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Lord Bruce of Donington: My Lords, I am deeply grateful to the noble Baroness for having replied in such terms in this debate. It appears that we are completely at one. She has emphasised the importance of our national parliament and in non-party terms. It is important for me because I have tried throughout my political life to fight precisely for that: the British Parliament reflecting British democracy. It seems, therefore, that we are at one.

The Minister gave an indication that she intends, and that the Government intend, to ensure meticulous observation of the provisions of the protocol. Therefore, there is no division between us. It is a completely non-party matter. There is no reason why the provision should not go into the Bill. It would be a completely non-controversial clause. It has the complete support of Ministers. In case there might be marginal difficulties lower down the bureaucratic line, the fact that the provision is incorporated in the Bill itself, would be an added authority to make quite sure that the will of the political leaders of the country becomes all-pervasive. The provision would then be enshrined in an Act of Parliament.

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So in the spirit of complete unanimity between myself and the Government--which is pretty unusual in these fields--I had rather hoped that the Minister would immediately accept the amendment. That would call old Bruce's bluff. However, it has not gone that way. So, with the utmost friendship, I regret that I shall be unable to withdraw the amendment. I ask for the support of the entire House, both Front Benches and all Back Benches, for the amendment.

7.55 p.m.

On Question, Whether the said amendment (No. 11) shall be agreed to?

Their Lordships divided: Contents, 39; Not-Contents, 66.

Division No. 3


Annaly, L.
Belhaven and Stenton, L.
Blatch, B.
Bruce of Donington, L.
Burnham, L.
Byford, B.
Clanwilliam, E.
Cumberlege, B.
Darcy de Knayth, B.
Dixon-Smith, L.
Eccles of Moulton, B.
Fookes, B.
Gage, V.
Harris of High Cross, L.
Howe, E.
Jenkin of Roding, L.
Kinnoull, E.
Kintore, E.
Lawrence, L.
Liverpool, E.
Luke, L.
McColl of Dulwich, L.
Monson, L.
Montrose, D.
Moynihan, L.
Newton of Braintree, L.
Northbrook, L.
Norton, L.
O'Cathain, B.
Park of Monmouth, B.
Pearson of Rannoch, L.
Rankeillour, L.
Rawlings, B. [Teller.]
Rennell, L.
Selborne, E.
Stoddart of Swindon, L. [Teller.]
Wharton, B.
Willoughby de Broke, L.
Wynford, L.


Acton, L.
Archer of Sandwell, L.
Berkeley, L.
Borrie, L.
Brooke of Alverthorpe, L.
Carlisle, E.
Carter, L. [Teller.]
Dean of Thornton-le-Fylde, B.
Desai, L.
Dholakia, L.
Donoughue, L.
Dormand of Easington, L.
Elis-Thomas, L.
Farrington of Ribbleton, B.
Gilbert, L.
Gladwin of Clee, L.
Goodhart, L.
Gordon of Strathblane, L.
Hacking, L.
Hamwee, B.
Hanworth, V.
Hardy of Wath, L.
Haskel, L.
Hayman, B.
Hollis of Heigham, B.
Hoyle, L.
Hughes of Woodside, L.
Hunt of Kings Heath, L.
Irvine of Lairg, L. [Lord Chancellor.]
Janner of Braunstone, L.
Jay of Paddington, B.
Jenkins of Putney, L.
Kennedy of The Shaws, B.
Levy, L.
Linklater of Butterstone, B.
McIntosh of Haringey, L. [Teller.]
McNally, L.
Maddock, B.
Mallalieu, B.
Milner of Leeds, L.
Mishcon, L.
Monkswell, L.
Montague of Oxford, L.
Nicholson of Winterbourne, B.
Nicol, B.
Ponsonby of Shulbrede, L.
Ramsay of Cartvale, B.
Randall of St. Budeaux, L.
Razzall, L.
Richard, L. [Lord Privy Seal.]
Russell, E.
Sandwich, E.
Scotland of Asthal, B.
Simon, V.
Simon of Highbury, L.
Strabolgi, L.
Symons of Vernham Dean, B.
Thomas of Swynnerton, L.
Thomas of Walliswood, B.
Walker of Doncaster, L.
Wedderburn of Charlton, L.
Whitty, L.
Williams of Crosby, B.
Williams of Mostyn, L.
Winchilsea and Nottingham, E.
Winston, L.
Young of Old Scone, B.

Resolved in the negative, and amendment disagreed to accordingly.

14 May 1998 : Column 1244

8.4 p.m.

Baroness Ramsay of Cartvale: My Lords, I beg to move that further consideration on Report be now adjourned. In moving this Motion, I suggest that the Report stage begins again not before five minutes past nine.

Moved accordingly, and, on Question, Motion agreed to.

Tax Credits (Initial Expenditure) Bill

Brought from the Commons endorsed with the certificate from the Speaker that the Bill is a money Bill; read a first time, and to be printed.

Patient Pack Initiative

8.5 p.m.

Earl Howe rose to ask Her Majesty's Government whether they will support patient organisations, doctors and the pharmaceutical industry in promoting the patient pack initiative.

The noble Earl said: My Lords, a simple definition of a "patient pack"--for those who are not aware of it--is medicine that is user friendly. A patient pack is one that has been prepared by the manufacturer rather than one made up from bulk supplies by the pharmacist. It is a pack which is of a size appropriate to the specific course of treatment and one which includes all the approved labelling and user information which may be necessary for the patient to get full benefit from the medicine.

Why should that be desirable? All too often medicines dispensed by the pharmacist in little brown bottles are taken home and then, out of ignorance, consumed incorrectly either in the wrong dosages or at the wrong intervals, or both, with the patient frequently omitting to finish the course. Not only does that fail to achieve the desired outcome for the patient; it is also wasteful and expensive for NHS budgets.

If instructions are misunderstood and a course of treatment is followed wrongly, the results may well be a return visit to the GP and repeat prescriptions, neither of which would be necessary if the medicine had been taken properly in the first place. The main benefits which spring from a patient pack are that the patient, because he is better informed, is more likely to take the medicine safely and correctly. Repeat prescriptions and waste are more likely to be eliminated and quality control of the medicine can be assured.

14 May 1998 : Column 1245

How significant are the problems I outlined? One indicator is a recent OPS survey which found that more than 40 per cent. of medicines prescribed had no information on the label about the length of time over which the medicine should be taken. It is no wonder perhaps that surveys which appear from time to time in relation to unused medicines suggest that large amounts of such medicines are thrown away every year because the patient failed to read the instructions properly and did not finish the course, had simultaneous courses of different lengths and wasted what he did not need--or thought he did not need--or simply did not understand that every course of medication needs to be completed.

The other side of the problem relates to over-prescribing. In 1993 the National Audit Office found that 14 per cent. by value of the items on multiple item prescriptions appeared to be excessive in terms of the underlying clinical requirement. Either way, its estimate was that up to £60 million worth of medicines dispensed in England each year may not be fully used.

Patient packs, every one of which contains a leaflet telling the user in simple terms everything he needs to know in order to understand his treatment and use the medicine properly, are a major step forward in reducing waste and wrong dosages and in improving awareness of possible adverse reactions. They bring benefits also to pharmacists. Up to 40 per cent. of a pharmacist's time is spent physically counting and repacking medicines. That leaves him commensurately less time in which to do what many would regard as his principal job; namely, giving advice and guidance to his customers. That advice and guidance can itself prevent waste and promote better compliance to the obvious benefit of the patient.

Those advantages for the patient pack have been widely acknowledged for a number of years. In 1995 it was agreed by all the major organisations involved in the delivery of healthcare in the UK--doctors, pharmacists, the pharmaceutical industry and the Department of Health--that an initiative to introduce patient packs as the standard method of dispensing all medicines should be commenced over a three-year period.

In the light of that agreement, the UK based pharmaceutical industry made a substantial investment in the equipment necessary to enable patient packs to be produced. Unfortunately, however, nearly three years on, not all is well. The initiative, though it is still proceeding, is faltering. It is doing so not because anyone has had second thoughts about the merits of the patient pack as a concept--if anything the reverse is true--but because the Department of Health expressed worries about the implementation of the project and, significantly, its cost.

The noble Baroness will, I hope, accept from me that it is not my purpose in this debate to cast a party political slant on the subject under discussion, but it is a matter of acute disappointment to many people that the present Government should have chosen to resile from the clear commitment of the previous administration to give unequivocal support to the patient

14 May 1998 : Column 1246

pack initiative. Indeed, there are many who think that it is an extraordinary thing to have done in the face of the EU directive, due to come into force at the end of this year, which will oblige the UK to supply patients with information leaflets about their medicines and clear and accurate labelling on all packs.

Personally, I do not believe that there can be any better way of complying with that directive than to manufacture and supply medicine in a patient pack. That is because some of the information is safety related and can only be provided by the manufacturer; for example, the batch-specific information which identifies the production run and governs the expiry date. The idea that pharmacists could simply keep a stock of loose leaflets in the shop to hand out to customers as and when needed fails to meet that important requirement, quite apart from imposing a gigantic shelf-space problem for pharmacists.

It is worth taking a moment or two to scrutinise the department's current position. It is saying, as I understand it, that the introduction of patient packs will bring with it unwelcome complexity in terms of the changes to dispensing rules that are needed. I simply do not understand that point. The changes to dispensing rules are quite straightforward. Their aim would be to enable a pharmacist to round up or round down the quantity of medicine dispensed to match the size of the patient pack.

The real issue here is the need to educate both doctors and pharmacists in what they should now be doing. But that complication is hardly a show-stopper. Doctors and pharmacists have already been on the receiving end of a large amount of information designed to encourage a rapid shift to patient pack prescribing and dispensing. Any mismatch between prescribing patterns and pack sizes will not be a major difficulty and there is agreement among pharmacists that it is less complex for them to dispense using the bounded rounding rules than to continue to split packs of medicine inappropriately.

The department's other concern is cost. It has assumed that the whole programme of conversion to patient packs will involve a transition period lasting three years, during which costs will rise. In a Written Answer in another place last December from the Minister of State, Tessa Jowell, the net costs for the family health services and the Prescription Pricing Authority of implementing the previous government's proposals were put at about £60 million over the next three years. The pharmaceutical industry does not understand this calculation or its underlying assumptions. Those calculations which the department has shared with the industry suggest that not only are they a worst case--perhaps even an impossibly worst case--but that they omit altogether any savings arising from the two main benefits of this initiative.

The first of the benefits relates to generic medicines. There is a perfectly valid concern that the price of generic medicines that are switched across to patient packs will go up. It is certainly true that more generic medicines than branded medicines have still to come on board the scheme and costs will indeed rise more markedly for this group of drugs. But the real question

14 May 1998 : Column 1247

is how much difference patient packs will make to the overall drugs bill for the NHS. The introduction of patient packs for generics will almost certainly enable more GPs to feel confident enough to prescribe generic products in circumstances where they would have prescribed a branded product before. As little as a 1 to 2 per cent. swing from branded to generic use would give a net saving in one year equal to the estimated costs of the entire patient pack initiative over three years. And that is before any account is taken of the savings to be generated from a reduction of waste.

I hope the Minister will not say that the reduction of waste cannot be relied on with certainty and is therefore a matter of speculation. For obvious reasons it is impossible to quantify such savings with any precision. But if it is true, as I mentioned earlier, that £60 million worth of medicines is thrown away every year, the scope for a very dramatic improvement is clear.

I should be grateful if the Minister would give us her own perspective on these issues. Does the department accept that significant savings are in the offing from the introduction of patient packs to offset--indeed, substantially offset--any additional costs? If she does not feel able to answer that question today, will she agree to allow representatives of the industry to sit down once more with Ministers and with DoH officials to look at the whole issue again? It is not too late to do so. The industry expressed its grave misgivings about the department's costings as soon as it saw them and it feels that it has not been given the opportunity to go through them in detail with officials.

The end that we should have in view is that all parties--industry, healthcare professionals and the Department of Health--should work together to ensure that patients benefit from the new regime which the European directive was designed to usher in. The regrettable fact is that this initiative, which is all about better care for patients and is supported by numerous professional bodies and patient organisations, cannot succeed as it should without the Government's backing. That backing, as the Minister will know, needs to include an amendment to prescribing and dispensing regulations. I believe that the barriers to agreement are not insuperable and I hope very much that the Minister will feel able to approach this matter again in her customary constructive spirit to the ultimate benefit of patients.

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