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I recently tabled a Question in your Lordships House on this very issue and was greatly reassured by the Governments reply. They said that there was no intention of changing the present arrangements in relation to dispensing doctors because that service in that area in particular and in many others like it is vital, particularly for elderly and disabled people. That is not least because the only retail pharmacist in the village or town is open for only a relatively short number of hours. The dispensing practice is open for much longer hours and is therefore readily accessible and a vital service.
I simply seek the Governments assurance that the principle underlying this amendment is accepted and that no change in relation to the services provided by dispensing doctors will be contemplated.
Baroness Masham of Ilton: I, too, support the amendment. I live in rural North Yorkshire when I am not in London, and the difference between the services in London, where there are many pharmacists, and those in the rural areas of North Yorkshire, which is the same size as Belgium, is vast. This affects not only the elderly and disabled but the many people who do not drive, and that must not be forgotten. When my noble friend asked his Question and the Government gave us an assurance that rural doctors would still be able to prescribe, that was very welcome.
Earl Howe: The noble Lord, Lord Faulkner, has very capably outlined some of the concerns which I am aware are current among members of the pharmacy profession in the community. In speaking to my own Amendment 112, which is grouped here, I should just like to add a few words to what he has said.
Life in rural communities has a number of features which need to be consideredalmost automaticallywhenever health services of any kind are planned. The distances that people have to travel to access services are greater than in urban areas; access to community services, including the voluntary sector, is more difficult because of the nature and sparseness of public transport links; and there can also be considerable degrees of social deprivation in rural areas, and hence greater health inequalities. It is for those reasons that there has been such support for the retention of dispensing GPs.
One worry that many people have is that the Bill now before us could have adverse consequences not only for dispensing doctors but also for rural communities more generally. The reason for that worry is the lack of clarity about how well PCTs are equipped to gauge the needs and preferences of those who live in less populated
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This finding represented a number of concerns raised in the earlier consultation exercise. One concern of the pharmacy community was that PNAs, as they exist at present, are disproportionately focused on cost-effectiveness and not enough on health need. It seems to me that, if that concern is to be dispelled, ways have to be found of reconciling the duty on commissioners to be cost-effective with their duty to meet perceived health need and to do this in a transparent manner that will command public confidence. The prospect of bringing this about is by no means assured. We simply do not know enough about how the needs assessment will actually work, nor whether PCTs will be fully up to the task of carrying them out. In particular, there is a fear that the way in which needs assessments are translated into service delivery could once again cause dispensing GPs to be under threat, this time as a direct consequence of decisions taken which would permit new pharmacies to provide NHS services.
Additionally, there is concern about the ability of PCTs to adapt with sufficient speed to the changes that are needed in the commissioning of enhanced and advanced services. It is quite telling that the latest available data from the NHS Information Centre suggest that, between 2006-07 and 2007-08, the number of out-of-hours services commissioned by PCTs from community pharmacy declined by 9 per cent. In the same period, the number of home delivery services commissioned from pharmacy declined by 47 per cent, and only 138 community pharmacies out of more than 10,000 were commissioned to provide prescribing services to GPs. Those figures do not give one much confidence that enhanced services are currently high on the agenda of PCTs, whether for rural areas or for the country more generally.
Like the noble Lord, I would be grateful for any reassurance that the Minister is able to give on this set of concerns. The next group of amendments will provide an opportunity to debate the subject matter of these clauses in a more general way, but this is undoubtedly a useful lead-in to a topic which is perhaps less straightforward than it first appears.
Baroness Cumberlege: When I was a Minister in the department, it was drummed into me that doctors prescribe and pharmacists dispense. The reason given was that it was good practice because it avoided the conflicts of interest that could arise when doctors were perhaps tempted to prescribe drugs that played into their financial interests.
The exception to that has of course been in rural areas. That is absolutely right, and I take on board what the noble Lord, Lord Walton, and the noble Baroness, Lady Masham, said. We need some exceptions. However, I am confused about what a rural area is. I can certainly understand that, in the highlands of Scotland, on the top of Dartmoor and in the Yorkshire
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I seek the definition of rural from the Minister. Voltaire said:
If you wish to converse with me, define your terms,
so I seek the terms of rural. The Oxford English Dictionary describes it as pastoral, which sounds a bit old fashioned to me, or agricultural, which is also rather vague. The Minister might say that it is up to the PCTs to define what is rural. That is not good enough. This is a basic block of government policy and we need to know what we are talking about.
The present system appears to define rural as one mile from a chemist shop, because GPs are allowed to dispense to patients who live more than one mile away from a pharmacy. This is a nonsense, especially when car ownership has increased considerably over the past few years and many pharmacists provide doorstep deliveries of medicines that they dispense. I have not found many GP practices that do that. Contrary to what the noble Lord, Lord Walton, was saying, I have seen pharmacies with much longer hours than GP practices. It is interesting that GPs talk about out-of-hours. Whose hours? It may be their out-of-hours but they are actually my in-hours. My in-hours are evenings and weekends, but that apparently is not what doctors have.
We know that pharmacists are experts in their field and, unlike dispensing doctors, we know that a pharmacist is dispensing the medication. A dispensing doctor does not have to have a trained pharmacist. A young person with an NVQ, with perhaps just a years training, could do it. Where a pharmacist does it, you get a second view, a check. Certainly, in my area, that second check has proved to be very valuable. Pharmacists also do medicine-use reviews, which have been useful.
The Government produced a very good White Paper, Pharmacy in England: Building on StrengthsDelivering the Future. I am an officer of the All-Party Pharmacy Group, from whose work quite a lot of that document arose. The document has 139 pages and a very interesting annexe, which is about health challenges and how pharmacy can contribute. The health challenges are healthy weight, healthy lives, smokingwhich is of interest to this Committeesexual health, alcohol use, an ageing populationwhich is perhaps also of interest to this Committeelong-term conditions, mental health, healthcare-associated infections, medication-related harm, drug misuse-related harm and health and work. Alongside every health challenge is a column on the long-term impact if it is not addressed. There is then a column which sets out how pharmacy can contribute, followed by one on the likely benefits and outcomes. It is very clear, very good and puts the whole matter into context. It is therefore clear that the Government feel that pharmacy has a future and that it has untapped potential. Having received the RCNs briefing, I was interested to see how it welcomed the integration of pharmacy into primary care.
It is wrong to confuse dispensing doctors and their service with the wide range of services that pharmacy provides, especially in health promotion. I receive the
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Pharmacists provide over-the-counter medicines, which a dispensing doctor does not, and they give advice. Very often, the advice one receives in a pharmacy is much more accessible than in a doctors surgery. You are on neutral territory, as opposed to a doctors waiting room or consulting room, which feels like their territory.
Baroness Howarth of Breckland: That is a question of opinion. I am likely to sit in my doctors waiting room and read the various pamphlets; I am certainly not going to do that in the chemist. I need the noble Baronesss help, because I have got a bit lost on where we are in relation to the amendments. I would be grateful if she could point me in the right direction. However, I just wanted to challenge her on what I thought was an assumption, not evidence.
Baroness Cumberlege: The noble Baroness is absolutely right to some extent, but this is anecdotal evidence. One talks to pharmacists and sees young people go into a pharmacy and get products from them that they would not dare to ask of a GP because they or their parents are known in the GPs area. One only has to think of sexual health and other such matters.
I am contributing to this debate because we are talking about dispensing doctors in rural areas. I am drawing a distinction between what dispensing doctors provide and what pharmacists provide. The two are often in conflict. That is a pity, but that is the way we are.
I am concerned, and again this comes from personal experience. In my area the GPs decided to go for dispensing, which would have closed our chemists. We would have lost a whole range of services because of the local GPs taking that action. When the chemist became very purist and stocked only medicines and things that were to do with ill health, the village rose up and said, No. We want our toothpaste, soaps and creams back. The pharmacy, which is part of a chain, reacted to that and we got the products back.
The GPs wanted to introduce dispensing, despite the fact that the whole village rose up and did not want them to dispense because they recognised what they were losing. The GPs went ahead with an appeal, but people in the village were fantastic about appearing at that appeal and won it by a margin of 80 per cent. I am anxious that, although I understand some of the strengths of dispensing doctors, we do not lose pharmacies as a result of the extraordinary system whereby the rural area is defined by one mile.
I ask the Minister to have another look at all this. I know it is a sensitive and difficult subject. One also ought to take into account value for money: when GPs dispense they get more per medicine dispensed than does the pharmacist. They get a grant to set up a new service and an added income of, on average, £127,000 each. GPs are not on the breadlinethey have done pretty well out of past contracts. From the Governments point of view, bearing in mind their expenditure and the financial situation we are in, some of these points need to be addressed, and it takes courage to do that.
What are we talking about when we say rural? And what are the Minister or her colleagues going to do about some of the anomalies that need to be addressed?
Lord Walton of Detchant: I want to raise one point. I cannot help feeling that the noble Baronesss experience is in some way exceptional. In the dispensing practice to which I refer in my town in Northumberland, and in several others in the same rural area, it is not the doctors who dispense; they employ a qualified and trained dispenser in a separate part of the surgery which is quite independent. The doctors themselves are not producing the medicines, the tablets and so on; they have a dispenser who is part of the practice. That is a good arrangement.
In passing, I ask that, if this amendment is to be pursued further, could we please have a correction of the two spelling mistakes?
Baroness Cumberlege: I am delighted to hear what the noble Lord has said, but it is not the norm for a qualified pharmacist to be employed by the GPs. They can employ anyone who has something like a years training, which is what many of them do, and of course you lose all the other advantages that pharmacies offer.
Baroness Thornton: The amendment of my noble friend Lady Gibson, spoken to by my noble friend Lord Faulkner, would amend this clause in two ways. The noble Earl, Lord Howe, and the noble Baroness, Lady Cumberlege, seek to amend the clause in a slightly different way. My noble friends amendment would require, first, that regulations made provision so that the services provided by dispensing doctors were included by the primary care trusts in their pharmaceutical needs assessment along with the circumstantial needs of older and disabled patients everywhere, but with particular mention of rural areas. Secondly, they would enable the regulations to make provision so that the pharmaceutical services to which an assessment must relate would include in particular the services of dispensing doctors.
The Government have always recognised the importance of dispensing services for those who cannot easily access a pharmacy, and recognise the value that patients put on them, as so eloquently expressed by the noble Baroness, Lady Masham. That is why, following consultation, my right honourable friend the Minister of State for Care Services Phil Hope made clear last
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Like my noble friend, I fully accept that the needs of older or disabled people must form part of a comprehensive assessment of pharmaceutical needs locally. After all, we know that older people are far more likely to be frequent users of their pharmacies, as are those with long-term conditions, but important as these users are, they are not the only groups to be considered. The important thing must be that primary care trusts undertake comprehensive needs assessments that are specific to their areas. I am not convinced that we assist them in this task by laying down in the Bill the types of needs or the kinds of services that they must or must not take into account beyond what we have already proposed. We run the risk of undermining their work or of omitting some aspect of critical importance locally that we may be unaware of nationally. I would not wish to fetter their discretion in this way, but I reassure my noble friend that it would, in my view, be a very odd assessment that did not, for example, consider the needs of older or disabled people or did not include, where appropriate, the services of dispensing doctors. It might be appropriate to make specific provision for such matters in the regulations to comeit is certainly appropriate for the information and guidance now being produced for primary care trustsbut that is best decided by all interested parties when drawing up the detailed regulations that will support implementation rather than it being in the Bill.
I turn now to the amendment tabled by the noble Earl, Lord Howe, and the noble Baroness, Lady Cumberlege, which is closely linked to that tabled by my noble friend. Their amendment adds a specific provision that the regulations require primary care trusts to have particular regard to the needs of rural populations when making their pharmaceutical needs assessment. Rurality is not defined by one mile. The rule is that patients in designated rural areas who live within one mile of a pharmacy should, with limited exceptions, use it. There is no intention to change the dispensing doctor arrangements. I am not sure that I am going to satisfy the noble Baroness in the definition of rural when I tell her that ruralityI am not sure that is a real wordis determined by PCTs. PCT decisions are appealable, and guidance has been issued to them on factors that they may consider. I will send it to the noble Baroness. I suspect that we will continue this discussion.
I shall address the more general points raised by the noble Earl about the capabilities of PCTs in the next group of amendments, which relate specifically to them, and shall not go into detail here. As noble Lords may be aware, in 2004-05, all primary care trusts in England were advised to develop a pharmaceutical needs assessment in preparation for the community pharmacy contractual framework and the reform of the existing control of entry regulations. It was envisaged that these assessments would equip each primary care trust to deal with control of entry applications for
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The noble Earl, Lord Howe, made a point about out-of-hours services and home deliveries. PCTs commission according to their assessment of local needs. A decline in numbers might be an issue, or it might be attributable to more pharmacies opening with extended hours or to pharmacies voluntarily providing home deliveries. I am not sure we have evidence of what is behind the decline. I listened carefully to what noble Lords said, but I am not, at the moment, persuaded of the necessity of including in the Bill the consideration of the circumstances of the rural population. However, I reassure noble Lords that any pharmaceutical needs assessment will have to consider the overall needs of the whole population in the primary care trusts area and be as comprehensive as possible. I stress that we expect primary care trusts that have rural populations to ensure that they take full account of their particular needs and circumstances. I hope I have been able to reassure the noble Lords sufficiently on these matters and ask them not to press their amendments.
Baroness Masham of Ilton: The Minister did not mention the out-of-hours services. Those in rural areas are really very difficult. I have to say to the noble Baroness, Lady Cumberlege, that an out-of-hours service in my rural area means going 10 miles on a Sunday and another three miles to get a prescription from the local supermarket. There are no pharmacists open at all apart from one pharmacist within the supermarket. It is the supermarkets that have closed down a lot of the small pharmacists.
Baroness Thornton: I say in response to the question raised by the noble Earl that I was including out-of-hours services in that, in the sense that PCTs commission according to their assessment of local needs.
Lord Faulkner of Worcester: I am sure that my noble friend Lady Gibson of Market Rasen will be delighted with the short debate that we have had on this subject and will have been gratified by the widespread expressions of support for the sentiments contained in the amendment that she tabled and to which she kindly asked me to speak. She will be particularly reassured by the Ministers confirmation that the needs of elderly and disabled people will be taken into account in rural areas in provision of dispensing services. I am sure that she will read the debate with great care and decide what she wants to do at the next stage. In the mean time, on her behalf, I beg leave to withdraw the amendment.
111A: Clause 23, page 27, line 16, at end insert
( ) requiring the Secretary of State to implement pilot schemes for Primary Care Trusts in carrying out Pharmaceutical Needs Assessments before they are rolled out nationally; and for those pilot schemes to be evaluated twelve months after they commence
Earl Howe: I shall speak also to Amendment 113. For a number of years, as my noble friend Lady Cumberlege mentioned, the Government have spoken of pharmacy as an untapped resource. The reforms that have so far been put in place have not really changed things appreciably, in the sense that patients use pharmacy in a way that might lead to improved health outcomes. For that reason, last years pharmacy White Paper, Pharmacy in England, and the Review of NHS Pharmaceutical Contractual Arrangements published by Anne Galbraith were welcome developments. Both those documents found that effective commissioning by PCTs in the area of pharmacy was still some way off. Four structural changes were recommended. I shall not go through them, but the fourth one is the only one to be contained in this Billthat is, proposals to change pharmaceutical needs assessments.
The White Paper and the Galbraith report identified major shortcomings in the ability of PCTs to commission pharmacy services. The strong implication of the White Paper was that PCTs needed to embrace what amounts to a cultural change if they are to come close to approaching world-class commissioning standards in this area. As we have just debated under the previous group of amendments, many in the pharmacy community do not think that PCTs are capable of writing accurate or robust PNAs that are kept up to date and respond to locally changing patterns of demand or need. The sort of thing that I hear from the pharmacy world is that very few PNAs have been updated since they were first introduced in 2005, largely because of a lack of resources. I am told that it is common practice for PNAs to be largely ignored in appeal casesthat is, cases heard to consider applications for new pharmacies to be included in the pharmaceutical list. Some PCTs do not have a PNA at all and many that do exist are simply a commentary on what services are currently on offer, rather than anything more forward-looking. Could the Minister tell us of even one example of a new pharmacy contract being awarded as a result of a specific need being identified for a new pharmacy within a PNA? There may be one, but I have not heard of it.
If this system is to work as it should, it is essential for PNAs to be continuously updated and to be linked to a PCTs wider strategic services delivery plan. The relevant regulations need to be quite specific on this score. In Amendment 111A, therefore, I am proposing that in order to make faster progress in the long run we should initially take things more slowly by introducing PNAs by means of pilot schemes. The Government have so far ruled out piloting PNAs on the grounds that that would delay their full benefits. I think I see things a bit differentlyin fact, I know I do. We embark on this exercise from where we are, not from
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