House of Commons Hansard Debates for 1 Nov 1989

Mr. Kenneth Clarke : The hon. Gentleman has entered unusual ground by attacking one of my civil servants by name and by quoting him out of context. The two areas that he refers to--child surveillance and minor surgery--were put into the contract at the request of the BMA. Mr. Shaw engaged in about 100 hours of negotiations with doctors on those services and on the details of how they would be described in the contract. The quotation he has just used describes what was happening at the later stages when we were drafting--crossing the t's and dotting the i's. Criticism should be aimed at the doctors who were closely involved, on the BMA side and on mine, in drawing up the details. The hon. Gentleman should not make cheap attacks on the civil servants involved when he is trying to find a reason to negate this patient-friendly contract.

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Mr. Cook : I am sorry that the Secretary of State believes that to quote his civil servants is to attack them. I was quoting the observations of those doctors who practise medicine, who have carried through exactly the kind of innovations that the right hon. and learned Gentleman is now making mandatory and who clearly from their comments do not believe that the regulations which are now being imposed upon them reflect medical expertise or advice.

The House is invited to pass this edict, which is being imposed despite the rejection of the profession and which was drafted on the explicit basis that it had best be done in writing. When they come to put up a museum to the Government, there should be a special place for this statutory instrument as a document which is one of the finest demonstrations of the Government's style, based on the conviction that the Government know what is good for the rest of us and on the belief that the more one ignores advice, the more one demonstrates the strength of those convictions. Fortunately, the day when the Government can be consigned to that museum is approaching. There is a sad irony in today's debate, which I am sure has not escaped the Secretary of State and which must privately trouble him. He has chosen to copy the Prime Minister's style of management at the very moment that his colleagues are queueing up to beg her to change it. We are told that the Conservatives want more consultation, listening and sensitivity. They are about to hear a speech from the Secretary of State which all experience warns us will show that he revels in the fact that he is ignoring the doctors' ballot and relishes the idea that he knows better than the GPs in their constituencies what is good for their patients.

The Secretary of State will then invite Conservative Members for the first time in the 40 years of the NHS to impose a contract against the will of GPs. That vote provides an interesting footnote to the turmoil of the past week. It is the opportunity for Conservative Members to show whether they really meant all those fine words about more consultation and listening, or whether the Prime Minister got it right, in that it will be "business as usual". Business as usual means that the Secretary of State knows best-- better than the 75 per cent. of GPs who rejected his contract and the 70 per cent. of the public who consistently rejected his White Paper. If the right hon. and learned Gentleman's colleagues fall for that, those GPs and that public majority may well conclude that the Government do not know how to change their style. If people do not like the style, they had better change the Government.

4.17 pm

The Secretary of State for Health (Mr. Kenneth Clarke) : There should be a wide measure of agreement between myself and the hon. Member for Livingston (Mr. Cook) on large parts of this contract. I suspect that there is a much wider measure of agreement between us than the weasel words that the hon. Gentleman has chosen to use would show to the outside world. I am sure that he agrees with me that we are dealing with one of the most important parts of our National Health Service--the family doctor service. I have said many times and am happy to say again that the British family doctor system is the particular feature of the British health care system that in large part accounts for the particularly high quality of health care which we achieve in this country.

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I begin gladly by paying tribute to the contribution that family doctors make to the Health Service. We have spent the past 10 years increasing the numbers of those family doctors. We have increased the number of people in their support teams and expanded the service that they provide. When we return in later debates to the details of the White Paper on the wider NHS reforms which I am putting forward, I shall repeatedly emphasise the key role that we will expect GPs to play in the new National Health Service in influencing decisions on implementing provisions for the development of services and the distribution of resources in their locality as never before. Where money follows their patients, the hospitals and community services will respond to GPs and their pattern of referrals even more than they have in the past. They will be the patients' advocates and guides within the NHS even more than they have been before. We begin, I am sure, by agreeing that the majority of general practitioners work extremely hard. Many of them are workaholics and they are certainly completely dedicated to their patients and to the NHS. In putting forward a new GP contract, my aim, which should be shared by all hon. Members, is to raise the standards of our family doctor service still higher by getting rid of the unevennesses that we all know exist from place to place. My other aim is to reward more fairly those who work most effectively in the family doctor service and to give incentives to best practice, new services and higher levels of performance wherever they are achieved.

We ought to remind ourselves throughout the debate--although we have not forgotten so far--that we are not deciding how much family doctors should be paid. That will be determined by the Government--as it always is--on the advice of the Doctors and Dentists Remuneration Review Body. Family doctors can be very well paid and deserve to be when they nake the full contribution that the best undoubtedly do to the National Health Service.

These regulations and the debate look at the subject from the patient's point of view. The House is deciding whether the Government are right to specify more carefully what family doctors should be paid for in future. The effect of our decision will influence the income of individual family practitioners, because it will determine to a large extent which of them are paid more than the average net remuneration recommended by the Doctors and Dentists Remuneration Review Body and which are paid less. That will be a fair reflection of the contribution that each doctor is making and the services that he or she is providing.

Mr. Andrew Rowe (Mid-Kent) : Is my right hon. and learned Friend aware that one of the practices in my constituency has set its face against increasing the patient list size? However, it has already worked out that, under the terms of the new contract, by providing the level of service it already provides, every partner in that practice will be about £4,000 better off.

Mr. Clarke : In assessing the impact on their incomes, doctors will look not only at the number of patients they have, unless they have an exceptionally low number of patients that could be expanded, but at the type of services they are providing, the targets they can hit and the new services they can add which will be encouraged by the contract because they will be better rewarded.

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Why are we introducing a new contract? There has been a difficult and protracted process of consultation and negotiation. The present contract is 25 years old and its weakness is that it does not reflect the huge changes that have taken place over that quarter of a century.

We are looking back to a contract that was drawn up by a Labour Minister who eventually introduced regulations that he had been induced to draw up in the face of the threat of industrial action with which general practitioners were confronting him. It does not specify clearly what services doctors should provide. There have been many changes in the past 25 years. I will remind the House of the key changes that have taken place during the years for which we have been responsible. They underline our motives which have been challenged by the hon. Member for Livingston.

Since 1979, the number of GPs in the National Health Service has increased by 20 per cent., from 25,614 to 30,789. Those numbers are likely to continue to increase. The average list size has fallen from 2,229 in 1979 to 1,928 now and that decrease in average list size is plainly going to continue. The number of practice staff--nurses, receptionists and other support staff--that make up the primary care health team has increased by 70 per cent. since 1977. We are introducing cash limits to target that help better, and the Government have made it clear that they intend to expand those primary health care teams and increase the help available to doctors to help them expand their teams by removing some of the limits that specify the type of staff who can be employed on primary health care teams.

Dame Elaine Kellett-Bowman (Lancaster) : Some of my doctors are worried that in future they may have to justify the employment of one of those members of staff. They feel that in those circumstances it would be difficult for them to plan ahead, because they would not know what they would be planning for.

Mr. Clarke : The Government will honour the commitment into which we have always entered, to reimburse 70 per cent. of the cost of all the staff employed by GPs from the relevant date, which is next April. Thereafter, when a post falls vacant, GPs will have to notify the family practitioner committee and the committee will have to endorse the continuing need for that post. The reason for that is that 70 per cent. of the cost of those jobs is paid out of public funds, so it is only fair that when the post is renewed, somebody should be given the opportunity to confirm that it is a justified use of public expenditure. I do not envisage that the average family practitioner committee will go around cancelling nurses' posts and rejecting receptionists or practice managers. However, we cannot simply say to the GPs that they can carry on hiring whoever they want and that the family practitioner committees will write off the cost. The post should be checked as it comes up for renewal when the existing contract holder withdraws.

There have been substantial increases in the number of doctors and their support staff, and there has been a dramatic decline in average list size. The last survey also showed the effects that had had on the work load of family doctors. The last survey was carried out in 1985-86 and showed that the average family doctor worked 38 hours a week on general practice. That 38 hours included calls made by the doctor when on call. That average will strike

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all of us as low. I agree with the hon. Member for Livingston that it is easy to find general practitioners who are working many more hours than 38 a week on their practices. The reason that the figure is low is that there is a huge variation in time from one doctor to another. When one finds a doctor who says that he genuinely works double those hours, it has to be borne in mind that almost one in four of general practitioners were found to work fewer than 30 hours each week on general practice, and the remuneration system should reflect that.

Mr. Michael J. Martin (Glasgow, Springburn) : On the question of the GPs' work load, does the Secretary of State care to comment on the fact that a Doctor Kermani at a health centre in Essex has stated that the Government will give GPs more work? He is being told by the Government to give information which is normally confidential between patient and doctor on the patient's housing, employment and family problems. Is that true?

Mr. Clarke : It is not, unless the doctor has the patient's consent to do so. The doctor's comment no doubt refers to the surveying of elderly patients when they are visited. That is an extraordinary description of the service, to which I shall return in a moment. The work we are specifying is work that is being carried out in every particular by practices somewhere in the country already. There is a great variation in the hours worked, and the remuneration should reflect that more accurately. Overall, remuneration has risen dramatically under this Government. We now have 20 per cent. more GPs.

Ms. Harriet Harman (Peckham) rose--

Mr. Clarke : No, I will not give way or I shall be giving way after every other sentence.

Doctors' remuneration has increased as well. We have 20 per cent. more doctors than when we took office and the average total remuneration is up by 37.2 per cent. ahead of inflation, to £67,066. The net remuneration --I am not entering into the argument about the value to doctors of many of the indirectly and directly reimbursed expenses which, as self-employed men and women, they are also given--is up by 22.3 per cent. ahead of inflation to £31,105. Our policy in government has been to increase the number of GPs dramatically, to increase the number of their staff, to bring down patient list sizes and to extend the range of services available by taking on nurses and support staff. We are paying doctors very much better than did the previous Government who, in their last years in office, allowed doctors' pay to drop. The numbers are continuing to rise and all those trends will continue.

Against that background, it is wholly reasonable to stipulate the patient services that we expect should be provided and to lay down some tighter stipulations about the availability to patients of individual doctors. That brings us on to consider the requirements of the contract. I described the hon. Member for Livingston as having used weasel words because he hardly addressed himself to any aspect of the contract. I suspect that, when we examine the items that we are specifying, almost all of which have been challenged by some of the GPs whose cause the hon. Gentleman is advocating, we will see that he actually agrees with them. Every time he mentioned en passant

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night visits or something of that kind, he accepted that. The Opposition dare not oppose the great bulk of the real content of this contract. They accept that it is in the patients' interest, and they know that they should support it.

I shall deal briefly with some of the things that even the hon. Gentleman would not have the nerve to challenge. One is the minimum 26-hour availability for patient services at times convenient to the patient. That is a minimum. Of course many doctors will be more available than that, particularly if they have large lists. A 26-hour minimum stipulation is not unreasonable for someone in full-time practice. Higher fees for night visits were agreed. Plainly, patients prefer that if they must have a night visit it should be made by a doctor whom they know or one of his partners or close colleagues. When the doctor carries out that work, it is right that he should be paid more than someone using a deputising service.

I am sure that payments for minor surgery are agreed. The new arrangements for payment of child surveillance should certainly be agreed. As I said, that provision was inserted at the request of the British Medical Association. The details were worked out with the BMA over an enormous period to reach their present stage.

We are giving a higher capitation payment to GPs for their patients over 75. When we pay that higher capitation, it is right that the GP or a member of his team, such as a practice nurse, should try annually to check the home circumstances of the elderly person. It is not enough to say, "We will pay you more for having somebody over 75 on your list whom you might know little about and see rarely." It is a reasonable stipulation to have an overall picture of how that person is coping. Somebody should visit the home and make sure that the home conditions are all right, that the patient is coping with the shopping and cooking and that, generally, nobody else's attention needs to be drawn to that elderly patient.

All those services cannot seriously be challenged. At some of the meetings I have attended, some GPs have queried the need for me to specify that they might do some of those things.

Mr. Derek Conway (Shrewsbury and Atcham) : My right hon. and learned Friend is defending his case very valiantly. Will the 26-hour availability that he mentioned for general practitioners, particularly those in large rural areas, include travelling time and not just availability in surgeries?

Mr. Nicholas Winterton (Macclesfield) : He has made that concession.

Mr. Clarke : Yes, that is correct. I am grateful for the support of my hon. Friend the Member for Macclesfield (Mr. Winterton). It is a concession which I made in negotiations with the GMSC. I made it largely at the behest of Conservative Back-Bench Members from rural areas who challenged me about the 20-hour requirement without travelling time for home visits--a proposition I originally made.

Mr. Michael Morris (Northampton, South) : On availability to patients, my right hon. and learned Friend referred to 42 weeks, which is accepted, and 26 hours. Is he aware that, if five days occur alongside the 26 hours, a general practitioner on call over a weekend will work for 12 days without a break?

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Mr. Clarke : I am grateful to my hon. Friend for pointing out that they are required to work for 42 weeks of the year. The hon. Member for Livingston shares the problem of several of my critics--he has not read the contract. He thinks that we are slashing holidays to six weeks. Ten weeks are available, not only for holidays but for study leave and other things. Nevertheless, the six weeks have nothing to do with the contract.

On my hon. Friend's second point, yes, that can happen, but it is when the doctor chooses to be on call because he or she wants to give that service and wants to be paid more and not use a deputising service. We are not saying that they cannot use deputising services sometimes, but, when they are on call themselves because they choose to be, they should be remunerated more for those calls than for using the deputising service. That will be in the hands of the doctor.

Dr. Lewis Moonie (Kirkcaldy) : How does the Secretary of State propose to enforce the contract?

Mr. Clarke : The role of FPCs will be greatly enhanced. For example, on the 26 hours-- [Interruption.] The hon. Member for Kirkcaldy (Dr. Moonie) laughs at the idea that any of this might be enforced. At least he is not claiming that it is onerous--yet that was the argument, by implication, of his hon. Friend the Member for Livingston. I am greatly strengthening the family practitioner committees because they have a duty to manage and develop primary health care services in their areas. The committees will be notified by GPs of their ordinary availability to patients. That will mean that, if someone is not making himself available for the minimum 26 hours at times that are convenient to patients, he can be challenged by the family practitioner committee.

The Opposition will not have the nerve to attack the new requirements to strengthen the activities of GPs on health promotion and disease prevention, which is an important part of our contract. Some doctors are against that, but I do not think that many members of the public oppose it. Plainly, the family doctor service is an important arm of the NHS in health promotion. As a result of the contract, when patients first register with their GP they will be offered a check-up and three-yearly check-ups thereafter. The check-ups will be fairly minimal, but will provide an opportunity to give advice on developing problems and to detect problems early. We have also set targets for proper levels of child vaccination and for screening for cervical cancer. The targets that we have set for vaccination are those recommended by the World Health Organisation. I do not see why we, with our National Health Service, should not set ourselves the objective of attaining World Health Organisation recommendations. Targets for cervical cancer are also important and make allowance for the fact that some women may refuse such tests and some may not require them. The 50 per cent. lower and the 80 per cent. higher targets reinforce all that we have done in recent years to improve screening for cervical cancer which, I remind the House, still causes about 2,000 deaths a year, most of which are wholly avoidable.

Mr. Nicholas Winterton : My right hon. and learned Friend makes an extremely good point and is developing his argument carefully and constructively. What happens if a doctor does his utmost to reach the target but does not

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do so, through no fault of his own? Is it right that, after all the effort and time the doctor has put in, he should not receive the full remuneration?

Mr. Clarke : All doctors are paid for vaccination and for cervical cancer screening. Those things are now an ordinary part of a doctor's duties. We are talking about a kind of bonus payment for hitting particular targets. We are trying to encourage a positive effort by all doctors, which many of them now make, to advise and encourage patients to vaccinate their children or to undertake screening tests at the required intervals. There are still some doctors who challenge the requirement to drive ahead with cervical cancer screening in the way that we have suggested. I had such a challenge from a doctor yesterday. However, most doctors do not object to that.

The only argument was about how the doctors are paid. There is a big difference between paying people for each item, according to the number that they do in a year, and the system that we propose, which sets a target level at which a bonus will be paid because all the efforts of the practice have succeeded in encouraging people to take steps that are in their interests and the interests of their families.

Mr. Nicholas Winterton : I must press my right hon. and learned Friend on this matter. I understand that the maximum bonus could be about £1,500. That is quite an amount of money to anyone, and certainly worth earning. If a doctor contacts every patient about cervical cytology or the immunisation of children but, because of religious or other grounds, does not achieve his target, is there any reason why that doctor should not be awarded the top bonus? He has done everything possible to reach the target.

Mr. Clarke : We shall measure the effort, and someone who is making such an effort has little to fear from our targets. We do not say 100 per cent. because we anticipate that some people who have religious or personal objections, which they are entitled to have, will not wish to undergo screening tests. That is why we have gone for 90 per cent. in one case and 80 per cent. in the other. Those are reasonable targets, which should certainly be reached by the most active practices.

Mr. Keith Bradley (Manchester, Withington) : Will the right hon. and learned Gentleman give way?

Mr. Clarke : No. I should like to get on. I am sure that this matter will be raised later, and I shall deal with it then. When I set out the contents of the contract, I do not believe that many speeches will be made in the House--whatever letters hon. Members may have received from a few GPs--to challenge much of it. The hon. Member for Livingston, in an attempt to achieve topicality, suggested that the way in which we set about achieving that contract somehow reflects an unfortunate style on the part of the Government. Over the years, I have been engaged in the process of negotiation and consultation many times, but I have never been engaged in one that has been so tortuous and protracted as our consultations on the contract. I have not been engaged in many negotiations where I have made more concessions than I have in this respect.

The distant origins of this process lie in the time when I was Minister for Health--I am glad to say that my hon. Friend the Member for Surrey, South- West (Mrs. Bottomley) now holds that post--and I tried to raise the

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question of improving the contract with the royal college. The process got going with the 1986 Green Paper on primary health care. The Government then held 10 public meetings in consultation on those proposals and we received more than 2,000 representations. The overwhelming tenor of those representations was that the contract should be addressed to improving health promotion and disease prevention. There was a great deal of public response and that response was channelled into the White Paper. We then had more than 100 hours of negotiation with the BMA negotiators to discuss all the points.

On 4 May, I had a long meeting with the negotiators, who are extremely tough. The hon. Member for Livingston claimed that those negotiators "rolled over". That is a surprising description given my experience of the general demeanour of the GMSC negotiators. In their opinion and in mine, however, we reached a settlement on 4 May. On behalf of the Government, I made some substantial concessions to reach that position.

I wanted to get rid of seniority allowances--I have Labour predecessors who tried to do the same--as I do not believe that they are performance- related, All they show is that one is growing older. I conceded on that, however, and so long as doctors keep their full seniority allowance, we required that people should go in for the postgraduate training allowances that we are now introducing. I conceded on the basic practice allowance figures, partly in response to arguments, which I did not altogether accept, about the impact of that allowance on women doctors. I was also pressed on the rural practice payments scheme, as I was by a number of my hon. Friends. I agreed to abandon my proposals on that, although I believe that they were advantageous to doctors living in sparsely populated areas. We have agreed to refer that matter to the central advisory committee and it will come back to us on it in due course.

Target payments are an important part of the debate, and I conceded on the lower levels of target payment. That is an important concession as, especially with vaccinations, a high proportion of practices will hit the lower target payment.

On 4 May, I proceeded on the basis of the concessions made. The negotiators then recommended the resulting agreement to their members, but, because of the internal politics of the BMA, unfortunately, all that went wrong and there was subsequent controversy about the contract. [Interruption.] According to the medical press, the vote was conducted in extraordinary circumstances. Long after the vote had been taken, I had meetings that were full of reasonably friendly rural doctors. They all told me that they had voted against the contract because they should be able to keep their rural practice allowance. They were astonished when I told them that we were not withdrawing that allowance. The level of knowledge, among all the campaigning, was slight.

Many of the people who forced the vote were attacking the negotiators as much as me. Given that I have had my difficult times with the negotiators I sometimes feel sympathy for them when I see the attacks upon them. Only yesterday I read The Journal of the Dispensing Doctors Association, which contained an editorial and an amazing article entitled "Willigo Wilson", both by Mr. Roberts and both of which attacked the chief negotiator of the GMSC,

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Dr. Michael Wilson. He is a pleasant and friendly man, but an extremely tough negotiator. I shall give a flavour of the type of attacks that he has faced.

The Journal suggested that "Willigo Wilson" should go because he had surrendered so miserably to the Government over the contract, and stated :

"A further contribution to the ensuing disaster for general practitioners was that Dr. Wilson accepted that the emphasis in the fight should be almost solely on the effects of the Contract on patients".

The article set out what the themes and aims of the GMSC should be and asserted :

"The interests of doctors and patients do not always coincide!" Having agreed that the interests of patients should be put first, the author of the article advises Dr. Wilson :

"I would remind him, as he splutters over his morning cornflakes, that military leaders have shot themselves for less!"

for conceding to the position reached on the contract. The editorial addresses me by saying :

"Yes, Mr. Clarke, the 1990 Contract will hit our wallets and I am not ashamed to admit it"

I have good news for the rather unpleasant Mr. Roberts--he is wrong. As I have already said, the new contract will not hit his wallet. The rubbish in The Journal , which is sent to all members of the association, no doubt inspired those members to cast an unreasonable vote against the contract and to mount unreasonable attacks upon Dr. Michael Wilson. He is an honourable man who defends doctors' interests, but, to be fair to him, he also remembers the interests of patients.

To be fair to the profession, I should note that doctors have re-elected Dr. Michael Wilson, who recommended the contract to them, as their leader. We all know that feelings about the contract are fading away rapidly as individual doctors find out more about it. With stuff such as that which appeared in The Journal still being written I wonder who advises the Opposition. Which section of the medical profession does the Labour party listen to when it trots out all its opinions? It is obvious that that medical opinion is not speaking on behalf of patients, but on behalf of the more hot-headed members of the BMA. Such people give the Opposition an inadequate briefing so that they can make selective attacks on parts of the contract.

Mr. Robin Cook : Since the Secretary of State has been so kind as to ask who advises us, will he state just which organisation, whether medical, the BMA, one representing patients or any other organisation concerned with health policies and medical politics, supports his proposal to increase the payments by capitation fees and increase the incentive for longer patient lists? I just want the name of one organisation.

Mr. Clarke : I do not believe that what we have done increases the incentive for longer patient lists. The Labour party's approach to the Health Service debate is to talk in terms of organisations. All it needs is for a couple of trade unions and associations to give their views and the public interest, public advantage and patient interest are instantly forgotten. The hon. Gentleman cannot challenge the patient advantages of the contents of my contract. All it needs is for a trade union to oppose it and he will vote against it. He cannot argue against the public interest involved.

The hon. Gentleman claims that capitation will encourage less time to be given to each patient. The main

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effect of increasing the capitation element is that it will give added reward to doctors who attract and retain their patients. The idea that we should turn away patients from a particular doctor when those patients want that doctor is extraordinary. I also find it extraordinary that patients will be attracted to a list of doctors who give less and less time to each patient. That is the argument that the hon. Gentleman has tried to put together.

If a doctor has a large list, it is unlikely that he will want to increase it--a constituent of my hon. Friend the Member for Mid-Kent (Mr. Rowe) has already decided not to. If a doctor wants to increase his list size, however, he must attract the patients on to his list. He is more likely to attract them if he offers them more time rather than less. If a doctor already has a large list, he is unlikely to want to increase it ; instead, he will consider the services offered.

At the moment, nearly a quarter of our practitioners work more than 30 hours a week. If a doctor is induced to try to expand his list, I do not believe that he will say that at least seven minutes for each patient is not available when that patient comes in for a consultation. Doctors must decide whether they will be able to put in the increased work to justify the increased list. The judgment of the attractiveness of a particular practice will be made by the patients.

I agree with Which? and everyone else that most patients want more time with their doctor. Therefore, the ones that offer more time are the ones most likely to attract patients. The hon. Member for Livingston has already conceded that the idea that most lists will go up is a mathematical impossibility. I advise him to talk to some of the medical lobbyists about that, because I have been unable to persuade some of them that the lists of all doctors will not rise as a result of my proposals.

The female doctors point is an important one. I am glad that the hon. Member for Livingston anticipated that I had never heard of the extraordinary sentence which he read from a publication of the Conservative Medical Society. To be fair to the society, it may have been written by an individual member; I cannot believe for one moment that it represents the policy of the CMS.

We are seeing an every-increasing number of women GPs and wish to do so. Without doubt, we shall see an increasing proportion of women GPs because, at the moment, about 40 per cent. of the trainees up and down the country are women. There are changes in the contract which make it easier to employ women. Part-time contracts are to be allowed for the first time. The valuable concept of job sharing, which professional women of this sort are perfectly capable of organising, is introduced for the first time into the family doctor service. It has been made easier to employ a locum when a women doctor is absent on maternity leave.

I have never been able to understand the argument that the contract is hostile to female doctors, unless it is argued that the contract must be so constructed that male doctors will be given a financial bonus for taking on a woman doctor. I have faced arguments in which that seems to be the proposition. The contract is so based on consumerism and patient choice that rising patient demand for more women doctors and patients' preference to go to practices with women partners will have a key effect and make career possibilities in the family doctor services ever more attractive to women.

Mr. Tim Devlin (Stockton, South) rose --

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Mr. Clarke : I am near the end of my speech and shall not give way as I have taken longer than I intended in this short debate. This contract is much more attractive than the previous one and for the Opposition to vote against it is perverse if they really mean it when they say that they are in favour of a patient-oriented service. What if some of the details are wrong? There is not much wrong in the drafting. There should not be, because, after we had reached the 4 May agreement, the consultation at the final stage of the drafting took months. The GMC was helpful and made helpful contributions to the drafting before we reached the present stage. Parts of the contract may be wrong and it may not be exactly as planned, although I believe that the impact on consumer patient services will be beneficial.

Sooner or later, the contract may be revised when new developments in practice come along. We shall take a look at the targets and consider which other services we should be encouraging. We should not wait another 25 years before doing that. If, in a few years' time, a successor of mine decides to take another look at the GP contract and start negotiating amendments to it, I hope that he will have less of a pantomime and a farce and can make more sensible progress than I or my predecessors at the Department have been allowed to make during the past two or three years. I also hope that he faces an Opposition who at last realise that all parties should be substantially on the patient's side in the disputes about the family practitioner service.

The patient must take advantage of the contract. We have taken the opportunity to make it easier for the patient to judge practices and choose a family doctor who exactly suits his or her family. The regulations will make it easier to change doctor, and this part of the contract will come into effect earliest. From 7 November in England and Wales and 22 November in Scotland, patients will be able to change doctors simply by registering with a new one. That removes the existing need for the patient to obtain the permission of his or her present doctor or family practitioner committee. That change was opposed by the negotiators during our discussions, but we have put it in place.

Under the regulations, GPs will have to provide practice leaflets. The last letter that I received on the subject was from the constituency of my hon. Friend the Member for Loughborough (Mr. Dorrell). One of his constituents wrote to me enclosing a copy of a practice leaflet that he had received. He said that this was the first time he had had any contact with his doctor for many years and thought that this was a highly desirable outcome of the discussions in which we have been engaged.

All over the country, GPs are producing leaflets and, from the information which the GPs will have to provide, family practitioner committees will produce local directories setting out the services available throughout their area. I hope that the Monopolies and Mergers Commission proposals to the profession are soon accepted, so that the information can be made available to the public, and doctors, if necessary, can promote their services, as long as they do so in a responsible and professional fashion. That will ensure that, once we have created a more consumer-oriented family doctor service, patients will be in the best possible position to take advantage of it.

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Therefore, I recommend the regulations to the House and ask for their endorsement. What we have done is wholly consistent with the Government's overriding objective of strengthening this vital public service and making our great National Health Service a better Health Service in relation to the family doctor service.

4.55 pm

Mr. Charles Kennedy (Ross, Cromarty and Skye) : The Secretary of State for Health is to be congratulated on his characteristically skilful advocacy of his case. However, in these affairs, he represents a somewhat Jekyll and Hyde character. This afternoon we have heard a different Secretary of State from the one whom we have seen and heard talking about doctors over the past few months on national television screens, on national airwaves and in the press. When the original agreement was concluded, I sat and watched the Secretary of State on Channel 4 news. The language he used was blunt and straightforward. He said that he had won his case against the BMA. That was not the tenor of his remarks this afternoon, because he has had some time to reflect. I dare say that passions have cooled on both sides of the negotiating table, but that was his frame of mind when he first approached the matter.

The Secretary of State this afternoon was not the man who enraged medical opinion--not just professional BMA opinion, but the very patient opinion the importance of which he was at such pains to stress in the later stages of his speech today. He was not the man who, on that infamous occasion, spoke of GPs being more interested in their wallets and incomes than in patient care and patients' standard of service. He presented a different face to us this afternoon. The negotiations are complete and the Secretary of State was right to say in his concluding remarks that there are significant passages of this contract which all of those who want to see an improved National Health Service, improved accountability, choice and sensitivity towards the patient as the consumer--in the non-profit sense-- would wish to embrace.

There is more than a suggestion in the behaviour and oscillations of the Secretary of State in recent months to suggest that this is one example where the Government, who have benefited so much from high-profile media advertising have, for once, found themselves at the sharp end of that type of advertising. The Government--perhaps all parties, given that we debate health issues year in and year out--have learnt an important lesson. The lesson is certainly relevant to the Government, who have been at pains to stress how much they are doing for the National Health Service, although, apparently, they are not persuading the public of that--they cannot turn around the political opinion polls on that issue.

Some of us criticise the Government year in, year out, about the damage done to the Health Service. Perhaps that has some effect in persuading public opinion. Once doctors began to tell patients of the damage and potential damage being done to the Health Service, they carried more credibility than any elected Member, and certainly any member of the Health Department, whether official or ministerial. The rash, intemperate and thoroughly provocative approach adopted by the Secretary of State over the past

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few months made what would always have been a difficult, convoluted and intricate negotiation--there is no debate about that--a far worse task. In part, that was due to the deliberately provocative style adopted by the Secretary of State. To a certain extent, the Secretary of State has got his comeuppance.

Mr. Devlin : Will my right hon. and learned Friend the Secretary of State comment on the fact that the House is substantially empty this afternoon? From what has been said, it seems that this matter should be one of great concern to hon. Members from both sides of the House. Perhaps, with the increased interest in the economy and the counter-productive propaganda put out by the doctors, particularly the BMA, which has turned hon. Members and people outside the House against the BMA, the contract which we are debating today--in which all of us are so interested--has ceased to be a controversial issue and my right hon. and learned Friend the Secretary of State has won the argument.

Mr. Kennedy : I shall be generous to both sides of the House and assume that, as hon. Members can now stand in the Lobbies and watch live broadcasts of these proceedings, hundreds of hon. Members on both sides of the House are gathered round the television screens hanging on to every word of those contributing.

I saw for the first time today an example of "doughnutting", whereby the few Opposition Members present congregated around their Front-Bench spokesman. We also had a little bit of that around the Secretary of State, but there was a bigger hole in the middle. [Interruption.] I see that my hon. Friend the Member for Ceredigion and Pembroke, North (Mr. Howells) has just joined me. I am sure that hon. Members will agree that he makes a convincing doughnut. Let us put down the somewhat meagre attendance to the televising of our proceedings.

If the hon. Gentleman thinks that the heat has gone out of the issue, he is somewhat misguided. When the new Session begins later this month and the new Health Service legislation is introduced, he will find that, although the contract issue will be over from a legislative point of view, the rumblings and knock-on effects will be with us for some time.

Mr. Kenneth Hind (Lancashire, West) : Will the hon. Gentleman give way?

Mr. Kennedy : If the hon. Gentleman will forgive me, I will not give way, as many hon. Members wish to speak.

As one would expect, the Secretary of State referred to capitation fees and to the effect of likely increases in list sizes, which he dismissed. It is important to mention that both salary and allowances are included in the capitation element of a GP's income. The Secretary of State has been tempted to reflect the tendency on the part of the press to total all the available allowances plus the salary of Members of Parliament and say that that is our effective gross income. The Secretary of State has been slightly guilty of that at times, but it is not fair.

The capitation element will increase from 46 per cent. to 60 per cent. Much as the Secretary of State may try to reject or counter the argument, the near-certain effect of that will be to increase list sizes. Surely it is not desirable

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for GPs, who should be spending more time with their present patients, to end up spending rather less time with more patients. The Secretary of State tried to counter that, particularly in response to the hon. Member for Livingston (Mr. Cook), by talking about the extension of the range of services and how that would make general practice more attractive. I welcome further information for patients and the greater ease with which patients will now be able to change from one surgery to another, although that is much overdue. But the logic of the funding arrangements that the Secretary of State is modifying under the new contract is that the greater the demand for the range of services being provided by a given practice, the greater will be the increase in the list size and the less time there will be available for each patient. I do not see how the Secretary of State can make the kind of case that he attempted to make in a rather mollifying way this afternoon and at the same time be consistent on the arguments that he is otherwise praying in aid for the new contract.

The Secretary of State referred to immunisation and the system of bonuses in the new contract, with lower bonuses for 70 per cent. vaccinations and 50 per cent. smears, and higher bonuses for 90 per cent. vaccinations and 80 per cent. smears. A key consideration here is how one defines a target population, as the Government have been at pains to do. That is particularly true in areas of rapid population change, not least in the inner cities.

The clear evidence of the Black report's in-depth analysis of take-up levels and health deprivation shows how difficult it is to get through to the very target groups that one is trying to reach on matters such as immunisation, preventive medicine and recall facilities. All too often it is likely to be the more socially confident, the better educated, those with slightly better incomes and so on, who take advantage of any additional facilities that are offered. Despite the best efforts of GPs, health authorities and the Department of Health, the people who are considered to be the most vulnerable, and so the most valuable to reach, are missed as a result of the demographic and practical difficulties that the Government are trying to address.

A great deal needs to be done to overcome problems created by lack of knowledge and fear about, for example, immunisation. It is clear that the Government have a major role to play in health education. The rather worrying suggestion that has emanated from the Secretary of State, not so much this afternoon as on previous occasions, is that almost all the responsibility for that can be landed in the front line at the feet of the general practitioners.

In deprived areas, or among the more deprived categories of the population, the direct patient-doctor contact may come only at the point of acute illness. In the build-up period, where preventive measures could be taken rather than waiting for the crisis, intervention and cure, all too often related social conditions, such as housing or the environment generally, play a stronger part than the general practitioners in the front line. The Secretary of State has given insufficient attention to that fact.

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