In raising on the Adjournment the matter of the charges on prescriptions under the National Health Service, I cannot, of course, bring in question either the law itself or the Regulations in themselves. I am concerned with certain problems which arise out of the administration of those Regulations.
It should be noted at the outset that it is on that very point that the present Government are distinguished from their predecessors. The view taken by the last Government, after looking at this problem, was that an attempt to collect a charge for prescriptions would be either impracticable or, when weighed against the inconvenience, the hardship and the cost of collection, would not be on balance a public advantage. It is the present Government who have decided against that decision to persist with an attempt to collect prescription charges.
Some reference was made in our debate on the Regulations to some of the problems that arise therefrom, and to which certain partial answers were given. I want to pursue some of the points that were then raised and were not satisfactorily answered.
First, there arise certain matters affecting hospital administration. Let us take the case which some weeks ago I put in the form of a Question to the Minister of Health, the case of a patient who comes, possibly with her child, to the outpatient department of a hospital. Medicines are prescribed, of which the child may be in serious and immediate need. The mother is not an exempted person under the Act and the Regulations, but being a poor woman, is in the position where she simply does not have 1s. left from the week's money.
What is the answer to that? What is the hospital to do? The Minister has suggested that he will leave it to the hospitals to find a way out, although they cannot, as he has said in answer to a Question by one of my hon. Friends, actually waive the charge.
If this problem arises at the chemist's shop, the Minister has provided the answer. The chemist, the right hon. Gentleman has told us, in effect, is to have one prescription in 48 which he can hand out free. I do not regard that as a very satisfactory arrangement. It imposes on the chemist the job of deciding to whom he is to hand out what will in effect be these free prescriptions. He is to be made a judge of suitability for receiving that bounty, for which task he is really not, in his job as chemist, at all well suited. He may well be asked to make invidious distinctions between one of his customers and another.
If we turn from the chemist's shop, where, at least, that answer prevails, to the out-patient department of a hospital, the Minister has so far given no guidance. Does the same answer as prevails at the chemist's shop—the financial provision which will enable one prescription in 48 to be handed out to someone who cannot pay—prevail also for the dispensary of the out-patient department of a hospital? If not, what remedy is available?
What is happening at a good many hospitals is that somebody who is already fairly hard-worked in the administration of the hospital is having to meet these cases out of something like a Samaritan fund and to keep a record of persons to whom 1s. has been advanced, in the earnest hope that it may be repaid. This means more work on the hospital staff. It means that on them is placed also the invidious task of trying to decide whether the person who says that he or she has not got 1s. is pleading it out of poverty, out of carelessness or out of a belief that if persons turn up without 1s., somehow or other their needs will be met.
There is another matter affecting hospital administration—prescriptions of less value than Is. It may be said that nowadays these are not very numerous, but they do occur and are prescribed for people to whom 4d., 6d., or 10d. is a serious matter of expenditure. If such a person has a prescription for less than 1s. and goes to a chemist's and says that since the prescription is less than 1s. he will not have it through the National Health Service but will buy it in the ordinary way over the counter, he may do so. But, if he goes to the out-patients department of a hospital, he is likely to find that the only way of getting it is to present the prescription form with a stamp on it for which he must pay Is. So far we have had no guidance from the Minister on this matter.
Apparently the chemist is under no obligation to inform the person that it is going to cost less than 1s. and that it may be more worthwhile for him to pay for the article than to pursue the prescription.
I am obliged to my hon. and gallant Friend. It may be that someone pays 1s. for a prescription for something which is less than 1s. in value. One does not always blame the chemist. The person may arrive when the shop is extremely busy and it is not the primary duty of the chemist to help the Minister to carry out this rather unfortunate scheme. This thread runs all through the Regulations. This Government, unlike their predecessors, have pledged themselves to the view that this scheme of a prescription charge can properly and decently be carried out. Apparently they proposed to do it by imposing a great deal of the rather tiresome and invidious work involved on persons who already have a great many other things to do and will receive no remuneration for carrying out the work of the Minister for him.
I turn to the position of persons who are exempt under the Act and under the Regulations. They, as is well known, are required in the first instance to provide the 1s. if they are given a prescription. Afterwards, they can get it back from National Assistance. It may be said that it is no great hardship for people to be asked to provide the first 1s. If a person is obliged to have prescriptions at regular intervals it may be said that on the first of the series he pays 1s. out of his pocket and is reimbursed and the 1s. with which he is reimbursed can be used to pay for the next prescription, the only hardship being that he has been asked to provide the 1s. in the first instance. But people who have a series of prescriptions are hit at in another way, to which I will refer later.
We should also notice that many of the people affected by this scheme are people to whom providing 1s. in advance, even though they are later reimbursed, is not a small matter. To any hon. Member of this House it may be a small matter to have to fork out 1s. and not bother whether we get it back afterwards or not, but I have had one or two very pathetic letters, and I am sure many other hon. Members have had such letters, which make it clear that to many people forking out 1s. even if one does get it back afterwards, is not a small matter. I believe that if greater attention had been given to the problem of administration it would not have been impossible to make sure that if we were to have the charge at all people should not have to find the 1s. in the first instance.
But supposing they are not people who have to have a series of prescriptions at regular intervals, the very fact of their going at irregular intervals, as may happen to any of us in taking medical advice, means that it is quite possible that their need for a prescription and 1s. to pay for it may fall in a week of other exceptional household expenses and the money is not to hand.
It is perhaps not so difficult for people in compact urban areas where the doctor, the chemist, the National Assistance Board area office and the post office are all within reasonable reach. But to people living in rural areas, where it may be a considerable journey to any of those places, which may be at some distance from one another, it is liable to create considerable hardship to people who can least afford to bear it, because the vexation of extra journeyings on elderly sick people is one which we ought not to overlook.
I turn to some of the effects that the levying of these prescription charges has on the medical profession. There is first a matter which occurred to everyone as soon as it was known that this plan of prescription charges was to be proceeded with—the question of the quantity of drugs that might be provided on one prescription. The information so far given to us by the Minister suggested that to begin with there had been no great increase in quantities ordered though in some areas there had been some increase in the case of the chronic sick.
I appreciate the courtesy of the Minister in letting me know that he could not be here himself, and I am sure that the hon. Lady the Parliamentary Secre- tary will answer for him as competently as can be done on this excessively unfortunate matter. If there has been no increase in the quantity ordered on one prescription it means that people who suffer from a chronic illness and have to get a series of prescriptions will bear an exceptionally heavy burden. There is, in fact, a special tax on the chronic sick. If, on the other hand, we do find that after a time doctors are in the habit of prescribing increased amounts, what then becomes of the effects which the Government hope to get out of this scheme?
We ought also to pay attention to the prescription of drugs which are dangerous if taken in too great quantities. A doctor who wishes to help a poor patient by saying, "I will prescribe a rather larger quantity for you than usual so that you shall not have too many shilling stamps to pay for," may well hesitate to do that in the case of say a diabetic or someone suffering from a complaint where it is imprudent to provide more than a certain amount. There again is an example of the unfair incidence of this tax on illness, which is what this prescription charge scheme is.
There is also the question of how many articles can be prescribed on one prescription form, and what happens when we compare a doctor whose handwriting is such that he can get a great deal on one form with the doctor who has a bolder style and who scrawls the same content over two or three pages? In the earlier stages the Minister said he did not want to make this a mere matter of handwriting, and I am sure we will agree with him, but I do not think he has yet told us what happens in this respect. I trust that the Parliamentary Secretary will be able to do so today.
There is the question of doctors, mainly in the country, who dispense their own drugs. On them is imposed the task of being a kind of tax gatherer. I am bound to say that if the late Government had proceeded, as wisely they did not, with this project, the comments of some of the organs of opinion of the medical profession about doctors being made in effect the Minister's tax gatherers in this matter might have been very acid.
Apart from that, a doctor who dispenses his own drugs has put on him yet another burden of clerical work. One of the criticisms the party opposite of the Health Service as a whole was that it imposed on the medical profession too much form filling, as they called it, when the doctors ought to be attending to the health of their patients. The effect of these prescription charges on the rural doctor who does his own dispensing is to give him yet one more piece of clerical work, and it is clerical work not only for him but for an employee in the office of the Executive Council.
The Minister told us in an earlier debate that so far, and making allowance for the Whitsun holiday, there was no evidence for the view that the number of prescriptions had fallen off. I wonder if the hon. Lady is able to say whether, with the comparatively short passage of time which has elapsed, it is possible to make any more definite judgment. Do these prescription charges seem to be causing a reduction in the number of prescriptions? If there has been a reduction in the number of prescriptions does not that mean that the effect of these prescription charges is to discourage people from getting the medicine and appliances which they need for their health? If there has not been a reduction in prescription charges, what is the object of the whole exercise, unless it is to collect money as a kind of tax on people who have to go to the doctor?
One of the numerous Ministers in the Scottish Office told us at one stage—in one of his engaging moments of candour —that the real purpose of this charge was to make people pay 1s. for their medicine so that they would have 1s. less to spend on something else, and that that would somehow help the country in the export drive. He took the view that this was a tax on ill health. If prescriptions are still coming in in the same numbers this charge is a tax on ill health, but if the prescriptions have fallen off it means that the effect has been to prevent sick people getting what they need. I trust that the hon. Lady will be able to tell us which of those two deplorable results the Government now expect to achieve.
I am sure we should all be grateful to the hon. Member for raising this matter and, in the first place, for agreeing with the principle of the prescription charges.
What the hon. Gentleman has said can be read in HANSARD, and we shall see what it means.
I am not so grateful to him for raising his second point, because if it were in fact true that there is all this disorganisation in hospitals as a result of this scheme the hon. Member should have come to the House with some evidence. He should have been able to say that in certain hospitals the staffs have been so heavily overworked that they are unable to cope with the scheme, and that they have so many cases of people who are unable to get medicine because they have not 1s. to pay for it.
If he could have produced those figures his case would have been very much stronger than the mere vague theorising which we have heard. I have been making inquiries this morning from the very large hospital in my constituency—the Southend General Hospital—and I have found that during the whole time the scheme has been in operation—not very long, it is true—there have been no complaints or difficulties. Within the first month they have had only 14 applications for exemption. I think it is quite monstrous to pretend that there has been wholesale disorganisation of hospital staffs and to conjure up a picture of hospital staffs being worked beyond the pressure which their nerves can stand as a result of the introduction of this Measure, without a single word of positive evidence.
I hope that when my hon. Friend replies she will give us some facts about this and let us know whether there are widespread complaints and whether hospital management committees have made representations to the Minister asking for extra staff to cope with the extra work involved. If that allegation proves to be mere theorising and vague generalising—as I do not doubt it is—I hope it will be exposed.
I think the last speaker has shown great confusion of thought. He does not seem to understand what this scheme is about. For instance, the hon. Member spoke about 14 applications for exemption, but there is no such thing as exemption from the charge in the out-patients' department. That is the point on which I should like the hon. Lady to concentrate.
I want to underline what my hon. Friend the Member for Fulham, East (Mr. M. Stewart) said about hospital charges, because this was discussed recently and the Minister of Health was asked what would happen if a patient in an out-patients' department had not 1s. He talked about the hospital using its discretion, but he refused to define what that discretion was. When I was able to get a Question on the Order Paper on 3rd July, I was told definitely by the Minister that the hospital authorities have no power to waive these charges.
In those circumstances, what is the outpatient to do? My hon. Friend spoke of some cases where hospitals were carrying a charity box, but that may not apply in all cases. Of course in the case of Southend, where everybody is very wealthy, the same difficulty may not occur in the hospital, and whether that hospital has a charity box I do not know. Some hospitals may not. I hope the hon. Lady will deal with those points, in particular, in her reply.
I am very grateful to the hon. Member for Fulham, East (Mr. M. Stewart) for the manner in which he has dealt with the subject, and I hope we can clear up some of the points which he raised, because I think there is a lot of exaggeration of the difficulties which might arise about this 1s. charge. I have been impressed by the fact that the hon. Gentleman, who comes from a congested London constituency, has not given any concrete case of complaints and has merely put forward what I may say was a hypothetical case.
There is exemption in the out-patients' department of a hospital, and people who can produce either their war pensions book or their National Assistance Board book, and whose card or prescription is stamped exempted, do not have to pay 1s. at all in the out-patients' department of the hospital.
Exempted cases will obtain medicine free and will not pay 1s. In reply to a Question by the hon. Member for Fulham, East my right hon. Friend the Minister said that he relied on the discretion of the hospitals, and I do not think I can add anything to what my right hon. Friend said in answering many supplementary questions on that occasion. The issue is confined to an incredibly small number of people.
I have taken the trouble to find out just how widespread these complaints and cases are, by inquiring of three of the very large London hospitals in congested areas—the London Hospital in the Mile End Road, the Hammersmith Hospital, which no doubt deals with many patients from the hon. Gentleman's constituency, and the Royal Free Hospital in Gray's Inn Road. Those three hospitals have given us this information: Up to yesterday, in the London Hospital they have had no case of a patient in the outpatients' department being unable to pay 1s. In the Hammersmith Hospital there has been one, and they paid from the Samaritan Fund—and whether it will be repaid or not I cannot say. In the Royal Free Hospital there has not been a single case.
I think the analysis of those three large London hospitals in working-class areas gives a fair estimate of how small this problem is, and, indeed, the point is met by my right hon. Friend's replies to supplementary questions, when he said that if the sort of circumstances arise, such as those which the hon. Member for Fulham. East envisages,
if the hospital deems it necessary that the person who has not 1s. ought to have this treatment or ought to have the medicine necessary, then, I have said, and I say it again, I am quite prepared, in those special circumstances, for the hospital to use its own discretion as to whether he should be asked to get the 1s. or whether he will be supplied with the medicine. Nothing can be clearer
than that."—[OFFICIAL REPORT, 12th June, 1952; Vol. 502, c. 389.]
In all our experience, the cases are incredibly few, as we see from our information from the hospitals. I think by that Question and answer and by its reiteration today, we have made it plain that we believe the hospitals will use their discretion in these cases.
Perhaps I may turn to the question of prescriptions which cost less than 1s.
I do not think I can make it plainer than in what my right hon. Friend said on that occasion and in what I have reiterated. The hospitals have discretion, and I am convinced that the people who staff our hospitals know how to deal with these cases in the very rare circumstances in which they arise.
So far as the prescriptions which may cost under 1s. are concerned, the patient who uses the National Health Service and hands in a prescription under the Service will pay 1s., as the hon. Gentleman quite rightly said. If in a chemist's shop the item can be bought across the counter—it may be such a thing as zinc ointment, or a bandage, or a jar of vaseline; something like that—the price will be marked on it. At any rate, it will be something like a standard price which the chemist can tell the patient immediately. I said on a previous occasion that of the whole of the prescriptions, under 1 per cent. cost less than 1s. From a recent check we find that only 16 out of 23,000 prescriptions cost the National Health Service under 1s. They all cost 11d. or more, so the margin of cheating—if I may use that word, for I believe the phrase was used about "cheating the patients"—is infinitesimal.
So far as actual prescriptions which have to be made up are concerned, the numbers are even smaller than that, because it is only most remotely possible that such a prescription would cost less than 1s. The items which may conceivably cost less, as I said, would be a jar of vaseline, a bandage, and so on, the price of which would be readily known. Even including those items, a recent check of some 23,000 shows that only 16 cost the National Health Service under 1s. They were 11d., or 11d. plus. I think it is a very small problem indeed. Quite obviously, a patient wanting only a bandage would pay 6d. across the counter for it, knowing it was under 1s.
So far as the question of quantities is concerned—and the hon. Gentleman the Member for Fulham, East asked me what evidence there was of any increase in the prescribing—there is a very small increase in quantities, so far as we can check, but this has been going only a month and I should not like to say that the figure is firm. It may be there has been a rush on the new 1s. prescription charge. So far as items on forms are concerned, there has been a slight rise from 1·57 to 1·7 on the limited survey which we have been able to make on the first month's trial.
So far as the chronic sick patients are concerned, people chronically sick are generally in-patients and get their medicine free. So far as the long-term sick are concerned—diabetic patients, for instance—it has long been the practice for them to have monthly or even two-monthy prescriptions, and in their case it would cost 1s. a month or 1s. in two months as the case may be. This is not a new method, for it has long been the practice that people like diabetics should have monthly or bi-monthly prescriptions. That enables them to visit the dispensary not so frequently.
So far as the rural doctors are concerned, it is fair to say that the method of paying and collecting the 1s., and the method of remunerating the rural doctors, was negotiated with their representatives, and the scheme was worked out with their agreement, and I do not think they have any long-standing complaints about any additional work they are doing or being asked to undertake.
Let us leave it then at complaints. The hon. Gentleman presented me with a Morton's Fork, saying, more or less, that whatever I said was going to be wrong—that if there had been a falling off in prescriptions it meant that people needing medicine were not getting it, or that if there had not been, it means that this legislation was a failure. That, I think, is a very false premise, because, in the first place, people who may be buying the odd item—a bandage or the like—will buy it across the counter, and thus will reduce the number of prescriptions.
Of course, we have had remarkably fine weather, and we have also had a Whitsuntide holiday, and, strangely enough, people do not collect prescriptions over holidays as much as they do over other weekends in the year. Taking that into consideration, we do not think there has been any serious falling off. So far as we have been able to assess, again from a limited number of areas, there has been under 15 per cent. falling off, even taking into account the better weather and the Whitsun holiday, when there was at least one clear day when only emergency prescriptions would have been dispensed.
My right hon. Friend has asked me to say that if hon. Members have specific cases of prescription charges causing these grave difficulties, which it has been suggested might be caused, he would be only too ready to investigate the circumstances of any hospital management committee finding these difficulties arise. In fairness to the Department, we should be told of such cases and of the hospitals who find such difficulties, which from our experience and inquiries we do not believe to be taking place.