I do not see the Minister present, but I am sure that he will join us very shortly. At least I hope so, because I am very anxious to get a reply to the subject I raise tonight, namely the question of disposable sterile syringes in the general medical services. The extraordinary thing about this Adjournment debate is that, having raised this subject, I find to my surprise that the half-way house which the Government claim to have reached on the question of disposable sterile syringes in itself has not been realised. This is, indeed, one of the points which I did not think I would have to raise tonight but to which I am afraid I shall have to direct attention.
First, may I deploy the general case for these syringes. For a long time—in fact, since 1945—the Medical Research Council has been concerned about the possibility that, with the increasing use of syringes, not only for pathological specimens but also in treatment, the danger of syringe-transmitted infections might begin to increase. The Council published a report in 1945. In 1962 it published another report making recommendations which it hoped the Minister of Health and the Secretary of State for Scotland would act upon. It did this to a background of the incidence of infectious hepatitis, of which there is no fully accurate knowledge. The Council can take it only from sample reports here and there.
Infectious hepatitis is not a notifiable disease. This is one of the basic reasons why the figures are not available. However, death duties accredited to infectious hepatitis, although they cannot by any means be all attributed to syringetransmitted infections, are nevertheless interesting, because they measure the size of the problem, to some extent. In Scotland, for which I have the most recent figures, they range from 1951 to 1961 a t the following figures: 23, 21, 19, 24, 19, 24, 21, 26, 17, 35, 26. I concede that that does not show any trend up- wards, and it does not reveal the morbidity from infectious hepatitis.
Then one has to take into account post-immunisation jaundice, from which three deaths were recorded in 1961, not under this heading, and the 25 deaths due to acute yellow atrophy of the liver, again not under this heading.
One wonders why these things occur. I noticesd from one of the reports of the Medical Officer of Health for Edinburgh—I think it was the 1961 Report—that he had an incidence of 155 cases amongst schoolchildren in one year. There were no deaths, thank heavens. Nevertheless, it is rather a high incidence best use in part at least of the use of improperly treated syringes.
I need not, I hope, deploy the arguments which the Medical Research Council in its Memorandum No. 41, published in 1962, put in favour of trying to achieve other methods of using sterile syringes than those presently available in general practice within the National Health Service. I draw the Minister's attention to pages 3 and 9, where this matter is adequately stated. I come to the question of the syringes themselves and—
It has been suggested in some quarters, particularly in Scotland, that a complete service should be brought into being for the general medical service. In the Questions I have put to Ministers on this issue I have been given Answers which have not dealt with this matter but which have pointed out that the provision for such syringes in hospital practice is allowed.
I will deal first with the general medical service, since I had intended originally to raise only this matter. In Edinburgh, I am told, the practitioners, through tie local medical committee, have raised this issue on a number of occasions and I have with me the minutes of the Edinburgh local medical committee extending from November, 1962, until some time last year. They show how completely frustrated its members are in their efforts to get satisfactory answers to their questions on this topic.
The Medical Officer of Health for Edinburgh has made an assessment of the cost of using these syringes in Edinburgh, not only by doctors in general practice but also by district nurses. He has come to the conclusion that the cost of providing disposable sterile syringes for a city of half a million people would be £2,000 a year. In terms of the incidence of the number of times disease is transmitted by syringes, this would be a fair economic bargain indeed, apart from the human gain.
I am told by Dr. Alistair Brown, who is an active protagonist in this cause, that no help has been received in this connection. I wish to refer in particular to the various matters which have been raised with the Scottish Office as long ago as November of last year and again by the Edinburgh medical committee recently, although no adequate reply has been received. When I first raised this matter with the Parliamentary Secretary in November and was told that this applied for hospitals but not for the general medical service, I received a number of letters from understandably irate doctors, including one from a group pathologist, saying that this service did not exist in certain parts of the country and that even in hospital practice these syringes were sometimes not available.
I wrote to the Scottish Office and the Ministry of Health and my last letter, of 20th March, was aimed at getting some up-to-date information. The Scottish Office has been more forthcoming and has admitted that its Health Department has written to five regional hospital boards on 27th February; but it is interesting to note that the letter speaks of the provision of syringes to general practitioners for the withdrawal of specimens for examination in hospital laboratories, as probably a part of the National Health Service Laboratory Service. The letter adds:
…this is in order to achieve a higher standard of sterility.
It should be remembered that syringes are either sterile or they are not. There is no question of standards of sterility. Those who have experience of general
medical practice know how difficult it is to get facilities properly to sterilise syringes. If one studies the Medical Research Council's Report it is obvious that the methods which doctors can employ in a busy practice are not adequate and that they should carry with them syringes which are in themselves sterile and which should not again be used in that round. They should have some help from the hospitals to maintain this service of using a sterile syringe which has been sterilised by a hospital or some other central depot, but which they should not be required to try to sterilise after having used it on another patient. This is the point that I seek to put to the Minister.
While the Ministry has tried to tell me that it has offered advice, I think it fair to mention the point made in the group pathologist's letter. He writes:
Sometime in November you asked the Minister about sterile syringes and Mr. Braine replied that 'hospitals had been authorised to provide sterile syringes free of charge to general practitioners'. I know this to be untrue so I wrote at once to our Regional Board for a copy of the circular which did the authorisation. There has been no circular and not even off-the-record guidance. I have been asked over and over again to explain which section of the N.H.S. empowers me to do as I have done for fifteen years, supply sterile syringes. The Ministry has tried to draft a circular on the subject…but can never make up its mind whether I am correct in making no charge or whether Clauses 16 to 18 of the 1946 Act would justify making a charge.
The position in Scotland has very well been drawn to attention by a letter in the British Medical Journal of 14th March, 1964, by Dr. Dowie, of Hamilton, Lanarkshire, which concludes:
The Minister says that this service"—
the supply of disposable syringes for pathological specimens:
exists; let him make sure it does in fact exist—now.
Dr. Dowie explains in a long letter that this is not the case in his area. He says that he has written a number of times to the Scottish Department of Health and also to the regional hospital board concerned without getting any satisfactory explanation of the facilities.
I hope that I have done a little to draw the Minister's attention to this very difficult problem, and I should like to ask him the following questions. First, can he state quite authoritatively that the service for the supply of sterile syringes for use in getting pathological specimens for hospital laboratories will be extended as speedily as possible, and that it will not be hindered by including the cost within the present budgets of the boards? Otherwise, we must all admit that there will be a varied pattern of behaviour by different boards, depending on how hard the various other demands are pressed on them.
Perhaps I may interpolate here the remark that the last sentence in the letter I received from the Ministry of Health, in particular, in which the argument of priorities is put, is very discouraging compared with the last sentence of the letter from the Scottish Office, which is very optimistic and encouraging, and tells not only of current practice but future intention.
Secondly, will the Minister make it absolutely clear that no charge will be involved either to the patient or the general practitioner for the supply of these sterilised syringes, whether or not disposable? My third point relates to the use of syringes within the general medical services. Can the Minister explain how the Government extend to inaugurate this service? I assume, of course, that the Minister has accepted the M.R.C. report, and that it is the intention to ensure that every doctor is able to call on some centre or hospital to give him an adequate supply of sterile syringes, disposable or otherwise and that it is the Minister's intention to cover the whole country with this kind of service. Fourthly, if such a scheme comes into being, will there be a charge for the syringe? If so, will it be a charge on the patient, or how will it be levied? Or will there be no charge whatsoever?
Those are the four important questions I want to raise. I am much concerned that the Minister should make clear his own position fairly in regard to his Answers to me on hospital supply, and I hope that he can give some hope to the General Medical Services Committee, which has put to him and his right hon. Friend on a number of occasions the hope that the supply of sterile syringes for the general medical services will soon be achieved.
The hon. Member for Greenock (Dr. Dicison Mabon) has long shown an interest in the subject of the supply of disposable sterile syringes. I listened tonight, therefore, with great interest to what he said. I can assure him that my Department is extremely interested in the wider use of disposable syringes, but this is part of our concern about the proper sterilisation of all syringes used in hospitals and in general practice. Nor can we consider the use of disposable syringes independently from such questions as tilt internal supply arrangements within hospitals and the reimbursement of practice expenses.
It might be helpful, however, if I first said something about the background to this question of ensuring the use of sterile equipment. It has been known for some time that what used to be considered the normal method of sterilising syringes—that is by boiling them in an ordinary steriliser—was not adequate to safeguard against certain dangers. The most important danger, and the on to which the hon. Member has referred tonight, is the possibility of imperfectly sterilised syringes spreading infective hepatitis, or jaundice. This disease can be serious and in some cases fatal. It is most important to guard against it. I am advised that the risk is particularly important where intravenous injections are concerned, that is to say, where the syringe is used to inject material into the blood stream or to remove something from the blood stream.
I should perhaps refer to a statement the hon. Member made in the course of a supplementary question to my hon. Friend the Under-Secretary of State for Scotland, namely that there was a growing incidence of jaundice, particularly in Edinburgh, arising from the use of non-sterile syringes and that the health authorities had reported this to the Scottish Office. I am sure that the hon. Member made this statement in good faith, but I am advised that no such report has in fact been received and the Edinburgh Public Health Department has confirmed that no statement to this effect was made by it.
As I have said, infective jaundice is a disease which can be associated with infection from syringes. While in most areas in Scotland it is not a notifiable disease, local health authorities make a practice of reporting cases to the Scottish Home and Health Department. I am told that that Department has no information to suggest that jaundice is on the increase. The consultant bacteriologist at the Royal Infirmary says that in his experience the incidence of syringe-spread infective jaundice has dropped steadily over the years.
With reference to the remark the Parliamentary Secretary made, of course I made the statement in good faith, but it is in fact sustained by the minutes of the local medical committee. That perhaps is where the confusion has come about. On 5th March, 1963, in Item 17 the reference is:
he had not made much headway with St. Andrews' House but had received their assurance that the matter would be taken up with the Ministry of Health.
That is more than a year ago.
I have made it clear that the Edinburgh Public Health Department has confirmed that no statement was made by them. This, of course, is the sort of question we could explore a little further. I know the hon. Member would not wish to spread alarm and despondency unnecessarily. This is a matter which we should certainly clear up, but my information is that the situation is not as the hon. Member has represented it.
In view of the danger I have mentioned, however, it is generally accepted—I concede this to the hon. Gentleman—that the old methods of sterilising syringes are no longer adequate and that good medicine demands the use of syringes which are made safe by methods which cannot be expected to be found in the ordinary general practitioner's surgery. There, I agree with the hon. Gentleman completely.
There are two methods of overcoming the difficulty. Ordinary syringes can be made quite safe by autoclaving, that is, by heat treating them in special equipment. It might be possible for some general practitioners to receive this service from hospitals, and I shall say something about this later. The second method, which has come into use more recently, is that envisaged by the hon. Gentleman, namely, that general practitioners should use disposable sterile syringes. These are made of plastic and are intended to be used only once and then thrown away. They are readily available from normal sources of supply. A general practitioner must, of course, if he buys them, be quite sure that they are completely safe to use and that, in order to ensure safety, they have been subjected to one of a number of processes, possibly irradiation by radioactive substances. As with other equipment which he buys, he ought to feel confident that the reputation of the major manufacturers and suppliers is high. There is nothing to suggest that this poses any particular problem.
However, there is one aspect of the matter which has, perhaps, escaped the hon. Gentleman. This is the legal aspect. The general practitioner's use of syringes for normal practice purposes is exactly like his use of any other form of equipment. Practitioners decide what equipment to use, and the total cost is met by the Exchequer. Exactly how these expenses are reimbursed to doctors is a separate question which I shall touch on in a moment, but, whatever may be done in that connection, there is no special reason why the initial spending of money should be taken out of the hands of doctors instead of leaving them free to run their practices in their own way, deciding what material and equipment to use.
In short, general practitioners are independent contractors, and we at the Ministry of Health would hold that in that capacity they are themselves responsible in the first place for incurring any necessary expenditure on equipment, although the Exchequer meets in full the cost of all the expenses which they incur by means of payments into their central pool of remuneration.
As the hon. Gentleman knows, it is some years since the representatives of general practitioners first suggested that there should be a free sterile syringe service for general practitioners either by providing practitioners with free sterilising facilities for ordinary syringes or by giving them disposable syringes. My Department has during this time expressed a great deal of sympathy with the general practitioner's point of view, but, because of the legal position which I have just mentioned, we have felt that we could not treat this matter differently from other questions concerning the supply of equipment. In a moment, shall endeavour to give the House details of the arrangements which some hospitals have been able to make to provide syringes for particular purposes.
Surely, it would not in any way compromise the general practitioner's legal position if he asked the Ministry to arrange for a supply of these disposable syringes on a voluntary basis? There could be no possible objection on legal grounds to that request, if made, could there?
I have not a great deal of time. I think that it would be better for me to try to follow the arguments raised by the hon. Member for Greenock and to try to mop up other points as we go on. As regards the general practitioner's own use of syringes in the course of his normal practice, we have felt bound to hold that he should himself, in the first place, incur the necessary expenditure, which would then be reimbursed in the normal way as for all other items of equipment.
I turn now to the arrangements which apply in the hospital service One part of the current expansion of our hospital services has been the development of central sterile supply departments and syringe services. There are now about 50 of these departments, with more than 50 others planned or intended to be developed as the new hospitals of the future come into use. But there are limits to the part that the hospital authorities can play in regard to the work of general practitioners. It is open to them, if they have spare capacity for sterilisation, to consider meeting the needs of local general practitioners, but an appropriate charge would be recovered from the general practitioner for the service provided.
There is, however, another aspect about which the hon. Member is already well informed. Sterile syringes are needed for taking specimens for subsequent examination in a laboratory, and it has been the practice in some hospitals to supply a sterile syringe without charge when a general practitioner needs one to take a specimen at the request of the hospital. Such an arrangement has the advantage that the provision of a sterile syringe and container would help to ensure that specimens reached laboratories in a thoroughly good condition. But clearly this advantage applies equally when the hospital ha s not initiated the request for the specimen, and hospital authorities have, therefore, been advised by my Department that when the request is initiated by the general practitioner they may supply him without charge provided that the specimen is taken for examination by the hospital laboratory. There is, therefore, no question of a charge being made to the patient.
Various ways have been suggested in which supply might be arranged, but, as my right hon. Friend explained in a recent letter to the hon. Gentleman, it is left to the hospital authorities to apply which ever method suits local or individual requirements. We would expect the type of syringe supplied to depend on that in use at the hospital.
The capacity of hospitals to provide this service must vary, in present circumstances, depending on local conditions, but we have asked hospital authorities to consider what they can do to provide it, either immediately where resources permit, or in the future as syringe services develop. In other words, we are keen to see this kind of service develop as rapidly as possible. But the degree of priority to he accorded to this compared with other hospital service developments is for the hospital authorities themselves to determine. I understand that similar advice has been given to the Scottish hospital boards by my right hon. Friend the Secretary of State for Scotland.
Depending on local circumstances and resources, therefore, hospitals will help in the way I have described, but this is only one aspect of the general question which the ion. Gentleman has raised. I think that he claimed that no authorisation had been given to hospital authorities. My Department's interpretation has been that tie hospital authorities have had the power to provide syringes for taking specimens and this was why it was not necessary to send them a circular. The point has been made clear to hospital author ties at two recent meetings with representatives of the boards.
Since the end of last year we have been engaged with general practitioners in discussions on the reimbursement of practice expenses. As I said, the question of providing a free service to general practitioners for the normal purposes of their practice cannot be looked at in isolation from the wider question of responsibility for providing general practitioners with all the various materials and equipment which they use in carrying on their practice.
Much depends on whether the hospitals have the equipment for sterilising the syringes. For instance, the system in the Royal Infirmary, Edinburgh, which I have seen, is very elaborate. I cannot imagine small hospitals having such a system. Is the hon. Gentleman satisfied that all the hospitals have the equipment necessary to sterilise the syringes before sending them out?
I cannot answer that question in any detail tonight. Only last month we took up this matter again with the hospital boards, but my information is that in every region there are hospitals meeting requests from general practitioners. There are admittedly more in some regions than in others. Extension must depend upon local resources and, as I have said, upon local priorities. The fact that the subject has been ventilated here tonight, that we ourselves have been pressing the matter and that this is one of the subjects which we have been discussing with the representatives of general practitioners will all help in this regard. I should not like to suggest that a complete service all over the country could be initiated tomorrow, but we are moving in that general direction.
In the course of our discussions with the general practitioners on reimbursement of practice expenses it would be quite feasible to consider the possibility of introducing some more direct form of reimbursement of expenses incurred on syringes. It is, perhaps, a little difficult to say at this stage that the administrative machinery which would be needed to do this could be justified, because one feels that the amount spent by any one practitioner on syringes and, above all, the variation of expenditure between different practitioners cannot be very great.
In spite of that, however, if the representatives of the profession wish to explore the possibility of a more direct form of reimbursement of expenditure on equipment, we would be ready to discuss this with them. I hope that what I have said on this will assure the hon. Member for Greenock that we are deeply interested in the subject he has raised and that we are anxious to make progress. I thank him both for raising the matter tonight and for the way in which he has done so.
The House is, and, indeed, should be, grateful to my hon. Friend the Member for Greenock (Dr. Dickson Mabon) for raising this subject tonight. The Joint Parliamentary Secretary's reply to my hon. Friend is one of the most unsatisfactory replies I have heard in an Adjournment debate for a long time. What the hon. Gentleman has revealed is a state of absolute chaos in the two Departments about the provision of syringes. Surely it is time that he and his right hon. Friend and the Secretary of State for Scotland got down to the question of providing an efficient free service of sterile syringes, disposable or otherwise, to general practitioners.
To mention one point which came at the end of his speech, the hon. Gentleman suggested that there might be great administrative difficulties in making a direct reimbursement for money expended by G.P.s on syringes. If that is so difficult and all that the hon. Gentleman proposes to do is to pay back the money that the G.P.s have paid for their syringes, would it not be far simpler administratively and from every other point of view to provide them free in the first instance? I hope that the hon. Gentleman will now get down to putting the supply of disposable, or sterile syringes on a sound, proper basis.
The hon. Member for St. Pancras, North (Mr. K. Robinson) should not have chided me for mentioning that there are difficulties, when he knows perfectly well—I do not need to remind him of what I said earlier—that a vital principle is at stake in regard to the way in which practice expenses should be reimbursed. What I said, and what he did not acknowledge, was that discussions were taking place with the profession—the hon. Member knows this as well as anyone. This is a matter which, among many others, we are prepared to discuss with representatives of the profession. I went out of my way to say that we would be ready to discuss it with them.
I would not have the hon. Member try to leave the House with the impression that we are dragging our feet in this regard. That is not so. This is a matter which has to be discussed with the profession and it is one which, for the reasons I have given, cannot be rushed. I repeat that I am grateful to the hon. Member for Greenock for raising this matter.