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Riddick, Graham

Robathan, Andrew

Roberts, Rt Hon Sir Wyn

Robertson, Raymond (Ab'd'n S)

Rowe, Andrew (Mid Kent)

Rumbold, Rt Hon Dame Angela

Sackville, Tom

Sainsbury, Rt Hon Sir Timothy

Scott, Rt Hon Sir Nicholas

Shaw, David (Dover)

Shaw, Sir Giles (Pudsey)

Shephard, Rt Hon Gillian

Shepherd, Colin (Hereford)

Sims, Roger

Smith, Sir Dudley (Warwick)

Smith, Tim (Beaconsfield)

Soames, Nicholas

Speed, Sir Keith

Spencer, Sir Derek

Spicer, Sir James (W Dorset)

Spicer, Michael (S Worcs)

Spink, Dr Robert

Spring, Richard

Sproat, Iain

Squire, Robin (Hornchurch)

Stanley, Rt Hon Sir John

Steen, Anthony

Stephen, Michael

Stern, Michael

Stewart, Allan

Streeter, Gary

Sweeney, Walter

Sykes, John

Taylor, Ian (Esher)

Taylor, John M (Solihull)

Taylor, Sir Teddy (Southend, E)

Temple-Morris, Peter

Thomason, Roy

Thompson, Sir Donald (C'er V)

Thompson, Patrick (Norwich N)

Thornton, Sir Malcolm

Thurnham, Peter

Townsend, Cyril D (Bexl'yh'th)

Trend, Michael

Trotter, Neville

Twinn, Dr Ian

Viggers, Peter

Walden, George

Walker, Bill (N Tayside)

Waller, Gary

Wardle, Charles (Bexhill)

Waterson, Nigel

Watts, John

Wheeler, Rt Hon Sir John

Whitney, Ray

Whittingdale, John

Widdecombe, Ann

Wiggin, Sir Jerry

Wilkinson, John

Wilshire, David

Winterton, Mrs Ann (Congleton)

Winterton, Nicholas (Macc'f'ld)

Wolfson, Mark

Wood, Timothy

Young, Rt Hon Sir George

Tellers for the Noes: Mr. Bowen Wells and Mr. David Willetts.

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Question accordingly negatived.

Question, That the proposed words be there added, put forthwith pursuant to Standing Order No. 30 (Questions on amendments) and agreed to.

Question accordingly agreed to.

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Mr. Deputy Speaker-- forthwith declared the main Question, as amended, to be agreed to.

Resolved,

That this House believes that privatisation offers the best opportunity for reversing the historic decline suffered by the railway system under nationalisation; and further believes that the privatisation of Railtrack offers the best future for Railtrack, and for passengers and freight users, by making greater use of private sector skills in managing the network and in providing greater scope for private capital investment in the upgrading of the railway system.

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General Practitioners (Night Service)

7.16 pm

Mr. Alex Carlile (Montgomery): I beg to move,

That this House shares general practitioners' concerns as to the continuing provision of a high quality service by night as well as day, given increasing demands; seeks to facilitate improved methods of work so that general practitioners can provide a more flexible, clinically appropriate and more modern way of providing emergency care outside normal hours which is right for patients, fair on the taxpayer and manageable by family doctors; believes there should be a right for general practitioners to transfer responsibility for out of hours care to another general practitioner without unnecessary interference by the Family Health Service Authority; supports the need for substantial, ongoing patient education campaigns on the appropriate use of the out of hours emergency service; and calls on the Government to take all reasonable steps to avoid industrial action by general practitioners.

It is a matter for regret that I have neither the attention-- [Interruption.]

Mr. Deputy Speaker (Sir Geoffrey Lofthouse): Order. Can we have some quiet on the Front Bench, please?

Mr. Carlile: Thank you, Mr. Deputy Speaker.

It is a matter for regret that we do not have the benefit of the presence of the new Secretary of State for Health on the Government Front Bench. The right hon. Gentleman would not be coming fresh to the situation, because he was once a junior Minister in the Department of Health, and should have a ready understanding of the issues that we shall discuss.

If the Secretary of State had come here, we might have been reassured that he had reviewed the stubborn attitude of the Minister of State, who as usual is grinning from his position on the Front Bench. Had he been born in Cheshire, he would not have needed transmogrification. Of course, it is still open to the Secretary of State to wind up the debate, but I think that we shall find that he does not like working out of hours, and so has decided to send his junior partner out on this call.

It is worrying that we should have a dispute of the kind that now exists on out-of-hours provision between Ministers, representing the Government, and general practitioners. It is extraordinary how the Government have managed to make fervent opponents out of a traditionally moderate profession. It is perhaps a pity that the Minister of State, who is present tonight, did not follow the slogans of his own patient education campaign in relation to this issue. One of those slogans, which one sees on surgery walls, reads, pithily, "Be nice, think twice." I realise that, for this Minister, that would have presented a formidable triple challenge.

Perhaps the Minister might take advantage of another of the slogans of the Government's rather weak patient education campaign: "Help us to help you." That is a bit bland but, if he repeated it when he got up each morning, he might find it easier to review this desperate issue between general practitioners and the Government. The leaders of GP professional groups could not be considered, even in the wildest of imaginations, to be revolutionaries set in a political cause against a Conservative Government.

I doubt whether Dr. Sandy Macara has a poster of Che Guevara on his wall; or that Dr. Ian Bogle has a poster of Danny Cohn-Bendit--or that they did even in their

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student days. Knowing those two gentlemen, I suspect that they were more likely to have been inspired by the likes of Winston Churchill and R. A. Butler, yet we find them challenging the Government because of their attitude towards the most basic part of the national health service--primary medical care.

For more than two years, the Government, led by the right hon. Member for Surrey, South-West (Mrs. Bottomley), the Minister of State and their colleagues in the Department of Health, have managed to reduce morale among GPs to a new low, to the very brink of industrial action. I and my Liberal Democrat colleagues want to avoid that, as do the majority of GPs, but there is a real danger that, unless the Government change their attitude now, the dispute will escalate. If it escalates, it will be to the disadvantage of patients. If it is to the disadvantage of patients, let it be known that, although the Government might try to blame the doctors, the Government will be to blame, not the medical profession; for it is plain that it is within the Government's capability to end this dispute successfully, if reluctantly.

If the Minister of State goes contrary to form and displays a change of mind tonight, we will hail that change. One always hails a good premiere. What one is rather bored by is a tedious repetition of past poor form.

Let us consider the problem, for there is a problem, that faces GPs. I have to confess--if it is a confession--to being a GP's son. I remember when we lived in Burnley in Lancashire, in the old house that contained the surgery, that, occasionally, the telephone used to ring at night and my father would go out to make a call. He had a big practice, but night calls were a rare occurrence in those days. Times have changed and demands have increased. By the time my father retired, the number of night calls had increased significantly, and the partners who succeeded him in his practice have been subjected to a burgeoning demand for night services.

By 1989-90, some 936,148 night visits were made by GPs. By 1993-94--albeit the statistics cover a two-hour longer period than in the year I have just mentioned--some 1.832 million night visits were made by GPs. The latest estimate that we have been able to obtain from the British Medical Association is that, in the past year, 2.3 million night visits were made. These are visits demanded of doctors by patients. A doctor turns down a night visit at his peril--if he does not attend and something goes wrong, he is in trouble. Doctors--or at least the health service--have to be able to meet that demand. The number of night visits has increased more than six times in 25 years, and it has doubled since the introduction of the new GP contract.

I should say that I am delighted to see that the new Secretary of State has joined the debate for a short time. I congratulate him on his appointment. As I said earlier, he comes to the Department of Health for a second time, I believe, and therefore with some experience. I shall repeat the hope that he might decide to wind up the debate himself rather than leave the out-of- hours provision to his junior partner, the Minister of State. It would certainly be helpful--I repeat this in his presence--to hear that the Secretary of State has immediately reviewed this very worrying dispute, which must have been taking up significant space on his desk when he arrived in his new office.

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I shall now return to the problems faced by doctors. An average of six night visits a month are made by doctors, and an average of 36 patient consultations per month are made out of hours. Many of those consultations, of course, are not night visits. There is much anecdotal evidence of greater weekend demand than many people think exists. It is clear that weekend demand has risen as quickly as night visits. Patient expectation, but not always patient responsibility, has risen. It is right in a debate such as this--I hope that hon. Members on both Front Benches share this view--to be quite robust about the attitude of patients and to ask them to be far more considerate than they sometimes are towards their GPs and out-of-hours provision.

In our consumerist society, legitimised by the patients charter, patients are expecting more at all hours from their doctors. For what should be an emergency service, the anecdotal evidence of misuse is striking. One doctor tells of a call for a home visit only to find when he got there that the family he was called to had gone out for a walk. Another tells of a man who complained that his hands had gone blue and that he feared a serious circulatory problem, only to be told, when the doctor arrived on the emergency call, that he had received some blue dye from the overalls that he had washed earlier that evening. One woman even woke a doctor in the middle of the night to ask him to deliver sleeping tablets because she could not sleep. Doctors are at times victims of the inconsiderateness of their patients, but they also find themselves picking up the pieces of a society broken by Government policy. They constantly have to deal with misplaced, often seriously psychiatrically ill, community care patients. They are often the only people to whom chronic schizophrenic patients, who have been dumped in loneliness in society, can go. They often have to deal with the drug and violence problems of inner cities and are at physical risk when they go out on night calls. In rural areas, doctors have to provide almost all the emergency medical cover. Indeed, they are often called out to do what turns out to be emergency dentistry, which they are not able to complete.

The situation is fraught with problems for GPs. In May of last year, after many months of negotiation, the BMA and the Government agreed on changes to GPs' terms of service. It had taken months to clarify whether GPs could use their own judgment to decide whether a patient required a home visit, which seems an extraordinary issue for the Government to argue about for so long, and it took many more months to decide how to implement a very small amount of flexibility in how out-of-hours care was provided.

Now, negotiations on the payment scheme have run into the sand, but it is not principally an issue about money. Doctors are not simply holding out for more money. The real issue that concerns the BMA is the form of the out -of-hours system. Doctors want to move away from a scheme that positively encouraged--perversely encouraged--GPs to undertake out-of-hours provision themselves, whatever the effect on their work, rather than use other people to do it for them, because they were paid more for doing it themselves, which seems irrational. An offer of £2,000, plus £9 for each visit, was rejected as, for many doctors, it would be a direct pay cut. It is extraordinary how the Government believed that they

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could offer doctors a pay cut as an incentive to accept a new contract. The offer was increased to a lump sum of £2,000 and a £20 fee for each night visit. That offer was also rejected, not on money grounds, but as a crude approach to the far more complex problems of the structure of and demand for out-of-hours care.

The Minister groans audibly when I say that the dispute is not mainly about money, which shows that he has not begun to understand the issues that the British Medical Association is trying to put to him. I suggest that he or, preferably, the Secretary of State, should meet Dr. Bogle and Dr. Macara shortly--I believe that the Secretary of State might well be intending to do so--so that a new view can be taken of what the dispute is really about.

The Minister for Health (Mr. Gerald Malone): It is not the British Medical Association that I have some difficulty understanding, but the hon. and learned Gentleman. In one voice he says that he is against what he says are the perverse incentives in the scheme. If I paraphrase him correctly, they are perverse incentives that mean that doctors are encouraged to do their own visits. What has happened is that, in the new fee structure, a different incentive reduces the perverse incentive that he criticised, yet he is criticising what we have proposed as well. Which does he prefer?

Mr. Carlile: I am afraid that I find that intervention totally incomprehensible. I suggest that the Secretary of State reads the submissions--if he will listen for a moment--presented to him by the BMA, start with a clean sheet and ignore the prejudices of his Minister of State, which have become the major obstruction to resolving the dispute. Sometimes it helps to take a new look. Perhaps the Secretary of State will do that.

Of course, money is part of the question. Indeed, Dr. Brian Hope of Salford suggested that not many Conservative Members would leave their lovers' beds for that sort of money unless it was to ask a parliamentary question. That was a rather unfair gloss on the real issue. It is not simply a pay dispute between a profession and its paymasters, but a dispute about realistic provision of high-quality patient care. The Minister can put his finger in the dyke, but the hole will grow unless the Government are prepared to study the structure of out-of-hours provision and produce a resolution for the future.

There is a way forward on six issues. The Government are right to support the development of GP co-operatives. They offer a good solution to out-of- hours care. Such co-operatives, however, cover only 17 per cent. of patients, and the National Association of GP Co-operatives would, I think, recognise that it will take a considerable time for them to be suitable for all types of area, particularly some inner-city practices and rural areas.

The whole profession, including the co-operatives, is united in the belief that the Government's £45 million offer has been made in a way that provides no equity between practices and areas of different types. My first suggestion to Ministers, therefore, is that they consider the way in which the £45 million has been offered and find out whether they can re- tailor it into a more equitable offer for general practices throughout the country.

In due course, I should like to hear from the Minister that the Government's door is open on the issue of distribution at least. It would be interesting to hear from him where that £45 million is to come from, however. Is it new money? That is a simple question and the Minister

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