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Column 288Flannery, Martin
Hughes, John (Coventry NE)
Hughes, Robert (Aberdeen N)
Lloyd, Tony (Stretford)
Mahon, Mrs Alice
Martin, Michael J. (Springburn)
Michie, Bill (Sheffield Heeley)
Pike, Peter L.
Ross, William (Londonderry E)
Smith, C. (Isl'ton & F'bury)
Thomas, Dr Dafydd Elis
Watson, Mike (Glasgow, C)
Williams, Alan W. (Carm'then)
Wise, Mrs Audrey
Tellers for the Noes :
Dr. Kim Howells and
Mr. Win Griffiths.
Question agreed to .
That the Promoters of the Cardiff Bay Barrage Bill [Lords] shall have leave to suspend proceedings thereon in order to proceed with the Bill, if they think fit, in the next Session of Parliament, provided that the Agents for the Bill give notice to the Clerks in the Private Bill Office of their intention to suspend further proceedings not later than the day before the close of the present Session and that all Fees due on the Bill up to that date be paid ; Ordered ,
That if the Bill is brought from the Lords in the next session, the Agents for the Bill shall deposit in the Private Bill Office a declaration signed by them, stating that the Bill is the same, in every respect, as the Bill which was brought from the Lords in the present Session ;
That as soon as a certificate by one of the Clerks in the Private Bill Office, that such a declaration has been so deposited, has been laid upon the Table of the House, the Bill shall be deemed to have been read the first and shall be ordered to be read a second time ; Ordered ,
That the Petitions against the Bill presented in the present session which stand referred to the Committee on the Bill shall stand referred to the Committee on the Bill in the next Session ; Ordered ,
That no Petitioners shall be heard before the Committee on the Bill, unless their Petition has been presented within the time limited within the present Session or deposited pursuant to paragraph (b) of Standing Order 126 relating to Private Business ;
That, in relation to the Bill, Standing Order 127 relating to Private Business shall have effect as if the words under Standing Order 126 (Reference to committee of petitions against Bill)' were omitted ;
That no further Fees shall be charged in respect of any proceedings on the Bill in respect of which Fees have already been incurred during the present Session ;
That these Orders be Standing Orders of the House.
"The Instrument has not yet been considered by the Joint Committee on Statutory Instruments."
That is no longer accurate. It was considered by the Committee this afternoon. We did not have time further to examine the instrument, but the Committee does not wish to draw the attention of the House to any defect in it.
Mr. Donald Dewar (Glasgow, Garscadden) : I beg to move, That an humble Address be presented to Her Majesty, praying that the National Health Service (General Medical and Pharmaceutical Services) (Scotland) Amendment (No. 2) Regulations 1989 (S.I., 1989, No. 1990), dated 31st October 1989, a copy of which was laid before this House on 1st November, be annulled.
I want to draw the attention of the House to a large number of defects in the regulations. I intend to do so briskly because there is just over an hour in which to debate them, and many of my hon. Friends wish to participate in the debate.
We have some fundamental objections to the regulations. I make no apology for having prayed against them and I make no apology either, for inviting my right hon. and hon. Friends to vote against them. Our first and very obvious objection, with which the Minister will be familiar, is that the GPs' contract is being imposed despite the overwhelming opposition of the vast majority of doctors in Scotland. Their dislike of and objections to the contract are shared by the public and are certainly supported by the Opposition.
I want to make it clear that not every proposed change is offensive or unacceptable in itself. For example there are provisions to give individual patients more information about practices and to give them the ability to move from list to list, there is an incentive for doctors to undertake their own night calls and there are a number of other matters with which there is no great quarrel and which will have a fair degree of support. But that is not the essence of the matter.
The imposition of the contract has been necessary because it represents a substantial switch in general paractitioners' incomes to capitation fees. There is no doubt that there has been a marked switch of emphasis. I understand that it is intended that capitation fees should rise from about 45 or 46 per cent. of the income of a practice to about 60 per cent. We fear that the effect will be that fewer doctors will see more patients and that that will build in an incentive to increase patient numbers and cut the time that a doctor spends with each patient. That has been considered over a lengthy period and there has been a spirited public debate. In the parallel debate on the English instruments, my hon. Friend the Member for Livingston (Mr. Cook) drew attention to the findings of the Select Committee on Social Services in 1987 which recorded :
Column 290"the proposal to increase the proportion of a general practitioner's income derived from capitation was universally opposed."
Since then, the opposition has become even more marked, more vociferous and more strongly based on public opinion.
As the Minister will no doubt concede, the proposals before us represent the reversal of a change in policy that took place in the 1960s. Until then GPs' remuneration was based almost entirely on capitation fees. That became unpopular and was widely considered as an unsatisfactory system. In 1964, or around that time, under the then Labour Government, there was a major renegotiation which produced a hybrid system. Capitation fees remained important, but there was a substantial switch to fees and allowances. At the same time the Government guaranteed two thirds of the cost of practice workers and a number of other matters.
That essential shift in the balance between capitation and other forms of income, was negotiated on the basis of experience and consensus with the medical profession and with those who were interested in the future of primary medicine under the Health Service. We are now seeing an about-turn. We are being asked to move backwards at the command of the new Right and if we do that it will be to the detriment of the service and the disadvantage of the patient.
No doubt the Minister will argue that there are safeguards in the new Scottish contract, and perhaps he will say a word or two about them. He may point to the operation of the Scottish rural practice fund which is well established and well understood and has been a well-targeted project based largely on a capitation element for smaller practices. Of course there will have to be an increase in the Scottish rural practice fund. I am particularly interested in how that will be paid and whether it will be indexed to keep pace with the cost of living or will take account of the substantial shift towards capitation fees in general practitioners' remuneration. Clearly, if the capitation fee becomes more important and increases as a proportion of the total, small practices are likely to suffer as it grows. If they are to get anything like satisfactory protection, it is essential that we receive assurances from the Minister that the rural practice fund will increase more than simply by the cost of living to take account of that. If our protestations are to carry any credibility, it would be very helpful if the Minister were specific on that point.
The deprivation allowance is a new payment introduced by the contract. It is referred to in paragraph 12 of the contract as an amendment to regulation 31. We know that deprivation is a problem in Scottish society. I draw the House's attention--I do not know whether the Minister is familiar with it--to an article that appeared in the 7 October issue of the British Medical Journal. The authors of the article, Vera Carstairs and Russell Morris, set out the stark facts of deprivation in Scotland and the marked connection between those facts and mortality rates. The comparison between the percentage value of components of deprivation in Scotland and those in England and Wales is harsh. Male unemployment is 12.7 per cent. in Scotland but 8.7 per cent. in England and Wales. The figure for housing overcrowding is 25.3 per cent. in Scotland but 5.8 per cent. in England and Wales.
Column 291Among the social indicators, 41.2 per cent. of the population in Scotland have no car, whereas the figure for England and Wales is 24.4 per cent.
The article says that 24 per cent. of the population of England and Wales live in what are described as affluent conditions--category 1 conditions-- whereas the same category embraces only 6 per cent. of the population of Scotland. That is a worrying factor and is perhaps a reproach to us all, but it is directly reflected in the workload of general practitioners and in the Scottish mortality rates. It is depressing to discover that mortality rates in Scotland are 16 or 17 per cent., depending on gender, above those in England and Wales. That is a startling fact.
The Minister may say, "So what?" There may be a tendency to shrug that off, or we may be told that it will be cured by a good dose of the enterprise culture blown away by the healthy enema of Thatcherism, but none of us believes that for a moment.
The impact of deprivation on GPs' work loads is well documented. Research shows that male patients in Scotland aged 65 to 74 have six consultations per annum, whereas in England and Wales it is only five. The figure for females is seven in Scotland and five in England and Wales. Perhaps that difference is marginal, but if it is aggregrated across the caseload of a busy practice or across a community it represents a substantial distinction and underlines the potential importance of the deprivation premium. It futher underlines the importance of how funds will be allocated once they are being paid. That is the second point that I ask the Minister to consider and say a little about.
I understand that over the years the Scottish Office has established acceptable methods of calculating deprivation factors in individual practices. I should like to know what the allocation to Scotland will be for the deprivation allowance. If it is to be paid on a population ratio, we should expect about 9 or 10 per cent., but clearly that would be a mockery given the facts to which I have referred and the overwhelming rate of deprivation in rural and industrial Scotland. I am told that the Jarman index suggests that a fair apportionment of the national total for Scotland would be between 15 and 20 per cent.
A decision must be made, in principle at least, between the Scottish Office and the Department of Health. I hope that the Minister will say that the allocation will be based on the incidence of deprivation and not on a more arithmetical calculation that depends on population ratios. I know that the Minister will be in a position to help us, and I very much hope that he will do so. I shall confine the rest of my remarks to list sizes because I am aware that I must discipline my comments if other hon. Members are to speak. It would be a tragedy if the considerable advantage which is enjoyed in the Health Service in Scotland were eroded. The average practice list in Scotland is about 1,650 patients. In England, it is marginally under 2,000. There is a significant gap between the two--one gap that I do not want to see closed.
The Under-Secretary seems determined to close that gap. That is the clear implication of his policy. The regulations are offensive because they impose a contract against the wishes of the majority of Scottish doctors and introduce changes which are not in the best interests of
Column 292patients. They make Scottish GPs more dependent on a simple head count. They build in a financial incentive to increase list sizes. They mean fewer doctors treating more patients.
The Opposition's interest is the future of the Health Service. Efficient general practice is the necessary foundation for the specialist services that often make the headlines. I fear that the regulations are another illustration of the Government's so-called business approach to patient care taking second place to accountancy practice. For that reason, I invite my right hon. and hon. Friends to oppose them.
The Parliamentary Under-Secretary of State for Scotland (Mr. Michael Forsyth) : I am astonished at the speech of the hon. Member for Glasgow, Garscadden (Mr. Dewar), who is normally more assiduous in doing his homework on these matters. He said that he had taken a lot of advice. I shall give him one piece of advice. It is certainly correct to say that GPs in Scotland enjoy smaller list sizes than doctors south of the border. One reason is the fact that, since 1979, under the Government, the number of GPs in Scotland has been increased by 14.9 per cent. The number of women doctors has been increased by about 60 per cent. Under the Conservative Government, average list sizes have fallen from 1,856 to 1,605. If we enjoy the benefits of smaller list sizes, it is because the Government have provided more doctors.
Mrs. Maria Fyfe (Glasgow, Maryhill) rose --
Mrs. Fyfe rose --
Mr. Forsyth : The hon. Member for Garscadden should take account of that fact. He has asked whether this will continue. The answer is yes. We will continue to increase the number of general practitioners. How can the hon. Gentleman argue that average list sizes will have to increase when he knows that the Government are committed to increasing the number of GPs and to increasing expenditure on these primary care services while the population remains broadly static? Elementary mathematics would enable anyone to determine that, in those circumstances, average list sizes cannot increase. I hope that the hon. Gentleman will now withdraw his accusation.
Column 293average list sizes will have to increase. If we are going to increase the number of GPs and the population remains broadly static--everyone agrees that it will--how is it possible to argue that average list sizes will increase?
Mr. Dewar : I am fascinated by the Minister's comments. Obviously, we will see what happens over the next year or two. If the hon. Gentleman is saying that no incentive is being built into the scheme to increase list sizes, he is the only person in Scotland who thinks so. He is used to being the only person in Scotland who thinks certain things. We have had to put up with that for a long time. Even the Secretary of State does not usually think the same things as the hon. Gentleman. The truth is that that incentive is being built in. If there is not the increase in list sizes that we predict, we will be in the odd position that the Minister's plans clearly have not worked as he intends.
Mr. Forsyth : On the contrary. The hon. Gentleman has changed his ground. He started off by arguing that the average list size would increase. The Hansard account will show that. He is now arguing that there will be an incentive for doctors to attract patients. That is entirely different from arguing that the average list size will increase. The hon. Gentleman cannot argue that the average list size will increase if the number of doctors will increase. The Government have increased the number of GPs in Scotland every year by about 100 and we plan to continue to do so.
The hon. Gentleman said that we shall see what happens in a few years. I take that as a tacit admission that his assertion about the average list is incorrect.
Mr. Robert Hughes : During the summer, I had occasion to visit a GP in Aberdeen as a result of a minor dietary indiscretion. He told me that the principal in the practice had retired, and that if he had known the Minister's plans, he would not have replaced the principal but carried on with fewer doctors. That is how list sizes will rise. Doctors will not be replaced. The Minister's fond claims that the number of GPs will increase will be found to be a gross overstatement.
Mr. Forsyth : I hear what the hon. Gentleman says, but his constituent was making the same mistake as the hon. Member for Garscadden. He is making a judgment, but no hon. Member, me included, and no doctor, knows what the result of the new contract will be for incomes. The contract will be priced not by the Government but by the doctors and dentists review body on the basis of evidence that the Government will give to it.
We have made it perfectly clear that the purpose of the contract is to encourage doctors to extend their range of services, and to ensure that those who provide screening and meet their targets, who encourage their patients to come for check-ups and who provide additional services such as day surgery will be rewarded for doing so. I do not know what kind of service the constituent of the hon. Member for Aberdeen, North (Mr. Hughes) provides, but many GPs in Scotland provide exactly the type of service that we want to encourage. They are the doctors who turn out in the middle of the night. The hon. Member for Garscadden was kind enough to acknowledge that there are many attractive aspects of the contract. There are doctors who are available at weekends and those who provide day surgery services. They are not sufficiently
Column 294rewarded for providing such extra services, and the contract will enable them to benefit in a way that has not been possible in the past.
Mr. Forsyth : There is no such thing as an average general practitioner, but some figures have been done as a result of the work study. If my hon. Friend will bear with me, I shall come to them later in my speech.
Mr. Forsyth : There are indeed average list sizes and budgets. I said that there is no such thing as an average GP. Each GP provides a range of services that are considered appropriate to his or her patients. The contract will reward most those doctors who do most for their patients, and encourage patients to choose their doctors. The hon. Member for Garscadden was good enough to say that the retention of the Scottish rural practices fund will make a difference to doctors in Scotland. I think that I am entitled to observe that the contract was negotiated on a United Kingdom basis--Scottish doctors were not prepared to negotiate on a Scottish basis- -and my right hon. and learned Friend was able to get the contract amended to reflect Scottish circumstances, including a reduction in list sizes required to qualify for basic practice allowance and changes, which are unique to Scotland, to reflect the position in rural and deprived areas. The pricing of the Scottish rural practice fund is a matter on which we shall be giving evidence to the doctors and dentists review body.
Mr. Forsyth : The hon. Gentleman is right to say that it has nothing to do with me. I should have thought that he would have been reassured rather than alarmed by that. I should have thought that the hon. Gentleman would be pleased that such a body will price the contract and look at the position. I should have thought that the hon. Gentleman would also give some credit to Ministers for having secured that. He wrote to me about the matter and has been prepared to discuss it in correspondence.
The hon. Member for Garscadden and I can perhaps agree to acknowledge the importance of the Scottish rural practice fund. I hope that he acknowledges that it will help doctors in rural areas. What will, of course, eventually matter is the weighting that is applied and the sums of money involved--if one is concerned with incomes rather than patient care.