Mr. Ian McCartney (Makerfield) : On a point of order, Mr. Speaker. This afternoon I obtained a letter from the hon. Member for Mitcham and Morden (Mrs. Rumbold), the Minister of State, Department of Education and Science, inviting me to donate more than £200 to attend a dining room function on the Terrace. That document carries the House of Commons logo. It comes from an hon. Member, but it invites me to send my cheque for £200 to a Conservative association. That is a grievous misuse of the House and an attack on the rights of hon. Members. I would ask for the matter to be investigated and for you, Mr. Speaker, to report back to the House.
Mr. Nicholas Bennett (Pembroke) : Further to that point of order, Mr. Speaker. I want to refer to the use of stationery and House of Commons envelopes in a different case. A letter was sent out to general managers of district health authorities in England and Wales by the shadow Secretary of State for Health on House of Commons notepaper. Paragraph 5 of the leaflet issued by the Serjeant at Arms on the use of the House of Commons emblem, stationery and post-paid envelopes says :
"Members who wish to send out circulars may purchase original House stationery, or, at their own expense, may photocopy or by other means reproduce that stationery."
It then goes on to describe what a circular is--
Mr. Speaker : Order. We all know that. Every hon. Member has that leaflet. In view of the pressure of time, I should say that the same rule applies to every right hon. and hon. Member. It is not in order to use House of Commons stationery for party political purposes. Complaints should be made to the Services Committee, not to me.
Mr. Dennis Skinner (Bolsover) : On a point of order, Mr. Speaker. You will know that when private Bills are brought before the House they sometimes have to go back for re-examination. At 7 o'clock today we are due to discuss the Associated British Ports (No. 2) Bill. That Bill started its progress two years ago when there was a balance of payments surplus. It was tiny, but nevertheless it was a surplus. During the Bill's passage we have acquired a £20 billion trade deficit.
Mr. Speaker : Order. The opposed private business has been put down by the Chairman of Ways and Means. It is in order, it is on the Order Paper, and it will be debated later tonight. It may well be a matter of argument later on tonight.
Mr. Speaker : Order. It is not the function of points of order to raise matters of a party political nature across the Chamber. They must be matters of order on which I can rule. The hon. Gentleman well knows the rules in that respect.
Mr. Eric S. Heffer (Liverpool, Walton) : On a point of order, Mr. Speaker. You say that you have referred the matter raised in the earlier point of order to the Services Committee. Does that mean that the Committee will report back to you so that you in turn can report to the House? This is a matter not just for the Services Committee but for the House, and it is you, Mr. Speaker, to whom we look to protect the interests of the House.
Several Hon. Members rose--
Mr. Speaker : Order. I am not taking any more points of order which are not points of order for me. We cannot have party political arguments across the House on any day, and especially on a day when we have great pressure.
Mr. Kenneth Hind (Lancashire, West) : On a point of order, Mr. Speaker. I seek your guidance on a matter which is vital to the running of the House. Is it in order for Front-Bench spokesmen, particularly the Opposition spokesman on health and social security, to send out in House of Commons post-paid envelopes, to every health authority in the land--
Mr. Speaker : Order. As I have already said, this matter has been reported to the Services Committee. A Select Committee is looking into the matter. I cannot say any more. I have already answered the point of order raised by the hon. Members for Pembroke (Mr. Bennett) and for Liverpool, Walton (Mr. Heffer).
Several Hon. Members rose--
Mr. Speaker : Order. I have already stated the rules, and I repeat them. It is not in order for hon. Members to use House of Commons stationery, or even the House of Commons facilities, for party political purposes.
"The Instrument has not yet been considered by the Joint Committee on Statutory Instruments."
The Government organise the business of the week. The Joint Committee on Statutory Instruments met yesterday and that item was not on the agenda. Under Standing Order No. 124, a duty is imposed by the House on the Joint Committee on Statutory Instruments to consider a statutory instrument
"with a view to determining whether the special attention of the House should be drawn to it"
on a number of grounds which are listed in the Standing Order. There does not seem to be much point in having a Joint Committee set up by the House to consider statutory instruments if the Government insist on putting on the Order Paper an item that the Joint Committee has not considered. We cannot possibly report the matter to the House and engage in deliberations. If we want any
Column 323information, the Standing Order requires us to give the Government the opportunity to present evidence to the Joint Committee. So we must take at least a week over the matter. Therefore, the Joint Committee's work is being deliberately frustrated by the Government not saying that, until the Joint Committee has reported, it will not be possible to debate the matter. It is quite outrageous that the Joint Committee, established by the House should be ignored in this way and specifically deprived of the opportunity of presenting a report on the statutory instrument.
Mr. Speaker : The House appreciates what the hon. Gentleman does for the House as Chairman of the Select Committee on Statutory Instruments. But today we are not to debate an affirmative order ; we are to debate an Opposition prayer and there is a rubric on the Order Paper to the effect that the instrument has not yet been considered by the Joint Committee. The prayer is in order.
That leave be given to bring in a Bill to empower councils and housing associations to terminate tenancies where the dependants of a tenant have been rehoused on account of the tenant's violence. Last Saturday I was visited in my surgery by a young mother of three children. She and her youngest child, a baby, are currently living with her parents and two other adults in a three-bedroomed house. I have a report from Kent social services saying : "In 1988 it was discovered that"
the two older children
"had been sexually abused. They were interviewed and disclosed that they had been abused by their father. Although he was interviewed by the Police no charges were laid as it was felt that they were too young to give evidence in Court. However, the disclosures were specific enough for Care Orders to be obtained on both".
Needless to say, the lady who spoke to me is most anxious to obtain a council house so that she can reunite her family. One might ask what has happened to the family home. The answer is that the husband continues to occupy the home. He is entitled by law to continue to occupy that ratepayer -subsidised home for the rest of his life if he so chooses. Even if he had been convicted and sent to prison, he would still have that right for up to a year and the ratepayer would have to pay for housing benefit to pay his rent. Battered wives and abused children live in a grey statistical area ; there are no firm statistics. We can study surrogate statistics--for example, the Children's Society says that almost 100,000 children left home last year, for one reason or another. We are aware of the growth in convictions for marital violence and we know of the tremendous increase in divorce, currently running at about one marriage in three. However, there is no way by which we can obtain accurate figures for offences committed within the home.
However, we can say with certainty that the case to which I have alluded is not an isolated example. There is a home for battered wives in my constituency where volunteers do excellent work. From time to time ladies in that home ask me to try to assist them to obtain a council house. Many of them come from local authority homes, and in almost every case the husband or common law husband continues to occupy the original home. Surely that is a great injustice. A man is given a subsidised tenancy so that he can house his family. That was the purpose of his being given the asset, but that purpose has now lapsed because--I must be blunt--of his wickedness. Is it right that he should continue to enjoy it?
Council officials tell me that in many cases the problem takes a second, sick twist. Possessed of that asset, the man is well placed to install another woman, who may not even know the story of the first family, and so the same sick cycle starts again. In effect, child abuse or wife battering is paid for on the rates, with the council being powerless to do anything about it.
What legal remedies are available? There are two. The first is the ouster order, under which a court can evict the husband or common law husband and can also make a banning order to keep him away from the home. That has two defects. First, it puts the onus of the legal action on the shoulders least able to carry it--those of the wife. In many
Column 325cases the principal witnesses are the children, and even if the wife plucks up the courage to apply for the order the last thing that she wants to do is to involve the children. Secondly, she would then be in the same home, when what is obviously needed is for the council to rehouse her so that her husband does not know the address. The council could then recover the original house so that its stock would not be one house down.
There is a second option. In the Housing Act 1985 the Government made a sensible stab at trying to do something about the problem and included provisions in a tenancy agreement to deal with that sort of case. Unfortunately, that also has serious defects. First, it cannot apply to any tenancy before 1985. Secondly, many councils have not yet amended their tenancy agreements, so even those with the most recent agreements cannot take advantage of the Act.
My proposed Bill would cut through all that. If the family had to be rehoused because of the misconduct of the husband, who was the tenant, my Bill would make that a prima facie ground for eviction by the local authority or by a housing association which also provides subsidised housing. It would be a civil measure, as is schedule 2 to the 1985 Act, so that there would be no need to prove criminal charges against the man.
I have received an early and constructive response from the Government, and I am grateful to note that two Ministers from the Department of the Environment have taken the trouble to be on the Front Bench. I am delighted to hear that they will consider the matter. I leave them and the House with this thought. The course of action that I have proposed would have four advantages. First, it would make it much easier for councils such as Canterbury with long housing lists to rehouse those unfortunate families. Secondly, it would take the legal burden from the wife, as the council could take the necessary action. Thirdly, it would eliminate the absurd expense to the ratepayer of having to keep a house going with only one person in it. Fourthly, it would send a clear message to violent husbands that the community is no longer willing to subsidise their activity. Question put and agreed to.
Bill ordered to be brought in by Mr. Julian Brazier, Mr. Alan Amos, Mr. John Bowis, Mr. Matthew Carrington, Mr. Neil Hamilton, Mr. Edward Leigh, Mr. Keith Mans, Mr. Iain Mills, Mr. David Tredinnick, Mr. Ian Taylor, Mr. Roger Gale and Mr. Ian Bruce.
Mr. Julian Brazier accordingly presented a Bill to empower councils and housing associations to terminate tenancies where the dependants of a tenant have been rehoused on account of the tenant's violence : And the same was read the First time ; and ordered to be read a Second time upon tomorrow and to be printed. [Bill 211.]
That an humble Address be presented to Her Majesty, praying that the National Health Service (General Medical and Pharmaceutical Services) Amendment (No. 2) Regulations 1989 (S.I. 1989, No. 1897), dated 15th October 1989, a copy of which was laid before this House on 16th October, be annulled.
I was much entertained to read in last week's Health Service Journal that a senior official had told the journal that the Department of Health expected Opposition Members to come out with all guns blazing in today's debate. I am much obliged to the Department for the constitutional innovation of informing the press of the tactics to be used by the Opposition.
I am being invited to come out firing to defend a profession which--as the whole House knows--voted overwhelmingly Conservative at the last election. I accept my democratic duty with a familiar resignation, as I know that, having accepted those votes, Conservative Members have no intention of defending that profession. I bring to the task a cold and clear perception that there is no prospect of support from them. I am well aware that, had the Secretary of State and I reversed roles and had I occupied his office during the past six months, there would have been no prospect of the BMA's senior negotiators rolling over and playing dead as readily as they have been doing since his announcement that he would ignore them and impose the contract regardless.
The Secretary of State and I are, however, probably in agreement on one matter. The important question is not whether the contract will inconvenience GPs, but whether it will affect patients : that is the issue on which the debate must turn. As I said in the July debate, there are areas of congruence between the Secretary of State and myself on the contract. For instance, I see every reason why GPs who arrange to make their own night visits should be paid more than those who do not ; nor do I see any objection to GPs being required to provide leaflets setting out the nature of their practice. I also find it impossible to oppose the proposal that the maximum holiday to which a GP is entitled should be cut--or, as one GPs' paper put it in a headline last weekend, slashed--to six weeks a year. I am happy to support such a suggestion, even when it is made by Ministers who have achieved some notoriety on account of their own holiday arrangements.
These issues, however, are not the core of the new contract ; they are the lace trimmings intended to make it more appealing to the eye. The key issue --the key clause--which has caused most GPs to decline to sign on the dotted line is the fundamental shift that it represents in the increase in the capitation element from 46 per cent. to a figure which, although undisclosed, will be at least 60 per cent. The effect--which we must assume to be deliberate--is to provide an incentive to lengthen patients' lists. I am familiar with the riposte from Ministers that the average list cannot lengthen because, as patients are poached from one GP by another, the average must stay the same. That is merely to restate the laws of arithmetic. Patients may choose. I do not wish to be contentious on that point. I am happy to accept that patients should have the choice. My contention is that whether patients choose or are poached, the average remains the same. That
Column 327conceals the fact that the contract is clearly designed to result in a smaller number of practices with longer patient lists. That is in flat contradiction to the policy pursued for the past 20 years by successive Governments, of encouraging smaller patient lists. In fairness to the Government, it also contradicts the trend of their policy throughout the past 10 years towards smaller lists.
Mr. Michael Stern (Bristol, North-West) : Will the hon. Gentleman explain why he objects to patients choosing their GP? Is he saying that the principle of smaller lists, which he believes to be common to both the Conservative and the Labour party, gives the House the right to direct patients to stay with a doctor whom they do not like rather than go to the one of their choice?
Mr. Cook : Absolutely nothing I said suggests that I object to the concept of choice. Patients have choice now and I am in favour of making that choice easier. However, I am not in favour of giving GPs an incentive to seek a longer patient list and of penalising those who, sensibly and in their patients' interests, decide not to take on more patients than they can handle, which would result in their having less time for their existing patients. That has nothing to do with patient choice, but everything to do with the incentives to be offered to general practitioners.
As recently as 1987, consensus on this matter was restated by the Select Committee on Social Services. Commenting on the then White Paper on primary care, it said :
"The proposal to increase the proportion of GP's income derived from capitation was universally opposed."
Patients' associations were among those opposing it. The statement continued :
"The case for further reductions in the GP's list size seems unanswerable."
It would be unfair to suggest that the Secretary of State has answered the case. He has chosen to ignore it. It is a powerful case. More patients on a list mean less time for each patient. The case is all the more powerful as we know that patients want more time with their GP.
The magazine Which? carried out a survey last month which concluded that nine out of 10 patients expressed a preference for more time with their GP. That is entirely reasonable because seven minutes, the average consultation time in Britain, is the lowest in Europe.
The Secretary of State is well aware of the Which? survey. We know that, because he quoted from it at the press conference when he announced that he was to impose the contract. He quoted the following :
"We think the new contract is likely to expand the services available to patients."
It is a pity that he did not quote the next sentence :
"We think the Government may have misunderstood how highly patients value the time they spend with their GPs. We do not think that you will get more time with the GP in the surgery. Less time with the GP may mean more time with the nurse."
"We think the new contract is likely to expand services to patients."
Column 328Surely that is crucial, because patients will get more choice. It is all very well for the hon. Gentleman to complain about practice teams, but through family practitioner committees the Government will give the teams better opportunities to help the GP in the practice. Surely that should be welcomed.
Mr. Cook : Hon. Members will observe that I quoted the passage that the hon. Gentleman was so anxious to put on the record. On his second point, it is ironic that he should make the case that the Government will rely on primary health care teams using other professionals and employees to provide services when, from 1 April next year, for the first time in the history of the NHS, his Government will place cash limits on exactly those professionals.
Apart from the Which? survey, there is also a study by Wilkin and Metcalfe of what happens when patient lists lengthen. It discovered that, as patient lists lengthen from 2,000 to 3,000 patients, the average contact time per patient falls from 30 to 20 minutes a year. There are already 3,000 practices with more than 2,500 patients per GP. Any contract that tried to meet what we know patients want would set out to reduce the number of practices with large lists.
Mr. John Bowis (Battersea) : Is not the answer to the hon. Gentleman's point to increase the number of doctors? Is he able to explain how doctors' patient lists will be expanded along his lines if more and more doctors will be available to share the work load?
Mr. Cook : The number of general practitioners has increased during the last 20 years. However, during the last 12 months, the period during which we have been debating the contract, the number of trainees in general practice has fallen. I shall express grave anxiety later in my speech about the fact that many of those trainees are now finding it increasingly difficult to enter general practice precisely because of the contract that is now before the House. Any contract that sought to meet patients' needs would seek to reduce the number of practices with large lists. Instead, the Secretary of State is seeking to increase their rewards. Logically, therefore, he expects the number of practices with long lists to increase. If the Secretary of State continues to deny that that is what he expects and wants, there is a simple way to convince us that that is not what he seeks.
I put to the Secretary of State the question that I put to him last July : if he does not wish patient lists to lengthen, and if he shares the consensus of the last 20 years that patient lists should be reduced, why does he not accept the BMA's proposal, which is on the negotiating table, to reduce the maximum number on patient lists from 3,500 to 2,500? Will he not accept that basic step, which would provide some protection to patients against general practitioners deciding as a result of this contract that the sensible and rational response is to hold as many patients as possible on their lists?
The Secretary of State for Health (Mr. Kenneth Clarke) : Does not the hon. Gentleman agree that that would impose an artificial constraint upon doctors? It would prevent a GP from taking on to his list a patient who wanted to go on to his list because the patient was satisfied that he or she would get good service from that GP. How
Column 329does that equate with the hon. Gentleman's unconvincing assertion that patient choice is one of the issues that he is bearing in mind?
Mr. Cook : No, it would not have that effect. The artificial barrier of 3,500 patients is already there. When a GP hits the 3,500 barrier, the practice takes on another partner. Under our proposal, practices would not be obliged to turn away patients. High patient list practices would be provided with a financial incentive to take on additional partners, thus increasing the tendency to reduce patient lists by increasing the number of doctors. That would provide greater, not less, choice to patients.
Patients are not the only victims of the proposal. The growing number of women GPs is another casualty. In parenthesis, may I say that I welcome the advent to our debates of the hon. Member for Surrey, South-West (Mrs. Bottomley). I hope she will forgive me if I say that our welcome to her, warm though it is, is as nothing compared to the unfeigned welcome that we give to the departure from our debates of her predecessor. Conservative health policies certainly can do with a woman's view.
I noticed the unfortunate statement earlier this month by the Conservative Medical Society, which urged an increase in Britain's population. It says :
"A return to enhanced birth rate would eventually allow more women to return to their prime task of bringing up their families as their profession whilst the young as yet unmarried provide the recruits to the health care profession as in the past."
I suspect that that passage was not drafted by the Secretary of State. He will be aware that, as a strategy for filling GP vacancies, it is deeply flawed. It requires six years at medical school, followed by a year in a hospital, followed by a year as a GP trainee to qualify as a GP. By the time that a woman has completed that, she will be in her late 20s, most likely be married and probably starting a family. Therefore, on the whole, women GPs seek more moderate list sizes. The average list size of women GPs is 35 per cent. below the national norm.
The fear is that, under the new entrepreneurial age being ushered in by the Secretary of State's contract, practices will want to take on not a woman partner but a partner who will play his full part--it will be "his" full part--in the competitive struggle to maintain income by pushing up patient lists.
I acknowledge that the contract contains new arrangements for part-time GPs, but that overlooks the fact that in the new war to attract and retain patients practices will not want part-timers. Since the first draft of the contract was published in the spring, there has not been a single part-time partnership advertised in Scotland. Curiously, much of the stress in the rest of the contract is to provide services for women and children, such as screening, immunisation, well-woman clinics and child health surveillance. All the evidence shows that women find it easier to accept those services from women doctors. If the Secretary of State is to meet his targets, the hon. Member for Surrey South-West had best take him aside and explain to him that he should make it easier, not more difficult, for women to enter general practice.
The issue whether GPs should be rewarded by numbers goes much deeper than whether there will be enough time for each patient or whether patients will have the right of access to a woman partner. At the heart of the debate is how we motivate the medical profession. The current edition of "Pulse" contains a profile of a GP practice in
Column 330Bristol. It is located on a council estate called Hartcliffe, which scores high on the deprivation scale. It has an unemployment rate of 30 per cent., and 48 per cent. of families are single- parent households. The practice does not believe that it will qualify for the new deprivation allowance because it is allocated on a ward basis and, because of affluence elsewhere, their wards score below the Jarman scale.
There are intense demands on the medical practice ; 70 per cent. of the children registered with it come from families in which one parent is under 21 and require considerable support. The practice has therefore adopted the conscious policy of reducing the patient-doctor ratio. It has succeeded in reducing it by 25 per cent., with the objective of increasing the amount of time spent on each patient. Far from rewarding it for that ethical decision, the contract will penalise it for not getting stuck into the competition to maximise list size. Here we glimpse the long-term damage of the contract. The Secretary of State has based his contract on the explicit premise that the only motivation he can recognise is a financial incentive. The majority of GPs spend most of their day not on activities that they have calculated will maximise the revenue of their practice but on activities that in their view best meet their ethical duty to their patients. It is clear from the many conversations that I have had over the past two weeks that many GPs feel deeply the insult that they saw in his comment that he is asking them to do only 26 hours a week. The majority of GPs do well over 26 hours a week, and many work easily twice those hours.
Yes, there may be a few passengers, and, yes, it may be that the only thing that will prod those passengers into greater productivity is the sharp stick of hard cash, but the tragedy is that the Secretary of State has drafted his contract to address the motivation of the minority. The danger is that he will therefore undermine the much finer performance of the majority of GPs, who are motivated by a sense of ethical duty and the public service ethos. If all that matters is meeting the minimum for financial reward, that minimum may become the maximum that anyone does.
Mr. Cook : I am sorry to have to advise the hon. Gentleman that the BMA negotiators did not agree to the contract. They recommended it to their members because there was an explicit understanding that if their members did not vote for the contract the Secretary of State would withdraw the concessions that they had negotiated. That was the precise basis on which they agreed to recommend it in the ballot. The hon. Gentleman's intervention brings me to my next point, which concerns, not the contents of the contract, but the style in which it has been negotiated. As the hon. Gentleman has reminded us, the contract was put to a postal ballot of BMA members. We have been repeatedly led to believe by Conservative Members that postal ballots are the model of modern trade unionism. In the postal ballot on the contract, the membership, in an 82 per cent. poll, rejected the contract by 76 per cent. to 24 per
Column 331cent. As the hon. Gentleman has reminded the House, that was in a ballot where the Secretary of State had the BMA negotiators on his side, recommending a yes vote.
A word other than "contract" is needed to describe this document. A word that captures more honestly the authoritarian, centralising nature of the Government who are imposing it would be "edict" or "decree". Those words more accurately capture the flavour of the document that the House is debating.
Perhaps it is a matter of indifference to patients whether the contract is negotiated or imposed. Contracts that are imposed have to be written in a bunker because they cannot go through a process of full consultation which involves taking the people on whom it will be imposed into one's confidence.
We are debating a detailed manual of how doctors should practise medicine daily in their surgeries, which has been written by civil servants in an office in Whitehall. When I read comments in the medical press about the contract, I was struck by the fact that, often, doctors who agreed with parts of the contract were appalled, nevertheless, at how amateurish the contract was in setting them out. For example, on child health surveillance, Dr. Curtis, of the British Paediatric Association, said :
"the proposals have been ill-thought out, not properly worked through and I am appalled at the rate at which they are instituted". Dr. Wilson, a pioneer in developing annual reports for practices, who voluntarily produced an annual report on his practice for five years, said :
"The information which the regulations demand is of little use. It seems to have missed the mark and instead of being for the field workers it is for the administrators back at head office." Dr. Brian Wiggins, who has specialised in minor surgery at his practice and has his own specially constructed surgery unit, says that be believes that the list of minor surgery has been drawn up by a bureaucrat with little surgical experience.
Fortunately, the bureaucrat in question broke cover last week. Mr. John Shaw, the under-secretary in charge of family practitioner services, addressed the family practioner committees' annual conference last week and explained why he had not felt able to indulge in face-to-face discussions with GP leaders on the new contract. He said :
"I took the view that in dealing with such detailed fine print the most effective way was to do it in writing."
So there we have it.