604

policemen, and other professionals. We may no

longer have cigarette advertising on television, but westill have a lot too many irrelevant smokes.

DISPENSING DOCTORS

THE dispute between dispensing doctors and thepharmaceutical profession is rather like one of thosefestering border disputes in a far-away part of the worldthat lies dormant for months at a time and then

erupts into a little bombing and shooting, which hitsthe headlines for a day or two before it once againdies down without anything having been resolved orany progress made. As the dispute at the momentappears to be in one of its dormant phases, now maybe a good time to review the situation.About 1 in 10 of Britain’s 25,000 general practi-

tioners is a rural doctor who dispenses medicines forhis patients as well as treating them. 1 In Section 39of the National Health Service Act 1946 it was laiddown that pharmaceutical services would normallybe provided by registered pharmacists and that,except as provided by Regulations, no arrangementsshould be made by an executive council with a doctoror a dentist under which he would be required toprovide pharmaceutical services. The relevant

Regulation, permitting doctors to supply drugs in

specified circumstances, is now Regulation 29 of theNational Health Service (General Medical andPharmaceutical Services) Regulations 1972. The firstpart of Regulation 29 reads as follows:

29.-(1) A person who:(a) satisfies the Council that he would have

serious difficulty in obtaining any neces-sary drugs or appliances from a chemistby reason of distance or inadequacy ofmeans of communication, or

’

(b) is resident in an area which in the Council’sopinion is rural in character, at a distanceof more than one mile from the premisesof any chemist,

may at any time request the doctor on whose list he isincluded to supply him with drugs and appliances.

In practice, it has been assumed that if a doctor wishesto dispense he should be permitted to do so for allpatients who live more than a mile from the pharmacywithout the initiative coming from the patients, thusperpetuating an arrangement that originally datedback to Lloyd George’s National Health Insurancescheme of 1911. The one-mile rule was a rough andready attempt to give precise expression to this

intention, but it has led to anomalies. Situations canarise where the doctor’s surgery and the chemist’s

shop are situated within a few yards of each other, butthe patient obtains medicines from the surgerybecause he lives more than a mile from the pharmacy.The fact that he lives more than a mile from the

surgery to which he has to go to collect medicinesdispensed by the doctor is not taken into account.Dispensing doctors are paid on one of two systems-either by an additional capitation fee to cover drugsand dressings (with the exception of a long list of

expensive drugs, which can be claimed for in addition1. Department of Health and Social Security. Health and Personal

Social Services Statistics for England and Wales, 1972. H.M.

Stationery Office, 1973.

to the capitation fee), or on the basis of a tariff, likethat used to pay chemists for prescriptions dispensed,but at a rather lower level. The doctor can choosewhichever method will suit him better.The abolition of the one-mile rule was mooted in the

1960s during the negotiations over the Charter for theFamily Doctor, but the proposal was dropped afterfierce opposition from rural doctors.2 The crux of thematter is that in existing circumstances there are areaswhere neither a general medical practice nor a retailpharmacy is viable unless dispensing rights go withit. There is thus a clear clash of economic interestbetween rural doctors and pharmacists. The ruraldoctor looks to dispensing, not only to enhance hisincome while he is working, but also to provide himwith a better pension when he retires. It has beensuggested 2 that, in the more sparsely populated areas,taking dispensing away from doctors might lead to theabandonment of some practices because they wouldno longer provide a viable income. Many ruraldoctors derive a significant proportion, perhaps up to25 %, of their net income from dispensing. On theother hand, retail pharmacists are not only professionalmen; they are also shopkeepers, and the lot of the smallshopkeeper has not got any easier in recent years.From the public point of view, to abolish or further

restrict dispensing by doctors may be to the detrimentof rural medical practice; but, if it is not worth whilefor a pharmacist to set up or continue in business in arural area, the public is deprived of his other services,as well as of the safeguards implicit in the dispensingof prescriptions by a man specifically and primarilyqualified in pharmacy. So the arguments appear to beevenly balanced. As far as the consumer voice hasbeen heard, it has been on the side of the doctors.The Women’s Institutes rallied to their support in1967 2 and the Consumers’ Association has criticised 4

the service provided by some pharmacists-though notin rural areas. However, although the chairman of theB.M.A. rural practices subcommittee was ready in1966 to claim 3 that doctors could provide a moreefficient dispensing service than chemists, becausetheir hours were not limited, this claim now has arather dated sound, even in many rural areas. The

public, if it is called upon to judge the issue, will do soprimarily on the grounds of convenience, and nowa-days there may not be much to choose between doctorsand chemists as far as accessibility is concerned. If itis slightly easier to see the doctor and collect anymedicine prescribed at one port of call, then thisconvenience may be offset by the prospect of a localchemist’s shop selling a wide range of non-pharma-ceutical sundries and medicines which do not requirea doctor’s prescription. In the short term, nothingmust be done which will imperil the viability of ruralmedical practice or threaten the legitimate interests ofthose doctors who already dispense medicines for theirpatients. But in the long term the right solution willbe one which lets doctors concentrate on doctoring,leaves pharmacy to the pharmacists, and finds alter-native ways of ensuring the viability of medical practicein sparsely populated areas.

2. Morgan Williams, B. D. Br. med. J. 1973, i, 92.3. ibid. 1966, i, suppl. p. 271.4. Which ? June, 1966, p. 204.