Dr.
Pugh: The Minister may be able to assist me. He has
pointed out the obvious conflict of interest that can exist when one is
both dispensing and prescribing medicines. That needs to be addressed.
He has suggested that the only way in which it would be addressed is
via the ethics committees of local GPs and so on. The issue will, of
course, be assessed, determined and established by the PCT, but is
there not provision in the legislation, particularly in relation to
where a prescribing practice differs radically from what one might
expect, to do things other than relying entirely on doctors’
panels judging
themselves?
Mr.
O'Brien: The hon. Gentleman asks whether there are other
provisions in this legislation. I am not aware of any. I shall consider
the matter and in due course confirm in writing whether that is the
case. It is a reasonable question, and I shall write to
him.
Mr.
Stephen O'Brien: The Minister seizes the point, not least
because his constituency has the same characteristics of rurality, at
least in part, as no doubt many of ours do. That factor has a big
effect on the availability of services and access to them in relation
to how the cash flows work for both doctors and dispensing
operations.
I was pleased
at the way in which the Minister put the Government’s case; he
did not go down the same track that was used in defence in the other
place by Baroness Thornton, who took issue with the proposal of pilots
on the basis that it would delay the national roll-out of PNAs for at
least two years. I thought that argument spurious, and I welcome the
fact that the Minister did not deploy it. Given his assurance, I beg to
ask leave to withdraw the amendment.
Amendment,
by leave, withdrawn.
Mr.
Stephen O'Brien: I beg to move amendment 145, in
clause 25, page 28, line 24, after
‘assessment’,
insert— ‘(e) for appeals to
the Secretary of State or a body in relation to the content of the
statement made by
PCTs.’. The
amendment would enable pharmaceutical services to challenge the content
of the PNA. It would ensure that when a PCT was failing to reach
standards in its PNA, a potential provider or other body could
challenge the statement. That sort of scrutiny will help to ensure that
the PNA meets a standard that allows sound decisions to be made on new
applications to provide pharmaceutical services.
At the
moment, the Bill does not guarantee that PNAs will contain reliable and
accurate data. I cite Earl Howe, who said in Grand Committee in the
other
place: “We
do not know how effectively PCTs will use PNAs, especially given their
record to date of disinvesting in enhanced services such as
out-of-hours opening and local delivery”.—[Official
Report, House of Lords, 11 March 2009; Vol. 708, c.
GC477.] I have
been in touch with the pharmaceutical services negotiating committee
and I pay tribute to it for its thoughts on the benefits of being able
to appeal to PCTs should they carry out the PNA negligently.
It would not
be appropriate for a negligent PNA to form the basis of granting
applications, and I am concerned that, regardless of the PNA standard,
it will still be used as the unequivocal method of determining
applications. The National Pharmacy Association
said: “It
should be understood that if a PNA identifies an unmet need, then there
is an obligation on PCTs, under normal circumstances, to secure
provision sufficient to meet that
need.” We
must therefore ensure that PNAs provide a rigorous assessment of needs,
and that they are kept up to scratch so as to avoid applications being
granted on the basis of negligent
assessments. The
adequacy of a PNA might cause concern to all those affected in cases
when the PCT has been classed as poor by the world class commissioning
assessment. Will the Minister clarify whether a pharmaceutical needs
assessment would still be used as a basis for granting applications if
the PCT that conducted it fell into the category of poor under the WCC
assessment?
As the
Bill stands, there is no mechanism by which applicants can question a
PCT’s assessment, even if it is perceived to be negligent.
Although the regulations prescribe some of the content of the PNA, what
is to stop a PCT from disregarding local needs in order to
prevent a particular service from succeeding in its application? I hope
that the Minister will respond to that
query.
Mr.
Mike O'Brien: Allowing appeal rights would be
fundamentally flawed for a number of reasons. I recognise the concerns
of the Pharmaceutical Services Negotiating Committee, which has raised
questions, but I shall also tell the Committee of some of my
concerns.
An appeals
system would lead to endless appeals from dissatisfied and potentially
conflicting local interests. There will always be some who take a
different view, and many of them will find that their commercial or
other interests are affected by an assessment. They will have many
different views on how that assessment might affect them. It is
therefore likely that a multiplicity of concerns would be expressed by
a significant number of individuals and businesses. We do not intend to
create
some kind of lawyers’ charter where we can
have a massive set of new bureaucracies to try and deal with it. We
need to avoid that. There is always a balance to be struck between
creating new bureaucracy and ensuring that people have the right to
make representations. They can make their representations when the
assessment is carried out. The assessment will take account of
them—or not—and the outcome will be there. Constant
appeals over an assessment, which could go on for years, could get
expensive. Secondly,
PCTs would potentially incur huge costs defending their decisions under
appeal. That is never justifiable in terms of NHS funding at the best
of times, and certainly not in the current economic climate.
Thirdly, as a
consequence, appeal rights could undermine the principle of
pharmaceutical needs assessment as set out in the Bill. This is
supposed to be a clear, robust view from the PCT. It is not supposed to
be the view of others. Lots of people will have different views and
commercial interests of their own, with particular views in terms of
their locality or many other things. This is supposed to be an
assessment carried out by those required to deploy the NHS funding as
to what their priorities are.
There is a
fourth objection. I am not aware of any corresponding appeal rights in
respect of other strategic commissioning documents such as the joint
strategic needs assessment which PCTs carry out. Where there are
concerns about a final pharmaceutical needs assessment or where there
are grounds to believe that the PCT has not complied with the
forthcoming regulations about PNAs, we expect much more straightforward
processes.
The proposed
legislation already requires us—under subsection (2)(d) to
proposed new section 128A—to set out in regulations the
circumstances in which a PCT must carry out a new pharmaceutical needs
assessment. How every assessment is determined will be a matter for
those regulations. For example, it would be triggered in prescribed
circumstances such as where a PCT has not complied with the forthcoming
regulations which set out how a PCT is to construct its assessment. It
might also be applied in circumstances where an assessment has resulted
in the PCT making faulty decisions about individual applications which
are then upheld on appeal.
I understand
the concerns expressed on this issue and on the capacity and capability
of PCTs in this area. I refer to earlier amendments under this clause
and the comprehensive support programme we are putting in place for
PCTs. We need to continue that work. However, I am not persuaded that
in this case, the appropriate way to proceed is to create an entirely
new and somewhat bureaucratic appeal process. I therefore ask the hon.
Gentleman to consider whether it is appropriate to withdraw these
amendments.
5pm
Mr.
Stephen O'Brien: I am grateful to the Minister for his
response, as much to me as it is to the Pharmaceutical Services
Negotiating Committee and others, who I am sure he has had
representations from. In effect, that was the response to the position
that has been put forward.
In light of
what the Minister said I am not minded to press the point—not
least because I am equally anxious to ensure that we do not introduce
any further levels of
bureaucracy; he knows I am genuinely concerned about
that. However, at the same time there is the issue about ensuring that
there is not just a simple draconian process which means that some
people’s interests could be cut off rather than pursued. If
there were some perverse experiences over a couple of years,
representations would flow into Government to suggest that there might
be a need for some form of appeal. However, on that basis, I beg to ask
leave to withdraw the amendment. Amendment,
by leave,
withdrawn.
Mr.
Stephen O'Brien: I beg to move amendment 135, in
clause 25, page 28, line 24, at
end insert— ‘(e) as to
differing assessment criteria for urban and rural
needs.’. This
is very much linked to the subject matter of our debate on the first
group of amendments under this clause. It should be recognised that
patients in rural areas may have needs that differ from those of
patients living in towns and cities. The amendment seeks to serve that
purpose. The area of a PCT may well span both urban and rural
geographies. There is no guarantee that it will take into account both
areas. We need to ensure that a PCT’s PNA acknowledges the
potential requirement for different services among different
populations. As
I discussed under the earlier group of amendments, patients in the
country make extensive use of dispensing doctors, as do the elderly,
who appreciate the convenience of being able to combine the collection
of medicines and their visit to the doctor without the burden of an
extra trip to the pharmacy. The Minister identified precisely that
service on behalf of some of his
constituents. I
must express an interest in the issue, as 24 per cent. of
England’s dispensing practices are in Western Cheshire
PCT—the main PCT of my constituency—and a further 13 per
cent. are in Central and Eastern Cheshire PCT, the other one that
serves my constituents. Cheshire GP Dr. Nigel
O’Callaghan—himself a dispensing doctor—recently
outlined the crux of the matter on the Chemist and Druggist website by
saying: “Why
not let patients vote with their feet and choose between GPs and
Chemists?” The
Dispensing Doctors Association similarly observed in its meeting with
me that patient choice was at risk of being restricted if appropriate
safeguards were not put in place to maintain a variety of
services. Having
not seen the regulations for PNAs, I can only judge the assessments on
their track record to date, which, as I have already discussed, is poor
in places and far from consistent. It is a worry that once again, the
Government may be jeopardising patient choice in rural areas by not
ensuring in primary legislation that PNAs cover a breadth of services,
of views, including those of patients, and of patient choice. We
support PNAs, but they must not limit choice as that defies their
objective. I therefore hope that the Minister is able to guarantee that
the PNAs will provide for rural and urban populations in their
PCTs.
Mr.
Mike O'Brien: There are many different criteria by which
assessments will need to be made. The first is, of course, the
rural-urban one, but “urban” is not a single
category—it deploys many different kinds of urban areas. There
are inner cities and suburban areas. There are
different ways in which categorisation can take place. Remember that
the criteria of choice and
access are different. The hon. Gentleman seems to
propose that we should, in some way, create a two-tier assessment
system, which discriminates in the criteria to be adopted between rural
and non-rural areas. I do not think that that is the right approach to
take.
Further,
regulating to differentiate between the criteria to be adopted risks
imposing on PCTs criteria that may not match their assessment of the
needs locally—or worse, risks omitting criteria that are crucial
to PCTs locally, of which we know nothing at the centre. In our view,
PCTs are better able to differentiate for themselves the mix of cities,
smaller towns, villages and remote rural areas, and are better able to
locally reflect the way in which they feel it is appropriate to do the
assessment, rather than seeking to impose—as the Opposition now
seek to do—central top-down criteria, by which they tell PCTs
what to do. Let the PCTs get on with it and do it themselves. Do not
apply this bureaucratic centralisation on them. I say to the hon.
Gentleman that I think it is time he withdrew the bureaucratic and
unnecessary
amendment.
Mr.
Stephen O'Brien: I think we have reached a point in this
Committee where just because the Minister says it, it does not mean
that it is. On this particular issue, I do not think that it invokes a
high degree of bureaucracy in quite the way he seeks to tease. The main
point is to emphasise the need to make an assessment that takes fully
into account the difference between rural and urban. I accept that to
some degree there is difficulty with the rather all-embracing word
“urban”, which can include not only suburban, but even
associated villages with an urban centre. I think of the villages that
immediately surround Chester; they are only as far from the main part
of the outer edges of Chester-urban as they are from the next village,
which under the current criteria, is counted in the rural
area. Indeed,
such matters lay at the heart of a dispute that was eventually happily
resolved, but not until a long and tense campaign had been fought to
get the local PCT to recognise the value of a dispensing doctor in the
rural area. That doctor was funding a satellite operation in a village
close to the edge of where a village would be regarded as being
connected with an urban, not rural, environment. As a sign of our
earnest approach to the matter and to make sure that we put it on the
record how important we consider such matters to be, I wish to press
the amendment to a
Division. The
issue is something to which we shall necessarily have to return for
reassurances, but I drafted the amendment to gain a guarantee from the
Minister that pharmaceutical needs assessments will apply to rural and
urban populations. Even given his qualification about the imperfection
of the word “urban”, it is a useful point by which to
demonstrate the determination on the part of the Committee not to let
that little aspect of the Bill rest and to show that it has large
consequences for many of our constituents, not least those who live in
combined rural, urban and semi-urban
areas. Question
put, That the amendment be made.
The
Committee divided: Ayes 5, Noes
8.
Division
No.
6]
Question
accordingly negatived.
Clause 25
ordered to stand part of the
Bill.
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