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To understand the impact of my amendment, we must go back to the complicated arrangements for remunerating pharmacists, and also consider what options are available to the patient who wants to avoid paying a high prescription charge where exemptions do not apply. As I understand it, pharmacists receive a dispensing fee of 90p per item from the Department of Health. They can receive a practice payment of about 70p from the PCT. There is a container allowance of about 3p and an establishment fee of approximately £25,000 a year. I understand that a few additional sums are available, and that reimbursement for the cost of drugs is made by the Department of Health through the PCTs. Item-purchasing costs to the pharmacists vary, but they fall into two broad groups; the costs of generic medicines under the tariff, and the costs of branded products under the PPRS. To defend the interests of NHS budgets and the taxpayer, the Department of Health exerts pressure on reimbursement costs by applying a discount system. This is published in the tariff, which I have studied in some detail.

A cursory examination of the tariff quickly reveals the wide discrepancy between the price of some products and the prescription costs to non-exempt patients. Sometimes the cost is far higher than the prescription cost; sometimes it is far lower. Yet the cost of most generic prescriptions is lower.

Doctors and pharmacists have devised different arrangements for lessening the impact of prescription costs on non-exempt patients. Some pharmacists stock a special category of medicines that substitute for prescribed drugs. These can be sold to the patient at a price that is less than the cost of a prescription as a sort of over-the-counter product. Some have tried to get round the prescription costs by simply selling the prescribed drugs to the patient at a tariff/branded product-plus price, but that has been stopped by the Department of Health on the basis that the prescription form used is for NHS prescription use only. Some doctors give their patients private prescriptions that bypass the NHS prescription arrangements. By using

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a private prescription, a patient can make substantial savings on the NHS prescription price, but only of course when the retail price is less than £7.20.

What would my amendment do? It would amend the National Health Service (Pharmaceutical Services) Regulations 2005 by making it a requirement to include on the packaging of any drugs or appliances a label showing the reimbursement price. There would also need to be some further amendment in the schedule under the section dealing with terms of service for pharmaceutical contractors. By inserting the words in the amendment, we would add an additional line on information that is provided to the patient indicating reimbursement costs. That being the case, we would have to define within the interpretation provision what is meant by reimbursement price. Retail costs would be meaningless for the purposes of my amendment. For generic products the price would be the tariff price and for branded products it would be the manufacturer’s list price.

In its report on Department of Health: Prescribing Costs in Primary Care of January 2008 the Public Accounts Committee recommended:

“The Department should do more to make patients aware of the costs of drugs, and hence the importance of not wasting them, for example by displaying on dispensed drugs information such as the cost of the specific items dispensed or an indication of the typical cost of items to the NHS”.

I presume that that comment must have followed an investigation by the PAC, itself following a report by the National Audit Office. I hope that the department will take that into account.

Is it practical to do all this? Yes, because the technology is there; it is already used on private prescriptions. What would the impact be? There would be greater transparency; it may well reduce the element of wastage; it would save the patient money; there would be some unquantifiable cost to the Department of Health, and perhaps Ministers can put a figure on that. However, that has to be set against the potential for reduced wastage. Since 1997, there has been a 59 per cent increase in the number of prescriptions issued by doctors. Some useful work has been done on wastage, sponsored by the Department of Health, by a joint team from York University and the School of Pharmacy in London.

I understand that the report, which is due to be published later this year, will deal with the psychology and behavioural effect in medicine-taking. It should give us an insight into issues of wastage and, I hope, it might even point towards the scheme that I am advocating. Equally it might point the other way. On that point, I thank my noble friend Lord Darzi for the letter that he sent to the noble Lord, Lord Palmer, and me, prior to this debate, setting out the department’s position.

In many ways, price labelling might have a far more interesting knock-on effect, particularly on sub-prescription-charge generic products. It could provoke a real discussion on the future of prescription charges. Is it fair to levy such a high cost on the non-exempt groups for low-cost generics? I suggest that it is not.



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9.30 pm

Lord Glenarthur: My Lords, I had not anticipated playing a part in the debate on either of these amendments, but about 25 years ago, as a Minister in the then DHSS, I played a part in the move towards generic substitution.

I have a positive view about the ambitions of both amendments, but there was one problem that struck me in the comments of both noble Lords. A difficulty might arise when you have to deal with a drug which is under patent; it will be extremely expensive in its early days. When the patents run out—I do not remember exactly how long, but three or four years after the time—the labelling to indicate the cost will be markedly different between the drugs that are under patent and those that are not. That could be quite misleading to all concerned, although I entirely take the point made by both the noble Lord, Lord Palmer, and the noble Lord, Lord Campbell-Savours, about the need to ensure we are talking about the sort of things that patients who use the drugs, whether they be under patent or generic, understand.

Lord Campbell-Savours: My Lords, that will be dealt with in the review, which takes place on the price as marked in the tariff.

Baroness Thornton: My Lords, I applaud the commitment of both noble Lords to this issue, but I am afraid I am not going to satisfy at least one of them. Possibly I might give some comfort to my noble friend, but it is not favouritism: there is an argument here.

The noble Lord, Lord Palmer, has added the words,

to the amendment he tabled in Grand Committee. His intention in adding these words is that it will be very clear to patients what good value for money they are getting from the NHS, including those who pay £7.20 for their prescriptions. My noble friend Lord Campbell-Savours has the shared intent of making provision for adding a label to medicines and appliances dispensed to patients by community pharmacists, to indicate the cost of the product.

While both of these approaches raise practical implementation issues, our primary objection is the impact these amendments might have on patients. As noble Lords know, further to this issue being debated during the passage of the Health Bill in 2006, we commissioned a piece of research on medicine labelling. The findings of this research provided clear evidence to support our case—to reject this proposition. The research, entitled Medicine Labelling Research, was published in 2007, and looked specifically at the effects of pricing information appearing on medicine labels, and addressed the question: would people continue to waste such high levels of medicine if they were aware of the actual cost of these products?

The key outcome of this research is that labelling medicines with prices has a much more complex impact on patients’ attitudes toward their medicines than may be expected. Both amendments would present a risk to patients who need their medicines to treat their condition

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effectively, because higher and lower prices on medicines are linked by patients to the quality of the drug, the seriousness of the illness, the importance of the condition and the patient’s own self-worth.

The research indicates that, for expensive medicines over £10, labelling may deter patients—probably the elderly—from taking their medicine, because of the uncertainty about the price or fear of being a burden to the NHS if the price is particularly high. These and other findings contributed to a conclusion in the report that, given the various routes of wastage, there seemed to be little possibility of reducing wastage by including pricing information, and that other ways had to be found. The patient’s perspective, we believe, must come first on this issue, and therefore I cannot support these amendments.

In addition, there are several significant practical concerns. It was clear in Committee that a number of noble Lords recognised such issues. Let us take the practical considerations. While it might be possible in most cases to provide an indicative cost by using the drug tariff reimbursement price, this will still, as my noble friend Lord Campbell-Savours recognises, be of limited value, because the drug tariff reimbursement price list is affected by such factors as out-of-pocket and broken bulk expenses that pharmacists can claim. It is also affected, conversely, by the amount that is deducted from pharmacists to compensate for the discounts they have received when purchasing items from suppliers.

There are many other practical considerations. In reality, implementation would be very complex. Dispensing contractors’ IT systems would need to have increasing functionality to put a price on a dispensing label; pricing databases would need to be up-dated, and dispensers would need to discuss the price with patients. For the amendment of the noble Lord, Lord Palmer, such changes would be required in a wide variety of NHS settings and the complexity would be increased by the intention to exclude prescriptions with a retail cost of less than £10, although some might come in and out of that band.

Furthermore, it would be difficult to justify such an approach in relation to EU single market law—I appreciate that that may not go down terribly well with the noble Lord, Lord Palmer—which describes the primary purpose of packaging and labelling as the identification and safe use of medicines.

The noble Baroness, Lady Barker, rightly recognised in Committee that the waste of medicines in the NHS has a resonance with the public. The department shares the very valid concerns of the noble Lords and others on this issue and is taking action. Medicines use reviews and repeat dispensing are in place. The department has also commissioned a very broad piece of research to establish the scale and cost of medicines that are not used and hence wasted, and to determine the varied and complex reasons why people do not take their medicines as intended. The outcome of this research, available later this year, will inform future policy development in an attempt to influence both health professionals and members of the public to reduce waste.



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I listened very carefully to what my noble friend Lord Campbell-Savours said about reimbursement. I will study carefully the detail of the noble Lords’ comments in relation to pharmacies, remuneration, reimbursement and medicine-labelling, and will provide a briefing on this. In the light of those comments, I hope that the noble Lord will feel able to withdraw his amendment.

Lord Palmer: My Lords, I thank the noble Baroness very much for that full reply, and I thank the noble Lord, Lord Glenarthur, for his comments. I believe that this is a terribly important subject, and I am honoured that I whetted the appetite of the noble Lord, Lord Campbell-Savours, in putting forward his amendment. I have been contacted by several GPs, who have also said that I should take this a step further. For example, when a patient is sent for a scan or an MRI, which, as we all know, costs in the region of £1,000, he should be made aware of how very costly it is.

I have it at the back of my mind that I should like to get together with the noble Lord, Lord Campbell-Savours, and perhaps jumble together the two amendments and bring them back at the next stage. However, in the mean time, I beg leave to withdraw the amendment.

Amendment 66 withdrawn.

Amendment 67 not moved.

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

Amendment 68

Moved by Baroness Stern

68: Schedule 5, page 55, line 13, at end insert—

“(1A) Unless otherwise prohibited under the terms of another Act, comments made under subsection (1) must be provided to the person who made the complaint and that person must be provided with an opportunity to comment on them.”

Baroness Stern: My Lords, I shall speak also to Amendment 69. These amendments have been suggested by the Joint Committee on Human Rights. As a former member of that committee, I am very happy to move the amendment in the unavoidable absence of the noble Lord, Lord Dubs. Perhaps I may give a brief explanation of the point at issue here, and I hope that the Minister will look favourably on the modest suggestion made in the amendments.

Clause 31 gives effect to Schedule 5, which will extend the remit of the Commission for Local Administration, which runs the three Local Government Ombudsmen, to enable it to consider complaints about privately arranged or funded adult social care. The Commission for Local Administration may investigate action taken by an adult social care provider or complaints that it receives. The Joint Committee on Human Rights welcomed this provision, which, it said,

However, the committee raised concerns with the Minister about one aspect of the provision—namely, that the person who complains is unable to comment on the representations made in response to his or her complaint.



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In replying to the committee, the Minister pointed out that the proposed new scheme is modelled on the existing procedure for dealing with complaints about local authorities and that the procedure would be largely a matter for the commission to determine. However, he noted that the usual procedure was for the complainant to be provided with the local authority’s representations and the commission’s provisional conclusions so that the complainant’s views might be taken into account before a final decision was made. He said that the Commission for Local Administration intended to adopt a similar procedure in relation to its enlarged function. Therefore, the Minister implied, there really was no problem, as good practice was likely to be followed. The Joint Committee on Human Rights felt that this was not good enough on the basis that an individual retains due process rights under the common law of procedural fairness at all times. This amendment would make the procedure fairer and put the requirement on a legislative basis, rather than leave it to the ombudsman’s discretion. I hope the Minister will accept this small improvement.

The Parliamentary Under-Secretary of State, Department of Health (Lord Darzi of Denham): My Lords, I thank my noble friend, Lord Dubs, who is not in his place, and the noble Baroness, Lady Stern, for tabling this amendment, which would place a requirement on the ombudsman to provide individual complainants with the providers’ representations and allow them an opportunity to comment. The amendment would also require the ombudsman to send its draft statement to the complainant, the provider and any other person who may have taken the action complained about, and take any comments into account before a decision on the complaint is concluded. I fully understand the desire to try to ensure that all parties are treated fairly under the new scheme. The ombudsman considers general human rights and the principles and values of equality as part of the overall approach to its job. The ombudsman is a public authority so it has to abide with the laws on human rights.

As noble Lords are aware, the ombudsman currently operates a scheme relating to complaints made by people about local authorities. Our general approach to the new scheme is, wherever appropriate, to design the detail of the scheme to be consistent with the way the existing local authority scheme works. We are confident that the ombudsman operates the existing scheme in a way which is fair to both authorities and complainants. In the current local authority scheme, the ombudsman generally shares representations with the complainant. It will take a similar approach in the new scheme. Its aim is to establish the facts of each case fairly and reasonably. It would normally be difficult to do so without seeking the views of the complainant about what a provider has said about the matter complained about.

However, sometimes the provider’s comments on a complaint may not be relevant, or are already known to the complainant, such as previous correspondence between the provider and the complainant. Or a provider may make a large number of comments, many of which, because they identify third parties, cannot be passed on to the complainant for reasons of confidentiality.

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Giving the ombudsman discretion over the information to be sent to the complainant helps to avoid making the process bureaucratic and time-consuming. It is, of course, in the complainant’s interest not to slow the process down.

With regard to the requirement to send copies of all statements out in draft to the complainant, which the amendment also seeks, I should point out that statements have to be produced for all complaints, including those that the ombudsman is not going to investigate, so it would serve little or no purpose for the ombudsman to have to share draft statements simply saying that there was nothing to investigate. There would be little that the ombudsman could do if the complainant then said they disagreed, but it would add another layer of activity to the process. Under the current local authority scheme, the ombudsman generally allows parties to see its provisional conclusions following an investigation in the interests of fairness. This system works well and avoids undue bureaucracy or delays in the process.

It is very likely that disregard for the ombudsman’s decision will be a pointer to poor performance generally and will attract the Care Quality Commission’s close attention. This is both an incentive to providers to comply and a lever to improve their services. In addition, there are significant powers in the Bill for the ombudsman to make public information about providers which do not comply with the recommendations.

While it is absolutely right that the procedure must be fair to the complainant and the provider, the amendment would require something that will in practice happen anyway, while risking a layer of additional bureaucracy and removing essential flexibility. It would also mean making a legal provision that would be a departure from the current local authority scheme and the legislation governing other UK public sector ombudsman schemes. I hope that I have been able to provide sufficient explanation and reassurance to the noble Baroness, Lady Stern, and that she will feel able to withdraw her amendment.

9.45 pm

Baroness Stern: My Lords, I am grateful to the Minister for that full reply. It was reassuring enough for me to take account of the lateness of the hour and seek leave to withdraw the amendment.

Amendment 68 withdrawn.

Amendment 69 not moved.

Amendment 70

Moved by Baroness Masham of Ilton

70: After Clause 32, insert the following new Clause—

“Admission of patients with spinal cord injuries

(1) The Secretary of State shall by regulations establish a national bed bureau for patients with spinal cord injuries to monitor and manage the availability of hospital beds for patients with spinal cord injuries.

(2) The bureau must in particular aim to meet the following objectives—

(a) to provide a single commissioning service across England and Wales for the provision of beds in spinal cord injury centres;



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(b) to work with primary care trusts and hospital trusts to co-ordinate information on the availability of hospital beds for patients with spinal cord injuries within each strategic health authority; and

(c) to ensure that beds are made available to patients with spinal cord injuries as soon as possible following admission, both when a patient is admitted for the first time and when a patient is urgently readmitted.

(3) Regulations under this section must stipulate—

(a) details of how membership of the bureau is to be decided,

(b) the terms of reference of the bureau,

(c) the types of information that hospitals must make accessible to the bureau for the purposes of establishing availability of beds,

(d) details of any pay or remuneration made to members of the bureau,

(e) any powers which the bureau will have to instruct hospitals to admit patients from outside their usual area.

(4) At the end of each financial year, the bureau must produce a report for the Secretary of State which outlines how each of the objectives in subsection (2) have been met and which makes recommendations as to how performance in these areas could be improved.

(5) The Secretary of State must respond in writing to the bureau’s report within two months of its reporting.

(6) Regulations made by the Secretary of State under this section are—

(a) to be made by statutory instrument, and

(b) subject to annulment in pursuance of a resolution of either House of Parliament.”

Baroness Masham of Ilton: My Lords, in Committee, this amendment had wide support from all sides, for which I am grateful. The noble Lord, Lord Tebbit, is a supporter, but is taking his wife to hospital today. The noble Lord, Lord Carlile, supports it too.

A spinal cord injury can happen to anyone at any time. It can be you, your dearest and nearest, your sons, daughters or grandchildren. You can fall from a fruit tree while pruning it, have an accident playing rugby or riding a horse, or dive and hit the bottom of a pool or a submerged object. You can have a road traffic or industrial accident; you can fall downstairs or down a mountain; or you can be injured on military service. It can happen in a split-second.


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