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Column 1234As more pharmacy applications are made, legal loopholes in the regulations are being found. Those loopholes do not allow any consultation with doctors and patients, so the views of those most affected may not be taken into account. That increasingly shows that the principles of the legislation have been so totally lost that it is being used merely for commercial purposes, often by retail multiples with potential losses to NHS.
A large number of villages in Lincolnshire--Welton is just one example-- have the same problem. Applications are constantly being made throughout the country. There is, therefore, a serious national problem and clearly reform is needed. It is not just a constituency problem, but I am delighted to come to the House and use the example in my constituency to illustrate it.
In preparing my speech, I was anxious to be fair to both sides. Of course, I have had a great deal of pressure from local doctors and local people, but I have also spoken to the secretary of the Lincolnshire local pharmaceutical committee, Mr. Noel Baumber, because I wanted to be fair to his side of the case.
It is worth while to relay the views of pharmacists, as they are also unhappy with the present system. They believe that pharmacists and doctors need to be remunerated on the same basis to remove any incentive on the part of doctors to overprescribe. They say that doctors benefit from a 10.5 per cent. margin on the cost of the drugs they provide, that their fee income is related to the number of prescriptions they prescribe, and that their dispensing income is added to their superannuation.
The chemists argue that such a conflict could not arise if GPs were not given incentives to dispense. They say that Baroness Cumberlege has confirmed that GPs can double their income by dispensing. They also say that dispensing is sometimes delegated to unqualified staff, who are not supervised. I cannot confirm the accuracy of those statements, but I relay them to the House. Lastly, the chemists say that pharmacy dispensing is better and less expensive. That is the views of the two sides.
Let us deal with what is important--us, the patients, the people, the country and the Government. It seems to me that we--the patients and the Government--must find a way to end the dispute between doctors and chemists.
First, the service should be run for the patients, and not for those working in the NHS. We should all believe that cliche , but the chairman of the local drugs committee, Mr. George Sutton, to whom I talked yesterday, told me that, as he attempts to hold the line between doctors and pharmacists, the protagonists seem to forget it as they argue over their remuneration.
It is no longer good enough for the Government to wash their hands of the dispute, Pontius Pilate-like, and say, "Come back to us when you have sorted it out yourselves". The Government should act; at the very least, they should reform the system, so that the FHSA is given proper discretion and the powers to respond to local opinion about what is best for the community. It should give reasons why it accepts or rejects local opinion, so that we can avoid the farcical situation in the village of Welton.
Local doctors have told me that the Minister needs to examine the apparent loophole in regulation 12 of 1992, which appears to allow the free entry of locally established pharmacies without recourse to a hearing. According to Mr. Sutton, the NHS appeals unit should
Column 1235be discouraged from reviewing a case unless the original hearing is clearly flawed. The FHSA sometimes wonders whether it or the appeals unit is the authority, because apparently all cases go to appeal. The next step would be to ensure that a doctor's decision about whether to employ a pharmacist will affect only the viability and income of his practice and not him personally. The third step would be to allow rural doctors to continue dispensing, even if a pharmacy opens up in the village. Why not? We believe in competition. The fourth step would be to introduce a full, free and fair market, so that the consumer can make his or her own choice about where to get a prescription. I urge the Minister to reform the regulations, before further damage is done to the rural NHS.
The Minister for Health (Mr. Gerald Malone): I am extremely grateful to have the chance to respond to the Adjournment speech of my hon. Friend the Member for Gainsborough and Horncastle (Mr. Leigh). It is an extremely important matter, and I congratulate him on securing the opportunity to raise it.
My hon. Friend always addresses himself to matters in this House with a great degree of elan. He often assaults the establishment, and, sadly, tonight I have the role of the dullard Minister who must respond to him about the technicalities and complex matters which govern how people in rural areas have reliable access to the dispensing of drugs.
Although it may be boring to go through all the complex policy matters, it is important to set them out. As my hon. Friend said, it is a complicated issue. There are tensions between pharmacists and dispensing doctors, because a prime policy role is involved in ensuring that all national health service patients receive the treatment they require. The public must also secure value for money in the way that drugs are dispensed. That has been the continuing policy of the NHS since its inception, regardless of where patients may reside--in urban or rural areas.
I will briefly set out the policy on dispensing. Principally, doctors diagnose and prescribe medication--that is their proper role, as my hon. Friend said--and pharmacists dispense medication. In the Government's view, that makes the best use of the complementary skills and experience of members of both professions, to the benefit of all patients. There should be no question of competition between the two professions, although I know that my hon. Friend has set out a case suggesting that that may exist.
It is Government policy to establish co-operation between the members of an integrated primary care team, particularly in rural areas. It is sometimes difficult to achieve that co-operation, and there may be tensions, but the Government must overcome them and ensure that the patient benefits in the long term.
Pharmacists are, of course, best placed to advise a patient how best to use his or her medicine to get the maximum benefit with the minimum side effect. That is extremely important in a number of contexts, not least of which is the conclusion of a course of drugs. Pharmacists can also advise on the use of medicines that are purchased
Column 1236over the counter--not only drugs that are dispensed but the increasing range of self-medication to which many people turn instead of using the primary care sector, and that is vital.
Mr. Leigh: What if the doctor at the health centre employs a pharmacist? Does not the patient then get the benefit of the advice of both a doctor and a pharmacist on the same premises?
Mr. Malone: As I go around the health system, I see a number of examples. It is not always the case that pharmacists and doctors, be they prescribing doctors or not, are in conflict.
I was, for example, in a health centre in Purfleet, Essex, seven or eight days ago, which was a general practice of six or seven partners and contained a pharmacy. I would suggest that the rules do not prevent that. It is quite possible for such a set-up to work quite happily together, not only to dispense the drugs that the primary carer prescribes but to provide the over-the-counter medication, which I believe will become increasingly important and which is becoming increasingly recognised.
There are models. The rules and regulations do not militate entirely against what I presume my hon. Friend is suggesting--a good market answer to the problems.
Let us move on to NHS dispensing in rural areas. It will be worth while to set out for the House where we are. I shall touch first on the one-mile rule--when pharmacists come into an area in which there are dispensing practices, dispensing practices are obliged to dispense only to those who live outside one mile of the immediate area. That rule was introduced in the early part of the century. Part of the problem that I suppose my hon. Friend is addressing is that there is a great history behind all this. In the 1970s, there were major problems between the professions, and that led to the Clothier committee, which reported in 1977.
It is probably not without significance that the difficulties and the tensions between those involved in primary care and pharmacists is that it took six years before controls on entry in rural areas were introduced in the House, in 1983. I am not quite certain, but I have a suspicion that my hon. Friend and I were probably unwitting partners in 1983--when we both entered the House--to the regulations that implemented those rules. I certainly do not remember precisely when it was, and I suspect that my hon. Friend does not either. The main features of the controls were that a pharmacy or doctor wishing to start dispensing had to show that it would not prejudice the proper provision of medical or pharmaceutical services. If permission to dispense is granted, it may come into effect over a period, and that is carefully put in place to ensure that the change in income of those who previously dispensed is not sudden. The controls are an attempt to strike a balance between providing the important services of a pharmacist wherever possible and ensuring that patients continue to have access to a dispensing service in areas where a pharmacy could never be viable.
I would ask my hon. Friend to bear in mind the history of the regulations. In the days when there were communities in which no pharmacist wished to set up, because there was no reason to do so, the regulations were introduced to allow GPs to dispense, which was a very important service.
Column 1237The present arrangements allow doctors to dispense to patients who live in rural areas that are not served by pharmacies, who would have serious difficulty in obtaining the necessary medication from a pharmacy, or who require immediate medication in the course of emergency treatment. In practice, however, the rules also allow doctors to dispense to patients who could easily visit a pharmacy at the same time as visiting their doctor.
In recent years, there has been a gradual increase in the number and proportion of dispensing doctors. During the same period, the average number of dispensing patients per dispensing doctor fell; so the number of dispensing patients has remained virtually the same. As for the operation of the Clothier regulations, family health service authorities are required to consult--among others--local community health councils. My hon. Friend mentioned consultation; this consultation is important, because it allows patients to express their views. There is also the prejudice test, with which my hon. Friend will be familiar. A family health service authority must consult any person on the medical list who is likely to be affected. I know--not only from what my hon. Friend tells me, but from the correspondence I receive--that there has been what I would describe as an uneasy truce between the two professions. The relationship is difficult: as my hon. Friend pointed out, tensions exist, and there are two debates. My hon. Friend set out one side of the argument, which is that dispensing doctors benefit unfairly from the arrangements.
I suggest that that is not so. My Department subjects the margins in relation to payments that doctors are able to receive in connection with drugs to close examination, on a continuing basis. My hon. Friend may think that that is a source of tension between dispensing doctors and pharmacists, but it is regularly a source of even greater tension between my Department and dispensing doctors. I strongly disagree with my hon. Friend's assertion that the system favours the needs of individual pharmacists rather than those of patients. We aim to ensure that
Column 1238patients living in rural areas enjoy the same range of services as are available to people living in urban areas. That has been difficult to achieve.
My hon. Friend may think that it is simple to make a bonfire of regulations, but it is more difficult than he imagines. A balance of provision has grown up over time; if we simply tore up the regulations that have developed, it would be to the detriment of patients, and would lessen their ability to gain access to and make use of a dispensing service. That is not to say that we should not listen to both sides of the argument--the pharmacist's case and that of the dispensing doctor--and decide how to proceed; that is perfectly proper.
My hon. Friend rightly referred to the free market. With the development of new health centre communities, we are seeing new ways in which dispensing services are provided, and they are free of the tensions that have existed between the professions before. I cited an example earlier that I expect to be repeated increasingly across the country: circumstances in which the medical profession and pharmacists decide that they have mutual interests in regard to both prescribing and dispensing.
I hope that, as time moves on, the tensions to which my hon. Friend referred will diminish. I am alert to the fact that those tensions exist, and have received a number of representations from both sides of the argument. As my hon. Friend knows, a number of issues are currently being considered by the courts, and I shall not comment on those. I shall return to them, however, once the courts have delivered a view.
Finally, I reassure my hon. Friend that it is the Government's overriding intention that all those who require access to drugs, by either prescription or dispensing--the patients--can get them in the most convenient way. I hope that we can proceed in a way that will diminish tensions between the two professions of pharmacy and medicine.
Question put and agreed to.
Adjourned accordingly at half-past Ten o'clock.
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