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General Practitioner Dispensing

Volume 476: debated on Monday 19 May 2008

Motion made, and Question proposed, That this House do now adjourn.—[Liz Blackman.]

I have given the Minister prior notice of exactly what I intend to say to enable him better to respond directly to the points that I shall raise.

I need to put my concerns about the future of GP dispensing into the context of two broader points. The first is that my constituents are becoming increasingly angry and frustrated about what they see as a persistent attack by this Government on local services. Locally, we have seen post office closures, and we have been spared the closure of our local, consultant-led maternity unit and 24/7 children’s wards at the Horton hospital thanks only to the intervention of the independent reconfiguration panel. Not surprisingly, my constituents are constantly asking what next public or community service will be taken away from them.

One of my constituents wrote to ask me to oppose the pharmacy White Paper, asking

“why is this Government so determined to destroy all quality of life for rural inhabitants? This village has lost its Post Office, and consequently its shop, is shortly to lose our next nearest Post Office, now our dispensary service is under threat. What will they destroy next?”

Secondly, this debate has to be seen in the context of the Government’s professed commitment to give NHS patients greater choice. After all, the Government have spent considerable amounts of money on ensuring that GPs have choose and book systems, the better to allow patients choice as to where they are treated. Indeed, last week, the Prime Minister in his statement on the draft legislative programme said:

“It is right to make it”—

the NHS—

“more accountable to local people, giving patients real power and control over the service they receive.”—[Official Report, 14 May 2008; Vol. 475, c. 1387.]

If the Government genuinely want to give patients real power and control over services they receive, the least the Government could do is to allow people the freedom to decide where they would like their prescriptions dispensed.

At the moment, there are some 5,872 dispensing doctors in the UK in 1,365 practices. Overall, they look after more than 8 million patients, of whom 3.5 million are dispensing patients. For reasons that I shall explain, these GPs mainly have rural practices. They provide the enormous benefit that patients can visit their GP and, at one and the same place, have their drugs both prescribed and dispensed. That service is being threatened by the Government.

I wish to reinforce the point that the hon. Gentleman is making. This debate has come to the attention of doctors in Cornwall and today I received an e-mail from Dr. Mark McCartney, who says:

“A new issue has arisen with the Pharmacy Bill which aims to end GP dispensing, another threat which may harm rural practices and services to patients, including small chemist shops as well as the GP’s own dispensaries.”

His whole practice, in Pensilva in my constituency, is very concerned.

There are dispensing practices throughout England that are very concerned because it would seem that the Government wish to give pharmacies a monopoly on dispensing.

There is, I suspect, some history that needs to be understood. When the NHS was set up, its establishment was a huge undertaking and no doubt required a number of political compromises with a range of groups involved in health care including GPs and pharmacists. I suspect that the big retail chemist chains such as Boots said that they would co-operate with its establishment only if they were given a monopoly of prescribing drugs in urban areas. Almost from the NHS’s inception, therefore, pharmacies had a monopoly on dispensing drugs in urban areas.

Since then, almost every other similar professional monopoly has long been discarded. One only has to think of the revolution in eye care and opticians that occurred when opticians’ monopoly to sell spectacles was taken away. However, the Government not only intend to retain the pharmacies’ monopoly on dispensing, but are clearly intent on strengthening that monopoly, as evidenced in the White Paper “Pharmacy in England”, which the Department chose to publish during the Easter recess, so it did not get the publicity that it perhaps deserved.

The existing dispensing rules already lead to some fairly ludicrous results. Here, I declare some interests. I live in the village of Bloxham, in my constituency. It is some 4 miles from Banbury, dominated by the spire of its parish church. It is a self-contained village, surrounded by fields for some considerable distance. It is perhaps one of the few villages in England that is so much a village that the Warriner school in Bloxham even has its own school farm. The village has a very good GP practice and surgery, which also has a dispensary, so that patients who attend Bloxham surgery can also have their drugs dispensed there. I am a registered patient at that surgery, although I have to say that I am a very infrequent visitor, as whenever Dr. Martin Harris, my GP, sees me, he rightly tells me that I need to lose a couple of stone in weight.

A pharmacy chain has applied to open a chemist shop in Bloxham. I am sure that residents of Bloxham and the surrounding villages will be genuinely delighted if a chemist shop is opened in Bloxham. The village is fortunate in having a diverse range of local shops and a chemist shop would be genuinely welcome. However, under the existing rules, the application by a pharmacy to open in Bloxham was a trigger for the primary care trust to review whether Bloxham continues to be a rural area. If an organisation called the NHS Litigation Authority decrees it to be an urban area, any incoming pharmacist who sets up will be given a complete monopoly on dispensing and the GP practice will no longer be allowed to dispense drugs for Bloxham residents. That might also lead to the GP practice being forced to cease dispensing before the proposed new pharmacy has been established.

The definition of what is rural is left to the individual primary care trust, but it is usually considered to be an area surrounded by open land with a limited number of shops or other facilities and poor transport infrastructure. The decision is subject to appeal, and an oral hearing has been scheduled by the NHS Litigation Authority in July. Once determined, there is no further appeal short of judicial review, and the decision stands for five years unless there is a major change in circumstances. Bizarrely, should it be determined that Bloxham is no longer rural, the GP practice will be allowed to continue to dispense drugs to patients in other villages such as Barford St. Michael or Milcombe, but not Bloxham—until the provisions of the Government’s White Paper in due course kick in.

Put shortly, under the existing rules GPs may not dispense to patients who live within 1.6 km of a pharmacy or who are deemed to live in a non-rural area. Almost everyone living in Bloxham considers that being told by the Government that they no longer live in a village is pretty crazy. But what really causes offence is the thought that they will no longer have any choice as to where their drugs are dispensed, and that they will be compelled, whether they like it or not, to go to a new chemist to get their drugs dispensed. Bloxham residents are concerned that they will no longer be able to get their drugs dispensed by their own GP, as in the past, notwithstanding that that is far more convenient and that they only need to park once—parking at the GP’s surgery is considerably easier than having to park near the shops in Bloxham. Why not give patients choice?

I congratulate my hon. Friend on securing the debate. I represent the south of Oxfordshire in Wantage and I have been inundated with letters on the matter. Does my hon. Friend agree that choice is the key issue? My constituents focus on the point that although it might be right to relax the rules regarding pharmacies so that they can dispense more drugs and give some medical advice, it is wrong as a quid pro quo to close down GPs’ dispensaries. My constituents simply want choice, and surely that is what they should be given so that they can continue to use the dispensary if they so choose.

I agree entirely with my hon. Friend. The Government say that they are keen to give NHS patients as much choice as possible, so why not give them choice about where they have their drugs dispensed? Why take away patients’ ability to have their drugs dispensed at their GP surgery if they so wish? It seems that the Government will allow choice in the NHS when it suits them, and will not when it does not. Is it simply that the Government wish to give the impression of choice, freedom and new regulation, when in reality they are being increasingly dirigiste?

One rationale given in the White Paper for the proposals was that present regulations do not take into account the distance that a patient must travel between the GP surgery and the chemist. The new proposals fail to address that, as the new regulations would still be unable to account for the distance a patient has to travel between their surgery, their home and the pharmacy. The solution proposed in the White Paper would simply result in fewer patients receiving the service.

I thought that the proposal to prevent the Bloxham GPs from dispensing drugs to local people was one of the crazier decisions that I had come across during my 25 years as a Member of Parliament, and so I asked the Office of Fair Trading if it would investigate what on the face of it seemed to be simply a strengthening of the monopoly against the interests of consumers. [Interruption.] It may be for the convenience of the House—[Interruption.]

Order. I am sorry to interrupt the hon. Gentleman, but I must say to the hon. Member for Romsey (Sandra Gidley) that we do not usually accept interventions from Front Benchers during an Adjournment debate, and certainly not from a sedentary position.

It may be for the convenience of the House, and of the hon. Member for Romsey (Sandra Gidley), to listen to the response I received from John Fingleton, the chief executive of the OFT, which is dated 28 April 2008. It reads:

“Thank you for your letter of 28th March with enclosures…requesting that the OFT consider your concerns about the monopoly community pharmacies have under pharmaceutical regulations in dispensing drugs in ‘urban’ areas, which you consider is against consumers’ interests. You ask that the OFT refers the matter to the Competition Commission to investigate.

To be clear, the OFT does have powers to refer markets in which we consider competition problems to exist to the Competition Commission for investigation. But as an alternative, and where more appropriate, we can also make recommendations to the Government for changes in existing…regulations.

In fact it was using these powers that in 2003 we investigated the role of community pharmacies in dispensing drugs. Our Report ‘The Control of Entry Regulations and Retail Pharmacy Services in the UK’ recommended liberalising the pharmacy market to allow any registered pharmacy with qualified staff to dispense NHS prescriptions.

Our investigation concluded that deregulation would give consumers greater choice, provide more competition and better access to pharmacy services.

We note your concerns about the monopoly position of community pharmacies in urban areas and the situation which may arise in Bloxham where consumers previously using the General Practitioners’ surgery dispenser may have to travel a distance to access the nearest pharmacy. We strongly believe consumers, particularly the elderly and infirm, should be able to obtain their drugs with utmost convenience, whether that be from a surgery dispenser or a community pharmacy and we hope this continues to be so in your area.

The Government response to our Report did not feel deregulation as the best course of action and it decided to modify the entry control regulations rather than abolish them. It has since developed far-reaching plans for reshaping the NHS and as you know polyclinics are part of these plans…our view remains that the retail pharmacy market should be liberalised and the Government is aware of this.”

Let us be clear about what is being said. The Office of Fair Trading is the organisation established by Parliament, by statute, to protect the interests of consumers. The OFT has made recommendations to the Government that it believes would give consumers

“greater choice…more competition and better access to pharmacy services”.

The Government have ignored the OFT.

The OFT believes that consumers,

“particularly the elderly and infirm, should be able to obtain their drugs with utmost convenience, whether that be from a surgery dispenser or a community pharmacy”.

Not only have the Government ignored the OFT, but they are, as I shall explain, going in exactly the opposite direction.

The Government’s White Paper, “Pharmacy in England”, was published during the Easter recess, as I mentioned earlier. Proposals in the White Paper, if implemented, would mean that any GP surgery with more than about 3,000 registered patients would not be able to dispense drugs. No GP surgery with a chemist within a mile of the surgery would be allowed to dispense drugs. The opportunity for dispensing doctors to continue dispensing would be completely dependent on whether a pharmacist decided to open a shop within a mile of their surgery. For example, the Montgomery House surgery in Bicester has a considerable number of patients who live in the surrounding villages. At present, if they need drugs prescribed and dispensed after a visit to their GP, it can all be done conveniently at the surgery. In future, if the Government have their way, my constituents will no longer have that opportunity or choice; they will be obliged to go elsewhere to have their drugs dispensed. Why?

If doctors are prevented from dispensing, the resulting loss of income for the practice will in many instances also mean a reduction in patient services. At present, the income from dispensing subsidises other services—for example, branch surgeries. Dispensing practices have examined the plans and foresee that they will have to close branch surgeries or make salaried GPs redundant. Where doctors are near retirement and sole practitioners, the prospect of surgery closure looms.

Is it all a ruse whereby the Government hope to help fund polyclinics? Will polyclinics be allowed to dispense drugs? Why does the chief executive of the OFT say in his analysis of the Government’s failure to take on board the OFT’s recommendations that the Government have

“developed far-reaching plans for reshaping the NHS and as you know polyclinics are part of these plans”?

During a recent debate on family doctor services, I intervened on my hon. Friend the Member for South Cambridgeshire (Mr. Lansley), the shadow Secretary of State for Health, who was pointing out that the introduction of polyclinics could threaten existing GP surgeries. I observed that communities were also losing their dispensaries, and asked:

“Is my hon. Friend aware that 8.5 million patients are in GP practices that dispense drugs? Under the Government’s White Paper on the future of pharmacy services it will be almost impossible for GPs to dispense drugs in the future. Why on earth remove patient choice in this way? This is yet another service that will be lost in villages in my constituency and colleagues’ constituencies.”

My hon. Friend responded:

“Yes, I am interested in what my hon. Friend says because in one particular respect the effect of the pharmacy White Paper, which was published during the recess, may well be to undermine dispensing by dispensing doctors, and it may all be part of a common process by the Government. The polyclinics are expensive beasts; they cost about £800,000 each, so money has to be raised for them. I suspect that in many cases the Government intend to ensure that they have a large pharmacy, which will take the pharmacy profits, and the dispensing doctors in local surgeries will lose out and shut down as a consequence.”—[Official Report, 23 April 2008; Vol. 474, c. 1317.]

Given that a large number of polyclinics will be in urban areas, there can be no possible justification for the Government’s allowing them to dispense drugs when they are not allowing GPs to dispense drugs. Do the Government intend to rewrite the NHS (Pharmaceutical Services) Regulations 2005 to favour polyclinics?

There seems to be no end to the Government’s meddling in the NHS. There have been nine major reorganisations of the NHS since Labour came to power, at a cost of £3 billion. The NHS is an institution that binds our nation together. In cities, towns and villages up and down the country, family doctor surgeries are part of the fabric of our community. The Government seem intent on imposing a polyclinic on every primary care trust area, which will inevitably put a substantial number of smaller local family doctor surgeries at risk. Again, if the Prime Minister is serious about the Government wanting to give patients “real power and control” over the service that they receive, why will the Government not let my constituents vote on whether they want a polyclinic imposed on Banbury?

Well over 1,000 GP practices in England will be destabilised as a consequence of the proposals in the Government White Paper on pharmacy. More than 8 million patients are registered with dispensing practices and thus potentially affected, and huge numbers of them will in future be denied choice about where, and by whom, their prescriptions are dispensed. It is estimated that between 5,000 and 7,000 staff employed in the dispensary and ancillary service areas of dispensing practices will be made redundant. That is a crazy situation. Will the Minister provide assurances that the Department will re-examine the proposals for dispensing doctors, and will he ensure that those appalling plans are not put into practice? Patient choice is allegedly a constant driver in all other aspects of Government health policy. Why not in dispensing?

Dr. Laurence Buckman, the chairman of the general practitioner committee of the British Medical Association, tells me that the implications of the Government’s pharmacy White Paper

“could be very severe indeed. The result might well be to terminate the rights to dispense of a substantial number of practices who rely on their dispensing income to subsidise the rest of the practice’s work. We believe that this could well mean that a lot of practices would cease to be financially viable and thus affect the provision of NHS services to their patients. This would be a perverse result of proposals that are intended to provide greater choice and access to patients.

Paragraph 8.7.2 refers to ‘transitional rules’ being required in the event that the loss of dispensing income financially destabilises a practice. ‘Transitional’ implies that such resources would eventually be withdrawn and so practices are and will continue to be under the threat of closure as it is unlikely that existing NHS income could be increased to cover the loss of dispensing…dispensing practices are popular with patients and provide an excellent service. Given that there is no public demand for any changes to the current arrangements, we do question why the Government seem so determined to generate so much uncertainly and to potentially destabilise the provision of local services.”

Dr. Buckman observed that

“in just about every patient survey that has been undertaken, dispensing practices are shown to be highly popular with patients. Indeed, the decision to have medicines dispensed with a practice rests with the patients themselves.”

The Prime Minister and the Government purport to give patients real power and control over the services that they receive, but it is clear that in practice the Government have no intention of giving patients either power or control over services. I hope that Ministers will seriously reconsider their proposals for GP dispensing.

I congratulate the hon. Member for Banbury (Tony Baldry) on securing this Adjournment debate, and point out that he has not given me much time to respond to the various points that he made. If I am not able to respond to them all directly, I will follow them up in writing. I thank him for giving me a copy of his speech in advance.

I should like to begin by responding to the challenge, “What next?” Record levels of sustained investment in the NHS—that is what is coming next for the hon. Gentleman’s constituents. Continued record levels of investment in his local schools—that is what is coming next. Measures that brought an end to mass unemployment will continue under this Government; that is what is coming next for his constituents. I assume that his constituents will benefit from free off-peak travel for pensioners, and from the winter fuel allowance, which was introduced by this Government.

Of course, the hon. Gentleman’s constituents, and those of the hon. Member for Wantage (Mr. Vaizey), will benefit from the extended opening hours in primary care that have come about as a consequence of the recent ballot of GPs, which was initiated by this Government. There will be evening and weekend opening; I am sure that the constituents of the hon. Member for Banbury will welcome that, too. It is interesting that he did not refer to the fact that there is a clear dividing line between the Government and Her Majesty’s Opposition on the issues. The Leader of Her Majesty’s Opposition has clearly stated that future decisions about primary care should be in the hands of the British Medical Association. The Government’s policy is that future decisions about primary care should be in the hands of patients. That is the nature of the health service that we seek—

I will not.

That is the nature of the health service that we seek to create. The idea that the Government have an agenda to impose polyclinics on a one-size-fits-all basis in every community in every part of the country is utter nonsense. That is disingenuous, because it is not the Government’s position.

On behalf of his constituents, the hon. Member for Banbury has raised a number of valid and legitimate points, which I shall deal with. On Bloxham, the current regulations covering NHS pharmaceutical services have been in place since April 2005. They replaced previous systems, which existed in one form or another since 1948—indeed, I understand that the regulations on rural areas can be traced back to 1936. The latest regulations implement a series of measures that were agreed between pharmacy and medical representative bodies back in 2001. It is important for the House to bear in mind the fact that the regulations that gave rise to the local PCT’s decision about which the hon. Gentleman is concerned are based on that accord between representatives of doctors and pharmacists.

It is a long-standing general precept, which all Governments have endorsed since the NHS came into being, that doctors prescribe medicines and pharmacists dispense them. In that way, patients receive the benefits of both professions’ expert advice, intervention and care. I have used the term “general precept” very carefully. We all agree that both medical and pharmaceutical services have developed significantly since 1948. Our White Paper set out ways in which pharmaceutical services should and will grow in the future.

It is also possible that a community pharmacy is simply not a viable proposition in every part of the country, especially in rural areas. Patients need to receive their NHS-prescribed medicines promptly and efficiently, which is where dispensing doctors can play a vital role by allowing patients to collect their medicines from a surgery’s dispensary without undertaking a lengthy journey to the nearest pharmacy. In the vast majority of cases, if the patient wishes to receive the services of a dispensing doctor, they need to live in a designated controlled locality—the hon. Gentleman has raised that point. The local PCT determines whether a particular area is rural or not. When it does so, it invites views from interested parties locally. Whatever the PCT decides, the decision can be appealed to an independent body, the NHS Litigation Authority, which is genuinely independent. As the hon. Gentleman knows, the question is whether Bloxham is rural in character. An appeal against the PCT decision has been lodged with the NHS Litigation Authority, and every opportunity will be given for people, including the hon. Gentleman, to make appropriate representations.

The hon. Gentleman has referred to the OFT. He has accused the Government of ignoring the OFT’s recommendations on community pharmacy services, which we did not do. We responded in July 2003 and did not accept the case for full deregulation. We decided to move cautiously in the recommended direction, and we announced a balanced package of reforms to the regulatory system. We introduced those reforms in 2005 and reviewed their operation in 2006. Overall, we have found that they opened up the market as intended without destabilising it, but the impact was genuinely uneven. The tendency for pharmacies that are open for at least 100 hours a week to cluster near each other in some places is considered in the White Paper, which is why we have introduced proposals for further reform and why we did not fully deregulate as the OFT wanted.

On the reference by the OFT’s chief executive to GP-led health centres, I cannot say what was intended by the reply that the hon. Gentleman received, and I am sure that the chief executive’s office will be pleased to help him further. GP-led health centres are designed to extend choice and offer convenient services. Indeed, £250 million of additional funding is available, and I wonder whether the hon. Gentleman will bid for some of those additional resources on behalf of his constituents.

The White Paper was not, as the hon. Gentleman has claimed, published during the recess; it was published while Parliament was sitting. It has received broad support from all those involved—the NHS, health professionals and business. The hon. Gentleman has referred to chemists’ shops, and I hope that the community pharmacy profession as a whole is not offended by the implication that its members are simply retailers. I am sure that the hon. Gentleman implied no such disparagement; pharmacists are, of course, highly trained and skilled professionals. However, not once has the hon. Gentleman mentioned his local pharmacist or referred to the comprehensive programme that we have set out to develop community pharmaceutical services.

It is absolutely right in a changing world that the Government should be prepared to engage in the reform of the NHS that most appropriately meets patients’ needs. Of course, that has to be done in partnership with the local population, which will be given every opportunity to comment.

The motion having been made after Ten o'clock , and the debate having continued for half an hour, Mr. Deputy Speaker adjourned the House without Question put, pursuant to the Standing Order.

Adjourned at Eleven o'clock.