!
Let us remind your Lordships of the background to our proposals. In 1983 some 334 million prescriptions were dispensed through the Family Practitioner Service in England: almost one million every working day. Current levels of prescribing are 40 per cent. higher than they were 25 years ago. Over that same quarter of a century, the range of medicines actually 1194 prescribed by general practitioners, as recorded in the pricing authority's master index of drugs, has doubled from less than 8,500 different items to some 17,000. The drugs bill now stands at £1,400 million a year in England—about £2,000 million in the United Kingdom as a whole. It has been rising by an average of 5 per cent. a year in real terms over recent years.
These are staggering figures, and while they reflect enormous advances in drug therapy, this alone cannot account for the full scale of the increase. The Government have a responsibility to consider whether this increasing expenditure can be justified. The question we set ourselves was: how could we best ensure that the taxpayer was getting real and lasting value for money—and this was certainly a theme of the noble Lord, Lord Ennals, when he was in office—spent on medicines while maintaining a fully effective service to patients? This theme is not new and obviously has general support from your Lordships, judging by the comments that have been made tonight. Your Lordships will be aware that our policies on the National Health Service in general are similar in this respect, that the principles are applied to all areas of the health service; and it is only sensible management and administration to do so, as the noble Lord, Lord Greenhill of Harrow, said.
The plain fact is that the need to contain the drugs bill has been on the agenda of every Government since 1948. There have been reports, inquiries, educational programmes, promises of co-operation and many more. But while many GPs have responded by more careful prescribing practice, I am afraid to say that there are still too many doctors who are guilty of slack and excessive prescribing. The noble Lord, Lord Kilmarnock, and others have suggested that a solution to the problem—which everybody seems to acknowledge—may lie in the Greenfield Report.
There were 14 main recommendations in the report. Only two of the 14 were about limitations on prescribing. The report recommended that generic prescribing should be encouraged, by providing a box on the prescription form which the doctor would initial if the proprietary form of a drug was required. In the absence of the prescriber's initials, an approved name or generic version of the drug would be dispensed if it existed.
The Government accepted all the working group's recommendations except this last one when the report was published in February 1982. Recognising that generic substitution was a contentious issue, we undertook full and widespread consultation on the proposal before coming to a decision. Given the British Medical Association's apparent enthusiasm now for generic substitution, as was expressed by the noble Lord, Lord Pitt, it may surprise some of your Lordships to learn that the BMA was then against the Greenfield Report's recommendation. The GPs on the BMA's General Medical Services Committee, whose then chairman was actually a member of the Greenfield Committee, voted it down. They foresaw problems of divided responsibilities for the treatment of patients if substitution was introduced. They felt that, unlike the limited list, doctors would never know what had actually been provided to their patients, making monitoring of side effects and adverse reactions more difficult.
1195 The noble Lords, Lord Kilmarnock and Lord Porritt, and the noble and learned Lord, Lord Wilson of Langside, accused the Government of a U-turn. I cannot conclude that I find the attitude of the BMA on this issue convincing or consistent. It is a fact that the BMA rejected the Greenfield proposal on generic substitution.
The noble and learned Lord, Lord Wilson, chided us for failing to follow up Dr. Greenfield's offer to do more work but, as Dr. Greenfield said, the committee he chaired had not looked in depth at some of the issues on which it made recommendations. The Government decided to rectify that on some of the key points—particularly limited list versus generic substitution. They looked very carefully at schemes in other countries and concluded that a limited list would work. There was, frankly, no point in asking the Greenfield Committee to carry on. Its recommendation on generic substitution, as I said, had been rejected by the BMA, and there was no reason to suppose that it would come up with any certain way of making savings that would be more acceptable to the BMA. The Government decided that the time had come to act, and acted they have.
I cannot accept, either, that doubt has been cast on the quality of generic drugs. There is no doubt about their quality at all. They are subject to exactly the same stringent licensing and quality control arrangements as branded drugs and, indeed, are often made by the same firms. They are already prescribed by general practitioners and widely used in limited lists in hospitals. Such minor differences as do occur are a matter not of quality, but of precise formulation and method of manufacture and are just as likely to arise between different branded versions of the same drug as between branded and generic ones.
When the BMA rejected the Greenfield proposal it suggested a scheme of its own, which would be entirely voluntary. The doctor would have to take a conscious decision to permit substitution by initialling a box on the prescription form, as the noble Lord, Lord Perry of Walton, described. But any doctor who wishes to can already write a prescription generically; indeed, we encourage him to do so. The alternative suggested by the BMA would most likely be used by doctors who already see the value of generic prescribing. I have to say that there is little reason to believe that it would have had any significant effect on those who, despite years of advice on these questions, have failed to alter their prescribing habits. Nor do I see that such a voluntary scheme is likely to save worthwhile amounts of money. Even if compulsory and across the board, it could not save more than about £35 million a year, because comparatively few branded drugs actually have direct generic equivalents. A voluntary scheme confined to the same categories of less essential drugs as our limited list proposals, so as not to damage research and important life-saving drugs, would be unlikely to save more than a few million pounds a year. Such a sum is no doubt worth having, but had we taken it, we would have precluded the possibility of alternatives such as the limited list, with its savings of up to £100 million a year. In return we would get an entirely voluntary scheme under which GPs could carry on prescribing exactly as before.
1196 If we strip away the rhetoric, what is the real issue? Should we continue to spend enormous sums of money on any new product which the industry cares to bring on to the market and promote, irrespective of price and therapeutic value: or are there areas in which sensible economies can be made without harm to patients? We believe there are, and we have concluded that there are two major areas in which sensible economies can be made and through which there will be no risk to patients. To suggest that we are advocating a two-tier system, as the noble Lord, Lord Ennals, suggested, really is not true at all. In the group of drugs to be covered by the limited list an adequate range of drugs will be available under the National Health Service to meet all clinical needs. There is no question of this being any sort of second-class service.
On the question of harm to the pharmaceutical industry, which was a point raised by a number of your Lordships, particularly the noble Lords, Lord Porritt, Lord Greenhill of Harrow and Lord Winstanley, I do not think it would be right for me now to go into the PPRS in any detail; but there is no reason why exports should suffer and there is no reason to suppose that research and development will be affected in the way that some people seem to think they will be. I do not believe that the list will result in the decline of the industry. The industry is a strong one, and the noble Lord, Lord Greenhill of Harrow, indeed described it so. The fact remains that the United Kingdom has about 4 per cent. of the world market in these drugs. The limited list accounts for less than 15 per cent. of the United Kingdom market. Therefore, we are talking about 0.5 per cent. of the world market for these drugs, and that is hardly a basis on which to talk about the total decline of research and development in the pharmaceutical industry.
The noble Lady, Lady Saltoun, was concerned, very rightly, about the elderly, children and people who might be affected in the way that she described. The scheme does not affect the prescription charge exemption arrangements. The elderly and other eligible persons will, of course, continue to be protected as at present. The medicines which remain available under the National Health Service will still enable doctors to prescribe all necessary treatment, and I suggest to the noble Lady that that is the key phrase there. All this list will mean is that in the groups concerned other drugs from the list, but perfectly suitable drugs, will be prescribed.
§ Lord Pitt of Hampstead
My Lords, I should like to take the Minister up on what he has just said. If I decide that one of my elderly patients needs Dorbanex, which is not on the limited list, and that particular patient gets his prescriptions free of charge, is he not affected?
§ Lord Glenarthur
My Lords, I understand the point which the noble Lord makes, but it does not detract from what I said just now. The fact is that if somebody has to be prescribed something, for whatever reason, whether he is getting a free prescription or one which has to be paid for in the way that prescriptions are paid 1197 for, a suitable drug of whatever type it is will be available. But I do not think that I can develop that theme any longer, because I have a lot of ground to cover.
The point which I should like to take up next was made by the noble Lord, Lord Rea, who indicated that this might lead to what I think is called trading-up. It is possible that these proposals might result in some increased prescribing of those medicines not affected by the limited list. However, medicines should only be prescribed when they are essential, as he himself will know, and in all cases the benefit of administering the medicine should be considered in relation to the risk involved. For example, indiscriminate use of antibiotics for minor ailments could well encourage antibiotic resistance; and he will be more aware of that than I am. Doctors do, of course, take a sensible approach to their prescribing to ensure that the safety of their patients is paramount, and I am sure that this approach will continue. The present system of prescription monitoring is likely to confirm this.
The noble Lord, Lord Perry, raised a question about long and approved names. It is a pity that he is not here to listen, because I would have asked him whether it was he, in the days when he considered such matters, who came up with the name Pericyazine. I hasten to reassure him and anybody else that this product is for the relief of anxiety. But I had better deal with him in correspondence.
The noble Lord, Lord Ennals, raised a question about the Guardian article today, and black and white lists. The Guardian article is a complete misunderstanding of the position. When the limited list is in operation there will need to be, as several of your Lordships have pointed out, a mechanism to keep its contents under review and to advise my right honourable friend on whether or not new drugs within the categories covered by the limited list should be available on the National Health Service. That is all that we have in mind. There are no proposals for separate assessments of safety and efficacy, which are already fully considered by the Committee on the Safety of Medicines in the context of applications for product licences.
There will be a statutory black list—this answers the point of the noble Lord, Lord Winstanley—of drugs that cannot be prescribed on the National Health Service. It is more useful for doctors to know what they can prescribe, so there will be for the guidance of doctors an administrative white list (a list of what is not on the black list) to help them choose which of the medicines available on the NHS they should prescribe.
I turn now to the areas in which we feel economies can be made. First, there are the more minor remedies which many people already buy from their local chemist and could have had prescribed by their doctor. These less important medicines include a wide range of cough and cold medicines, indigestion tablets, vitamins, tonics and the like. The noble Lord, Lord Porritt, accuses us of interfering in clinical matters. I really cannot agree that in this context our proposals hold up to the label "sinister" which he put on to them and which the noble and learned Lord, Lord Wilson of Langside, supported.
My Lords, perhaps the noble Lord will give way for a moment. These minor remedies may be of considerable importance to pensioners and people who cannot afford to buy the varieties, which may be necessary to them, out of their own pockets. They are not able to obtain them under the National Health Service on prescription in respect of which they are exempt from paying. That is my point.
§ Lord Glenarthur
My Lords, I understand the point of the noble Lady, but the fact is that the taxpayer cannot afford to pay for every single item that is readily available over the counter of the local pharmacy. The point I made earlier about people who really need medicines being treated in a way in which they will certainly get their medicines still holds good.
The British National Formulary advises that many of the enormous range of medicines in these categories are of no proven value or are inappropriately formulated. This covers some of the points which the noble Lady might like to consider. This is the BMA's own advice. I therefore find it difficult to understand its insistence that in the case of all these drugs of no particular value, doctors should have an absolute right to prescribe at the expense of the NHS.
The second group covered by the limited list are the benzodiazepine tranquillisers and sedatives. Many doctors are rightly concerned about the readiness with which these are prescribed and the length of time they are prescribed for. Despite what the noble Lord, Lord Kilmarnock, says, the many letters that we have received from patients have not allayed these fears. To put it bluntly, there are still too many of these pills, given to too many patients, for too long.
When we published the provisional list of drugs—I stress the word "provisional"—to remain available for National Health Service prescription in these categories our intention was always that it should simply provide a framework for consultation.
My Lords, the noble Lord made a most important statement when talking about certain of these drugs. He said that the Government's view was that many of these patients have been prescribed too many of these drugs, for too long. Is the noble Lord saying that as a general statement, or is he saying that some particular patient has been prescribed too much of a particular drug, for too long? The noble Lord has made a very general statement and it is a very damaging one.
§ Lord Glenarthur
My Lords, it was certainly not intended to be damaging or to relate to any particular patient. But the fact is that there are many doctors who accept that a great many of these sleeping pills—the benzodiazepines—are given out, too many patients forget them—one cannot be specific about individual patients—and they have been given them for too long. It seems from what I hear that it is a very widespread practice which really ought to be stopped. That is why we are setting about this particular proposal. As the noble Lord, Lord Winstanley, will realise, we are just removing from this particular list certain drugs and leaving perfectly adequate drugs for people who need these items.
1199 I was saying that the basis of the provisional list was a framework for consultation with all interested parties to ensure that drugs which are essential for the treatment of particular conditions are not accidentaly removed from NHS prescription. There is no question of treating people with contempt, as the noble and learned Lord, Lord Wilson of Langside, suggested.
The fact is that the provisional list certainly had a medical input to its formulation and was simply a basis for consultation. Obviously one has to consult upon something: the proposed list was it. I hope that will reassure the noble Lord and also the noble Lord, Lord Winstanley. It is a fact that has been widely misrepresented.
The response from those consulted has, apart from the BMA and the Association of the British Pharmaceutical Industry, been generally constructive. Even individuals in the drug industry have in the end been realistic about the limited list, for while the ABPI is gloomily prophesying the end of the National Health Service, individual companies are urging us to accept their products onto the list. They see that they have a future in this country, just as much as they have a future in France, Germany, Switzerland, or in any other country that does not allow every medicine on the market to be prescribed at public expense.
From the medical profession, more than 1,000 individual doctors across the country have given us helpful ideas and comments, despite the BMA's resolution that they should not co-operate in any way.
Their views, together with those of other interested parties, have been carefully considered by an expert group of advisers under the chairmanship of the Chief Medical Officer, and the final list to be introduced on 1st April will be based on their advice.
Obviously I cannot tonight comment on the contents of the final list, but I shall certainly ensure that the Chief Medical Officer is made aware of the comments made on individual drugs, particularly by the noble Baronesses, Lady Darcy (de Knayth) and Lady Masham. The noble Baroness, Lady Darcy (de Knayth), asked particularly about the "Brompton Cocktail". This will be all right. It is a major analgesic containing controlled drugs and is not affected by our proposals. It contains morphine or diamorphine, cocaine and alcohol. It is potent and dangerous, I am assured—and it certainly sounds it—but no doubt it is extremely effective.
So far as the question of one month's supply is concerned, we shall certainly look again at that point, but so far no real evidence that would save money stems from it. We would have to pay three times as many dispensing fees for patients on long-term therapy who now obtain, say, prescriptions for three months at a time. It is interesting that the BMA has been vehemently opposed to this suggestion in the past. Has it really changed its mind, or is it simply playing for time on the limited list? I do not know. Anyway, I shall certainly consider the point which the noble Baroness has raised
The noble Lord, Lord Winterbottom, asked whether the Dispensing Doctors' Association had been consulted. No, it was not consulted. The association is a small, breakaway group in opposition to the BMA 1200 and is not recognised as representing the medical profession. It did, however, submit its views in writing, and these have been taken into account. So far as dispensing doctors are concerned, we intend the limited list to meet all clinical needs. If, with the advice we have received, we succeed in that, then there will be no reason for a general practitioner to issue a private prescription to an NHS patient. That said, we have taken note of the many representations made on behalf of patients in rural areas, and we are still considering their position.
At present ours is the only country in the developed world where the state will pay for whatever drug a doctor wishes to prescribe. It is certainly very rare nowadays for a doctor in private practice to feel free to prescribe any expensive brand that he wishes and to expect his patient to pay, regardless of the cost.
The noble Lord, Lord Kilmarnock, made five suggestions and I shall study those again from the Official Report. I should like to pick up now one suggestion—
§ Lord Kilmarnock
My Lords, as there is no right of reply on an Unstarred Question, perhaps I may intervene. I believe I am right in saying that 12 speakers in the debate this evening have asked the Government to think again. I, as the Minister has acknowledged, submitted a five-point programme. Will the Minister undertake to convey that programme to his right honourable and honourable friends, and also to the Acheson Committee, which is actually studying the list at this moment?
§ Lord Glenarthur
My right honourable friend certainly studies all that transpires on this kind of issue in your Lordships' House, and this particular debate will be no exception. On the noble Lord's third point, we certainly welcome all proposals for savings and hope that we may have constructive talks with all interests when this particular issue has come to a conclusion. These talks will be additional to the limited list and not an alternative to it.
The noble Lord, Lord Rea, in explaining the significant advances in prescribing practice which he and his partners have achieved has shown that there is much more to be done. As the noble Lord, Lord Kilmarnock, and others, were keen to stress, of course there is much that can be achieved through co-operation between Government and the profession on prescribing issues. Agreed measures could lead to a further significant saving in the drugs bill. With our encouragement, and as the noble Lord, Lord Winstanley, said, 40 per cent. of our hospitals have already drawn up their own limited list, different though they may be from one another, and some National Health Service practices do it as well.
Finally, the noble Lord, Lord Winstanley, asked me one important question: how would the new rules be brought into effect? I can tell him that regulations will be laid to amend the terms of service for doctors and pharmacists which are at present set out in Schedules 1 and 4 to the NHS General Medical and Pharmaceutical Service Regulations of 1974. Those will come forward in due course, and they are subject to the negative procedure.
1201 The fact remains that generic substitution alone would not encourage doctors to think more carefully about their prescribing, nor would it achieve the very necessary and immediate savings in the drugs bill that we must have in order to protect essential developments in other parts of the health service. Our limited list proposals do. They offer no threat whatever to the safety and wellbeing of patients. That is why we are so firmly committed to them and why we believe them to be fully justified.
My Lords, before the noble Lord sits down, may I ask whether this House will have a chance to see and discuss the revised limited list before it is adopted?
§ Lord Glenarthur
My Lords, the list is under consultation at the moment. It is much more important, I think, for doctors and experts to discuss it. That is what we entrust the Chief Medical Officer and his panel of experts to do. They will complete it in due course and then the list will be published.