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Mr. Hayes : I have become accustomed to the fact that the BMA has done for sensible political argument what myxomatosis has done for rabbits. I found it rich that the hon. Member for Livingston (Mr. Cook), who, to give him credit, has occasional moments of lucidity, criticised my right hon. and learned Friend's handling of the GP contract. Good heavens, in 1975, 7,800 GPs sent in their resignation letters. In 1975 there was industrial action by consultants and threatened industrial action by junior doctors.
I have always assumed that the House of Commons went barking mad only towards the end of July. It appears that there is also barking madness during the spillover period.
The House should analyse carefully, precisely what the Opposition and some of the other parties are voting against. They are voting against "Promoting Better Health," against the White Paper that received much professional acclaim, and against a higher capitation fee for rundown areas. They are voting against giving women doctors the opportunity of part-time work--not just half the hours but a quarter, which has never been in any contract before.
The Opposition are voting against screening and preventive medicine. They are voting against giving every person over 75 on a doctor's list the opportunity of getting a visit from either a GP or a member of the practice team. That is remarkable. They are voting against immunisation targets--for example, rubella immunisations, about which the hon. Member for Kircaldy talked. Our immunisation figures are appalling compared with World Health Organisation statistics. Surely setting targets is the way forward to protect our young people.
The Opposition are voting against payments to GPs for minor surgery and against the postgraduate training allowance. That does not seem to make any sense.
Column 361are now four Opposition Members here during this debate on an Opposition prayer. However, I should not be too critical and try to score too many party political points.
These sensible measures were recommended by the BMA's negotiating committee. If only the BMA had not played such a foolish political game by winding up its members to such a degree that they believed that any contract from the Department of Health came from the jaws of Hades, there would not be such a mess and misunderstanding.
The only difficulty of which my right hon. and learned Friend the Secretary of State should be aware is targeting. Many general practitioners throughout the country to whom I and many of my colleagues have had the opportunity of speaking are worried about targeting because they feel that they are meeting their targets now. They are worried that when they go to the family practitioner committees they will find that the family practitioner computer has gone horribly wrong. I ask for an initiative from the Department to ensure that FPCs get their act together to help GPs to look after their patients in the best way.
The Opposition are voting against some very sensible preventive health measures. I regret that. I am sure that my hon. Friends will join me and my right hon. and learned Friend the Secretary of State in supporting these health measures, which will help patients in our constituencies.
Mr. John Battle (Leeds, West) : We should take the contract in the full context of the Government's health policy. Last weekend, the Government announced that 11 health districts would be chosen to carry out some comparisons of practice, as a prelude to introducing the White Paper proposals on the NHS. We had hoped that the Government could agree that it was crucial to have a comprehensive evaluation before any of their health proposals were implemented. Like others, we have regularly suggested that such an evaluation should include fuller assessments of health needs, especially assessments
Column 362that are locally and regionally sensitive. I say that as one who represents Leeds, West, which includes a section of the inner city. In August, in response to the publication of the monitoring report by the Office of Population Censuses and Surveys on infant and perinatal mortality, the former Minister for Health rejected further research on the wider social causes of ill health. He contemptuously dismissed regional and social factors. The principles in the contract, in terms of the index of social deprivation proposals, will be undermined because that research has not been carried out. We all accept that any serious and major reform always involves risks, but it also imposes costs. It is difficult to carry out a genuine reform on the basis of a reduction in service. Unless an evaluation is carried out at an earlier stage, major mistakes, which later need correcting, may be made. The impression is that the reviews, and the contract as the vanguard for them, will set cash limits in concrete.
I remember the early days when the Departments of Health and Social Security were one Department. There are echoes now of what happened then. We were promised the great social security reviews--with the tag, of course, that they would be at nil cost, which in practice meant that they were reviews with a reduction. We all know of the great suspicion that this measure will end up as a cost-cutting exercise. To see this, we need simply to glance at the Government's practice, at the experience of cash limits which were imposed on, for example, the social fund. Budgets initially set at the centre included built-in factors based upon a declining take-up. Such approaches end in a reduction in service to the people and undermine sensitivity to local needs and demands. The people in need are left out. At the heart of the Government's approach is the issue of cost-benefit analysis. It may satisfy accountants, but it does not serve human needs. Emphasis on quantity can undermine the quality of provision. It may be forgotten that the purpose of the exercise is to serve people.
I am reminded of the inner-city initiative during the late 1970s and early 1980s. A former Secretary of State for the Environment introduced the urban programme monitoring initiative. That showed an obsession with monitoring on a quantitative basis, annual reports and micro-levels of accountancy, which resulted in officers being instructed to count the number of trees in environment improvement schemes and to send the information back in a report to the Department of the Environment. Pensioners in mini-buses provided to take them to luncheon clubs had to fill in journey measurement and time sheets. That was not the practical purpose of the programme, but is that the kind of contract monitoring which is envisaged in these proposals?
We are moving in a direction where "Yes, Minister" becomes real life, but it is a little too close to reality. I remember one of the "Yes, Minister" programmes about a totally efficient hospital which had a brilliant input and output ratio. In average accountancy terms, it ran perfectly--because it had no patients, as it had not yet opened. Unfortunately, patients would have messed up the ledger entries. Perhaps it is therefore better not to include patients at all. Human beings with whom we are dealing are not totally efficient animals.
Turning to the specifics of the doctors' contract, the Secretary of State might tell us what the assessment of the family doctors' future role in health care is. The emphasis
Column 363is emerging in the community care proposals, with which we have yet to deal. The change will surely shift the work in the direction of local GPs because there will be fewer people in hospitals and institutions. We are told that there will be a welcome emphasis on prevention, health promotion and primary health care.
How much space will there be in the contract for home visits? Will the system simply be based on a bonus payments approach, or will there be a genuine increase in service provision, as is needed? Several questions will arise. Will the need for GPs to pay attention to costs, budgets and annual reports distract them from the quality of care that they offer? Will the paperwork and accounting reduce patient contact time? Will the good intentions of dealing with primary preventive care be undermined by budget considerations and bureaucratic proposals?
There seems to be further contradiction when we take the contract in the context of the Government's proposals. What is proposed for the doctors is to challenge their autonomy and unaccountability in the contract. However, under the proposal for hospitals there is a real possibility that self- governing hospital trusts will become privatised and independent, as is being proposed at the Leeds general infirmary. In other words, there will be a fragmenting of local provision, which contradicts the Government's approach to doctors' practices. On the one hand, they say standardise and on the other they say opt-out. When their proposals are put together, collective and co-ordinated provision in the Health Service will be undermined. We welcome the introduction of child health surveillance services. Let us hope that that will not be dealt with simply in terms of remuneration. It will increase the work load, but more importantly, it should recognise that there are unequal starting points in the country's health provision. If we study birth weights, it becomes more than obvious that good health is not evenly distributed throughout the nation. The strains on some health authorities are greater than on others. The recent OPCS report on baby deaths published in August highlighted that the health divide between Britain's more prosperous regions and the poorer regions is growing wider. Although the perinatal mortality rate for England and Wales in 1988 was 8.7 per thousand and the infant mortality rate was nine per thousand, the regional breakdown shows big variations throughout the country within that improving trend.
The Select Committee on Social Services said last December that Britain's infant mortality record is not improving as fast as it should. The Committee called for further research into the links between baby deaths and social deprivation. That research has yet to be initiated by the Secretary of State. That sensitivity to an area analysis demands a much more comprehensive approach before the contract can be introduced.
There is also the question of interpreting and enforcing the contract. If a GP wants to increase his list size, he would do best by attracting fit and healthy patients whom he sees rarely and who make few demands on his time. The long-term sick will be more time-consuming and he will do better if he refers them to another GP down the road. That is a perversion of the provision of health care to those who need it.
Column 364Not every person in Britain has an address as some are homeless and others live in hostels and accommodation for the homeless. What is the provision in the contract for them? It is, incredibly difficult to arrange doctor provision for hostels in order to provide care for the homeless or mentally ill.
On enforcement, we have a stark reminder of what happened to the nurses. This morning I received a letter from a nurse in my constituency. She asked what will happen to community staff and especially preventive medicine. She said that she had been a health visitor and that she does two district jobs --she is both a specialist in diabetes and a mothers and babies health visitor. However, she is still waiting for her grade to be settled. She sees others doing less and with fewer qualifications moving to the H grade. We have a long way to go before the contract can be settled. If the experience of the nurses is anything to go by, we will have to wait years for implementation to be sorted out if the proposal is not first solidly thought through.
In their eagerness to transfer social costs into market prices, the Government manage to demonstrate gross insensitivity to the detailed effects of their proposals. Our challenge is to a Government who seem to be entranced by the business man's ethic of profit. The euphemism is now the "discipline of the market". In the current edition of The Salisbury Review I was interested to read an article by Ian Crowther entitled : "Thatcherism and the Good Life."
He said :
"A modern business enterprise, by its very nature, has as its highest goal the maximisation of profit ; what it provides in the way of goods or services is secondary. But to force this commercial model on every other species of corporate life--for example, on public service broadcasting, the health service, the legal profession and the universities--is to betray either an indifference to non-economic motives or an ignorance of how in reality they are sustained. If it is obvious--as surely it must be, that the highest loyalty of a soldier or a policeman or a fireman can never be to material gain, it should be hardly less obvious that there are others in the community--among them dons, doctors, nurses, teachers and lawyers-- whose character would be altered irrevocably and for the worst if the pursuit of profit, instead of being incidental to their professions, were to be made central to them. Britain would be the poorer, literally, if millions of its citizens did not still think of service as the primary and profit as the secondary motivation in their working lives.
That they do so is testimony to the truth that man is not just an economic being but a moral, social and political being as well." I would have hoped that those were the motives driving the Government but we know that that is not the case. However, perhaps the Government will bear in mind the parallel with the poll tax. We reminded the Government that if it was not thought out it would be brought back time and again with alterations.
Mr. Conway : On a point of order Mr. Deputy Speaker. The hon. Gentleman is a solitary figure on the Opposition Back Benches and he is trying to spin out the debate for the Opposition. However, even his colleagues are not listening. I would be grateful if you would bring the hon. Gentleman back to the subject of the NHS contract.
Column 365it may save the country from the turmoil it is experiencing with the poll tax. I hope that they will withdraw the contract. If they do not, the British people will pass judgment at the appropriate time and elect a Government who adopt a different approach from the market-driven one of the present Government.
Mr. Nicholas Winterton (Macclesfield) : I have only a few seconds in which to participate in this important debate. I congratulate my right hon. and learned Friend the Secretary of State on his positive and rather more agreeable presentation of the Government's case on the GP contract. I only wish that what he said had carried a majority of not only general practitioners but the people of the country. As yet, my right hon. and learned Friend does not carry a majority of either doctors or the people in what he is seeking to do in the contract-- [Interruption.] My hon. Friend the Member for Shrewsbury and Atcham (Mr. Conway) points out that he may obtain that majority in the future but he does not have it now. There is considerable evidence to suggest that the contract is somewhat misguided. I have grave reservations about the increased percentage of doctors' remuneration that will come from capitation. It will go up from 46 per cent. to 60 per cent. I have performed considerable service on the Select Committee for Social Services and I can say from experience that one of the greatest services a doctor can provide is not minor operations, immunisation or screening but the counselling and advice that he gives either on a visit or in his surgery. The contract will lead to a position in which doctors have less time to spend with individual patients rather than more. My remarks have been much supported by the Select Committee. If my right hon. and learned Friend reads our latest report--the eighth report --he will see that we say on page 38 :
"A number of observers indicated their concern that increasing the proportion of GP income from capitation payments and the introduction of indicative drugs budgets could mean GPs will pay greater attention to the workload and financial implications of having some groups of patients on their lists."
I have said that to my right hon. and learned Friend before. The report continues :
"They indicated that this could mean refusals to accept elderly or chronic sick patients who apply to join the practice."
My right hon. and learned Friend assured the Committee : "the Government intend to minimise this likelihood and that the number of chronically sick could be taken into account in determining actual or indicative GP budgets".
However, I must point out to my right hon. and learned Friend that the working paper on GP budgets does not explain how such patients will be defined and identified. Our views were strongly supported by the Health Visitors Association and by others such as the Faculty of Community Medicine, so we are not speaking in isolation.
Indicative drug budgets are another relevant issue. Clearly, there is downward pressure from Government on the cost of drugs, but surely effective prescribing should not be judged in terms of medicine costs only. Medicines provide excellent value for money compared with many other forms of treatment. Keeping patients out of hospitals or out of community care by appropriate medical
Column 366treatment is both socially and economically advantageous. I hope that the emphasis on capitation and the Government's clear move to cost-limiting and cost-fencing the family doctor services will not lead to a less good service than we have at present. For the reasons I have expressed and for others that I have not time to express, I cannot support the Government in the Lobby tonight.
The debate has been useful in sounding a cautionary note for the future of the family doctor service and I hope that the Government will take heed. We are debating today the effects that we think the new GP contract may have. It could mean that patients have less time with their doctors, when we all know that they want more time and should have more time. It could mean elderly and chronically ill patients being culled from their GPs' lists. It could mean a widening gap between the service that one receives if one lives in a well-heeled suburb and the service provided in a deprived, inner -city area. It could also mean that patients have less chance to choose a woman GP, and there is much to justify those concerns.
The Secretary of State flatly denies those concerns and simply asserts that patients will receive better care. However, if he is confident of his case and certain that his predictions about the beneficial effects of the contract will be justified, let him give the House the following assurances. He must monitor what happens to list sizes and not talk merely about average list sizes. He must monitor the length of consultations and what is happening to immunisation and screening. He must monitor the number of women GPs, the ability of the elderly and the chronically ill to have the GP of their choice and the gap between the inner cities and the suburbs. He must give the House and members of the public a commitment that, if his contract has the effect that we fear, and which he denies, he will come back to the House and amend the regulations.
The main concern expressed this afternoon has been that the effect of the new contract will be that patients have less time with their doctor. Once again, the Secretary of State has asserted that that will not be the case, but there is a widespread belief that an increase in the capitation element of a GP's income will lead to an increase in list sizes, and that an increase in list sizes will lead to less time for each patient. That view is shared by Which? magazine, the magazine of the Consumers' Association, by the Select Committee on Social Services, about which the hon. Member for Macclesfield (Mr. Winterton) spoke, and by the Patients Association. The Secretary of State responds by saying that none of that will happen because we shall have the same number of GPs and patients, so average list sizes and consultation time will remain the same. The Secretary of State is content to say in defence of his contract merely that average list sizes will stay the same. Previously, the Government had supported a reduction in list sizes--a trend which had been supported by successive Governments--yet that aim
Column 367appears to have vanished today. We are talking only about whether we can prevent list sizes from increasing as a result of the contract.
We need to continue to reduce list sizes because it is only with smaller list sizes that doctors will be able to expand their preventive work and health promotion work. It is only with smaller list sizes that they will be able to play a real part in providing care in the community and to respond to the demands of patients which have rightly increased. In the past 10 years, the average number of visits made by patients to their doctors has increased by 35 per cent. That is one statistic that we never hear from the Government. Above all, the Government should be presenting measures to reduce list sizes and to increase the time each patient has with his GP because that is what patients want, as all surveys show. Most notably, the Which? survey discovered that more than 90 per cent. in its survey listed time with their GP as their priority. However, it is clear that the proposals will not increase patient time and that is disappointing.
Worse still, there are good grounds for believing that patients will have less time with their GP. Increasing the fee per patient--which is what the capitation element is--as a percentage of doctors' incomes provides doctors with a direct incentive to take on more patients. The Government have been muddled about that. In July, the Secretary of State said :
"It is totally illogical to suggest that the new contract will increase average list sizes."
However, in October he said :
"We fully recognise that the high capitation element in the new remuneration system does not favour small list practices." That is the case, because if one gives a financial incentive for doctors to increase their list size, they will do so, as GPs themselves believe. The widely held view is that increased list sizes will result not in doctors working longer, but in patient consultation time becoming shorter.
The Department of Health report on GP weekly work loads in 1987 showed that they spent about 38 hours seeing patients, plus 31 hours on call and six hours on other medically related work. If GPs work more hours, the quality of patient care will not improve. I do not want to see GPs dropping asleep in their surgeries in the same way that we see junior hospital doctors dropping asleep in the wards. General practitioners already have a full working week, yet under the contract they will be expected to take on more patients, to perform minor surgery, to carry out regular checks on the elderly, to carry out more immunisation and more childhood screening, to run anti-smoking clinics, alcohol control clinics and well person clinics, and to advise on diet, exercise and stress. As the hon. Member for Northampton, South (Mr. Morris) pointed out, they will be expected to do all that in addition to taking on extra patients to increase their income.
If the best doctors attract larger lists, it will turn good doctors into bad doctors, as my hon. Friend the Member for Kirkcaldy (Dr. Moonie) said. The number of GPs is not fixed, as the Secretary of State would like to make out. Therefore, his argument about the average does not hold. GP numbers could quickly drop if demoralisation sets in again. Once again, general practice could become an
Column 368unattractive option. Women could get squeezed out, and earlier retirement could certainly mean a reduction in the number of GPs. Only one in four GPs are women. That means that many women patients do not have the chance to choose a woman doctor and, therefore, must have a male GP. We need to continue the trend of an increasing number of women becoming GPs, but the contract threatens to reduce the number of women GPs. We must examine the figures. Women and men GPs have different working patterns. There is no such thing as the average GP. There is the woman GP's working patterns, hours and list sizes and then there is the male GP's profoundly different working pattern, hours, and list sizes. An effect of the contract--no doubt in an effort to squeeze out lazy and uncommitted GPs--is that the Government will squeeze out those women GPs who have fewer patients on their lists and work fewer hours. The reason why they work fewer hours is that women GPs, like most working women, must combine their work with their family responsibilities, whereas male GPs, like most men, leave family responsibilities to their wives.
If we are concerned to increase the number of women GPs, we must not discriminate against people for having smaller list sizes and working fewer hours. My hon. Friend the Member for Glasgow, Springburn (Mr. Martin) mentioned differences in care in inner cities and suburbs.
I now refer to the hidden agenda. My hon. Friend the Member for Leeds, West (Mr. Battle) was absolutely right. The Government think that the family doctor service is costing too much. Cash limiting--
Mr. Ian Gow (Eastbourne) : On a point of order, Mr. Deputy Speaker. Is it not a disgrace that the hon. Member for Peckham (Ms. Harman) should afford so little time to my hon. Friend the Minister, whom all hon. Members are waiting to hear with the greatest impatience?
The problem is the hidden agenda. The hidden agenda is about public spending. The Government think that the family doctor service is costing too much. They are cash- limiting support staff and drug budgets, and they are encouraging GP budget holders to opt for cash limited budgets. Their ultimate aim, of which the contract is part, is to increase list sizes and to reduce the number of GPs and, as a result, reduce public spending on the family doctor service. 6.52 pm
The Minister for Health (Mrs. Virginia Bottomley) : I thank hon. Members for their kind and undeserved comments. I am delighted to take on this role. I pay a warm tribute to my predecessor, now the Minister of State, Home Office, my hon. and learned Friend the Member for Putney (Mr. Mellor), who magnificently piloted the Children Bill through the House. It is a Bill in which I had a special and particular interest.
I cannot fail to be aghast at the remarks of the hon. Member for Peckham (Ms. Harman). She had her eye on the wrong target. She represents a constituency in which I worked for many years. I know directly the difference
Column 369between the best of the good general practice, which demonstrates the excellent service provided by a family practitioner, and the general practitioner who is not available, who uses an answering service and who does not provide all that the hon. Lady and I want for those in the inner cities. Many hon. Members have referred to the particular problems of the inner cities, and that is why a special premium is to be available in those areas. The key must be how we can ensure that our family practitioners, who are one of the most important elements in our National Health Service, can play a fundamental part in primary health care and can achieve the standards which all of us want.
Before discussing the regulations, I must pay a tribute to the other members of the practice and primary health care team. I was not particularly sympathetic when the hon. Member for Livingston (Mr. Cook) dismissively referred to other members of the team. Frankly, a chiropodist, a clinic nurse, a counsellor and many community nurses can play a crucial part in improving patients' well-being. Were the hon. Lady to have castigated the Government for failing to have refined the regulations and the contract for the past 25 years, she would have been nearer the mark. But to become agitated about the fact that now, at last, the Government are facing the responsibility of specifying precisely what we want general practitioners to do can only be a virtue and a force for good in the welfare of our people. Can it be wrong for any mother to know that children are to be more vigorously assessed, that their development is to be checked, and that immunisation is to be robustly pursued? Too many people are fearful of medical practices generally, and anything that we can do to encourage general practitioners to pursue the World Health Organisation targets and to look to the welfare of their patients must be good.
Can there be any objection to women having cervical cytology robustly pursued and ensuring that targets are met? I spent many years as the vice- president of the Women's National Cancer Control Campaign. In years gone by, had we thought that general practitioners would have reached targets like these, we would have welcomed them. Can there be anything objectionable in knowing that elderly relations will be visited? How many people over 75 are fearful of contacting their general practitioners and feel that they do not want to trouble them with their ailments? Often those over 75 can have their lives significantly improved and their medical conditions addressed by a visit and by assessment. That is welcome indeed. Time and again, the Foundation for Age Research has said that relatively simple medical treatments can often improve and enhance the quality of life for our elderly.
Can anybody object to payments for training and education? Anybody who examines the British National Formulary will see the speed with which medication and technical science have moved forward. Having served on the Medical Research Council, I know the speed of change and the importance of making sure that our general practitioners are promoting and encouraging the most up-to-date and best practice. As patients, all of us have rising expectations about what we want from our medical practitioners. The contract is about promoting patients' choice, providing information, and letting patients choose who they go to. That is the answer to those who fear the capitation allowances. The crucial point is that people should know
Column 370what is available and how much patients welcome the move towards greater health promotion and disease prevention. My hon. Friend the Member for Derbyshire, South (Mrs. Currie) has done a great deal to promote and encourage awareness of the importance of health promotion. How many people welcome the possibility of regular lifestyle checks and scrutiny when they go to their general practitioner?
I have not delayed the House in speaking about the role of women doctors. They have a crucial part to play. I welcome the fact that 50 per cent. of medical students and 40 per cent. of trainees are women. Many of the steps that we are taking are good news for women. Above all, the patient--the consumer who, too often, is not regarded--will be able to say, "I want to see a woman doctor." That will work as fast as any of our other objectives at ensuring that women doctors are available and have a crucial part to play.
My hon. Friend the Member for Northampton, South (Mr. Morris) spoke about the information that was forthcoming. I can tell him that the statement of fees and allowances, the red book, will be available later this month--well ahead of the schedule that he anticipated. My hon. Friend the Under- Secretary of State is shortly to make a statement about information technology in general practice. We want to ensure the well-being and safety of our Health Service. General practitioners have a crucial and vital part to play in primary health care. My right hon. and learned Friend the Secretary of State for Health has spent many hours in discussion. The regulations and the new contract provide the basis for an effective service that takes care of patients. I urge hon. Members to vote against--
It being Seven o'clock, Mr. Deputy Speaker-- put the Question, pursuant to order [27 October] :--
The House divided : Ayes 214, Noes 319.
Division No. 365] [7.00 pm
Abbott, Ms Diane
Adams, Allen (Paisley N)
Archer, Rt Hon Peter
Ashdown, Rt Hon Paddy
Banks, Tony (Newham NW)
Barnes, Harry (Derbyshire NE)
Barnes, Mrs Rosie (Greenwich)
Beith, A. J.
Benn, Rt Hon Tony
Bennett, A. F. (D'nt'n & R'dish)
Bray, Dr Jeremy
Brown, Gordon (D'mline E)
Brown, Nicholas (Newcastle E)
Brown, Ron (Edinburgh Leith)
Bruce, Malcolm (Gordon)
Buckley, George J.
Campbell, Menzies (Fife NE)
Campbell, Ron (Blyth Valley)
Campbell-Savours, D. N.
Carlile, Alex (Mont'g)
Clark, Dr David (S Shields)
Clwyd, Mrs Ann
Cook, Robin (Livingston)
Cunningham, Dr John
Davies, Rt Hon Denzil (Llanelli)
Davies, Ron (Caerphilly)
Davis, Terry (B'ham Hodge H'l)
Dunwoody, Hon Mrs Gwyneth