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The right hon. Member for Plymouth, Devonport (Dr. Owen) has just entered the Chamber. No doubt he has been busy on television and radio. The right hon. Gentleman who is sitting next to me, and who suffered defeat in yesterday's local elections should know that the Bill was drawn up by Government lawyers, some of whom were fed up to the back teeth with the way that the Government are treating them. They have produced a dodgy Bill and passed it to the hon. Member for Weston-super-Mare, who used to be a Minister and now has little or nothing to do apart from manning the Agriculture Select Committee and being trampled on by the hon. Member for Derbyshire, South (Mrs. Currie) on occasions. I think that they said, "We feel sorry for Jerry" because he is supposed to be one of the knights of the shires, "Can we give Jerry a leg-up?" We have a Bill on the shelf. It is about weights and measures. It is about allowing the manufacturers of weights and measures equipment to sell faulty equipment more easily because the Bill will allow inspectors who might not even be inspectors." They could be frustrated lawyers running away from the Lord Chancellor. The Government say to the frustrated Chairman of the Select Committee on Agriculture, "Jerry, you will only have to come in on the occasional Friday and smuggle through the Bill." Those were the words used by my hon. Friend the Member for Paisley, South. The Government are occupying a private Members' day with their own Bills. We found them out the other week. Instead of authentic private Members' Bills that are drawn in the top six in the ballot, the Government, together with some of the Whips, are passing their Bills on to Tory Back Benchers and telling them to smuggle them through because nobody--
It being Eleven o'clock, and Mr. Deputy Speaker's-- intention to interrupt proceedings pursuant to Standing Order No. 11 (Friday sittings) having been made known, The Chairman-- left the Chair, without Question put.
Committee report Progress and ask leave to sit again.
I am glad to be able to tell the House that, late last night after prolonged discussions, I reached agreement with Dr. Michael Wilson the chairman of the general medical services committee of the British Medical Association and his negotiating colleagues on all the major outstanding issues involved in the new contract proposed for family doctors. I now expect a contract on the lines agreed to be introduced for family doctors throughout Great Britain with effect from 1 April 1990. My Department is now preparing a new statement of fees and allowances and regulations for consultation on minor details with representatives of the profession and I will lay the regulations in their final form before the House in due course.
The new contract will introduce new performance bonus payments for those doctors who reach the Government's targets of 90 per cent. coverage for childhood immunisation and 80 per cent. coverage for screening for cervical cancer. I have also agreed to introduce new lower-rate bonus payments of one third of the full rate for those doctors who attain 70 per cent. for immunisation and 50 per cent. cover for cervical cancer screening.
The negotiators have agreed my proposal that the fee paid where a night visit is made by a doctor from the patient's own practice should be three times the fee paid when the visit is made by a deputy.
To meet representations put to me on behalf of doctors in small practices, I have agreed that the higher fee for night visits should also be paid when the visit is made by a doctor from a small rota of local general practitioners, so long as the rota does not include more than 10 practitioners.
I had originally proposed that the new contract should require GPs to be available to patients for 20 hours each week in surgery. To meet representations put to me by rural doctors in particular, I have now agreed that the terms of service will require GPs to be available for 26 hours on average over five days each week and that this will include availability in surgery, health promotion clinics and for home visits. In recognition of the work that some GPs do elsewhere on health-related activities in the public service, for example in community hospitals, this commitment can be reduced to four days in individual cases subject to agreement with the family practitioner committee.
The GMSC and I have always agreed that additional payments should be made to rural practitioners and that the present system of rural practice payments needed to be updated. We have not yet agreed on the fairest method, but we are confident that we will be able to do so. We agreed last night that work on revising the scheme would be taken out of the present negotiations and considered by the central advisory committee on rural practice payments.
We also reached mutually satisfactory agreements on minor surgery, seniority payments, the basic practice allowance, funds for practice teams and premises and new higher capitation payments for GPs serving deprived areas.
Column 478We also agreed to submit joint evidence to the doctors and dentists review body about pricing the new contract in such a way as to meet the Government's policy objective for the general medical services in that the joint evidence would refer to the profession's acceptance of the Government's intention that the proportion of the remuneration of GPs arising from capitation based payments will reach 60 per cent. from 1 April 1990.
There were large areas of the new contract on which we had always been in agreement with the profession. I am glad to say, therefore, that, for example, the proposed new payments for surveillance of young children and the new higher capitation payments for patients over the age of 75 with whom doctors retain close contact were never at any time the subject of controversy between us.
The negotiators undertook to commend last night's agreement to the profession for implementation with effect from 1 April 1990. This agreement is a very significant step in the development of the family doctor service in our National Health Service. The new contract will be very different from the old one. It will ensure that the highest rewards go to the most hard-working doctors and that incentives and rewards are given to those who introduce new services and hit high standards of performance. I think that the negotiators and I are agreed that it provides the foundation for significant further improvements in the quality of primary health care for all our NHS patients.
Will the right hon. and learned Gentleman confirm that the negotiations have never been about how much is put from the public purse into general practice but rather about how that money from the public purse is to be distributed? Therefore, his comments about general practitioners feeling for their wallets were deeply offensive and unnecessary. Will he now apologise for the thuggish way he has conducted the negotiations?
Does the Secretary of State recognise that many believe that his aggressive style during the negotiations was a deliberate ploy to distract from doctors' opposition to the White Paper and to muddle in the public mind the issues of the White Paper and those of the contract? Will he guarantee that the cash limits for general practice ancillary staff and premises, which were set up under the Health and Medicines Act 1988, will not be so low as to prevent doctors from achieving the screening and prevention targets that are to be put into the new contract?
Will the right hon. and learned Gentleman recognise the widespread concern about giving disproportionate financial incentives to doctors to increase their list size when patients get better care if doctors have more time for each patient? Will he guarantee that he will keep a close eye on how the capitation element works in practice and take action if it creeps above 60 per cent.? Will he recognise that the row that he has been having with the doctors will be as nothing compared to the wholesale opposition from the profession and the public to his plans to destroy the NHS?
Mr. Clarke : Like my hon. Friends, I found the hon. Lady's opening remarks somewhat surprising. If she now supports the contract as agreed last night, the most amazing U-turn has been performed by the Opposition.
Column 479The contract as agreed reflects the performance targets and higher capitation levels on which the Government have always insisted. We have agreed with the profession a reasonable package which meets its requirements and those of the many doctors who have made representations to us on the details of how we achieve the Government's aims in the contract. The profession is now satisfied that we are pursuing the aims we were always pursuing in a practicable and sensible way.
I shall quote myself in full since the hon. Lady referred to my remarks about doctors feeling for their wallets. I said that I wished that the more suspicious doctors would stop feeling for their wallets whenever I mentioned the word "reform". I said that because the first reactions to my proposals were that many doctors, quite unreasonably, believed that somehow we were aiming to cut their incomes as soon as we started talking about a contract. We have now satisfied all doctors that there was never a threat to the overall level of general practitioners' incomes and that we were merely seeking to reward those who work hardest and hit the highest standards under the contract. Now that we have satisfied the negotiators of the GMSC on that point, I trust that the rest of the medical profession will be readily reassured.
I agree entirely that it is right to stop muddling up the contract for the remuneration of general practitioners with the White Paper reforms. The GMSC agrees with us about that. The issues have been muddled in recent campaigning. Many people have interpreted general practitioners' concern over the details of their contracts as fundamental opposition to our aims. The BMA negotiators last night agreed that they share our aims as set out in the foreword to the NHS review. They accept that we should aim to achieve a better service for patients. As we discussed matters fruitfully last night, I trust that we shall be able to do so on the White Paper and pursue our common aims in agreed ways as we develop our proposals for new methods of running the Health Service. I gave assurances yesterday about cash limits for ancillary services and said that we would honour commitments that we gave in passing the Health and Medicines Act 1988.
I do not accept that our measures are a drive towards bigger lists. We are agreed about increasing capitation, and it helps to improve the quality of service if those who work hard are rewarded and doctors are encouraged to attract and retain their patients. Above all, list sizes will be determined by whether patients are attracted and retained by services, and, of course, they will not wish to go to a doctor who is too busy to see them.
The agreement clears the way for more constructive discussion on the National Health Service White Paper "Working for Patients". I welcome the improvement in atmosphere that I am sure will result from our agreement. The bulk of the medical profession wants to join us in discussing the details of how we implement the Government's agreed aims to improve the Health Service for British patients.
Dame Jill Knight (Birmingham, Edgbaston) : The fact that this long- running business of settling the new contract has been concluded satisfactorily will give much satisfaction and pleasure to Conservative Members and people outside the House. I congratulate my right hon. and learned Friend on sticking firmly to the underlying aim and thrust behind the contract--to improve pay for those doctors who work hardest. My right hon. and
Column 480learned Friend has never wavered, and there is no question of any U-turn. We admire him for always accommodating the BMA when it has asked for meetings over the past months. Some women doctors appeared to think that the way in which the contract was developing would disadvantage their opportunities within the profession. Will he reassure me that that is not so?
Mr. Clarke : My hon. Friend knows as well as I that this has been a long-running subject. I share her relief that the long negotiations have at last come to an end with the agreed settlement. I thank her for her remarks, which are well worth bearing in mind as we proceed with the White Paper proposals for the reform of the Health Service. We must stick determinedly to our aim of improving the service, but we will be prepared to discuss with representatives of the profession, in as much detail as they want, how the aims can be achieved, and I think that last night was a good omen.
I have received many representations about women doctors. Although some of the fears that were expressed were misplaced, we endeavoured to ease the problems in our discussions last night. When my hon. Friend studies the details of the agreement, she will note that the change of basing payments from personal lists back to practice lists, and some of the changes that we made to the basic practice allowance, were designed to meet, among other things, the fear that we might accidentally deter women doctors from being admitted into partnerships.
Mr. Menzies Campbell (Fife, North-East) : I welcome the fact that agreement has been reached, not least because it shows that the Secretary of State now accepts that doctors, especially rural doctors, had real and substantial fears. I suspect that, on mature reflection, he may consider that the observation about doctors reaching for their wallets should not have been made. Will he clarify the protection that will be given to inner- city doctors, given the transient nature of their lists, which makes it more difficult not only to increase lists but to meet targets? In his statement, he referred to "Great Britain". Does last night's agreement supersede the draft contract issued to Scottish general practitioners by the Scottish Office Minister with responsibilities for health?
Mr. Clarke : I agree that it is important to give increased capitation payments to rural doctors and those who work in deprived areas, and both those groups were discussed yesterday. Both sides are agreed on the aim for rural doctors, but cannot agree on the method. Each side believes that the proposal that it is putting forward is fairer to rural doctors than the competing method. I have agreed that the matter should be referred to the specialist committee to decide how the current arrangements should be revised--we both agree that they should be revised--and in the meantime the current system will continue, which will reassure doctors north and south of the border. We are introducing new higher capitation payments for those who work in inner-city areas. We are agreed on the basic principle of how to make the higher payments using an index known as the Jarman index. We have agreed to hold further discussions on precisely which areas will be covered. The choice is whether we have a high addition concentrated on few areas or whether it should be spread more widely over deprived districts.
Column 481This is a Great Britain agreement, and Scottish and Welsh negotiators were present yesterday. The agreement will apply to England, Scotland and Wales.
Mr. Roger Sims (Chislehurst) : I join in extending congratulations to my right hon. and learned Friend on the diligence and patience with which he conducted the negotiations and the success that has crowned them. There has been much confusion between the contract and the White Paper, for which the profession must accept some responsibility. What will be the mechanics of explaining to doctors what has been agreed so that there will be no future
misunderstandings? Does he agree that if reasonable men can reach agreement on the contract, it should be perfectly possible to reach understanding in discussions on the working papers that accompanied the White Paper, which worked towards ends that surely all of us share--the best possible National Health Service, which is in the interests of professionals, politicians and patients?
Mr. Clarke : I thank my hon. Friend for his comments. Rather perversely, I enjoy prolonged negotiations, which obviously goes back to my murky past as a lawyer. These were quite the most difficult and longest negotiations in which I have taken part since those that I had with the Chief Secretary to the Treasury about the greatly increased money for the Health Service this year. As we agreed that we shall spend it ever more wisely, the two are closely related. My hon. Friend's point about explaining the mechanics to doctors is extremely important. I shall consider as rapidly as possible how I can most quickly communicate with all general practitioners so that they are aware of what has been agreed on their behalf. That is a great weakness in the Health Service, which gives rise to needless controversy. Half the people who work in it have no direct access to clear information about what is being proposed and done. The result is that they rely for a lot of their information on strange articles in specialist journals and leafleteering, which gives rise to unnecessary concern.
I agree with my hon. Friend that the agreement admirably demonstrates how the profession and the Government, who are both firmly committed to improving the National Health Service, can agree on details as long as we are prepared to thrash them out.
Mrs. Margaret Ewing (Moray) : The Secretary of State made it clear that the issue of rural practice payments has been referred to the central advisory committee. Will he clarify when he expects such negotiations to be completed, because it is of particular interest to areas such as mine and throughout the Highlands and Islands of Scotland? It would be helpful if he gave an indication of the time scale that is envisaged.
The Secretary of State will be aware that many women doctors work part time. If the basic practice allowance is not to be made available to those with lists of fewer than 400 patients, has he estimated how many women GPs might be excluded from receipt of that payment?
Mr. Clarke : I cannot say how long it will take for negotiations to be completed, but we shall ask the committee to resolve the matter as quickly as possible. There is no difference of principle between us, and it probably requires the assistance of the specialist
Column 482committee to work out the methodology and how we should revise and bring up to date the present arrangements.
As I said to my hon. Friend the Member for Birmingham, Egbaston (Dame Jill Knight), we have made significant changes to meet the fears expressed by women doctors. I do not think that the new contract will deter the taking on of women partners. Indeed, it recognises to a greater extent than before concepts such as job sharing and being a full principal with a part-time commitment. The ever-growing interest in matters such as female screening for cancer will make women practitioners more attractive to partnerships because we are giving incentives for high performance in that part of medicine. Partly in response to the worries of female doctors, we have moved to the basic practice levels first set out in the proposed Scottish contract. We have put the rural matter on one side because of the fears of rural doctors north and south of the border and in order to seek a sensible agreement.
Mr. Ivan Lawrence (Burton) : I, too, congratulate my right hon. and learned Friend on a settlement that everyone will welcome with relief and I congratulate him also on his healing words. Is he aware that two conclusions can be drawn? First, my right hon. and learned Friend is the antithesis of the fool and the knave that he has been portrayed as by the medical profession. Secondly, the unscrupulous use of the fears of the old and the sick which has been undertaken by general practitioners, certainly in my constituency, turns out to be little more than a bargaining ploy in these contractual negotiations. Will my right hon. and learned Friend therefore be even more determined to press on with his National Health Service improvements, despite what opposition may be set up by the now discredited general practitioners?
Mr. Clarke : I was not going to return to some of the topics on which my hon. and learned Friend has touched, but I note his views. Certainly, on occasions, hard words have been exchanged. It is my experience--I am now in my second stint at the Department of Health--that medical politics is no place for the squeamish. They are never conducted on the same restrained level as matters of war and peace and other issues in British politics. I am glad to say that it has been my experience that agreement can be reached in the end and that, after a dispute is over, people appear to forget it entirely and no one can quite remember what the fuss was all about. That is likely to happen on this occasion.
My hon. and learned Friend is not the only person to feel that some of the points aimed at patients, as opposed to those aimed at me, were perhaps unwise. No doubt, he will make inquiries about what is proposed to be done about the 11 million leaflets that were published as part of the recent campaign.
Mr. Ron Leighton (Newham, North-East) : The Secretary of State will know of the critical reception given by doctors in the London borough of Newham to his proposals. Although this is a separate matter, will he give a guarantee that general practice will not become a cash-limited service and that there will be no compulsion for doctors to become budget holders?
Column 483White Paper to make the family doctor service cash limited, as he puts it. We have made it clear that practice budgets are open to GPs who want them. Those who expressed an interest in them will discuss the details and negotiate the size of the budget before contemplating whether to go on.
Drug budgets remain an important issue which we must settle. They will be indicative drug budgets, which means that there will be an indication of what the doctor should spend and, if he overspends, he will have to justify that to another doctor and explain his clinical practice. The important point about drug budgets from the point of view of the people of Newham and elsewhere is that there is nothing in our proposals that will ever lead to any difficulties for patients. There is certainly no question of any patient ever being refused the medicine that he or she needs because of anything that the Government have proposed or anything else in the offing for the Health Service.
Mr. John Watts (Slough) : Following this welcome outbreak of sanity in the BMA, and now that the doctors' wage claim has been settled on terms which are basically the same as those originally proposed by my right hon. and learned Friend, which they said would prove so disastrous, may we expect to hear less from the BMA in the way of hysterical and untruthful assertions about the effects of the contract and the NHS reforms, which have worried so many of our patients and some of our doctors in such an unnecessary and wicked way?
Mr. Clarke : I must be fair to Michael Wilson and his colleagues who, along with my team and me, worked hard to reach a sensible package and an agreement. At the end, we parted on extremely good terms, both sides believing that we had improved the relationship between us. I share my hon. Friend's hope that that will continue and that we shall continue to discuss in the same spirit other matters arising out of the NHS White Paper that have been made more contentious than they need be. I am sure that the average member of the public cannot understand how such a highly qualified profession as the doctors can get into a dispute with the Government when we all agree that we are entirely agreed on the policy's objectives.
Mr. Kevin Barron (Rother Valley) : In view of what has been said by Conservative Members, will the Secretary of State accept this point? In my contacts with general practitioners in my constituency, both personally and through letters, no one has brought up the issue of the contract. It is not in dispute and has not been in the BMA's leaflets. The only time that I had a conversation about the contract was last Monday, the bank holiday, when my family doctor called at my home because one of my children was sick, and that conversation was about reaching set targets for cervical cancer screening. In my district health authority area women can go to a general practitioner, a family planning clinic or an out-patient service provided by the local health service. Has the right hon. and learned Gentleman discussed in detail the setting of these targets and collection of statistics showing whether those targets are being met? That is important, in view of the complicated arrangements that exist, certainly within my district health authority.
Column 484the contract. The Government always stated our aim that four out of five at-risk women should be screened against cervical cancer because it is an unnecessary and avoidable form of death for many women. We were able yesterday finally to agree that the Government's aim of 80 per cent. cover for cervical cancer screening was a sensible target to set. The change that I made was to introduce a new lower target of one third of the value of the full one for doctors who were not able to get immediately to the 80 per cent. target, but were able to get to 50 per cent. or more. I am sure that what we agreed last night will raise the level of screening and protect more women than would otherwise have been protected from the risk of death from cervical cancer.
Mr. Ian Gow (Eastbourne) : Without apportioning blame, does my right hon. and learned Friend agree that there has been an imperfect understanding by doctors of our proposals for their contract and of our proposals in the White Paper? Will my right hon. and learned Friend now do two things? First, will he communicate directly with GPs about the terms of the agreement that he reached yesterday and which we all welcome so warmly? Secondly, will he ensure that, in the continuing discussions about the implementation of the White Paper and the genuine exchange of views that is taking place, where necessary the Government will communicate directly with those doctors whose co-operation and assistance in his reforms are essential?
Mr. Clarke : I welcome my hon. Friend's advice and share the views that lie behind it. I caused to be sent to every GP, for the first time ever, copies of our contract proposals as they then stood. We have not moved away from those aims in what we have agreed today. When the leafleting campaign started, I sent every GP an explanation of my reply to the allegations in the leaflet. Unfortunately, I do not think that my communications are the sole source of information for doctors. I attribute no malice to anyone, but I think that often doctors do not read what they regard as mail coming from the Department. Many comments about what we were doing soon came flowing in from newspapers, other commentators and, dare I say, Opposition spokesmen which rapidly gave the impression that, for example, we would force doctors to have enormous practice list sizes. That was a red herring from beginning to end.
I take my hon. Friend's point that we must ensure that these contract details are firmly brought to the attention of GPs. They have been agreed by their negotiators, whom they trust, and I am sure that they will accept their commendation. We have to do a great deal to rebuild the trust of family doctors and to persuade them that we are not threatening their incomes, practices or well-being ; we share with them the aim of improving the service.
Mr. Harry Cohen (Leyton) : Has the Secretary of State been so busy declaring war on GPs that he has concluded a disappointing contract for patients? That is particularly true for women, in view of the cervical smear figures that he has provided. The targets of 80 per cent. and, especially, 50 per cent. are too low. If the target for immunisation is 90 per cent., why cannot the target for cervical cancer testing be 90 per cent.? Is not the 50 per cent. figure an abysmal sell-out? That will be the target to which GPs work. Is this happening because te Secretary of State does not give women's health a sufficiently high priority or
Column 485because he will not give enough money to health authorities to ensure that a computer call and recall system operates properly? As GPs will have their budgets limited, there is no incentive for them to deal with patients who contract HIV or have AIDS and who will be an expensive cost in budgets in future years. Should not the treatment of patients with HIV now be a subject for their contracts?
Mr. Clarke : I shall consider seriously having the hon. Gentleman with me on future occasions when I am discussing these matters, as he thinks that I have not gone far enough in the targets I have set. A target of 100 per cent., for example, for screening for cervical cancer might be ideal in an ideal world, but the test is voluntary. We all know that some patients will not respond and that others will refuse to have the test--for understandable reasons. We ask the doctors to explain and promote the benefits of the test to their patients. The general medical services committee agreed yesterday that the 80 per cent. target, which the Government thought was reasonable, was correct. The committee also persuaded me that it would be fair to introduce a lower target for practices that find it impossible to achieve 80 per cent. the first time, so GPs will receive one third of the bonus payment if they reach 50 per cent. However, our aim is the same--to raise the level of screening. We need to consider new services for AIDS patients in using our new powers to draw the cash limits for payments for improvements to premises and practices, especially if there is a need to develop new clinics because there is a particular problem in an area. I agree that AIDS is a growing problem for particular practices in some areas. I am sure that the GMSC and I will continue to address the way in which we help such GPs to deal with this serious problem.
Mr. Patrick Thompson (Norwich, North) : I join hon. Members and people outside in congratulating my right hon. and learned Friend on bringing common sense back into the negotiations. Does that not show that the Government are listening to valid points put by doctors and others? I hope that my right hon. and learned Friend will confirm that that foreshadows constructive discussions on the Government's White Paper. Does he agree that whenever the Opposition enter the debate, they only add to the confusion and distress felt by many patients?
Mr. Clarke : I agree that we have been listening carefully to the representations of many hon. Members, who have, in turn, met GPs in their constituencies. Our proposals on rural practices, for example, and some of the changes we have made to the targets strongly reflect representations made to me by my hon. Friends and others in the past few weeks. We will continue to adopt the same approach. We have said throughout that we want constructive discussion on the working papers that we have put out because we intend to work in partnership with the profession in the implementation of the White Paper proposals. It is not for me to comment on the interventions by the Opposition, for which I am not responsible. However, I suspect that they feel a deep sense of disappointment that we have made a significant advance and that the way is now clear for the continued smooth implementation of the White Paper.
Mr. Alistair Darling (Edinburgh, Central) : May I press the Secretary of State for a statement on resources? It is all very well to set standards, but unless there are additional resources to carry out testing, such as cervical smears, little will be achieved. The Secretary of State referred to AIDS. As he may know, Edinburgh has a high incidence of AIDS infection. It is not good enough to say that discussions about increased resources for the treatment and detection of patients with AIDS are a matter for the future. We need resources now and we should recognise that there is a growing problem in Edinburgh and it is spreading to the rest of the United Kingdom. What will the Secretary of State do about it? Do we have to wait until the problem arises in London before he realises that AIDS is a real problem?
Mr. Clarke : I said a moment ago that the last prolonged negotiations in which I was engaged were with my colleagues at the Treasury on resources for the National Health Service. The priority that the Government gave to putting extra resources into the Health Service was demonstrated clearly by my right hon. Friend the Chief Secretary to the Treasury last autumn, when almost £2 billion extra was put into the Health Service. My Department is now the second highest spending Department. We spend more than the Ministry of Defence does--which is more than the Labour party could ever say--and if we carry on as we did last autumn, we shall rapidly catch up the Department of Social Security. This agreement is no substitute for resources. However, we are putting in resources on a scale that no previous Government have ever achieved and we are matching that with new proposals to ensure that the resources provide ever higher quality care.
The Government have put vast resources into research into AIDS and into developing new services north and south of the border. It is true that the problem is at its most acute in Edinburgh and, after Edinburgh, in London. It will be news to the hon. Member for Leyton (Mr. Cohen), who said that the problem would come to London soon, that it is there now. The Government have one of the best records of any Government in the developed world in responding to the threat of AIDS, both in resources for treatment and in public health education.
Mr. Neil Thorne (Ilford, South) : I also congratulate my right hon. and learned Friend on his determination to ensure that the taxpayer gets good value for money and that doctors who conscientiously carry out their duties are rewarded properly. In that regard, he is encouraging doctors to refer as few cases as possible to hospitals, and that must be good both for the practitioners and their patients. Will he shortly introduce a similar contract for consultants, some of whom are giving good service but others of whom are not? That is one of the major reasons for the long waiting lists in some areas.
Mr. Clarke : I do not quite agree with my hon. Friend in the way in which he described our proposals on referrals. Under the new contract, we shall have more information than ever before about the pattern of referrals and we shall find out more about how doctors refer their patients. We want the right use of the hospital service and the right level of referrals. At extremes, some doctors may refer far too many people by referring everybody to the hospital as a way of avoiding decisions themselves. At the other extreme, there may be doctors who do not refer
Column 487anybody, even when they should seek specialist advice. All the best GPs would agree that what is required is a good level of clinical practice so that GPs know when they should refer.
Consultants will be affected by the White Paper changes. Districts will have more control over what consultants do by being able to agree with them a job description which can be revised each year. That will help us to ensure that consultants have their efforts directed to the prime needs of patients in the area, which could include tackling waiting lists. Many of our proposals are aimed at ensuring that the whole service is brought up to the standards of the best. That means that we do not have to tolerate indefinitely the fact that waiting lists for similar operations can be enormous in one town, but much lower in another. Part of the reason lies in the system. It needs to be reformed, and in our proposals we are tackling the problem that my hon. Friend has described.
Mr. Norman Buchan (Paisley, South) : The Secretary of State said that he was looking forward to the continuance of constructive discussions. Does he consider that constructive discussions have been helped by the violent and intemperate language of some of his Back Benchers, who have referred today to the greed of doctors and to evil and wicked behaviour? Will the discussions be helped by his Back Benchers' concentration on the taxpayer rather than the patient? Will the Secretary of State recall that taxpayers are also patients? Is not the White Paper still under massive questioning by the medical profession? We are pleased that an agreement has been secured which will allow more sensible discussion, but it does not go to the heart of the problem. The White Paper is still pushing in the direction of the private and away from the social. It is still not concentrating on the need for a fully social profession serving the community. The White Paper is still dominated by thoughts of cash. It is time that we thought of health instead.
Mr. Clarke : We have attacked vigorously some of the leaflets that have caused needless alarm to patients. The fact that my hon. Friends responded as they did made it clear to people using such leaflets in the campaign that they would not deter the Government from pursuing their aims. It also had the significant effect of persuading everybody that we should have sensible negotiations and that any amount of trying to frighten patients for the purpose of deterring the Government from their policies would not work. I assume that the leaflets are now a matter of the past.
It is a parody to say that the White Paper is concerned primarily with cash. Our main involvement with cash and the Health Service is that we continue to put in huge amounts, above inflation, and we have expanded the resources available to the Health Service at a rate that previous Governments have never been able to attain. The purpose of the White Paper is to improve the service for
Column 488patients. The profession agrees with us about that and we look forward to working with it constructively to achieve that aim.
Mr. Nicholas Bennett (Pembroke) : My right hon. and learned Friend's proposals will be especially welcomed by GPs in rural practices in Wales. Can he tell me what he thinks the average remuneration of such GPs will be under the new contract? Is he looking at the problem of over-counting, because it is reported that in some inner-city areas as many as 20 per cent. of patients have moved away? The new agreement should contain a proper basis for paying doctors.
Mr. Clarke : It is difficult for me to give some sort of average figure for rural doctors in Wales. We would need to take a little more account of the circumstances of individual practices. I remind my hon. Friend of the examples that we gave at the back of the document that I sent to all GPs. They showed how the earning capacity of a doctor could be affected, given various list sizes, depending on the services that they provide. We shall have to update that to give every practitioner a clear idea of where he or she stands in relation to the new proposals.
My hon. Friend asked about over-counting. That has been a problem in the past, and I am sure that at one time if the lists of all GPs were added together the total would have been greater than the population, because many deceased people remain on a doctor's list for a long time. At long last we are making rapid advances in the introduction of information technology, and GPs records are very much better than they were. We can eliminate the problem of patients appearing on more than one list and should certainly have more reliable figures to work on by the time the new contract comes in next year.
Mr. Dennis Skinner (Bolsover) : Will not the Secretary of State's statement be for ever known as the Vale of Glamorgan settlement? Is it not right to say that, notwithstanding all the letters that hon. Members have had from constituents and from doctors complaining about the White Paper in general, doctors in the Vale of Glamorgan acted during the by-election in a way that frightened the living daylights out of the Government and the Prime Minister in particular? That is why she has sent this lackey to the Dispatch Box after meeting the doctors to arrange the settlement. Will the Minister now go the whole way and carry out the wishes of millions of constituents and completely withdraw the White Paper?
Mr. Clarke : The hon. Gentleman understands, and, of course, it was a considerable frustration to me, that I could not proceed with the discussions before last night. I suspect that that was also a considerable disappointment to some people who campaigned on our behalf in the Vale of Glamorgan and elsewhere. I do not think that the action of the doctors was for party political reasons, because I assure the hon. Gentleman that the vast majority of doctors vote Conservative. By an unhappy coincidence they had summoned a conference of their local medical committees for last week and felt unable to proceed with any meaningful negotiations until the conference was over. We settled last night about an hour after the polls closed, which was a considerable misfortune.
I hope that some of the doctors who have been distributing stuff in Glamorgan reflect on what they have been putting out. I hope that some of the people who voted
Column 489in mid-Glamorgan will look back on some of the leaflets to see what they said about excessive list sizes and so on in the light of last night's agreement.
Mr. Quentin Davies (Stamford and Spalding) : May I offer my congratulations to my right hon. and learned Friend on his outstanding ability and on the success with which he has conducted and concluded these negotiations in very difficult circumstances? Does he agree that the reduction in the fixed element of the increase in the weighting of the performance-related classification element of GPs' remuneration is an important principle and a welcome part of the principle of economic rationality in the family practitioner service? Will he be encouraged to go further in applying that principle in reforming the National Health Service as a whole?
Mr. Clarke : I am grateful to my hon. Friend. I certainly share his belief in the value of performace-related payments because they encourage the very best standards of service in the NHS and elsewhere. I am keen on the whole idea of performance-related payment systems in many walks of life. We have them for general managers in the Health Service, and I agree that that principle and others mean good value for money for the patient and are the kind of principles that we should apply as we implement our NHS reforms.
Mr. Harry Greenway (Ealing, North) : May I ask my right hon. and learned Friend to say more about what is behind his remarks on higher capitation for deprived areas? I have one or two such areas in my constituency. They concern me very much and certainly need help. Last night, GPs in my constituency said to me that they would like a greater right to refuse patients more quickly than at the moment. Is that implied in the agreement? In an urban area such as my constituency GPs have said that the optimum number of patients per GP is 1,700. Will the agreement change anything?
Mr. Clarke : I can tell my hon. Friend that 1,700 is below the average list size. I do not know the details of particular practices, but I accept that in some places lists cannot be as big as they are elsewhere. That applies especially in scattered rural areas or in areas of social deprivation where the demands are likely to be heavier per patient. That is the reason for this system and we are still discussing the details with the profession. The Jarman index is accepted by everybody as the best measurement of social deprivation for the purpose of assessing capitation fees. We still need to settle precisely which districts it will apply to. We were near to agreement last night, but decided to have further discussions at official level to finalise the details.
I am not quite sure about my hon. Friend's point about the ease of refusing patients. It has always been the case that, except in exceptional circumstances, a GP cannot be forced to take a patient. It is obviously much better for the GP to be a willing recipient of the patient but in unfortunate cases where a person can get nobody to take him the family practitioner committee has to retain the right to oblige a practice somewhere to offer medical services.
Column 490has demonstrated that a substantial body of medical opinion has accepted the principle that some change and some improvements are needed in the Health Service? Consequently, does he agree that the Government are right and the Opposition are wrong?
Mr. Clarke : Clearly, I agree with my hon. Friend. It shows that there never was any deep-seated rift or division of aims between ourselves and the medical profession. Many doctors agree with our aims and with many of our proposals in the contract and in the White Paper. The belief that the whole profession is up in arms against us is a complete myth. It must be a sad disappointment to the Opposition to see that we can make progress on the contract because they know that we can make similar progress on the White Paper. I have every intention of doing that.
Mr. Gary Waller (Keighley) : As my right hon. and learned Friend has rightly said, the welcome agreement now leaves the road open for a sensible and rational debate about the merits of the White Paper. Does he agree that that debate can now be even more rational because there is no excuse whatever for leaving elerly and sick patients with the idea that their general practitioners will not have the time, resources or the prescriptive budget to treat them and that they might be turned away? Mr. Clarke : I agree that it is extremely important for us to continue to make clear that there never was, there is not now, and there never will be any circumstances in which elderly people will be turned away from their doctors or refused treatment as a result of any proposals by this Government. That is a total misunderstanding of what we propose and has aroused needless fears. We should all join in making sure that elderly people are reassured. The ideas being put about are total nonsense and we should now get back to a sensible debate about the proposals.
Ms. Diane Abbott (Hackney, North and Stoke Newington) : I have a letter here from a Mrs. A. M. Downes. Does the Secretary of State accept that thousands of elderly people are concerned about the cash-limiting proposal? Can he explain it further to my constituents? If the Government aim in some sense to put a ceiling on what GPs can spend, how can that be done without GPs running out of money at some point?
Regarding the capitation statement that is being negotiated for the deprived areas, is the Minsister aware of how complex this question is? Areas such as mine in Hackney will have special problems. Other areas have special needs because of the high percentage of elderly people who need much more time spent on them and who cannot just be pushed in and out to achieve cost effectiveness. Will the Minister agree that it will take more than this statement and the agreement on the contract to quiet the fears of the thousands of people with whom I am in touch and who are concerned? Conservative Members should take seriously the letters from constituents.
Ms. Abbott : Conservative Members must have received hundreds of letters from constituents, as I have. Those constituents would be alarmed indeed if they could see Conservative Members giggling and chattering through
Column 491this portion of the debate. Will the Minister answer two particular points--about the cash limiting and about the complexity of the nature of how privatisation might work in deprived areas?