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Mr. Devlin : I am grateful to the hon. Gentleman for giving way again. Representing, as I do, part of inner-city Teesside, I am, like him, concerned about this matter. A point that he has omitted to mention, which he might like to consider, is the additional funding that will go to GPs

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under the Jarman index of social deprivation, which is one of the new features of the contract. Will he also comment on the new system of visiting and inspection for the over-75s, a particular target group which is often overlooked in inner-city areas?

Mr. Kennedy : The Secretary of State said that the measures taken for the over-75s meet with general approval, and they have not been a source of any serious or significant contention. They are to be welcomed. I have no criticism of that. That section of the population will grow as people live longer, more active and healthier lives, and that is a welcome trend. Therefore, those measures do not go to the heart of today's debate.

With regard to social deprivation and the indices that can be used to show it, we have still not overcome the fundamental difficulty that Black discovered, to which I referred earlier. The problem will not necessarily be conquered by a simple statistical change. An increase in the range of services, material on those services and increased patient choice in the GP's surgery cannot be expected to overcome fundamental social problems which prevent people from going to the GP's surgery until illness strikes, as a result of ignorance, lack of education and counselling from an early age, when most of the interface can and should take place with the family doctor service. That fundamental difficulty cannot be overcome without going much futher than the measure we are discussing this afternoon. I do not wish to detain the House, so I shall conclude with one issue which the Secretary of State mentioned towards the end of his speech--the position of female general practitioners. He was quite right to mention the increase in the number of women GPs, which has almost doubled in the past 10 years. They now represent 22 per cent. of all general practitioners in Britain and 25 per cent. of general practitioners under the age of 40. The demographic shift is most apparent and is to be welcomed.

The Government claim to welcome that development and say that they want to encourage that trend. The primary care White Paper referred to

"special arrangements to attract women to General practice and to encourage their appointment to the vacancies which occur". That is a noble sentiment indeed, and I do not think that there is much disagreement on that until we look at the contract. The likely effect of the new contract will be exactly the opposite of encouraging more women GPs into the Health Service, particularly because of the inbuilt disincentives it offers to part-time and flexible working arrangements.

I shall cite just one example. At present, on average, a part-time female GP brings about £15,000-worth of allowances by joining a general practice. If the practice pays her £18,000 which, on average figures, is about one third of a senior partner's annual salary, the practice is getting about 20 hours a week for an annual net outlay of £3,000 per year. Under the new arrangements, that female GP is likely to bring £6,000 or less in basic practice allowances, so there will be a major and significant shortfall, which represents an equally major and significant disincentive. The cost of employing her will therefore be much greater and the likely result is that, instead of additional part-time, flexible working arrangements being available as the Government claim and wish to enhance, the opportunities for female general practitioners will contract as GPs do exactly as the

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Secretary of State says that they will not do, and build up their lists to make up for the financial shortfall which will occur. The contract is a discriminatory measure in that cardinal respect. As I said earlier, many aspects of the contract are to be welcomed and carry all-party support. But there are also major aspects which have been thoroughly divisive and have not been helped by the belligerence with which the Secretary of State has pursued his case. In his previous post at the Department of Health, he was the only Minister I have ever come across who thought that BMA was a four-letter word. As soon as he came into any contact with that organisation, he seemed to adopt a most intransigent attitude and decide that it must be gloves off. On this occasion, when the BMA took the gloves off, he began to bleat and complain in a rather plaintive fashion. One does not normally associate bleating with the Secretary of State, but we shall give him the benefit of the doubt. Generally, the motives behind the contract cannot be divorced from the motives involved in the broader issues arising from the White Paper and the legislation which will follow. Despite those areas in which significant progress has been made and which are not the subject of partisan disagreement this afternoon, it is clear that the basic motivation is the reduction of medical costs within a political context to suit the whims of the Prime Minister much more than to suit the priorities of the patients.

Mr. Kenneth Clarke : Would the hon. Gentleman care to point out one respect in which the contract will reduce costs?

Mr. Kennedy : Reduction in costs will occur in the very last example which I cited, relating to female GPs. That is a cost reduction in terms of the employment of those general practitioners and in terms of the availability of employment for female GPs. That is an obvious example.

The motto should be "people first" in health care. Sadly, it is proving increasingly to be "cash first, people last", and on this occasion the profession, in a rather muted sense, is somewhere in between as a result of the contract.

5.15 pm

Dame Jill Knight (Birmingham, Edgbaston) : I do not know whether the speech of the hon. Member for Ross, Cromarty and Skye (Mr. Kennedy) meant that his minuscule party will be voting for the motion. If that is his intention, he will be voting against a large number of excellent provisions for patients and doctors.

My right hon. and learned Friend the Secretary of State is not only a much- maligned man, but a most unfairly maligned one. His opponents use every trick in the book to twist his words and muddy his intentions. I thought that he was being exceptionally mild and magnanimous when he told the Conservative party conference : "I do not think the BMA have been trying to be entirely helpful."

Mr. Devlin : Will my hon. Friend give way?

Dame Jill Knight : No, I wish to get into my speech first. I thought that the description by the hon. Member for Ross, Cromarty and Skye of my right hon. and learned Friend's attitude towards the BMA was not accurate. I

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thought that, when my right hon. and learned Friend most recently expressed his views on the BMA, he was being rather sweet. If that was an accurate comment on the recent activities of the BMA, I tremble to contemplate how members of the BMA would behave if they were trying to be unhelpful.

I do not think that my right hon. and learned Friend's comment was accurate. The BMA has not only been obstructive, but has been intentionally misleading, putting the fear of God into elderly, sick and nervous people in the consulting rooms of its members. I find that very difficult to forgive. Members of the BMA have distributed leaflets which they must have known, not to put too fine a point on it, contained blatant lies. They misled people over the Health Service review and they are doing it now over a contract which is good for doctors and excellent for patients.

It will be excellent that the over-75s will have an improved service. Elderly people are well aware that many of their aches and pains are due to age, but I have heard of frequent cases where doctors hurriedly dismissed those aches and pains without checking. A great deal can be done to improve the hearing, sight and general comfort even of the elderly, and an annual check-up is exactly what they need.

I like the plans to improve health promotion clinics, immunisation and screening for cancer. I am interested in the women's national cancer control campaign. Now, due to the new contract, it is coming on stream with more energy than ever. I approve of regular assessments of the development of children. That used to be done far more than it is today by the ordinary school medical service ; there have been gaps in that and I am pleased that it is clearly stated that children are to have regular assessments.

I am glad that there will be additional staff in the surgeries, especially chiropodists and physiotherapists. That is a new and good idea--

Ms. Harman : It is not new.

Dame Jill Knight : It is certainly a new idea to encourage all doctors to have such people in their surgeries. I will not answer any more sedentary interventions from hon. Members who do not know the whole position. These additional people are to be the rule rather than the exception.

It is sensible that doctors should be available to patients on an eyeball- to-eyeball basis for at least 26 hours a week. We appreciate that they work more hours than that because of travelling time, filling in forms and so on, but it is excellent that this improved service for patients is to be introduced.

So much for the way that the contract helps patients, but there is also a great deal that it will do to help doctors. The hon. Member for Ross, Cromarty and Skye claimed that my right hon. and learned Friend said that general practitioners received an average of £65,000 per year--

Mr. Kennedy : I did not.

Dame Jill Knight : The hon. Gentleman said that the sum quoted did not include expenses.

Mr. Kennedy : I said that when the Secretary of State referred to the total gross income of general practitioners, he was adding together salaries and allowances. I drew a comparison with the way in which members of the press talk about Members' salaries. They add up office

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allowances, living allowances and salaries and make people think that we are millionaires. Some Conservative Members are millionaires, but some of us most definitely are not.

Dame Jill Knight : That is exactly the point that I am trying to make. As usual, the hon. Gentleman is wrong. My right hon. and learned Friend has always said that the sum of about £67,000 per annum includes expenses--

Mr. Kennedy : Sotto voce.

Dame Jill Knight : That is not true. I have my right hon. and learned Friend's press release, which clearly states that the sum includes all expenses. A press release cannot be sotto voce. Indeed, my right hon. and learned Friend has been fair in his remarks about average expenses.

For the first time, doctors will receive specific payments for carrying out certain duties such as minor surgery in their surgeries. It is a good and useful service because it alleviates the work load on hospitals, but previously doctors have not received a specific payment for that work. They will also receive payments for health surveillance and health promotion.

It is worth uttering a word or two on the subject of postgraduate education allowances. Although some doctors go to great lengths to keep abreast of all medical developments, others do not. There is to be an allowance to encourage doctors to keep up to date. There will also be increased payments for night visits--I hope that the Opposition favour that. Necessary improvements to doctors' premises will also attract specific payments, and there will be an increase in capitation fees.

One matter that worries me is the proposed supplement for every patient living in an area of deprivation. Not all needy people live in such areas. Perhaps my right hon. and learned Friend would say a few words about what "area of deprivation" will actually mean. Does it mean that doctors will receive additional payments for looking after people who live at certain addresses in rundown inner-city areas? Part of my constituency is an outer- city area, and people ignore the fact that, for example, there are more one -parent families in that part of Birmingham than there is in the inner city. I hope that my right hon. and learned Friend will bear that in mind and think not only of where the patient lives, but the extent of his need. I appreciate that that is not always easy to delineate. Under the contract, it will be easier for patients to change doctors. There will be much less bureacracy and patients can just turn up at a surgery and ask to be put on a doctor's list. I am sure that all hon. Members know of vexatious patients. Some doctors will have to have those patients on their lists. If a doctor says that he does not want them on his list any longer, they are passed around like a parcel. Under the contract, will a doctor have the right to say that he does not want a particular patient on his list? That needs to be clarified.

I ask my right hon. and learned Friend to repeat, in every speech, the following points--even though he and I know that they should be superfluous : first, that he has an unwavering and inflexible commitment to the principles of the NHS ; secondly, that he believes in an NHS funded largely out of taxation giving free medical treatment to everyone regardless of means ; and thirdly, that not for one moment will he contemplate privatising the NHS.

Repetition may be boring, but some people have such thick heads that only by repetition can we get the right

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ideas into them. We must continue to repeat the truth. I am sick and tired of listening to accusations against the Government and Ministers that they want to privatise the NHS. Anyone who listened to the words that are used would know perfectly well that the allegations are untrue. All the attacks, all the aggro, all the unfairness will not, I hope, deter my right hon. and learned Friend from continuing to improve the NHS. Of one thing I am certain : he will go down in history as having been a great, reforming and improving Secretary of State.

5.29 pm

Mr. Michael J. Martin (Glasgow, Springburn) : I should like to ask the Secretary of State a number of questions. Let me say first, however, that all the general practitioners in my constituency to whom I have spoken --and most have approached me--have said that they want the Secretary of State to know that his contract stinks. It is absurd for any hon. Member to say that the BMA executive supported the right hon. and learned Gentleman ; anyone who knows anything about negotiation will be aware that there is a difference between expressing support and telling the membership, "This is the best that we can offer."

The question of changing doctors worries me. It is easy for the Secretary of State to say that if a patient turns up at a doctor's surgery he must take that patient on. In London, chronic traffic congestion means that it can take hours to cross from south to north ; if a GP whose surgery is in the north-east takes on a patient who lives in the south-west, emergency call-outs are bound to be a problem. As the hon. Member for Birmingham, Edbaston (Dame J. Knight) pointed out, patients can be vexatious, and, unfortunately, some are even deranged. Such a patient might deliberately pick a GP whose surgery is on the other side of the map, just to be awkward. I did not oppose parental choice in regard to schools, but it has nevertheless thrown up numerous problems. Excellent school buildings are half empty, and the Government are taking no steps to find out why. It is all very well for them to say that parents are still making up their minds ; we have expensive buildings to keep up. While Springburn was being redeveloped, it took us about 10 years to establish a health centre that is now second to none. We managed to persuade doctors to leave their converted shops in the high street and to provide the community with chiropody-- notwithstanding what the hon. Member for Edgbaston said about that--as well as eye tests, dental checks, nursing sisters and a chemist, all under one roof. A large health centre may contain six or seven practices. Let us say that some of those doctors are not attracting patients, and that their existing patient lists are dwindling. The Secretary of State may say that the patients are switching to other practices within the centre, but let us assume that they are going elsewhere. In such circumstances, a conscientious doctor will have to pay higher overheads because of the new contract.

I know that the patient is all-important, and that he has the right to decide. If I did not like my doctor I should want to leave his practice. If, however, overheads must be spread among fewer doctors, what help will the Government give? What help will they provide when patients who quite enjoyed visiting a health centre are cut off from it by a new road, and the doctors' list suddenly

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becomes smaller? Conservative Members shake their heads, but patients in my constituency have decided to stop visiting their health centre because the road is too dangerous to negotiate, and doctors are losing patients through no fault of their own. The Secretary of State mentioned preventive care. In a middle-class community where people are relatively well off, a woman who becomes pregnant is more than likely to want first of all to find out about pre-natal care. In parts of my constituency, however, conscientious doctors know that, unless they go out and knock on the doors of women who have been housed under a "difficult to let" scheme, such women will not obtain the care they need.

We have been told that deprived areas are to receive an allowance. Bureaucrats, however, are terrific at drawing a line around an area on the map and designating it an area of deprivation in which a supplement is payable. An afluent area may contain one or two deprived streets, and the local doctor will know that he must visit the neighbourhood himself if he wants to obtain patients. I hope that we shall be told tonight that that will not happen.

The Secretary of State must be aware that, in areas of high unemployment, the problems for practitioners are getting worse and worse. Most people are visiting their surgeries suffering from depression because they are out of work ; wives, too, arrive complaining about the pressures put on family life. I worry about the way in which the Government seem to think that practices should be run like nice, efficient businesses. A GP's work is not like a job churning out alarm clocks, for instance, in which payment is made for results. The Government's proposals will mean that the more sympathetic the doctor, and the more prepared he is to listen to patients, the fewer patients he will have.

A year ago, my wife had a serious operation. Two members of the local practice had said, "I will give you a prescription ; you will be all right then." The third listened. He made an appointment with a consultant, and my wife obtained the necessary operation--from which, thankfully, she has now recovered. But what would have happened if all three doctors had been under pressure, and had not listened? A doctor who sits signing a prescription while the patient is still talking does not inspire confidence. [Interruption.] I did not hear what the hon. Member for Staffordshire, South-East (Mr. Lightbown) just said, and I do not approve of the practice of speaking from a sedentary position.

When the Secretary of State glibly talks about choice and says that patients can move, he forgets that, even if they are dissatisfied, elderly patients may not be able to get around as well as they did when they were 30 or 40 years old so they may have to content themselves with the local practice. He must know that in many inner-city areas, our communities are getting older. That puts a burden on GPs. In areas where the community is young and upwardly mobile, a GP may have only a few elderly patients while in other areas where the community is becoming ever more elderly, he may have many. Comparisons must be made and allowances built into the system. I heard what the Minister said about the emergency doctor service. I do not knock that service, even though it is privatised. I would rather have a doctor in the surgery

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who is fresh then a doctor who had answered four or five calls the night before. We should examine the deputising service and in some cases encourage it, provided that the doctor does not lose contact with his patients or simply take the easy option. Doctors in the deputising service go out with a driver. Doctors may be afraid to go to areas with a high level of crime and drug problems. There have already been reports of assaults on doctors. Doctors have been called out by a bogus caller and assaulted for their drugs when they arrived in the street where they were expected. At least if doctors go on emergency calls with a driver, they will have some back-up. I hope that the Minster for Health will examine thoroughly all the matters to which I referred, particularly the problems in inner-city areas, and that she and her colleagues will see that there are vast differences even within tightly knit communities.

5.42 pm

Mr. Michael Morris (Northampton, South) : I deeply regret having to speak and vote against the regulations. I do not vote against my party lightly, particularly on an issue that involves my family, whom I try to keep out of politics. However, occasionally one must do what one believes is right.

I declare an interest immediately and it proves that I know something about general practice. My wife has been a general practitioner for over 25 years, initially in the inner-city area of Hackney in London and for the past 16 years in Bedfordshire. At the Conservative party conference in Blackpool in 1973 she received a phone call asking her to stand in on an emergency basis in Biggleswade because there was a shortage of GPs. Blackpool conferences were different then. In those days people were allowed to speak against the motion and the debates were not fixed as they were this year. In those days speakers knew and worked in the National Health Service. This year we listened to a doctor who did not work in the National Health Service telling us how marvellous the proposed reforms were. I found that cheeky. Moreover, I understand that he is not particularly successful in private practice.

I have several other interests to declare. I have been a member of the Public Accounts Committee for the past 10 years and the member of that Committee who has asked the most questions about the National Health Service. The health side of what was the Department of Health and Social Security hardly covered itself in glory in the past 10 years. I expect that my colleagues on the Committee will agree that it is not an exaggeration to say that it was probably the most badly organised Department in the Civil Service. Perhaps now that we have an independent Department of Health, that will change. It certainly needs to do so. I also serve on the Council of Europe's health committee and I advise two pharmaceutical companies. I think that I can claim to know at least as much as the Secretary of State about the National Health Service.

The negotiations for the new contract have followed a familiar pattern. First, the Department issued a set of proposals. The Secretary of State has often been at pains to tell us how long the negotiations have lasted. After all this time and with so many civil servants and officials who are doctors in the Department, one would think that the initial cockshy would be somewhere near a contract that would be acceptable to all parties. But what did we have

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in February? We had far-reaching proposals for changing both the terms of service and the remunerative system of general practice. My hon. Friends seem to forget the juxtaposition of those factors. The changes in the terms of service--one of the key platforms-- were to include no opting out of the 24-hours-a-day cover, which is right, and direct consultation in the surgery for at least 20 hours per week spread over five days. The Department seemed to forget about home visits. Doctors were to be required to live within a reasonable but undefined distance of the surgery. Several other conditions, which are well known to my colleagues, included regular medical assessments, practice leaflets, and production of annual reports. I listened to my colleagues with some incredulity. I wonder how many of them have read the statutory instrument issued by the Department of Health which sets down the required content of annual reports. They are to be long. Perhaps some of us should write a similar annual report for our constituents. [ Hon. Members :-- "We do, every four years."] Some of us do it more often than annually. Changes in the percentage of the square footage of a surgery devoted to the reception, surgery or nurses' surgery cannot be of the least relevance. Other questions have to be answered in the annual report, the purpose of which is questionable. Family practitioner committees will have to be informed of other professional commitments. That is perfectly fair. The changes to the remuneration system altered 50 per cent. of the revenue of an average GP's practice. The Department was not simply tinkering at the fringes of the regulations ; it introduced a wholesale change in remuneration. Out went seniority, group practice allowance, vocational training allowance, postgraduate training allowance, supplementary basic practice allowance, supplementary capitation, cervical cytology fees and child immunisation fees. On top of that, the basic practice allowance, night visit fees and rural practice payments were changed. That is a long list. In came capitation fees of 60 per cent. We have all heard a great deal about advisers in recent weeks. Advisers have suggested that 60 per cent. will be only the start. Will it be 70 per cent. in a few years' time and 80 per cent. a few years later? My hon. Friend the Minister must state that 60 per cent. will be the maximum and that it will not be changed.

The proposals state that in order to receive full remuneration a doctor must have 1,500 patients, reach cervical cytology and immunisation targets, provide annual check-ups for the over-75s, medicals for newly registered patients and medical assessments every three years for patients aged 16 to 74, undertake minor surgery, organise health promotion clinics, establish staff training, produce a practice leaflet, provide an annual report, accept child surveillance responsibilities, attend specified post-graduate training sessions and carry out night visits on a practice roster. It does not end there. Last year, I was happy to support the changes to fees and allowances that were incorporated in the Health and Medicines Act 1988. I have long believed that that element of GP work should be cash-limited. However, this afternoon my right hon. and learned Friend said that there will be a review not just of new ancillary staff but of existing staff. When a nurse leaves a practice, the family practitioner committee will have the right to say to the doctor, "You may not have another nurse." I very much hope that that dimension, which has not been highlighted, will be dropped.

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The Health and Medicines Act also contains provisions relating to isolated general practices and computerisation. The Bill that will come before the House in a few months' time will impinge on general practice. The main items for discussion are practice budgets for those with over 11,000 patients, particularly drug budgets, the medical audit and the recomposition and reorganisation of the FPCs. Each will lead to a new list of proposals before their introduction. Throughout the summer months there was negotiation under duress. I met the Secretary of State several times. By August, there was a second edition of the contract. Seniority payments were mixed up with postgraduate allowances and seniority payments. The new two-tier system relating to cervical cytology and child immunisation is to be welcomed, but it is compulsory and will create problems in towns and cities that have large ethnic populations. That issue must be addressed.

Promises were made about rural practice payments, adjustments to the basic practice allowance and transitional payments to help small practices. That is greatly to be welcomed. The point that I made in an intervention about the 26 hours and five days need to be examined. The majority of general practices do not have access to a standby deputising service. It is all very well for hon. Members with inner-city seats to assume that all general practices have a deputising service. In many areas of the country they do not. It cannot be right, as the hon. Member for Glasgow, Springburn (Mr. Martin) said, that any general practitioner should be on call for 12 days before he gets a break.

All this starts on 1 April 1990. The White Paper proposals to which I referred start a year later. That, by any yardstick, is a pretty tight timetable. It would have been better to roll it out as we went along, but my right hon. and learned Friend has decided otherwise. All these changes to the terms of service will have to be brought about in each surgery in fewer than six months. What other business would be expected to face a 50 per cent. change in its revenue within six months?

Family doctors are already busy people, as are their ancillary staff, but they will have to modernise and introduce computers. What, however, are the facts? Only 25 per cent. of general practices are fully computerised, and only a tiny percentage of FPCs have packages available to control everything from the other end. Those of us who are involved in health matters have received a mailing shot about an argument between the Department of Health and the private companies that are producing the software for the 25 per cent. of general practices that use computers. If something is to be up and running by next April, there should be no argument about who owns the software, with the GPs perhaps having to buy it off the particular company involved. I hope that when she winds up, the Minister for Health will deal with that point. It is absolutely central to getting everything moving by 1 April 1990.

All these changes are supposed to produce value for money, but can one find the figures? The only figure that I have found in either the first or second edition of the contract is the 50 per cent. reduction in the benefit that is to be paid to general practitioners. That is on record. As soon as the terms of service are in writing--I shall be grateful to know whether they are yet in writing and whether the red book has been updated--they will have to be priced by the review body. I hope that the statement of

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fees and allowances will be available by 1 January 1990. Every practice is making its plans which will come into effect on 1 April, so I hope that the Minister will confirm that the statement of fees and allowances will be published by 1 January 1990.

There have been many changes to the administrative and clinical system. GPs can do without the additional problem of having to speculate about revenue. No one should be expected to negotiate for half the final package just on faith. Is the Minister able to say what the cost of the changes will be? I know that the Public Accounts Committee, of which I am a member, will investigate that question with interest. It is only right that we should have the Government's forecast of the cost of the changes.

Very welcome though the new Minister for Health is at the Department, she will have to tighten things up a bit. Following the imposition of the agreement, we know that the directives on the national priorities for family practitioner committees arrived weeks late. I am glad to see that my right hon. and learned Friend the Secretary of State has returned to the Treasury Bench. He promised to give general practitioners six months' notice of any changes. We are five months away from implementation of the scheme, so we have already lost a month.

I deplore the abuse that has been showered on hard-working general practitioners--in my constituency and by my friends. Equally, I deplore the British Medical Association's advertising campaign. I spent 20 years in advertising. The BMA should fire its agents. I also deplore the assertion that GPs earn about £65,000 a year. That figure includes staff salaries, medical supplies and their share of medical premises expenses. They are not minor items. The taxable figure is £31,105. No Member of Parliament would expect his or her salary to be judged on a basis that included the secretarial allowance. Commentators such as Dr. Vernon Coleman in The Sun are being mischievous when they suggest a higher figure.

I deplore the lack of time, the bureaucracy that has been imposed on general practitioners, the unreality of the annual report and the intrusion into certain patients' lives, just to meet an arbitrary target. It will undermine the long-standing doctor-patient relationship which has never hitherto been based on financial considerations. That relationship is in danger of being changed. The new contract that is being imposed on GPs will not aid or improve general practice.

The passing of the regulations will be sad for general practitioners. General practice is the one part of the National Health Service that is admired the world over. The pressure that the new bureaucratic contract forces on GPs must mean that they will have less time for patients, and hence patient care. All the surveys show that every patient wants more time, not less, with his doctor. I fear that doctors who traditionally have counselled and consoled the bereaved will be forced to reduce some of that work.

This is not the freer, caring society for which I thought the Conservative party stood. I regard this as a bureaucratic system imposed from above, and I think that it should be rejected.

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6 pm

Dr. Lewis Moonie (Kirkcaldy) : I should like to begin by quoting from a letter sent to me by Dr. Michael Wilson, who is chairman of the general medical services committee of the BMA. It puts a rather different perspective on his views from that rather misleadingly given by the Secretary of State. It says :

"For the first time in the history of the health service, a Secretary of State has decided to impose his own contractual terms. There are some desirable components, but there are also important elements which are misguided and ill-conceived, for example, the target payments for immunisation and cervical cytology, and the shift towards a more capitation based payments system. Attached to this letter are more details of our views on these elements.

There have been misleading reports in the media that general practitioners would be taking industrial action as a result of this imposition. I deplore the fact that the public may have been disturbed in any way by these reports, and have written to the Secretary of State to make it clear that the BMA was not responsible for this press speculation.

At a recent meeting, the Committee decided firmly against any form of action which would be damaging to patients. In order to protect patients' interests, which remain paramount, and to sustain general practice in the NHS for the future, we will subject key aspects of the contract to a careful audit to provide us with information on the contract's defects and the problems arising from its imposition." That paints a different picture from the one that the Secretary of State attempted to paint this afternoon.

I support most of the principles and motives underlying the contract, although I disagree profoundly with some of the changes proposed, which have not been properly thought out and will almost certainly damage rather than enhance the primary care service. The Secretary of State was good enough to acknowledge that we probably have the best primary care service in the world. We must remember that it is run very cost-effectively and that it takes only 7 per cent. of total resources devoted to health care.

There are two underlying objectives for the new contract, both of which are laudable. The first is to improve the health experience of the population, and the second is to provide a better and more uniform service. It is essential to consider the new contract in the context of the Health and Medicines Act 1988 and the Government's proposals in "Working for Patients", which contain a third objective, again with which I do not disagree, of cost containment to exert downward pressure on the inexorable increase in health care costs year on year. It does the Secretary of State no credit to suggest that that is not the case. He should defend honestly that laudable objective.

We are trying to make the service more cost-effective, and there is no doubt that the health of the British people needs to be improved. The Government have targeted immunisation in childhood and cervical screening of adult women. We now immunise against polio and diphtheria--fortunately, mainly diseases of the past--whooping cough, measles and mumps, which sadly are still subject to regular epidemics, and rubella, which is a mild disease in itself but which has horrendous consequences for the next generation if a pregnant woman has the misfortune to have an attack. Massive improvements have been made over the past decade or two. Better vaccines are available, so therefore much of the fear and prejudice associated with vaccines, particularly whooping cough vaccine, has been overcome, and there have been tremendous improvements in the methods by which we ensure that the service is

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delivered to its target population. The same applies to cervical screening, which is responsible for thousands of preventable deaths every year. The failure of the present system to prevent those deaths is a national disgrace.

There is no doubt that, nationally, there is wide variation in the quality and standard of primary care and, regrettably in its accessibility. It is over a decade since Knox and others in the Dundee department of geography commented on this mismatch between the siting of GP practices in the centre of towns and the siting of the population on the periphery. Sadly, much of that problem has not yet been corrected. Housing schemes are ill-provided with basic services and do not have regular transport links to surgeries, and many people who live in them are on low incomes. I accept that inner London has particular problems that are the equal of those in smaller cities. That raises the first anomaly, because without a major effort to tackle the twin problems of multiple deprivation and poverty, all the Secretary of State's efforts in the contract are doomed to failure. I do not propose to repeat the comments made by the hon. Member for Northampton, South (Mr. Morris) on the detailed proposals of the contract. I have the greatest sympathy for the hon. Gentleman's predicament tonight, and I welcome his rational opposition to the proposals. I see several critical deficiencies in the Secretary of State's proposals, which negate the good intentions of his objectives. He grossly understates the importance of collective, rather than individual, action in health care. That has been a major failing of the Government's philosophical approach to society since they took office, so we should not expect them to change their approach on health care.

There are long-standing deficiencies in the present service that the Secretary of State has failed to tackle, such as the fragmentation of responsibility for the community's health between district health authorities and family practitioner committees. The Minister should learn from the far superior administrative system in Scotland, where one health board is responsible for each area and provides a single coherent purpose to health care, which is sadly lacking south of the border. I shall give some examples from my county of Fife, which is a mixed agricultural and industrial region and which in many areas has massive problems associated with the recent loss of the mining industry. We have immunisation rates of well over 90 per cent. and a target of immunising 100 per cent. of children who are able to take the vaccine over the next few years. The successful introduction of the new measles, mumps and rubella immunisation, which was piloted in the county over the past three years, is being followed in other counties and again has achieved high target success. There are lower, but still rising, figures for whooping cough. Over 75 per cent. of children are immunised against it, which compares favourably with other areas. We are proud of that success story, but it is the product of an enormous collective effort by GPs, health visitors, the community health service, health education and effective and enthusiastic leadership from the health board. The service is underpinned by an equally effective computerised call -up system, without which we would not have a hope of reaching the target population.

On cervical screening, there is a collective commitment to improving the take-up of the service, backed up by research into why women fail to attend for screening,

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despite beng sent an appointment and despite it having been followed up. Those facilities are starting to pay off in higher take-up rates.

Our GPs need no further incentive to improve their rates. They do not need bonus payments, which they will attract anyway because of the level of service that they are providing. They have been given the tools, support and leadership of the health board ; they require no further incentive than their professional pride to ensure that standards are maintained.

Why has the Minister failed to benefit from our experience in Fife? Why is he introducing an untried alternative when there is such a patently successful system north of the border? There is no guarantee that the system that he has introduced will succeed, and he has produced no evidence to suggest that he has any expectation other than his own prejudice to support it. Are the Minister and his Department blind? Are they unable to see it? Can they not afford the eye tests which they brought in last year? Without an efficient system, the best GPs will be unable to meet their targets. The Minister's proposal is doomed before it is introduced, and he fails to realise that.

The second factor that obstructs the Minister's good intentions is the nature of the primary care system. GPs are self-employed, and that is one reason for the vast variation in standards which they apply. They can choose what level of service to give.

I thought it was a bit rich of the Minister, in reply to my earlier intervention, saying that GPs signing a contract was all that was required for family practitioner committees to ensure the proper level of service was provided.

I assure the Minister that GPs, as with any other body of people, vary in the quality of service that they give. I cannot see the FPCs following them around to see how long they spend in the car as a proportion of their 26 hours of patient commitment per week, or to see whether they finish surgery early because they are going to the golf course or somewhere else. Without a proper monitoring system, how can one say that the contract will be properly enforced? Many GPs have a captive population of patients who are prevented, for geographical reasons, from moving to another doctor. There are few teeth in the contract to improve that.

Why does not the Minister look at the option of a salaried service in areas which have difficulty in providing a service under the present system? Why is there such a deafening silence about medical audit? I know why--it is so difficult to bring in.

Although I am a member of the medical profession, I have been a stern critic of it for the past 20 years and I have a stronger track record than the "Johnny-come-latelies" on the Conservative Benches who criticise only when they see that their own political futures could be damaged.

The Secretary of State professes to recognise the problem of working in deprived inner-city areas. Has he recognised that inner-city GPs earn well below his much-touted average earnings, let alone the combined salary that the popular press has quoted so frequently or even the average target taxable earning. We know of GPs whose take-home pay is less than £1,000 a month. Averages blur the difference between them and GPs who earn fat salaries, mostly in the home counties and in other areas where there are plenty of extra perks and extra fees to be earned. There are not many fat salaries to be earned in Tower Hamlets or in the centre of London. I can tell the

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Minister that for a start. GPs there cannot afford nice premises, even if the buildings are available and if one takes into consideration the percentage of the cost which the Government so generously provide--70 per cent. I can assure the Minister that 30 per cent. of £1,000 will not provide much in the way of premises in the centre of London.

Any allowances that the Secretary of State proposes for deprived city areas will go no way towards solving those problems. GPs in those areas cannot find suitable staff to work for them. It is not a question of not being able to pay them. One of the reasons why they use deputising services so frequently, as other right hon. and hon. Members have said, is that it is unsafe for them to visit many parts of the area after dark. They cannot afford to employ a driver as a bodyguard and the police are no help as they refuse to accompany them. At least with a deputising service there is a nice large driver sitting in the car downstairs to provide some form of back-up. This is another problem in the delivery of health care which is not being tackled.

It is easy for us to say that we have noble intentions with the contract, and that as long as GPs all work hard it will be all right. It will not. We have to change the system within which GPs are trying to operate ; otherwise, we will not be able to change the result of what they do.

The Department of Health seems to be incapable of conducting the most elementary investigation in the real world in which GPs have to operate. The Department is bloated--although not quite so bloated as it was earlier this afternoon--by a large increase in the number of people that it employs directly in central services.

The saddest failure of these proposals is the change in the balance of remuneration between basic practice allowance and capitation fees. That will penalise the better GP who knows, because he or she faces the fact every working day, that a better, more comprehensive service is possible only with fewer patients. It is not so much that there will be a tendency for a bad GP, who gives a poor service, to attract as many patients as possible on to his or her list, as that a good GP, who wishes to reduce the number of patients on the list, will be unfairly penalised by the reduction in basic practice allowance and the move towards a larger capitation fee-- unless the capitation fee is much larger than the Minister anticipates.

If GPs wish to engage another partner to provide a better service, they will suffer a catastrophic fall in income. Why has the Department of Health failed to set proper targets for list sizes? There is adequate information available to make it clear that the ideal size of a practice is between 1,200 and 1,500 patients per GP--well below the current level. I do not expect the Minister to achieve such a target overnight, but he should certainly set that target now. If the Minister's objective is to reduce list sizes to a level at which all the good things he has talked about can be achieved, he should structure the payment system in a way that will make it desirable to do so--by penalising GPs who have too many patients on their lists. I assure the Minister that GPs with a list size of more than 2,000 patients do not provide the service that he imagines they are providing.

It is not possible to do so. Is this vaunted commitment to greater care only a facade to hide his real objective of a cheaper, nastier service?

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The Secretary of State has had a glorious chance to improve primary care with this contract. His failure to do so is due as much to the incompetence of his Department as to his own arrogance. I hope that it is not too late for him to think again.

6.16 pm

Mr. Jerry Hayes (Harlow) : I was disappointed with the speech of the hon. Member for Kirkcaldy (Dr. Moonie). He started well, as he seemed to support just about everything that the Government are doing, but he lapsed into momentary incoherence when he talked about the catastrophic decrease in GP incomes. He overlooked the fact that the Government have said that there will be a transitional period of two years when bringing in the regulations to stop that happening. It would be helpful if right hon. and hon. Members read the regulations.

Dr. Moonie rose --

Mr. Hayes : I shall not give way.

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