Pharmacies and the NHS

Oliver Colvile Excerpts

Wednesday 20th November 2013 Westminster Hall

[Ben Gummer]

I could not agree more with the hon. Gentleman. I will address that point.

There are three separate groups that each present different and particular problems. The scandal to which the hon. Gentleman alludes, which was uncovered recently by an excellent piece of journalism in The Daily Telegraph, shows how the NHS, customers and taxpayers have been ripped off by the drug companies that are coming in and double invoicing—they are issuing credit notes to pharmacists but invoicing full amounts to the NHS. That situation is outrageous, but it is inevitable when the market is so complicated and lacking in transparency. That is the first of several problems with special drugs.

Category M drugs are incredibly complicated. In the parallel trading of pharmaceuticals across the European Union—just to take one issue—it was often beneficial to import drugs from Greece or southern Europe to the UK because of the price differences between the pound and the euro. The reverse is now true, which means that there is sometimes a shortage of supply in the United Kingdom.

The situation is addressed by a quota system imposed by the pharmaceutical companies, which inevitably causes difficulties for pharmacists because sometimes five people, rather than three, want a particular drug one week. At that point, the pharmacist rings up the wholesaler and says, “I need two more prescriptions.” The wholesaler will then say, “Actually, I don’t have them.” The pharmacist will then have to phone the supplier to ask for two prescriptions, and if the pharmacist cannot get the prescriptions from the supplier, they have to go into the secondary market to buy from another pharmacist who is keeping the prescriptions in stock. The other pharmacist, completely understandably, takes a margin on selling the drug to the pharmacist who requires the prescription.

[Oliver Colvile (Plymouth, Sutton and Devonport) (Con)]

My hon. Friend might be aware that I am vice-chairman of the all-party group on pharmacy. The right hon. Member for Rother Valley (Mr Barron) and I considered the issue about 18 months ago, and we produced a report. Unfortunately, the Department of Health does not seem to have taken an awful lot of action and has rather pushed the report into the bottom drawer. Perhaps my hon. Friend might be willing to meet the chairman of the all-party group and me so that we can share our report.

[Ben Gummer]

My hon. Friend wrote and published his report before the Minister was appointed to his position, so I am sure my hon. Friend is calling on new ears and eyes that are able to consider the problem afresh.

Another problem is that pharmacists are completely at the mercy of the demographic that they happen to serve. The averaging of pricing operated by the PSNC means that if pharmacists happen to be selling a particular pharmaceutical in their area because of a high incidence of diabetes and are making a loss, and if they are not selling many drugs on which they might otherwise make a profit that allowed them to break even or make a small margin, they are immediately disadvantaged—just because of their geography.

If, however, a pharmacist happens to be in another location with a low incidence of diabetes but a high incidence of another condition that requires a high-margin drug, the pharmacist will do very well—not because of business acumen, not because they are running a particularly good service, not because they are friendly to customers, who want to come to see them, but just because of where they happen to be and the health indicators of their particular area. That cannot be right.

The third problem with the regulated market is that, because of the price changes of particular pharmaceuticals that happen every day and every week, it is impossible for businesses to plan, as they are uncertain of their future margins.

Those are all classic problems of trying to regulate a market. It would be good for the Opposition spokesman, the hon. Member for Copeland (Mr Reed), to take note of what happens when people try to regulate a market to the degree that his party—not him, I am sure; he is one of the more sensible members of his party—wishes to on energy prices. Such regulation results in inflated prices across the spectrum, as has happened in many instances in the drugs market in the United Kingdom. Good customer service is not incentivised, and good pharmacists are crying out to be rewarded for quality. Furthermore, innovation and supply are restricted.

I could go into those problems in far greater detail across the sector. The problems frustrate pharmacists and, no doubt, Ministers, who ultimately have to write the cheque on behalf of the taxpayer.

The third area I will address before I give others an opportunity to contribute is the essential problem at the heart of the debate. Of course it is understandable that we have ended up with a regulated system, because there is only one customer for most drugs. Indeed, if I understand things correctly, 80% of prescription drugs are bought by the NHS on behalf of people who are entitled to free prescriptions. Because of the way in which we have set up our health service in this country, it is impossible to extract the kind of value from the big pharmaceutical companies that other countries are able to extract, as there is only one purchaser. I do not know why in this country we have not got to a position of questioning the business motives and ethics of big pharmaceutical companies, as the United States has for many years.

I should qualify all that by saying that, of course, within the pharmaceutical sector there are the most fantastic companies that are innovating, contributing upwards of £12 billion a year to the UK economy and employing thousands of brilliant people across the country. We should be proud of those companies, but it is surprising that we have such an unquestioning attitude to those enormous interests, which have a relationship with the NHS and general practitioners that could be generously described as corporatist. That is unhealthy in driving innovation, in encouraging responsibility and, most importantly, in ensuring transparency. That is precisely why we get scandals such as the one raised by the hon. Member for Upper Bann (David Simpson). If there is an opaque market, frauds will be committed against the interests of the taxpayer.

I have, I hope, opened up the debate a little so that we can discuss some of the issues. I do not have any prescriptions for how we might deal with them, other than the general principle, which I hope the Opposition will agree with, that liberalisation is generally a good thing. If we deregulate this market—not the quality of the people dispensing pharmaceuticals, but the commercial side of the market—to allow pharmacists to offer more services more innovatively and more cheaply, and if we encourage competition in NHS purchasing and price-setting, we will do something on behalf of taxpayers and patients. I have put forward a group of questions to open up the debate, and I am grateful for the contributions that will follow mine.

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[Oliver Colvile]

Plymouth, Sutton and Devonport.

[Mr Barron]

I am sure Hansard will put that right anyway—I could have said “somewhere in the south”. The hon. Gentleman mentioned the all-party group, and we had a session on pharmacies easing the burden of emergency care. We had several witnesses, one of whom—Paula Wilkinson—was the chief pharmacist at Mid Essex Clinical Commissioning Group. She showed us a publication that the CCG was sending round mid-Essex called “Why wait to see your doctor or nurse? See your pharmacist first!” It is part of the health care on the high street initiative that the CCG is running, and she focused the majority of her comments on that initiative, which she said nudged—that is very much Government-speak—people towards using the pharmacy first. Like another witness, she focused on the expanded role that pharmacies could play in serving patients with minor ailments.

Paula said—this is quite interesting, and I would be interested in the Minister’s comments—that for people on low incomes, prescriptions often provided a way of gaining free access to medicines that are otherwise available over the counter without a prescription. She said that meant that patients on low incomes were perversely incentivised to attend their GP or an A and E service to get prescriptions. She believed consideration should be given to providing some free medicines without prescription to those on low incomes. Clearly, if a patient has been on a medicine for a long time, that would not be that challenging, and a professional such as a pharmacist could extend the period without having to go through any rigmarole and clogging up the rest of the system.

The A and E report that came out last week showed that 40% of people who attend A and E have nothing whatever done to them, which is an extraordinary statistic. Indeed, 50% of people who are blue-lighted—an ambulance or paramedic goes out to them—are not admitted to hospital. We need to look at certain issues in primary care services and, to some extent, in the acute sector if we are to deal with such people.

Community pharmacy provides a common ailments service—we call it a minor ailments service in Rotherham —in 10% of England, and people are encouraged to go to the community pharmacy as part of that. A nationally commissioned service would reduce pressure on GP surgeries and, subsequently, on A and E. Recent reports suggest that 56 million to 57 million visits a year could be managed by pharmacists, freeing up GPs to manage more complex cases, and I agree.

Pharmacists support people with long-term conditions to manage their symptoms, improving access to care for people in the most deprived areas and increasing capacity to treat patients out of hours and in the community. The Minister will be well aware of this, but about 75% of NHS expenditure goes on people with long-term conditions. This winter, quite a lot of them are likely to end up going to A and E and clogging up the system because they have, for whatever reason—they may be forgetful as a result of other problems, such as dementia—not adhered to their drugs regime at home. Managing such people in the community using professionals such as GPs, nurses and pharmacists is a better way of caring for such people. We have few systems to deal with these things, although the hon. Member for Plymouth, Sutton and Devonport (Oliver Colvile) will no doubt tell us what is going on in his constituency with healthy living pharmacies, so I will not go into that. These are, however, major issues, and the strengths of pharmacists should be used a bit more.

I mentioned the question of medicines adherence. Under the present general pharmacy contract, it is pharmacists’ duty—and they are paid for this—to take in unused medicines. It is extraordinary that every year medicines costing hundreds of millions of pounds are prescribed and then are unused, for whatever reason. It is a difficult situation. The 2010 report by the York health economics consortium and the school of pharmacy at the university of London suggested that up to £500 million could be generated in England in just five therapeutic areas—asthma, diabetes, raised blood pressure, vascular disease and the care of people with schizophrenia—if medicines were used optimally. Those are all long-term conditions on which taxpayers’ money is spent. The report rightly said that sub-optimal use of medicines and waste undermine the £12 billion investment in medicines by the NHS.

Pharmacists do quite a lot of work which, although it is contracted to the NHS, is not always laid out nationally or used by local health partnerships. The hon. Member for Ipswich pointed out that pharmacists were not included in the publication that he cited. A medicines use review is a review of a patient’s medicines—prescribed and non-prescribed—to promote adherence and to support the optimal use of medicines; 2.8 million MURs were provided by community pharmacies in England in 2012-13. Since 2011, pharmacies have offered a new medicine service to provide additional support to patients who are starting to take certain medicines for long-term conditions. An evaluation of the effectiveness of the NMS is due soon, and more than 640,000 people starting to take new medicines have benefited. That is adherence —making sure that people do as their prescription sets out.

The York and London review, which is entitled “Evaluation of the Scale, Causes and Costs of Waste Medicines”, goes into the question in great depth, and clearly the problem will never be eliminated altogether. Nevertheless it is clear that in this country people sit and write out prescriptions and people take them away and effectively put them on the shelf. The patient might use the medicine for a couple of days. Perhaps they do not like the side-effects, and indeed that is unavoidable on occasion. However, some medicines are stored in bathroom cabinets, and when they are emptied the medicines are taken back to the pharmacist or thrown away, which costs the nation hundreds of millions of pounds. We must question whether some of those medicines, given that they are not used, should be prescribed in the first place. However, that is a wider issue for health professionals, not me.

More than 57 million GP consultations a year involve minor ailments. If we rolled out the scheme that currently covers about 10% of England, we could greatly reduce pressure on those services, and GPs could get on with more important things. The patients could be moved to pharmacies, and more than £812 million of GP capacity could be freed for other things.

In 2009-10, 140,000 people chose their community pharmacy to set a quit date and 62,000 had successfully quit smoking by the fourth week, which was a 13% increase on the previous year. Pharmacists give support in a wide variety of public health roles, including flu vaccinations, international normalised ratio-testing clinics—monitoring and adjusting the dose of the blood-thinning medicine warfarin—and asthma clinics.

There has been much debate in Parliament about changes in the Health and Social Care Act 2012. The Minister was on the Committee that considered the measure. Two things were writ large in that Act. First, we have now put into statute the need to reduce health inequalities—but they are not reducing. Everyone is living longer, but in terms of social class things are still going downwards. Pharmacists could work on reducing health inequalities in areas where there is known deprivation. That should be a major aim. Secondly, the Minister will remember the emphasis on population health. In view of the statistics that I have read out, I think pharmacy has a major role to play in improving population health.

Public health problems were very bad 150 years ago, and they involved the environment—bad housing, bad sanitation and bad water. The public health issues that this century will suffer from will be to do with individual lifestyles. I read out some statistics about smoking cessation and pharmacies, and I believe that community pharmacists are the gatekeepers to the national health service. Far more people visit them than any other part of the NHS and they have a major role to play. The sooner we alter the current mode of contact and move away from the situation where pharmacists get the bulk of their money just churning out prescriptions to one where they cover wider issues within communities and look after the health of the population, the better we shall be.

[Oliver Colvile (Plymouth, Sutton and Devonport) (Con)]

It is a pleasure to serve under your chairmanship this morning, Dr McCrea. I congratulate my hon. Friend the Member for Ipswich (Ben Gummer) on securing the debate. I have tried on one or two occasions to get a debate on pharmacy, and he has beaten me to it and introduced the debate very successfully. No doubt he has more pull with the Speaker’s Office than I do. I thank the Minister for attending, too.

I got involved in the pharmacy story when in the 1990s resale price maintenance on non-prescription medicines became a big issue. The chief executive of Asda—I do not think that he was a Member at the time—was very keen to get rid of RPM on non-prescription medicines because he felt the market should be much more open. Quite a debate has taken place over the years on how to liberalise the pharmacy market in a big way.

At that time, community pharmacists were concerned about whether their trade would be reduced and the effect on their livelihoods. We must recognise that community pharmacies play a significant role in the high street economy. People are regularly drawn into town and city centres to spend money and visit the community pharmacy at the same time. I have followed developments with interest. I congratulate and support pharmacists, who do an incredible job. As the right hon. Member for Rother Valley (Mr Barron) pointed out, they are the first point of contact for people who need help.

I understand the concern of my hon. Friend the Member for Ipswich about the lack of liberalisation in the market and the need for transparency. I am always one for a lot of transparency—more sunlight normally produces it. During the 1980s and 1990s, the Conservative Government made sure that town centre retail developments and new supermarkets were assessed, to find out the implications for other supermarkets and food retailers. Regulation of town centres has been going on for a while. That was also to do with the sequential test.

[Steve Baker (Wycombe) (Con)]

My hon. Friend reminds me that we often complain that our town centres are in decline; he may have given us the reason.

[Oliver Colvile]

I agree that supermarkets have had an impact, but my point is about trying to protect small businesses in town and city centres.

[Steve Baker]

That is not quite what I meant. I pointed out that our town centres have been regulated for a long time, and that they are now in decline. Perhaps we should liberalise more consistently, and should have done so for a long time.

[Oliver Colvile]

The bigger issue, frankly, is car parking in town centres. Outside town centres people do not pay charges for car parking, but they do in town centres: so where do they go? In my constituency, I suspect that they end up at the Marsh Mills Sainsbury’s or elsewhere.

Two other big issues affect the pharmacy profession, one of which is the criminalisation of dispensing errors. If pharmacists make a mistake, they can be prosecuted and potentially sent to prison, whereas GPs, for whom I have a great deal of time, do not suffer the same prospect. The Department of Health is looking at that, and I hope that it will come to a conclusion on how we can equalise the situation and ensure a more level playing field.

The other issue is the sharing of data between pharmacists and GPs. I raised the matter during a recent statement from the Secretary of State for Health on the whole business of how pharmacists could play a part in helping to relieve accident and emergency units. The Government are keen to ensure that more and better data sharing takes place. I have a slight concern in that my understanding is that the process would be run by the Department of Health, but I recently read in an article that the Department was suggesting that the responsibility would lie much more with the local commissioning boards. If the Minister can respond to that confusion, that will be helpful.

We need to ensure that pharmacies play a much better role. They need to be the first point of call for people seeking help from professionals, as that would help to relieve GPs. During the summer recess, I visited the Keyham healthy living pharmacy, which is a brilliant organisation in a deprived community. Life expectancy differs by 11 years between the suburbs of Plymouth and Devonport, which is where the Keyham pharmacy is located. The pharmacy offers not only flu vaccinations, but also smoking cessation services and other such things. It is a service that certainly needs to be available.

Finally, there is concern about how we can improve how people feel about pharmacies to ensure that they are used in a much better way. If pharmacies were used to deliver flu vaccinations, that would take some pressure off our accident and emergency units over the winter. We have discussed an important issue this morning, and I am delighted that you, Dr McCrea, have been in the Chair to ensure that we get some positive comments.

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[Jim Shannon]

I thank my hon. Friend for that helpful contribution. The contributions from him, my hon. Friend the Member for Upper Bann (David Simpson) and others may focus the Minister’s attention.

On the availability of medicines, I have read that the National Institute for Health and Care Excellence has approved fewer than one in three medicines since 2005. A recent letter from nine major pharmaceutical companies to The Daily Telegraph started with something that I agree with. I am sure that any Member and, more importantly, any doctor or care worker in the NHS, will also agree with it:

“Medicines should not just be seen as a cost.”

They should first and foremost be about healing and curing illnesses. The letter continues:

“They are an investment and an essential part of improving patient outcomes. Yet…the proportion of medicines refused by NICE is only increasing.”

That is a concern for me, too. Jonathan Emms, UK managing director at Pfizer, has said:

“Right now NICE is saying ‘no’ too often. It is blocking many innovative new medicines from reaching the UK patients who need them most, medicines that are often readily available in Europe.”

Will the Minister say what contact he has had with NICE about not making available in the UK drugs that are available in other parts of Europe?

Although it is hoped that the agreed deal will save the NHS £1 billion over two years, it is essential that that saving goes into making more drugs available for the healing of those who need them and not simply the healing of the deficit. Will the Minister assure me and the House that the savings made will go into the provision in the UK of drugs that have been widely tested and that are widely available in Europe?

[Oliver Colvile]

Does the hon. Gentleman recognise that drugs and medicines can be dangerous if they get into the wrong hands? Pharmacies also have to face people using the internet to acquire drugs, which is an option that does not carry the same regulation that we expect in the domestic market.

[Jim Shannon]

I thank the hon. Gentleman for that contribution. It is something that many of us have highlighted and I know that the Minister has spoken about it in the past. The availability of drugs on the internet is an anomaly in the system, and perhaps the Minister can give us an indication of how best to deal with it.

Back in April, we were told that the number of cancer drugs on the approved list was to be halved. Will the Minister commit to ensuring that the savings will be used to increase the amount of drugs that might save lives and give a better quality of life?

I read the story of a mother with terminal cancer, who was forced to fund herself a drug that she believed would give her extra time with her young children, after being refused by a special Government fund. I find such stories incredible, hearing about the real heartache and issues that impact on family lives, and yet we—as collective representatives—are unable to help and assist as we should. In America, Obama is trying to bring in a health care system similar to ours. It is referred to as Obamacare—people say that it will make or break him, and it probably will. We, however, seem to be turning ourselves into an American system, whereby we have to fundraise to get treatment. That is certainly not what my constituents or I pay our taxes for, and I am sure that others agree with me.

I want to make a quick comment about Northern Ireland, where our Health Minister abolished prescription charges. That was done on the understanding that cheap generic drugs were not prescribed. Health is a devolved matter in Northern Ireland, and our Minister made a decision, which I support entirely. Will this Minister—I ask this with respect—liaise with the Northern Ireland Minister, Edwin Poots, to ascertain how the scheme is working and how we have been able to stick within our budget in Northern Ireland on prescription drugs?

The right hon. Member for Rother Valley (Mr Barron) made a valuable contribution today. One of the things that he referred to was the drugs that people have and do not use; they sit until they go out of date and are then dumped. In Northern Ireland, the Minister, the GP surgeries and so on have taken steps to ensure that the prescription of drugs is better controlled. Sometimes, people might run out of drugs, rather than having extra in the cupboard, but such steps help and take away wastage in the system. The right hon. Gentleman made that clear in his contribution.

Over the years in Northern Ireland, through the Minister and in co-operation with the pharmacies, we have also tried to reduce the number of people attending accident and emergency. If people have a minor ailment, they should go to their pharmacist or chemist; he or she will be able to give some direction on what needs to be done. There are ways and means of good practice, to which I have referred on many occasions. I say what we do in Northern Ireland with humility, but we actually do some things very well. If such things are done well, they can be a marker for elsewhere.

Time is flying past, but changes clearly need to be made soon. Yes, pharmaceutical companies and pharmacies need to make a profit, but that must be done in the right way; we need legislation in place to ensure that that is done in such a way. Yes, NICE must protect people from drugs that promise all, but deliver nothing, and yet that cannot be used to count pennies and to justify saying no to drugs that will make a difference.

Finally, yes, Government must make savings, but those cannot be taken from the most vulnerable by denying them treatment; any savings should be used for new drugs, to give people a better chance of life, for the sake of our constituents in the whole of the United Kingdom of Great Britain and Northern Ireland. We are not talking simply about numbers on a hospital list—the changes need to be made, and made soon.

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[Steve Baker]

My hon. Friend is absolutely right and I am extremely grateful to him for bringing that up. We pretend that we live in a capitalist society—I have said this in the House before—but if our system is capitalism, I am not a capitalist. We have an absurd hybrid system, in which the state constantly intervenes in order to give people rents. It is peculiar that we call it a free market society.

The purpose of our all being here, of course, is to improve our constituents’ lives. When I say such things, my intention is to ensure that my constituents—all our constituents—have better access to pharmacies. In the House, we have a real consensus about an increase in the services offered by pharmacists being of benefit to all our constituents. What I want is for the Government to get out of the way, not to use taxpayers’ money to provide the payments that my hon. Friend mentioned and to allow pharmacists to get on and best serve the public in a way that is in the public’s best interests—a way that can be discovered only through experimentation and entrepreneurship.

On pricing, I want to make the point that in this country we are not good at haggling. We should haggle over prices and drive them down. The hon. Member for Strangford (Jim Shannon) talked about the scandal of some simple and inexpensive medicines that ought to cost pennies, but cost very much more. What I see at work there could be something that I witnessed when I was a contractor working with Government: Departments are not good at driving down prices. They tend to accept the price that they are given—“Oh, that must be the market price.” No—they should set the market price by demanding that they are charged less and, if suppliers do not provide the goods at a lower price, they should go elsewhere.

That brings me to generics and parallel imports, a subject touched on earlier. We ought to be making sure that the big pharmaceutical firms do not hold the NHS over a barrel. I have heard some of their arguments, and of course producing a new drug is an expensive business, but we should not be held over a barrel. In a market society, people should be held to account to drive down costs and drive up quality.

Johnson & Johnson, based in my constituency, has a wonderful credo, which was written when the basis of a free society was under threat in an earlier time. That credo sets out the principles on which the industry should be founded, and one such should be: no legal privileges, wherever possible.

[Oliver Colvile]

During the all-party group inquiry, we looked at that issue. One suggestion for easy identification of who was exporting and importing pharmaceutical products in this country was to look at VAT returns—when I ran a small business and was VAT registered, I had to fill in a piece of paper that recorded what level of EU trade I had ended up doing. I approached the Treasury on the matter, but it was not willing to participate and help, but that seems to me to be a way in which we could identify who the offenders are. We had some difficulty in identifying the offenders.

[Steve Baker]

My hon. Friend has identified what might be a missed opportunity because an enormous effort is going into preventing that fraud. With the opportunities that electronic communication offers today, it should be possible to use some of that information in other contexts. With that in mind, I will turn to the internet.

Clearly, everyone wants to ensure that prescribing takes place properly, but when people have been prescribed medicines it should be possible for them to buy over the internet in appropriate circumstances. I am particularly aware that homeopaths have had great difficulty with the internet because of the need for people to present physically to buy a medicine.

We cannot have it both ways on homeopathy—either the medicines are relatively harmless and can be treated with scorn by the medical profession, in which case they should be freely available on the internet, or they are dangerous and should be tightly regulated. Homeopaths’ experience suggests that people can take responsibility for themselves and buy products on the internet.