House of Commons Hansard Debates for 25 Jul 1989

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encouraging the development of GP community hospitals such as the one in Malton under threat of closure, ending arbitrary restrictions on patient choice--

Mr. John Greenway : Will the hon. Gentleman accept from me that the chairmen of Scarborough health authority and Yorkshire regional health authority have categorically stated that Malton community hospital is not under threat of closure? There is only a review of the services of the peripheral units within Scarborough district. The hospital is not under threat of closure.

Mr. Kirkwood : I accept that. It is always dangerous to stray into another Member's constituency issues. I shall only say, in Mr. Asquith's famous words, that we should all just wait and see. In 1985, Dr. Wilson was in the business of trying to promote some of the very matters that arise in the current draft contract. The list that he sent to the Government also included improving services in isolated rural communities. Those proposals could have been the basis of an exciting new and agreed blueprint for the future of primary care. Instead, because of the Government's ineptitude in handling negotiations, the contract will mean that GPs will spend less time with individual patients and less time on preventive medicine and health promotion. It will be extremely difficult to make the contract work in rural areas at all.

My constituency is a rural area and no one there is in favour of using competition as a way of improving primary care in rural areas. The Government's disinterest in the development of primary care is illustrated on the first page of the proposed contract document, where it says that central to the Government's plan for improving general medical services is

"increasing competition between the providers of the services." None of my constituents who have heard of that new proposal believes that competition is central to his other hopes for the development of primary health care in the NHS. The existence of facilities is the crucial factor. There are few practices within easy reach of my constituents or competing hospitals to which they can turn. I do not see how the new proposals sit easily with the provision of primary care in rural areas.

That applies in particular to how the proposals will tend to increase list sizes. Two years ago, when the original White Paper on primary care "Promoting Better Health" was published, we warned that establishing a direct link between the number of patients on a GP's list and GPs' remuneration would have severe consequences in rural areas. Since then, the position has been made worse. There is now much more emphasis on the income available to GPs in rural areas being related to the size of their lists.

In my constituency, the proportion of total income derived by GPs is in the region of 27 per cent. and the contract that we are debating takes that to 60 per cent.--55 per cent. plus marginal changes. That will have a catastrophic effect on income. I understand that the rural practice allowances are still under consideration and that the so-called tartan contract has been extended to cover other parts of the United Kingdom. But we cannot escape the fundamental problem in rural areas in Scotland that general practitioners currently receive 27 per cent. of their income from capitation fees ; but under the new scheme that will be at least 55 per cent.

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The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman) : Rural practice allowances are still being discussed. Therhas been no decision. We recognise and understand the pressures on rural practice in England, and an announcement will be made in due course.

Mr. Kirkwood : I am deeply concerned about rural practice in England, but I also have more than a passing interest in rural practice in Scotland. I accept that the Government made a concession, and I said that it was welcome at the time, but the effect in Scotland will be dire. Some practices face a massive loss in income and may go out of business. That will lead to doctors retiring early and to some practices not taking on new partners or waiting a year or two before deciding to do so. I accept that in wealthy areas some practices will have the means to attract entirely new patients ; that is what the Government are trying to achieve.

Let me deal now with the effect of increased list sizes on prevention. Average list sizes will inevitably increase because of the fall in the number of GPs for the reasons that I have just explained. Within that average size there will be stark changes that will tend to act to the detriment of patients. Doctors will have less time with individual patients and less time for time-consuming preventive medicine and health promotion. Nor will there be time for doctors to visit factories and schools or to take the health promotion message to those areas which are missing out. If the increase in the link between pay and the number of patients is not designed to increase list sizes, what do the Government think they are doing increasing the capitation income?

I welcome the fact that, as the Minister said, the system of rural practice payments, is set to continue in England and Wales. We hope that that is true. They were properly taken out of the negotiations and, as I said at the time, we welcome that. However, will the Minister confirm that so far there has been no decision to impose changes to the rural practices payments and that he will continue to consult? Even if there are no other negotiations on the contract details, which the Secretary of State seems to be saying is the case, will discussions at least continue on that aspect of the rural practices payments scheme ?

What other important areas will be changed by the draft regulations on rural areas that the Minister discussed with the doctors? There is great concern. I cannot believe that he does not know that already. People such as Dr. Farrow, the chairman of the rural practices committee of the General Medical Services Committee, described the original proposals as

"a devious blow and would probably result in the rape of the rural practice."

Dr. John Ball, the chairman of the general medical committee, a Government- appointed committee, said recently that even if rural practice payments continue in their present form, the new proposals would mean that half the English and Welsh practices that have fewer than 1,500 patients will not survive. In Scotland, where list sizes are lower, 25 per cent. of practices would not survive. Those are the sort of terms that we are talking of.

Finally, let me deal with the unrealistic nature of target payments that are being proposed. The Borders area health board has achieved 92 per cent. immunisation. It has always given proper priority to achieving a high immunisation rate, which is in the interests of everyone. However, the Government system of performance-related

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pay is causing concern further south. The current targets for screening and immunisation remain unrealistic, and will be made more so because of the extra time spent dealing with the bureaucracy inherent in the contract. The systems of paediatric and geriatric surveillance that the contract stipulates are time-consuming and will produce very little reward in return for a high degree of effort. The Government's system, even in its modified form, will not work. It will be difficult to decide on the base number of patients. FPC and general practitioners' lists rarely agree because of the lists' ever-changing nature. GPs in deprived areas will be penalised because the migratory population that they serve will make it difficult to trace target groups, and even then they must be convinced of the need for screening and other provisions. Cultural differences mean that many women are anyway reluctant to undergo smear testing. There is also a need for exclusions from immunisation. I refer to whooping cough and the pertussis vaccination that is the subject of medical controversy of which the Minister is surely aware. A number of patients have medical histories that prohibit them from receiving vaccinations against whooping cough, and they should be excluded from any calculation of a general practitioner's vaccination target. Evidently I did not explain that point very clearly, because the Minister's brow is furrowed. Nevertheless the Government's system of target payments for cervical screening and immunisation schemes are unrealistic.

The Secretary of State must return to the conference table to renegotiate the terms of the new contract. If he does not, it will be the first contract in history that has not been implemented by agreement, and we shall move into a period of non-co-operation by general practitioners that will not be in the interests of the Government, doctors or patients. Certainly it will not be in the interests of people living in rural areas. I hope that the Government will properly consider all those matters when giving the right hon. and learned Gentleman future instructions as to whether to continue negotiating with the General Medical Services Council.

9.1 pm

Mr. Jerry Hayes (Harlow) : The hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) says that the Government should return to the negotiating table. The truth is that the Government reached an agreement with the General Medical Services Council and British Medical Association negotiators that was welcomed by Dr. Michael Wilson and recommended for acceptance by the BMA's membership in true trade union style. The trouble is that, in true trade union style, Dr. Wilson and the BMA so whipped up the blood of the association's members that they rejected the agreement. Only a few weeks after sensible negotiations, and after sensible concessions were made by Ministers, the BMA said, "This sort of agreement comes from the jaws of Hades," and the doctors became upset.

The hon. Member for Livingston (Mr. Cook) was right, for once, to bring to the attention of the House the serious difficulties facing the Health Service, particularly in respect of waiting lists. It may be helpful if I quote the BMA's chairman on that issue :

"The sum of human misery represented by those record figures is a scandal without parallel in any technically developed country."

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I am certain that the hon. Member for Livingston and his right hon. and hon. Friends agree with that sentiment, as will the rest of the House. But it was expressed by Dr. James Cameron, chairman of the BMA, in 1978. Nothing changes very much. Lord Donoughue, writing in his memoirs about Labour Government cuts--I do not want to go too much into old history--commented :

"It was the usual rag bag of random cuts in public investment cuts in education, the National Health and public industry investment were imposed in full Half the cuts were in capital investment." I shall offer one more quotation from the past :

"I do not believe that the problem"

of soaring waiting lists

"would be solved by any means by simply holding on to a large number of small, uneconomic hospitals."--[ Official Report , 10 May 1977 ; Vol. 931, c. 1087.]

One can imagine what the response of the hon. Member for Livingston and his right hon. and hon. Friends would be if that remark had been made by my right hon. and learned Friend the Secretary of State, or by my hon. and learned Friend the Minister. In fact, that statement was made by the then Labour Secretary of State for Social Services, David Ennals.

What has changed, however, is the amount of money that is pumped into the Health Service. I do not necessarily agree with the argument that relates such expenditure to gross domestic product, but it is used from time to time. When the right hon. Member for Plymouth, Devonport (Dr. Owen), who is not now in the Chamber, was Health Minister in the halycon days of the Wilson Government, that Government were spending 4.8 per cent. of GDP on health. In the days of David Ennals and the Callaghan Government, the figure was 5.3 per cent. Now, in the wicked days of the Thatcher junta, we are spending 6.1 per cent., and that does not include private health care. Nor does it take into account the fact that the economy is positively booming, and not on the rocks as it was in the days of the last Labour Government.

The trouble is that none of us knows where the money is going. We do not know the cost of treatment and operations, and if we do not know that, how on earth can we plan for the future? That is the essence of the reforms in the White Paper, and what we should be discussing this evening.

It is probably the exception to the rule, but I have read the motion very carefully. It has all the balance of a wet blancmange. At one moment the hon. Member for Livingston (Mr. Cook) wobbles on the subject of the Prime Minister ; at another he wobbles on private health insurance. Not so long ago, it was easy for the hon. Gentleman to have a crack at the Prime Minister for using private health care. The fact is that we have a democracy, and people have the right to choose : that is the basis of Government policy, although the hon. Gentleman disagrees with it. My right hon. Friend the Prime Minister has done something very important in stating publicly that the Government's aim is to make the Health Service so good that people will neither want nor need to use private medicine. As the hon. Gentleman said, they use it now to jump queues. The White Paper proposals will stop the queues forming in the first place. I cannot understand the Opposition's paranoia about private practice. I could understand that paranoia if the Government were proposing a Health Service that was not free at the point of delivery ; I could understand it if they were proposing a Health Service that would not be funded

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primarily from taxation. Those, however, are the major principles behind the proposed reforms, as is made categorically clear. The West Essex health authority, in my constituency, has one of the 22 longest waiting lists in the country. My people are waiting two years for hernia operations.

Mr. McCartney : That is how a Tory Government treat them.

Mr. Hayes : I do not consider it right or fair that my constituents should have to wait two years for a hip or cataract operation, when the health authority could have the opportunity of giving the patient the choice of going a little further up the road and having the operation done privately--provided that the patient does not have to pay for it and the health authority does not have to provide any more money. That strikes me as absolute common sense. We are proposing to allow people choice and the chance of having their pain and suffering removed quickly.

Judging by what we see on television and in the newspapers, hear on the radio and, indeed, hear from Opposition Members, one would think that the medical profession was 100 per cent. against the proposals. But those of us who go around the country speaking to the presidents of the royal colleges, to general practitioners and to hospital consultants can tell Opposition Members that those people--including the British Medical Association and the Joint Consultative Council--are in favour of medical audit. They have been pushing for it for years. They are also in favour of resource management : many of them have been pushing for that for years. They are in favour of money travelling with the patient, because they know that it will lead to the abolition of the efficiency trap.

Without those three fundamental foundation stones of policy, there will not be self-governing hospitals or GPs' voluntary practice budgets. If self- governing hospitals are as wicked as some people say, people will not want to take up the proposal. If voluntary budgets are as hopeless as some people say, GPs will not put their names in for them. It is a matter of choice. There is agreement about the fundamental reforms of medical audit, money travelling with the patient and resource management, and as the Secretary of State said earlier, those constitute 80 per cent. of the proposals.

I was bemused by something said about the GPs' contract. Many hon. Members have talked to a large number of GPs over the past few weeks. Anyone who has read the letter from Dr. Michael Wilson will see that they are in favour of the main thrust of the contract and have been pushing for many of the major proposals of the contract for a number of years. However, I am saddened when GPs tell me that they cannot see the point of visiting someone over the age of 75. They say that it is a waste of time. I cannot understand GPs who ask why on earth they should bother about screening when it simply means that they will find more things wrong with the patient. I cannot understand GPs who ask why they should have to immunise in the way the Government say, even though our figures are well below what the World Health Organisation advocates. That is absolutely wrong.

The Opposition were right to have some doubts about private medical insurance. However, they could have had more doubts if the Government were planning to offer overall tax relief for private medicine. That would be

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totally wrong because it would withdraw a great deal of funding from the Health Service. That is not the case. The Government are trying to help the elderly, many of whom may have been trade unionists, who had many options open to them through their companies and who find as soon as they retire that those options stop. It is all a matter of choice.

I am not criticising the hon. Member for Peckham (Ms. Harman), but when she goes home tonight she will go back to a nanny. There is nothing wrong with the hon. Lady having a nanny to look after her children. She does not receive tax relief for it, although some say that she should. She is probably not satisfied with the sort of cover available to her children in the community. However, it is her choice. There is not a great Labour party campaign against nannies and there is not a whacking great trade union of nannies which pays the Labour party. Therefore, it is hypocritical for the Labour party to criticise the Government's proposals in this way.

I have read the motion carefully. I hope that the hon. Members for Livingston and for Peckham will look carefully at the first line and welcome with enthusiasm the Prime Minister's pledge and support what she has been saying, as it is a laudable aim.

9.14 pm

Mr. Ian McCartney (Makerfield) : Having listened to the hon. Member for Harlow (Mr. Hayes), I have decided to tear up my original speech. The hon. Gentleman and I have one thing in common--we are both members of the Select Committee on Social Services, which has considered the review being proposed by the Government. Its final report will be produced on 10 August. I am rightly bound by the rules of the House not to discuss its contents, although they have been widely discussed in The Independent, The Guardian and other newspapers.

Whatever the recommendations of the Committee, its

members--including many Conservative Members--were influenced by the evidence received through cross-examination, personal interview and other means when considering carefully the Government's proposals. Throughout the Committee's investigations, the attitude of the Secretary of State, which he displayed today, was sometimes foolish and sometimes insulting. With one exception, he displayed the same attitude to and perceptions about the working role of the Committee, despite the attempts of its members to try to tease out of him the Government's intentions for implementing their proposals. The hon. Member for Harlow is a barrister. He proved tonight that if a barrister is given a brief he will argue that black is white. On 24 May, the Committee produced an interim report based on evidence received and the cross-examination of the Secretary of State and his senior officials. The hon. Member for Harlow signed that report. Time will not allow me to go through all the report's conclusions, so I shall read only two with which the hon. Member for Harlow agreed. The report says :

" A programme of persistent improvement will provide a more effective way forward for the National Health Service than the search for a radical reconstruction of the service.' "

The hon. Member for Harlow agreed with the report's final conclusion, which says :

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"If the Government's proposed timetable for introducing the vastly greater changes to the health service proposed in the White Paper is adhered to, we have serious fears that the stability of services and continuity of patient care may suffer during the years of transition to a new, untested system. As we said in our Report last year : the strengths of the NHS should not be cast aside in a short-term effort to remedy some of its weaknesses'.

That remains our considered view."

That was the considered view of the hon. Member for Harlow on 24 May. I am saying not that he is trying to bring his profession into disrepute, but that in the white heat of argument this evening--

Mr. Hayes : Will the hon. Gentleman give way?

Mr. McCartney : I will give way in a minute.

The hon. Gentleman is trying to protect the Government, which is an honourable intention for a Conservative Member, but he is suffering from amnesia about the evidence that he assisted in taking, which he supported only a few weeks ago.

Mr. Hayes : The hon. Gentleman should read the report carefully. Although I am unable to talk about the report until 10 August, a minority report will be produced in due course. Everything with which I agreed in the report is a matter of public record. I have never said that I wholeheartedly agree with the Government's timetable. The part of the report to which the hon. Gentleman referred was written after we had heard from the Secretary of State. As will be apparent from the next report, the Secretary of State made it clear that the projects will be pilot projects in all but name. He further said that they would be evolved and run in, which satisfied me, and I hope will satisfy the hon. Gentleman. I should be grateful if he did not misrepresent the work of a respectable Committee.

Mr. McCartney : Far be it from me, a member of the Committee, to misrepresent it. I fear that, following the example of many barristers in tight corners, the hon. Gentleman is wriggling. The report in question was produced and voted on after interviews with the Secretary of State, accompanied by officials of his Department, on two occasions.

Mr. Hayes : It was written before that.

Mr. McCartney : I have made my point, and the hon. Gentleman will have to be content to allow history to determine whether my or his version is more acceptable to the nation--if indeed the nation decides to take note of what either of us has said.

Rather than being acceptable to the communities covered by the district health authorities, the review is provoking panic in many areas. For example, I have in my area the Wigan health authority, one of the largest metropolitan areas in Britain in terms of population and geographical size, with four parliamentary constituencies. It contains a number of district hospitals.

That authority has reached the interim conclusion not to support the concept of opting out, but it is fearful that competition will mean that the district hospitals will not be able to compete in the ever-increasing scramble for resources. The health authority takes the view that resources have been cut consistently every year by the Conservatives through the north-west regional authorities and through political appointments such as the chairmen of the region and district health authorities.

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In other words, the district health authority's political chairman and the politically appointed district general manager have come up with a radical new idea following the decision not to opt out. Their idea is to close all our district general hospitals. Their proposal would asset-strip and sell off the land to whatever speculator would like to purchase Whelley, Billinge, Atherleigh and Astley hospitals and the Royal Albert Edward infirmary in Wigan. Their argument for asset-stripping such a large organisation of its district resources is to amalgamate them into one component.

Within the last 48 hours, on the ground of an emergency financial crisis, it has been decided to close one of our hospitals which cares for the mentally confused elderly and people suffering from senile dementia. Because it is claimed that an emergency exists, it is proposed not to consult the community health council, the patients' representatives or the patients' relatives.

I understand that, perhaps even this evening, those patients are being moved out into the private sector. The community health team, the social services and those involved in the care of the people in that hospital have not been consulted about the adequacy or otherwise of the alternative arrangements in the private sector. Astley hospital is to close following an announcement in recent days. A few months ago, a Minister came to Wigan to make a triumphant speech about the local Royal Albert Edward infirmary, stating that that hospital was safe in the Government's hands and that a multi-million-pound development project would go ahead. On that occasion, my hon. Friend the Member for Wigan (Mr. Stott) and I stood outside in the rain trying to make the point that a scheme was afoot to close that hospital. That was greeted with denials. Last week the health authority, in closed session, was informed that the Wigan Royal Albert Edward infirmary was indeed to close.

Assurances were given by the regional chairman, and even by the Department, that new developments taking place at Wigan infirmary would continue. We were assured that it would have a place in the 1990s as a modern district general hospital. Last week, the authority was informed that it was to close.

Not three years ago, the Department said that Billinge hospital would be developed in the 1990s on a district basis with the latest maternity facilities. We were also assured that it would have facilities for the short-term care of the mentally ill. On that basis, we agreed to the closure of a nursing facility in Leigh. That was closed and sold off for a housing development.

It was announced that weekend facilities at Billinge maternity hospital would close, and there is a long-term proposal that the maternity unit at Billinge hospital will close completely. It does not service just the Wigan health area, but also parts of the St. Helens and Knowsley health authority area, which are two of the most socially and economically deprived areas in the north-west region, which is one of the most socially deprived regions in the United Kingdom.

The facilities for the mentally confused at Billinge hospital are so overstretched that Wigan borough council social services department is having to retain patients who would, under normal conditions, be contained in the units at Billinge and at other facilities at the Leigh end of the authority. Because of the cash crisis, the social services department is having to take on the nursing requirements

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of the mentally confused and the elderly ambulant, in growing numbers. That is the reality of, and the background to, the Government's proposals.

Not one part of the Government's proposals has shown that there will be any new financial resources available to my authority. What is happening, in advance of the proposals, is an asset-stripping job on a grand scale. Public assets worth hundreds of millions of pounds will be sold, and not one local person will be asked if they would like Wigan hospital, Billinge hospital, Leigh infirmary, Atterleigh hospital and Astley hospital to remain open.

None of us is in the ball game of keeping open hospitals that need to be closed if alternatives are provided, but we are opposed to the naked opportunism of those politically motivated people in the Health Service-- people who have been appointed by Conservative Members and Conservative party members--who are asset-stripping on their behalf in advance of the Health Service reviews.

I ask the Secretary of State--with whom I have clashed several times--to institute an immediate inquiry into why Wigan health authority, on the grounds of an emergency, is taking patients out of hospitals and dumping them into the private sector, without any consultation with the social services or with those people who are currently responsible for looking after them. The least that the Secretary of State can do is give them a commitment that he will look into that within the next 24 hours.

I hope that, when the report is produced on 10 August, the Secretary of State will respond effectively to it.

Mrs. Audrey Wise (Preston) : I have listened with the utmost attention, as my hon. Friend represents a constituency in the north-west, to the catalogue of disasters that are befalling his area. I do not want to compete with him by raising larger issues, as he has done, but I would like to draw my hon. Friend's attention to a small but significant matter which has occurred in my area, which shows the madness caused by the so-called search for efficiency. Preston district health authority has saved the magnificent sum of £1,500 during the past year by cutting the availability of free incontinence pads for elderly ladies. Whether we look at the large scale, as my hon. Friend has done, or at the small scale, as I have done, the picture is the same.

Mr. McCartney : My hon. Friend is correct. On the day that the former Under-Secretary visited Wigan and salmon sandwiches and a huge banquet were provided in Billinge hospital, babies were being born and the supply of nappies had to be restricted. That shows the Government's priorities.

I hope that the Secretary of State will, after 10 August, take into account the views in the majority report, and that he will assure the public and Opposition Members that he will not ride roughshod over the doctors, the midwives and the nation, who are totally opposed to the proposals.

9.29 pm

Mr. Tony Baldry (Banbury) : I hope that the House will understand if, given the short time left in the debate, I do not propose to give way as much as I would like.

I think that hon. Members agree that the ultimate purpose of the National Health Service must be to improve services to patients. The White Paper's proposals will do that by giving doctors and medical staff more

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control, by cutting central administration controls, devolving managerial power and by allowing general practitioners to become budget holders and hospitals to become self-governing--all within a framework of a publicly funded Health Service. In that way, patients will come first. The ambition of everyone must be to ensure that each and every patient in the NHS is treated as an individual. Central to the NHS, as with every publicly funded service, must be money. It is interesting that, during the debate, we have heard little about money. The Opposition's motion must be the first motion on the NHS tabled by the Leader of the Opposition that has not alleged that the NHS is underfunded. That is perhaps because the Opposition have recognised that, whatever funding proposal they put forward, the Government will always more than match it.

Over the past 10 years, the Government have persistently and diligently provided more money for the NHS. In 1978-79 the Health Service budget was £7.75 billion and in 1989-90 it is about £26 billion. National Health Service spending has increased by 36 per cent. more than inflation and has grown more rapidly than the rate of growth of the real economy. Health spending has risen from 4.8 per cent. of GDP 10 years ago to 6.1 per cent. now. If we reverted to the funding of the NHS when the Labour party was in government, we would have to cut the number of doctors and dentists by about 14,000, the number of nurses and midwives by 67,000 and the number of hospital patients by 1.5 million.

Of course, the National Health Service always faces fresh challenges. For example, 70 per cent. of NHS costs are labour costs, and there has been a dramatic and welcome increase in the number of NHS employees over the past 10 years--5,800 more doctors and dentists. Their pay has grown 25 per cent. more than inflation since 1979. Nurses, whose pay fell under Labour--they received increases below the rate of inflation for three years--have seen their pay rise by 45 per cent. more than inflation since 1979.

As well as trying to ensure that doctors and nurses and those working in the NHS are well remunerated, there are also the challenges of an ageing population and of medical advance. In response, the Government will clearly have to provide ever more money for the NHS, but we all have an interest in ensuring that that money is well spent. As my right hon. and learned Friend the Secretary of State has said many times, the NHS is not a business, but clearly it can be more businesslike.

It is right that the Government should devolve greater powers and responsibility to local levels. For far too long, the NHS has been over- administered and under-managed. This has led, for example, to the Public Accounts Committee discovering, according to a report published last year, that in the five districts whose operating theatre usage was studied, only 72 per cent. of available sessions were regularly scheduled for use and of those about 23 per cent. were cancelled, often at short notice. Consequently, only half the daytime operating theatre sessions were used-- no wonder we continue to have long waiting lists for cold surgery. The Public Accounts Committee concluded :

"Traditional practice and habits, framed for the convenience of consultants and staff must be reviewed as necessary."

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Furthermore, all too often the lunatic situation arises that if a hospital does more work it simply runs out of money more quickly. That is a lunatic efficiency trap. The proposed internal market will replace that efficiency trap with a much better system whereby the more contracts that are won to provide services, the more work is done and the more money secured. Hospitals that increase their referrals will also increase their income.

Let us be clear that there is a consensus on the need for an internal market. In a speech a year ago at Guy's hospital, the hon. Member for Livingston (Mr. Cook) said :

"Personally, I can see merit in greater flexibility that permits health authorities to convert cross-boundary flows of patients with cross-boundary flows of cash."

That is exactly what the internal market is about--correlating cross- boundary flows of patients with cross-boundary flows of cash. The right hon. Member for Plymouth, Devonport (Dr. Owen) observed that

"bringing the disciplines of the internal market into the NHS is the most important single reform I would advocate, for it can work with the grain of the NHS and not weaken its ethical basis." As the Prime Minister has made clear, the internal market has nothing to do with privatising health services but everything to do with improving them.

That leads us to the background of the general practitioners' contract and the recent debate. The House should recollect that the GPs' draft contract has had a long gestation period. We have almost forgotten, in the mists of time, the Green Paper "Promoting Health Care--An Agenda", which came out in April 1986. That Green Paper was followed by the White Paper "Promoting Better Health" in November 1987 and that, in turn, led to long negotiations with representatives of the GPs on the detailed proposals.

All hon. Members will have had a letter from Dr. Wilson factually reporting that the general practitioners have voted against accepting that contract. Interestingly, no argument was advanced in that letter to explain why general practitioners had rejected the contract. It would have been very difficult for Dr. Wilson to advance such arguments, because the General Medical Services Committee contract was the very contract that he and the other negotiators had recommended for their own members.

I am looking forward to a happy recess because the general practitioners in Oxfordshire voted in support of the proposed contract.

Mr. Mike Watson (Glasgow, Central) : Will the hon. Gentleman give way?

Mr. Baldry : No, there is very little time and I made it clear at the start of my speech that I did not intend to give way. The hon. Gentleman, who was not even present then, can hardly expect to intervene now.

It is difficult for Dr. Wilson and the GMSC to suggest that a contract that they negotiated and agreed is flawed in some way. I have yet to see, and I suspect that other hon. Members have yet to see, any detailed proposals from the GMSC on how the contract should be improved.

The background to the contract is that spending on GP services has risen by 50 per cent. over and above inflation during the past 10 years. The number of GPs in practice is up by 20 per cent. and their support staff are up by 50 per

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cent. Despite that, real concerns remain about the present GPs' contract because it does not sufficiently reward zeal or quality and it is not sufficiently sensitive to patients.

It seems to be suggested that by increasing the proportion of doctors' remuneration that comes from capitation, we shall force doctors to take on more patients and undermine the quality of care. The case for making a significant proportion of GPs' income dependent on capitation is not new. That case was made by one of the authors of the National Health Service, Nye Bevan himself, on the founding of the NHS. He said :

"I cannot dispense with the principle that the payment of a doctor must in some degree be a reward for zeal, and there must be some degree of punishment for lack of it. Therefore, it is proposed that capitation should remain the main source from which a doctor will obtain his remuneration."-- [ Official Report, 30 April 1946 ; Vol. 42, c. 55.]

Nye Bevan saw capitation as one of the underlying principles on which general practitioners should be rewarded. Moreover, nothing in the Government's proposals would increase doctors' average list size. Patients will register with the practice of a doctor who they think gives the right quality of care and the right amount of time. GPs' list sizes are falling from an average 2,200 to under 2,000 now. Just as it is impossible to invent new patients, so it is mathematically impossible to increase the average list size.

I hope that, during the summer, GPs will reflect that the contract that they have been offered is a good one and that many concessions have been made by my right hon. and hon. Friends in the Government, after listening to representations that they undoubtedly received from hon. Members on both sides of the House. While the Government's health proposals will not solve everything, they will make several important advances, extend patient choice, encourage enterprise in hospitals and among GPs and improve the quality of patient care and treatment in the framework of a publicly financed Health Service. 9.46 pm

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