Standing Committee E
Thursday 1 February 2001
[Sir David Madel in the Chair]
The Minister of State, Department of Health (Mr. John Denham): I beg to move amendment No. 206, in page 30, line 1, leave out from `Chapter' to second `services' in line 2 and insert `
``pharmaceutical services'' means services of a kind which may be provided under section 41 of the 1977 Act, or by virtue of section 41A of that Act; and
``local pharmaceutical services'' means such pharmaceutical services (other than practitioner dispensing'.
The Chairman: With this it will be convenient to discuss the following amendments: No. 39, in page 30, line 2, leave out `(other than practitioner services)'.
Government amendment No. 207.
No. 280, in page 30, line 4, leave out from beginning to end of line 8.
Government amendment No. 220.
Mr. Denham: Clause 29 is the first of 13 clauses dealing with local pharmaceutical services. It may be helpful if I briefly set out how those clauses relate to each other.
Clause 29 establishes a pilot scheme for a local pharmaceutical service. Clause 30 introduces schedule 2, which deals with the process by which health authorities develop pilot schemes and submit them for approval. Clauses 31 and 38 deal in different ways with the relationship between local pharmaceutical services pilot schemes and existing arrangements. Clause 32 deals with the review of pilot schemes, and clause 33 with their variation and termination. Clause 34 deals with the legal basis under which pilot scheme agreements can operate, while clause 35 makes provision for meeting preparatory costs.
Clause 36 deals with prescription charges, and clause 37 with the status of pilot schemes in relation to other NHS legislation. Clauses 39, 40 and schedule 3 deal with establishing local pharmaceutical services as a substantive and permanent part of NHS arrangements following the pilot stage. Clause 41 provides powers to make further provisions in relation to that.
Many of the provisions in those clauses are modelled directlysometimes word for wordon the equivalent provisions for personal medical and dental services introduced under the National Health Service (Primary Care) Act 1997. Local pharmaceutical services are a key element of our programme for pharmacy set out in ``Pharmacy in the Future'', which we published in September.
I think that the Committee may agree that, for too long, the NHS has underused the skills and expertise of pharmacists. ``Pharmacy in the Future'' demonstrates for the first time that the Government are committed to putting that right. Community pharmacies provide a necessary and well-valued service throughout the country. Studies have repeatedly shown that patient satisfaction with dispensing services is high. People have a growing recognition of what else community pharmacists can do, not least in helping people to deal with minor illnesses and make better use of their medicines.
Mr. Philip Hammond (Runnymede and Weybridge): Will the Minister place on record the value to local communities of GP dispensing services in areas not served by pharmacies?
Mr. Denham: Dispensing GPs do indeed provide a valuable service, particularly in areas where community pharmacy services are not available. Although the general preference is for the full range of pharmacy services to be available, dispensing GPs provide a service valued by patients that would not otherwise be available.
It is generally recognised that the current contractual framework for community pharmacy needs improvement. The national framework fails to provide sufficient incentive, and does not properly reward good quality and service at the expense of those who provide only the bare minimum. We want to reform that national framework. At the same time we want to provide a more flexible alternative. There are already many good examples of local projects under which pharmacists provide extra services on top of the national requirements. What is missing at the moment is a proper framework for local agreements to bring all the elements into a coherent whole, tailored to specific local needs. Local pharmaceutical services pilot schemes will provide that.
As with personal medical services, the legislative framework in the Bill is deliberately flexible and open. The emphasis is on local imagination and innovation, free from the constraints of the rigid national contractual framework.
Mr. Hammond: We are very supportive of the idea of local flexibility, free from the constraints of rigid national contracts. Will the Minister assure the Committee that the local pharmaceutical services pilot scheme will not go along the route followed by personal medical services. The latter started by emphasising local flexibility and freedom from the rigidity of national contracts, and has moved in the direction of more rigidor, as the Government would say, more uniformnational contracts. Can he assure us that it will remain a locally flexible scheme?
Mr. Denham: PMS has been a significant success for the Government, with 22 per cent. of all GPs operating under PMS from April and with more to come forward next year. As our experience of PMS, and that of GPs, grew, we were able to combine local flexibility with some essential core elements in the PMS contracts, and it is interesting that that did not dissuade GPs from signing up to them. It would be wrong to rule out core elements in local pharmaceutical services contracts. We must proceed in the light of experience, and the emphasis will be, as it is with PMS, on the development of schemes that are appropriately tailored to local needs and to providing additional local services.
We look forward to schemes that combine traditional dispensing services with greater levels of pharmaceutical care. Pharmacists in such schemes would not just supply medicines, but actively manage them. They would work with GPs and primary care services to help to ensure that patients get the right medicines and the help they need to make the best use of them. That could include the periodic review of individual patient's medication or even domiciliary visits to discuss and assess any problems they are having with their medicines. It could involve a continuing role in therapeutic monitoring for people taking warfarin, for example, or help for asthmatics with inhaler techniques. In many local schemes pharmacists provide enhanced services, and there are opportunities for many more.
By allowing pilot schemes to include other services, pharmacists may be used as a base for other activities. Health authorities are already involving pharmacies in health education campaigns. For example, pharmacists provide smoking cessation counselling or particular services for drug misusers. Some pharmacies could be a convenient local centre for chiropody or similar services.
The Government have been deliberately open about who may be parties to pilot schemes. Although existing independent contractors will no doubt be at the forefront, we have not ruled out others being involved if that is the best way of meeting local needs, including NHS trusts and primary care trusts. We could also have schemes in which the pharmacy owner contracts for the dispensing service to provide the facilities, but it is a named individual pharmacist who contracts directly to provide the associated pharmaceutical care.
Participation in pilot schemes will be voluntary and discretionary. For pharmacists and health authorities that choose to make use of the new framework, LPS means exciting opportunities to provide better and more cost-effective services to patients. We have shown what can be achieved with personal medical services and with personal dental services, the time is right to achieve the same in pharmaceutical services.
Our amendments to the clause improve the drafting of the definitions. Amendment No. 206 makes it clear that local pharmaceutical services means services that may be provided under the existing legislative framework with one exception: that is, dispensing by doctors and dentists to their own NHS patients. That exception does not imply any desire to exclude dispensing doctors from the opportunity to take part in innovative local contracts. It is simply that the opportunity to do so already exists within personal medical services, and it would be confusing to include that in local pharmaceutical services as well.
Amendment No. 207 clarifies that the exception applies to all GPs, whether performing general or personal medical services. In the same vein, amendment No. 220 ensures that the definition in paragraph 1(3) to schedule 3, which deals with post-pilot arrangements for LPS, is consistent.
I shall anticipate amendments Nos. 39 and 280 tabled by the rt. hon. Member for North-West Hampshire (Sir George Young), which would put dispensing doctor services back within the scope of the local pharmaceutical services pilot schemes. I hope my explanation of their exclusion will reassure the rt. hon. Gentleman that the amendments are unnecessary. The Government have sought to avoid confusion and duplication of provision rather than exclude dispensing doctors from innovative approaches to dispensing.
Sir George Young (North-West Hampshire): I shall speak to my amendments Nos. 39 and 280, and also respond to some of the more general points that the Minister made. Amendments Nos. 39 and 280 are about equality of opportunity between different groups of GPs. Deleting ``other than practitioner services'' and subsection (9) on the definition of practitioner services would give GPs providing general medical services the same opportunity to take part in LPS as GPs who provide personal medical services. I do not see any reason to create a differential between the two types of practitioner. It would be perverse for the opportunity to be made available to one group of GPs, but not to the vast majority.
Under the clause, it will be possible to provide additional services such as diagnostic testing and investigative procedures in an LPS scheme. A GP may wish to apply to provide those services, and it is important that a patient's care is properly co-ordinated and integrated. I was not wholly persuaded that because GPs could apply under a different scheme, they were excluded from taking part in this one. To avoid any future problems LPS pilot schemes should be introduced with care, to ensure that there is equity in the way in which rules are applied. The Minister's amendments have dealt with some of the concerns of the British Medical Association's general practitioner committee, and we will discuss amendment No. 219 later.
I would like to touch on the issue of GP dispensing, which was raised by the Minister and which my hon. Friend the Member for Runnymede and Weybridge (Mr. Hammond) mentioned in his intervention. My amendment is about the ability of GPs to take part in the new arrangements. The Government seem to overlook the importance of GP dispensing. Some 3.5 million people get their prescriptions not from the local pharmacist, but from their GP. There are 4,400 dispensing doctors in the UK. Committee members may know that there has been a long history of conflict between pharmacists seeking to establish new community pharmacies, and GPs who act as dispensing doctors, as well as between pharmacists with established pharmacies and GPs seeking to become dispensing doctors. Progress has been made between the professions towards stability.
The reason for my interest in the matter, and for my amendment, is something that happened in my own constituency in north-west Hampshire. In Tadley, 2,000 patients used to get their medicines dispensed at the Woodland GP practice. There were clear advantages in that for them. It avoided the need to visit a chemist as well as a doctor. All the patients lived at least a mile from a chemist. The area, which is predominantly rural, was designated a controlled area, which allowed the GPs to dispense. The GPs and their patients were happy.
Then someone in the health authority, who apparently had nothing better to do, decided to re-designate part of the practice area as urban rather than rural. There is no definition of a rural areait is a subjective exercise. However, the notion that because someone in the health authority re-designates the area, my constituents put down the White Paper on rural affairs and pick up the White Paper on urban matters, is optimistic. The important thing is that, without the patients or the community health council being consulted, the machinery was activated to stop the GPs dispensing. That had implications for all the patients, because the income from dispensing funded additional equipment such as an ultrasound scanner.
In a rather Kafkaesque process involving the pharmacy application board, Baughurst Common was designated as urban and not rural. That was that; the area was no longer controlled and chemists could then dispense there, because they can dispense in both controlled and uncontrolled areas. However, GPs can dispense only in controlled areas. I took the matter up with the then Minister of State, who is now the Secretary of State, and shared my problem with him. He wrote back on 27 May 1998. His letter states:
I am sorry to hear that the change of classification of Baughurst from a controlled to an uncontrolled area, may jeopardise the number of services the Woodland Practice currently provide to patients at their surgery. However, the statutory responsibility for handling applications for the provision of pharmaceutical services rests with the Health Authority and, on appeal, to the Appeal Authority. Ministers have no power to intervene, and indeed, it would be inappropriate to do so for individual cases.
The Minister may have had a good alibi then, but with the fresh measures and the relevant clauses now before the Committee, he has no alibi. If he believes, as I do, that in the circumstances that I have set out it was wrong to deprive patients of a one-stop shop because someone wanted to open a new pharmacy, I ask him to say so and to undertake to amend the Bill if it does not have the flexibility that I want.
I yield to no one in my admiration for community pharmacists. As the Minister said, their skills have for far too long been undervalued, their informal advice can save people a visit to a GP and the dispensing income can keep open a chemist's shop that would not be viable without that income flow. We need a balance, but the Department's literature on this point is unbalanced. The Minister referred in his opening remarks to ``Pharmacy in the Future''. I could find no reference to dispensing GPs there. A reference at paragraph 2.9 misses the point. It states:
``Patients find it convenient to have a community pharmacy very close to their GP's surgery.''
Yes they do, but they might find it even more convenient if the GP did the dispensing. Paragraph 1.8 comes close to my ideas in referring to ``one-stop primary care centres'', with the pharmacist and GP ``under one roof''. I am in favour of that, but it is not quite the same as GPs doing the dispensing.
Paragraph 1.4 of the document states that people should get their medicine
``at a place of their choosing'',
but, as I have explained, the present system does not permit that, if the place of their choosing is withdrawn.
I am slightly more worried about paragraphs 4.13 and 4.14. Perhaps the Minister will reassure me when we consider schedule 2. A free for all is apparently envisaged. I do not mind pharmacists opening businesses if they want to, but I object to a pharmacy opening with the consequence that a GP must stop dispensing. The omission that I am concerned about also occurs in the document that the Minister circulated to the Committee, ``The Health and Social Care Bill: Local Pharmaceutical Services''. There is a passing reference at the end, at paragraph 4.12.1, but paragraph 4.12.3 states:
``The Government has decided not to include dispensing doctor services within LPS schemes themselves.''
The explanatory notes state at paragraph 142:
``The parties to pilot schemes may therefore include, amongst others, individual pharmacists, retail pharmacy businesses and dispensing appliance contractors.''
There is no reference in the explanatory notes to GPs. It would appear that they cannot play the game in question.
I should like a clearer response from the Minister to the question put to him by my hon. Friend the Member for Runnymede and Weybridge. What is the role of dispensing doctors within the Government's vision of local pharmaceutical services? Can we have an assurance that there will be no repetition of what I described happening in my constituency? Will there be a level playing field between GPs who want to take the route that I have outlined and others? Perhaps the Minister can bring us up to date with the proposed regulation changes. I understand that the Pharmaceutical Services Negotiating Committee and the general practitioners committee of the BMA have been engaged in discussions to try to resolve the long-standing disputes. However, I understand that the regulations need to be changed to bring stability to the world of rural dispensing.
I hope that, if not in response to the present debate, then at some time in our proceedings, we shall be told more about dispensing doctors than we have so far and be given a clear assurance about what happened in Tadley.