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Lord Palmer: Many Members of the Committee may be aware that I tried to introduce a similar amendment in the previous Health Bill and that I got a degree of support from all sides of the House. I place on the record how grateful I was to the Minister for her letter

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on this amendment. The notion behind reintroducing it is, first, to reduce the number of repeat prescriptions that must be prescribed and, secondly, to ensure that patients finish the course of prescribed drugs. Next, again, is the intention to emphasise the value for money that, by and large, most patients who have a prescription are getting.

Something that I have loved about the House since becoming a Member nearly 20 years ago—only five Members of the Committee were here before me—is the tremendous learning curve that one goes on to. Since reintroducing the amendment, I have spoken to lots of general practitioners and pharmacists. I was rather shocked to discover that some prescribed drugs cost literally pennies, whereas others cost hundreds of pounds.

I can understand the Government’s reluctance to have much sympathy with the amendment, but it crosses my mind that, if I were to bring it back on Report stating that any drug costing more than £10 would have to be clearly marked on the prescription, that would make it abundantly clear what fantastic value for money people in England get at £7.10 or in Scotland. I am sure that the Minister is aware that Scotland is about to do away with prescription charges at a cost of £65 million a year, which seems slightly extraordinary.

I think that there is quite a strong case for looking at this again. I know that the noble Earl, Lord Howe, was initially quite supportive when I brought this issue back during the passage of the previous Health Bill. Like all these things, once you start digging into it, it seems extraordinary that some drugs are incredibly cheap and others are incredibly expensive. One of my colleagues outside the Committee asked me whether anyone was putting me up to this. No one is putting me up to it; my main reason for introducing this amendment is simply that I am convinced that it is a very good idea that people realise what they are getting for their prescription charge. I beg to move.

Baroness Barker: I have been in this House for almost 10 years. One thing that I learnt fairly early on is that the noble Lord, Lord Palmer, is one of the great free spirits of this House and one Member who not only thinks and speaks for himself but causes some of the rest of us to sit back and think in ways that we had not anticipated. I say that in all sincerity.

I have listened to the noble Lord on previous occasions when he has moved similar amendments and I have a great deal of sympathy with what he is trying to do. Those of us who sit through most of the debates in your Lordships’ House know that medicines management and the waste of medicines in the NHS have a particular resonance with the public. We know, too, that many people on low incomes are put off seeking and taking treatment by the disproportionate cost to them of prescriptions.

I do not want to make a general speech on prescriptions policy, because now is not the time for that, but my money is on the Minister coming back and explaining to the noble Lord, Lord Palmer, that even the same drug prescribed in a different place and at a different time may have a different cost depending on the method

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of purchasing it. A PCT may have a bulk discount and so on. Therefore, that is quite difficult, as is isolating the cost of a drug from the treatment.

However, I am enormously sympathetic to the noble Lord’s desire to get through to the general public an appreciation not just of the cost of medicines but of how they themselves can be responsible about medicines. Therefore, I suggest to the noble Lord that he moves his idea in a slightly different direction by looking at the prescription forms and the general messages about the cost of medicines, together with ways in which the general public can access information about managing medicines more efficiently themselves in discussion with their clinicians. That might be one way of moving nearer to what the noble Lord is trying to achieve, which I think is entirely laudable.

Lord Campbell-Savours: We are really out of knockabout territory on this issue. In my view, this is a very serious amendment because it requires greater transparency. I congratulate the noble Lord. I had originally intended to table something similar on Report, and I am pleased that he has helped us with his amendment because I am still working in that area.

We can expect the Government to reject the amendment. I may be wrong but I suspect that that is the case. I should like to use this amendment to appeal to those outside who can help us to table something perhaps better on Report. We have to address a number of issues which may prove difficult in implementing a system of this nature, but I should like to know what they are in some detail so that we can argue them out on Report in a more mature and sensible way.

There may well be a problem of price identification, which the noble Baroness, Lady Barker, has just referred to. Also, is it the retail price that should be shown? Perhaps another price would more accurately reflect the actual cost to the National Health Service. What happens in the case of drugs that are both over the counter and prescribable? There may be different price structures there. Do issues of competition arise? What is the view of pharmacies and the pharmaceutical companies on this level of transparency on the market more generally? What would the impact be on NHS procurement policies? Does it have implications for the export and import pricing of drugs?

I am bringing up issues that might complicate things, but I do so only because I strongly support the principle and should like to know what the arguments against it are so that we can sit down and work out, if the Government do not accept the principle at this stage and elsewhere on this Bill, how in future we can make it work on the Floor of the House and ultimately convince the Government of the principle.

I support the amendment. I would not like to tell the Committee the annual cost of my drugs to the health service, but I suspect that they run into many thousands of pounds. To be frank, I should like to see on every bottle, every injection and every pill box what the costs are to the NHS. It is in the public interest that we all know what we are costing the taxpayer.

Baroness Finlay of Llandaff: The spirit of the amendment is important, but there is a danger here that patients might be made to feel guilty that they are

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incurring high drug costs. It would be important for staff always to be aware of the true cost of equipment, the drugs they prescribe, admissions and so on, as staff in the NHS are often not truly aware of the costs that they incur with the things that they do. Sometimes they open packs and chuck them away or are not careful with them, or they use one type of equipment that is a lot more expensive than another.

The spirit behind the amendment is to be commended, although I have a feeling that it is not quite right in the way that it is put together and there could be a downside. However, perhaps we need much more open and transparent pricing across the whole of the NHS for both staff and patients.

Earl Howe: The noble Baroness, Lady Finlay, has made a good point in sounding a warning that patients might, as it were, die of embarrassment or guilt rather than go to the doctor and get a renewed prescription. Nevertheless, I am sympathetic to the amendment of the noble Lord, Lord Palmer, as I have been in the past. One could regard this as part of the “responsibility agenda”, the term often used to denote our collective wish to get patients to take responsibility for their own health and their own care.

My only detailed point is one that has already been flagged up in various forms: it is difficult to refer to the actual cost or the full retail cost of any drug. Those are elusive, will-o’-the-wisp terms. I suggest that the noble Lord might consider replacing those terms with “the recommended retail price”, which is something you can pin down. I hope that he will not let this go and that we will have a chance to debate it again.

Lord Walton of Detchant: This is an interesting amendment and important in principle. The only difficulties that I foresee are some of the points that have been made already by my noble friend Lady Finlay and the noble Earl, Lord Howe. Are we going to give the retail price? Will it include the pharmacist’s dispensing fee? Many hospitals have a rule that even if a doctor writes a prescription for a proprietary preparation, the hospital may dispense the generic alternative, which will be much cheaper. The patient getting it from the hospital might meet someone getting the same drug from the local pharmacist and say, “Why is mine costing so much less than yours?”. All kinds of problems arise if one fulfils the amendment as printed. However, it is well worth pursuing so long as we can get it right.

7 pm

Baroness Cumberlege: I support what has been said by noble Lords. I think that the points made by the noble Lord, Lord Campbell-Savours, were very pertinent. I would like to join those who want to make something like this happen. The idea of putting in a floor is a good one—a £10 floor or whatever—but it needs some detailed work. That would be very good, and I am sure it would reduce the cost of drugs.

Baroness Thornton: I sympathise with the intention behind the amendment, as has every Member of the Committee who has spoken, as it encourages patients

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to finish their prescribed medicines and to realise the value for money they are getting from the NHS. As noble Lords might anticipate, there are several significant reasons that lead me to believe that this amendment should be rejected.

The noble Lord, Lord Palmer, is completely consistent in his view, and I do not believe for one minute that anyone would put him up to anything. He will remember the debate he had with my noble friend Lord Warner on this issue during the passage of the Health Bill 2006. My noble friend’s greatest concern related to patient attitudes to price labels. He promised that the issue would be taken forward with a proper study, and that study took place. I recently wrote to the noble Lord, so that he could read the detailed findings of the research. For the benefit of the Committee, the research question was whether people would continue to waste such high levels of medicines if they were aware of their actual cost. The researchers looked specifically at the effect of pricing information on medicine labels.

Qualitative research, in the form of focus groups, took place as well as a literature review. It clearly showed that labelling medicines with prices has significant challenges. The noble Lord, Lord Palmer, will have seen from the detailed findings how complex this issue is. The first key point is that it showed the risk that the noble Lord’s amendment could present to patients who need their medicines to treat their medical condition effectively. We would not want to deter such patients from taking their medicine because they fear being a burden on the NHS if the price of their medicine is particularly high. That is particularly an issue for older patients. I can think of several of my own acquaintance who would be horrified if they knew that their medication costs the NHS thousands of pounds a year, as referred to by my noble friend.

Lord Palmer: Elderly patients would not pay prescription charges at all, would they?

Baroness Thornton: I am referring to the cost of the medicine and the effect of putting pricing information on medicine labels. Equally, we would not want to deter someone who benefits from a relatively cheap medicine, who may perceive, albeit wrongly, that the lower price is linked to a lower-strength medicine or a lower level of care. The second key point, to quote the conclusion, is that:

“Given the various routes to wastage (most of which seem to be beyond the control of the patient), there seems to be little possibility of reducing that wastage via pricing information”.

The findings of the research are sufficient in their own right to oppose an amendment of this nature, but it may also be worth quickly highlighting some other practical challenges. One is calculating the full retail cost of drugs and appliances. Several Members of the Committee have mentioned that. While suppliers will publish a list price for products, that is not necessarily the cost to the NHS of supplying the product to the patient. There are other elements to take account of, such as the service fee paid to the dispensing contractor and any discount arrangements. Dispensers would not be in a position to know them all at the time of dispensing.

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The scope of this amendment also means that it would affect far more than just prescriptions dispensed by a pharmacy or dispensing doctor in primary care. Prices would also need to be included on prescriptions dispensed, for example, by appliance contractors, out-of-hours service providers, hospital out-patient departments and walk-in centres. A practical challenge is the complexity of implementation. Changes to IT systems, including mechanisms to establish prices and to label medicines appropriately in all the NHS settings I have just mentioned, would be required. Costs would be ongoing as well as one-off. There is no evidence about how such costs and potential savings would compare.

I hope the noble Lord will sympathise with my reasons for feeling that this amendment should be rejected. However, to reassure him, I would like quickly to stress the fact that the department has action underway to address the very important wider issues on medicines adherence that this amendment has raised. Two of our well established policies—medicines use reviews and repeat dispensing—contribute to this agenda. An MUR’s purpose is to improve a patient’s knowledge and effective use of medicines through face-to-face consultation between the pharmacist and the patient to help reduce medicines wastage. Repeat dispensing makes it possible for patients to have their medicines dispensed in instalments for up to a year without having to contact their GP surgery. As each instalment is dispensed, the pharmacist checks that the medicines are still needed and are being used appropriately by the patient, thereby helping to reduce waste.

Furthermore, my noble friend Lord Darzi points out as a result of the intervention of the noble Baroness, Lady Finlay—it is not often that one gets briefed by the Minister, but I have been on this occasion—that the next-stage review recommendation is to ensure that those who incur the most expenditure should also be accountable for it, which raises some interesting questions as we move forward.

The department has commissioned research, currently in progress, to establish the extent to which medicines are not used and hence wasted and how much that costs, as well as to determine the varied and complex reasons why people do not take their medicines as intended. The outcome of the research, which will be available this year, will inform future policy development for influencing both health professionals and the public to reduce the amount of unwanted medicines and provide value for money for the NHS. We need to wait for the outcome of that research so that any progress that we make is evidence-based. While I share the valid concerns of the noble Lord and others about the waste of medicines, I hope that he will feel able to withdraw his amendment.

Lord Monson: The Minister said that my noble friend’s amendment would do very little to curb wastage. Would it not encourage patients who are prescribed medicines to take at home to take good care of them and not mislay or lose them? Furthermore, if they have been overprescribed, not by accident but because they needed fewer of the painkillers or whatever it was they were prescribed, would they not say to the doctor

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on the next occasion, “Look, I don’t actually need of 60 of these; 30 will do because I’ve got plenty at home”? Little things like that could add up to quite a lot in savings for the NHS.

Baroness Thornton: Those are very good suggestions, all of which involve patient education and the prescribers of the medicines taking their job seriously. However, it would not necessarily involve the labelling of pricing.

Lord Palmer: I am grateful once again for the support that I have had from all sides of the Committee. Greater transparency is an important factor in what I am trying to achieve with the amendment. I said in my opening remarks that one is opening something of a can of worms, and I quite accept the point made by my noble friend Lord Walton of Detchant that I have perhaps not worded the amendment quite as technically or as brilliantly as I might have. The noble Baroness, Lady Cumberlege, mentioned that the proposal might help reduce the overall cost of drugs, which must be a very good thing. The noble Lord, Lord Campbell-Savours, talked about the fortune in drugs that he uses. I should perhaps have reminded the Committee that, being diabetic, I do not pay prescription charges, but I dread to think what I get free of charge on the National Health Service due to my condition. I am very grateful for the Minister’s reply, and I thank her again for her letter. I may still consult her and bring back the amendment in some revised form, perhaps having spoken to my noble friends Lord Walton and Lady Finlay and the noble Baroness, Lady Barker. In the mean time, I beg leave to withdraw the amendment.

Amendment 115 withdrawn.

Clause 28 agreed.

Clause 29: Breach of terms of arrangements: notices and penalties

Amendment 115A

Moved by Baroness Thornton

115A: Clause 29, page 30, leave out lines 26 and 27 and insert “In Part 8 of the National Health Service (Wales) Act 2006, before Chapter 2 (disqualification) insert—

“Chapter 1ANotices and penalties”

Amendment 115A agreed.

Amendments 115B to 115E

Moved by Baroness Thornton

115B: Clause 29, page 30, line 30, leave out “or” and insert “services or general”

115C: Clause 29, page 31, leave out lines 2 to 6

115D: Clause 29, page 31, line 6, at end insert—

““practitioner” means a person included in an ophthalmic list or a pharmaceutical list, and”

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115E: Clause 29, page 31, line 8, at end insert—

“( ) In section 107(9) of that Act, after “included in” insert “an ophthalmic list or ”.”

Amendments 115B to 115E agreed.

Clause 29, as amended, agreed.

Clauses 30 and 31 agreed.

Schedule 5: Investigation of complaints about privately arranged or funded adult social care

Amendment 116

Moved by Earl Howe

116: Schedule 5, page 52, line 21, leave out “, or is connected with,”

Earl Howe: I shall speak also to Amendments 117 and 120. These are probing amendments, which I can cover quite briefly. In new Section 34A of the Local Government Act, we see that the definition of “adult social care provider” is,

I do not fully understand the phrase, “is connected with”. An activity that is connected with the provision of adult social care could include almost anything, such as the servicing of a van used to deliver food to a care home, yet we would surely not wish to say that the person engaging in that activity was an “adult social care provider”. The definition seems to encompass a wide range of people, and I should be glad if the Minister could explain how wide the range is intended to be in practice and why we need what appears to be a rather loose form of words here.

The provisions relating to the procedure that the local commissioner has to follow when investigating a complaint include a particular action: new subsection (4) says that the commissioner may obtain information and make enquiries as he sees fit but that he may also,

I question that power. If someone wishes to be represented, and there may be all sorts of perfectly good reasons why they may wish to be, then to my mind they should not be prohibited from appointing someone to act for them. What lies behind the provision? Would it enable the local commissioner to decline to deal with someone’s independent advocate or a member of their family?

I raise that question particularly in the light of the provision in new Section 34G(3), which says that for the purposes of an investigation a local commissioner has the same powers as the High Court in respect of the attendance and examination of witnesses and the production of documents. If that is so, we are surely dealing with a quasi-judicial process. It does not seem right that the commissioner should then be able to deny someone the right to be represented in that process.

A number of provisions govern the way in which a local commissioner must announce his decision on the matter he is investigating. If he decides not to investigate,

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or to discontinue an investigation, he must make a statement to that effect and say why he has made that decision. If he completes an investigation he must also make a statement setting out his conclusions and recommendations, which he then must send to various parties, including the complainant and the adult social care provider. The recommendations, naturally enough, may include action to be taken by the adult social care provider concerned. We then find in new Section 34H(8) that the statement must identify the adult social care provider concerned unless the provider is an individual and,

I ask the Minister what kinds of circumstances might apply in which the commissioner could decide not to disclose the identity of the provider. Most would say that a person who had been found to have done something wrong should not be protected by public anonymity. On the other hand, I can see that there is an argument for protecting the identity of someone who has been in receipt of an unfounded complaint, but the Explanatory Notes shed no light on whether this kind of consideration would bear upon the local commissioner’s decision, or whether other considerations would. I would be grateful if the Minister could explain the thinking behind this provision. I beg to move.

7.15 pm

Baroness Barker: Amendments 118 and 119 are grouped with that of the noble Earl, Lord Howe. Before I speak to them, I echo the noble Earl’s comments on Amendment 116 about associated activities. Being familiar with this area of work, I had made an assumption that those words were included in the Bill to encompass things such as the provision of support, brokerage or care management. I was not until I heard the noble Earl that I realised quite how far and widely they could be interpreted. Clearly, they should not. I would be interested in the Minister’s reply.

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