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House of Commons

Friday 3 November 1995

The House met at half-past Nine o'clock


[ Madam Speaker-- in the Chair ]

National Health Service (Fundholding)

Motion made, and Question proposed, That this House do now adjourn.--[ Mr. Conway. ]

9.34 am

The Minister for Health (Mr. Gerald Malone): I am pleased to have this opportunity to debate such an important topic. The House will find it interesting to have an opportunity to explore how far statements made by former Opposition spokesmen on fundholding now reflect the views of the current team or, indeed, the views of the people they represent. General practitioner fundholding is one of those issues that appear to divide Opposition Members. It certainly has in the past and it will be interesting to discover whether it will today. Perhaps we shall be given a clearer view of their proposals for the future of primary care and, perhaps, some final acknowledgement of the important role that fundholders have already played in reshaping local health services to benefit patients. I will return to that subject later.

First, I want to make clear what the Government are doing in the primary care sector and fundholding in particular. It is widely recognised that the NHS is in a constant state of change and development. That is not surprising and there are a number of reasons for that. Medical technology, public expectations and other pressures all require the NHS constantly to change and adapt. The same is true of all other health care systems. We need only to look around the world to realise that many countries are not coping with the pressures, whereas in this country the NHS, as it is shaped by Government policies, is coping. The conclusions that I draw from those international trends is that the United Kingdom is out in front, while other countries are following our lead.

The Government's overriding aim in that process of change is to ensure that the quality of NHS care we have tomorrow is better than we have today. I want to set out the four key aims for the NHS. First, we want to make services high quality and effective, focusing on the care of individuals as well as improving the health of the population, as set out in "The Health of the Nation". I hope that the House will recognise, as I am sure the public recognise, that "The Health of the Nation" strategy is an extremely important development, leading the NHS away from simply coping with problems to positively developing the health of the nation and moving more towards prevention than we have ever previously been able to do.

Secondly, we aim to give patients the right services in the right way. It is not just about improving the quality and range of clinical services and developing the patients charter, but about ensuring that services are accessible to

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people. The NHS must be at the heart of every local community. Patients must be confident that the organisation of services reflects what they want and need, rather than what others think they should have.

At the core of the reforms is the point about putting patients' care first. The changes that have occurred and the move from the acute to the primary sector ensure that treatment is taking place in an appropriate setting, as near to the patient as possible. Under the old NHS patients were pushed around the system; under the NHS as we envisage it today, patients will find services much closer to where they live.

Thirdly, we want services to fit together in a seamless way, with no gaps or overlaps and with strong links between all parts of the NHS. Many people with varying degrees of expertise work within the service. Now, the consultant cannot work in splendid isolation from the community midwife; nor can the GP from the social worker. Only through partnership among professionals can we the secure highest quality of care for patients. What underpins that aim is the principle that when the patient is being treated, he should not notice when he is moving from one element of care to another. Care for the patient should be seamless.

Lastly--and I make no bones about this point--we must give patients as much as we can from the money available. I am always astonished by the Labour party constantly saying in debates that getting value for money and putting the mechanisms in place to achieve that are almost unimportant. The taxpayer is now putting record levels of money into the health service, yet the Opposition think that unimportant. The truth of the matter is that that money is not only for the men in grey suits--the accountants and financial directors or, indeed, the Treasury--but embraces those in white coats who are now far more involved in managing the NHS than ever before. Benefits can also be obtained through improvements in clinical effectiveness and audit. That is part of the process that has been under way since 1990 to ensure that the NHS is accountable in detail to Parliament and the public. In essence, it means ensuring that decisions are made at the right level by those in the right place who have the right information.

I wonder whether Opposition Members would disagree with any of that. I would be surprised if they could. They say that they share our objectives, but, when the mechanisms are put in place and we debate them, they say that the mechanisms are wrong. If they sign up to those objectives, it is all the more amazing that they can continue their opposition to fundholding. I cannot think of a better example than fundholding that meets all the four aims necessary to improve the NHS.

I now cite examples of the ways in which fundholders deliver the key principles. First, they make services responsive to the needs of patients and they make them more accessible. There are examples of that happening all over the country, as I see when I visit GP practices, fundholding and non-fundholding. For example, in Buckinghamshire, the patients of Dr. Maisey and his partners no longer have to attend the local district general hospital for radiology or out-patient services.

Patients at a practice in Ealing now have access to a range of complementary medicine at the practice, which is increasingly what patients want. Under fundholding, if patients think it desirable and doctors think it a clinically

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appropriate way to deliver treatment, that is what happens. Before fundholding was introduced, those patients had to go into hospital for orthopaedic, rheumatic or physiotherapy treatment. Patients agree that life is much better when fundholders can use their discretion and ensure that care is delivered closer to the patients. One of the arguments constantly used by the Opposition is that in fundholding we have created a two-tier health service. Yes, we do have a two-tier NHS--the NHS that we had in 1989 and the NHS that we have now in 1995. Let me give the House an illustration of the difference. Under the old NHS, the number of people waiting more than 12 months was 223,311. This year, the figure is 32,194. The average waiting time under the old NHS for in-patient or day case admission was 9.3 months, whereas the average time now is four months. Under the old NHS, there were 38,900 hospital doctors; there are now 44, 600. There were 3,051 medical school places available; there are now 3,315.

The Opposition say that we have cut the national health service and that we, as a Government, have not been decent custodians of it, but the opposite is true. The service has become far more effective and is now a top-tier NHS. That is what the Opposition would dismantle.

Mr. David Hinchliffe (Wakefield): I am interested in the Minister's comments about the two-tier system which he denies that fundholding has created. I should like an answer to the questions that I have been asking him and the Secretary of State for some time. If there is not a two-tier system, why are my constituents, who are waiting for treatment at Pinderfields hospital in Wakefield, being asked whether they belong to a fundholding practice or not? Why is it that patients from fundholding practices needing certain specialist treatment can get it while patients from non-fundholding practices cannot?

Mr. Malone: I am glad that the hon. Gentleman has given me the opportunity to deal with that point. As he well knows, when we set out to introduce fundholding, there was agreement with consultants and the medical profession as a whole as to how we would view priorities. Every emergency is treated as a priority and the treatment is similar. Where fundholding bites is in the purchasing of marginal care in hospitals where there is spare capacity for fundholding patients. Of course, when people present to have certain needs addressed, the question to which the hon. Gentleman referred will be asked because it has to be determined whether there is a contract with the fundholder for that particular service. What amazes me about the Opposition's comments about there being a two-tier system is that they imply that everyone across the country was treated in the same way under the old NHS. I said that in 1989 there were 223,311 people waiting for treatment, but they did not all wait the same length of time. That time varied from region to region, and waiting lists still vary from region to region. It is absurd that the Opposition denigrate the fact that we have been making progress. They wish to denigrate the fact that using fundholding in a different way from a health authority to purchase margins of health care is providing better treatment for patients.

The Labour party is, as it has always been, the party of levelling down. It does not ask why health authorities are not purchasing their health care in the same innovative

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way as fundholders so that patients benefit. The purpose of fundholding is to create a leading edge by which others will inform themselves of best practice. It also creates targets to which others may aspire.

Mr. Bernard Jenkin (Colchester, North): Do not Labour's complaints about fundholding fail to make it clear that fundholding is advantageous to patients? Does my hon. Friend recall the time when there used to be a multi -tier health service across the country? The treatment that one received and how long one had to wait for it was a lottery, depending on where one lived. Does he remember that the two-tier system of 1979 meant that, if one could persuade the picket line to let one through, one was treated, but, if one could not cross the picket line, one went without treatment?

Mr. Malone: My hon. Friend is absolutely right. It is important for patients and the country as a whole that we demolish the two-tier argument. The Opposition use it to suggest that it is unusual that waiting times vary across the country, but that has always been the case.

Mr. Hinchliffe: At the same hospital?

Mr. Malone: When there were 223,000 people waiting for treatment, there were of course different waiting lists at the same hospital, but then people had to buy care to move up the waiting list. Now, the NHS treats people within an average of four months rather than nine months. That is the system that we have developed.

Mr. David Congdon (Croydon, North-East): Does my hon. Friend agree that, as the evidence shows that GP fundholders get no more funding per patient on their list than equivalent non-fundholders, the reality is that fundholders use their purchasing power far better than the bureaucracies of the health authorities? Is not the challenge for health authorities to bring their use of purchasing power to the level of that of fundholders?

Mr. Malone: My hon. Friend is right. If that were the question asked by the Opposition, I might have some sympathy with them. I was coming to the point raised by my hon. Friend. Fundholding is about making services more coherent and providing stronger links between the primary and secondary care sectors and within the primary care team. It is these fundamental changes that have delivered the margins with which fundholders are able to buy additional care for their patients.

There is an example of that in Manchester which shows how fundholding can help a practice focus on how to be better organised, involving the whole primary health care team. Doctors there have greatly improved the practice for patients by reducing non-attendance and improving immunisation services. The practice will not stop there, and that is one of the characteristics of fundholding. The doctors and professionals concerned are keen to move the boundaries ever further forward and they are looking to develop a wide range of in-house services not previously available.

But that is only part of the story. Fundholding is not just about improving services. Our strategy under the "Health of the Nation" White Paper is central to the aim that I set out earlier of improving the health of the population as well as delivering first-class health care. GPs are ideally placed to make a major contribution to that. Their dual role of needs assessment and direct patient care puts them at the leading edge to achieve genuine health gain.

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For example, there are new and novel solutions to meet problems being faced by the community. In County Durham, Dr. Derek Brown has developed a scheme called "Positive Parenting" to help parents of children under five move safely through concerns that they may have over their children's health, be they speech difficulties or sleeping.

In such ways, GPs are using the flexibilities of the fundholding scheme to seek improvements in the health of the population. Who better than fundholders can demonstrate how doctors, directly involved in managing resources, can secure not only better care for their patients but better value for money for that care?

Mr. Stephen Timms (Newham, North-East) rose --

Mr. Malone: I will give way in a moment.

The point about managing resources is absolutely crucial. On fundholding, the Labour party has been slippery. It has moved towards the principle and said that the principle is all right. Now I understand its policy to be--it may change yet again today--that, sure, it thinks that it is fine to be a fundholder, but it will not let the medical profession get their hands on the funds. That is the most patronising, absurd attitude towards the medical profession that I can think of. The use of the funds, and the responsibility that that brings, has transformed much of primary care in our country.

Mr. Timms: In view of what the Minister is saying about fundholding, will he clarify whether it is the Government's intention that all general practitioners should become fundholders, and, if so, in what period does he envisage that taking place?

Mr. Malone: If GPs wished to become fundholders, I would very much welcome it. But it will not be compulsory. The Government's policy has not changed. [Laughter.] The Labour party's health spokesman, the hon. Member for Fife, Central (Mr. McLeish), may laugh, but when we introduced fundholding, I remember Labour Members' tales of how it would never happen in practice because doctors would not like it. Yet now more than 50 per cent. of the population of England and Wales are served by fundholders. Not only do the doctors like it, the patients like it as well.

I see the process rolling forward, not by compulsion, but in an entirely voluntary way. The Government are not forcing them. It is peer group pressure. When one doctor sees what is happening in a fundholder's surgery and the improvements that the fundholding practice is able to bring to bear on patient care, there is a "me too" principle-- [Interruption.] There is a "me too" principle of being able to do better for the patients.

Mr. Michael Stephen (Shoreham): Does my hon. Friend remember that, when we introduced fundholding, the Labour party predicted that doctors would be going bankrupt all over the country? Has that scare story been realised?.

Mr. Malone: No, it has not, but it is useful for my hon. Friend to remind us of what the Labour party was saying about fundholding. We shall contrast with some interest what it was saying, and what we recollect of it, with what--perhaps--it will say about it today. I should like to look at some other examples. In Glossop, there is the development of a homeward bound unit for people with learning disabilities, which has

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provided an ideal link between leaving a long-stay institution and moving into the local community. Not only does it provide a better, more integrated service, but that unit saves the NHS more than £500, 000 a year in in-patient costs.

I use that specific example of a saving which can now be spent on patient care to take head on the other argument against fundholding that the Labour party uses: that it absorbs far too much in management costs and that it is an inefficient use of funds. I find that a rather surprising argument. We are for ever seeing the rather lugubrious face of the shadow Chancellor of the Exchequer popping up on television saying that the problem with the Government is that they are not prepared to invest; that they look at short -termism and are not investing in services.

Well, proper management in fundholding is such an investment. Let us get the amount of it in context. The amount that has been invested in fundholding management is 0.1 per cent. of the total NHS budget. That investment is well worth while. The House should consider what just one fundholder can achieve. If one fundholder saves £500,000 for the NHS, which can be deployed in further patient care, just think of what is happening across the country.

Doctors who are directly involved in managing those resources at the grass roots are getting better value. Overall, fundholders have achieved efficiency savings of more than 3.5 per cent. a year in return for increased management expenses. Not only have they achieved it once, but have done so every year since the scheme began to operate.

Ms Margaret Hodge (Barking) rose --

Mr. Malone: I shall give way in a moment.

The savings have been achieved by releasing the innovation and ideas in primary care on better ways in which to deliver services.

Ms Hodge: Two questions arise. We are not talking about additional administrative costs as a proportion of the total NHS budget, but as a proportion of what was previously spent on GPs. By how much has that increased? Will the Minister reply to the point raised by the hon. Member for Croydon, North-East (Mr. Congdon)? Do not GP fundholders receive additional moneys ostensibly to cover those administrative costs? Are they not better off than GPs who are not fundholders?

Mr. Malone: The hon. Lady persists in refusing to recognise the point which I happily concede: of course fundholders get extra money for administration. I point to the fact that not only is that a good use of public money--an investment, as the shadow Chancellor of the Exchequer would no doubt tell us if he were making this speech. Such investment has produced greater efficiency in health care and has delivered a net benefit of about 2 per cent. Those funds can then be devoted to patient care and would otherwise have been lost. So I make no apology for saying that good management in fundholding is right. Investment must be at the proper level. As long as it continues to drive more efficiency and better patient care, it is a proper deployment of public funds.

The illustration that I have given the House of how freedoms have worked is just a portion of what has been happening across the country. GPs are now able to

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manage NHS resources to improve the care for their patients--the freedoms and services that the Labour party wants to end; taking away from patients the improvements that they have seen and enjoyed. Only the Labour party would wish to make services worse for patients. Indeed, what it probably means is that it would be satisfied if the worst in the land was the criterion on which every service should be administered.

That is the implication of the Labour party's argument about two-tierism. If it thinks that those who are doing better are doing unfairly by their patients, the clear corollary must be that, to introduce fairness into the system, everybody must proceed at the pace of the worst. That is not an agenda that this House or the public would accept, and it is certainly not an agenda that the 50 per cent. of the population think is realistic for the way forward. I should like to move to the important role of new health authorities in supporting primary care. It is a key feature-- Mr. Henry McLeish (Fife, Central) rose --

Mr. Malone: I will give way in--

Mr. McLeish: It is on the previous point.

Mr. Malone: In that case, I shall give way.

Mr. McLeish: The Minister has talked ostensibly about the 50 per cent. of GPs and the population covered by fundholding. I expect that a fair chunk of his speech will be given over to the other innovations and activities of non-GP fundholding practices throughout the country.

Mr. Malone: I will certainly be dealing with joint commissioning in due course. May I say that I am delighted to see that the number of GP fundholders in the hon. Gentleman's constituency is rising. That is indeed good news for the people in Fife. There seems to be a remarkable connection, because when the right hon. Member for Derby, South (Mrs. Beckett) was Opposition spokesperson on health, fundholding in her constituency rose to 87 per cent. It is not yet quite at that level in the hon. Gentleman's constituency--it is about 30 per cent.--but we all hope for progress. Similarly, we look for great strides to be made in Peckham in increasing fundholding. The role of health authorities will be extremely important as we bring together district health authorities and family health service authorities to make a coherent whole. We must continue to develop our service with the new health authorities so that they have the confidence to deliver the services patients need. Fundholders do not lack confidence. We have seen their confidence to try out new ideas, to extend influence and to seize opportunities. That work must be supported by the new health authorities, which will be able to look at the needs of the population locally and more directly. Not everybody is at the leading edge or sees the world in that way. With the new health authorities in place, we need to translate the enthusiasm of some into the willing commitment of all; that will be the most important task of the new authorities. For the first time in England, we shall have single authorities looking strategically at the whole range of primary, secondary and community services in their areas. They will be able to assist in the

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process of meeting the four aims: making services high quality and effective; giving patients the right services in the right way; ensuring services fit together; and getting as much as we can from the money available.

We have now set an agenda related to primary care for the authorities to follow; those on the ground now need to see, feel and believe in the benefits. I expect the new health authorities to work with all GPs and primary health care teams and to involve them in the process of delivering a primary care-led service. GP fundholders are at the forefront of the changes and health authorities must tap into their enthusiasm, their innovative ideas and their ability to get improvements in the care provided to all patients.

I am slightly surprised that the hon. Member for Fife, Central and the rest of the Labour party seem to think that joint commissioning is a great innovation; it became possible only under our health service reforms. It has happened to some extent on a voluntary basis, in different ways, and I welcome that. But joint commissioning is not a policy that has been rolled out in a comprehensive way, as fundholding has been. It is not a policy under which one can measure the benefits across the country as one can do with fundholding. Of course, I welcome the fact that the new health authorities will have a duty to consult all GPs about the commissioning of services. The joint commissioning policy misses the fact that, under fundholding, it is the individual doctor who decides what is best for patient care. Commissioning is, perhaps, a bit of a revamp of the old system under which committees decided these things. Representatives of doctors were involved and the Labour party would probably like councillors to be involved as well. That is the way in which Labour wants to take the policy forward. They will not concede the important principle that what has driven forward the reforms and has made everyone try to catch up with the fundholders is the idea that the funds follow the patient and are secure in the hands of the GP fundholder.

I recognise that not all GPs will be fundholders; not everyone wishes to be one. However, a clear majority now do and they must be supported. Fundholding should be developed comprehensively so that we can take it forward even beyond the existing successes.

I find it extraordinary that the Opposition are pushing the supposed merits of GP commissioning over fundholding. We have always had some locality purchasing in GP commissioning, but the fundholding model devolves purchasing power from health authorities to GPs to provide greater sensitivity to patients at a grass-roots, practice-by-practice level and ensures that decisions best reflect the needs of individual patients and the local community. The information that we get from those who participate in joint commissioning exercises is welcome and many of them have innovative ideas. However, joint commissioning is not evenly spread across the country. Giving power to the individual doctor is at the core of our policy and it clearly works. I believe that the Opposition finally recognise that fact.

Only a few weeks ago, the right hon. Member for Derby, South finally acknowledged the beneficial developments made by fundholders. She said at a conference:

"We want genuinely to pay tribute to the role that you as fundholders have played in kick starting and developing innovative practice in both primary care and the acute sector. None of it has gone unnoticed and all of it is valued and is worthwhile."

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Although those words may have been used to placate the fundholding conference she was addressing, the second half of the policy was missing: "We value you, but we are going to take your power of choice away by depriving you of your budgets." If the right hon. Lady had been entirely honest, she would have given that message. She went further and said that Labour proposed to keep the flexibilities introduced by this Government. Is this a signal of yet another change in Labour's position? We shall wait and see what the hon. Member for Fife, Central has to say.

We were told at first that Labour would end the fundholding scheme within the first 100 days of a Labour Administration. Then we were told--the hon. Member for Newcastle upon Tyne, East (Mr. Brown) developed this policy in a sub-fugue:

"It is our intention to phase out fundholding over a period which may be as long as three years."

As fundholding rolled out and became more popular, the Labour party began, inevitably, to roll back from the argument and we heard that it was "individual practice fundholding" which would be phased out. I am not sure what that means, but I suppose that it sounds more comfortable than closing fundholding practices.

What further changes can we now expect? The truth is that the Labour party has now waved the white flag in terms of the rest of the improvements that the Government have brought to the health service. I suggest to the hon. Member for Fife, Central that Labour should complete the surrender and use this opportunity to make a fresh start, to move forward and to accept fundholding as it is. Such a step would be welcomed by doctors and patients.

The only changes that I am interested in making now involve looking at how we can spread the benefits further. Fundholding is and remains the Government's preferred option for involving GPs in purchasing. It is obvious that most GPs agree, as more than half are expected to have chosen that option by next April.

I turn now to the new opportunities for fundholding. The community option, which has been a great success for those who have taken it up, will take root soon. The community option gives GPs control of their immediate practice environment: the budget for their staff; community nursing services; the prescribing budget and direct access to diagnostic tests for their patients. All our expectations have been surpassed. More practices have chosen to enter community fundholding than entered the first wave of the scheme in 1991. There will be about 1,000 GPs in the community scheme alone.

Standard fundholding is not standing still either. It has been changed and developed, and it has been made simpler and more coherent. From next April, it will cover virtually all elective surgery and out-patient services. The changes to the scope of the scheme should resolve many of the bureaucratic problems reported by trusts which were caused by their not knowing which services were in the scheme and which were not.

The argument against the point that there is too much bureaucracy is simply this. We are happy to cut bureaucracy where we can do so. The White Paper "Putting Patients First" and the work that followed showed that we could relieve the burden of bureaucracy on GPs enormously. I am always happy to entertain suggestions about how we can do that. Under standard fundholding, everything will be included except emergency and urgent work, and the very rare and most expensive treatments.

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In all, more than 3,000 GPs in more than 1,200 practices have applied to be fundholders from next April. That will mean that about 14,000 GPs, more than half of all the GPs in England, will have chosen to be fundholders. Between them, they serve more than half the population. I am confident that a similar story is emerging in Scotland, in Wales and in Northern Ireland. These are major developments, yet the Labour party would seek to put them in reverse.

I shall now say a word or two about total purchasing. From next April, GPs working at the 51 pilot total purchasing sites will have started purchasing all services for their patients. I have been especially impressed when I have visited the total purchasing pilots and seen all the work that is being done.

In Bromsgrove, GPs have employed nurses to visit patients admitted as emergencies. That has helped both the GPs and the health authority to understand better why some patients remain in hospital longer than others. It has also helped to ensure that patients are discharged appropriately into the community, and that the primary and community services are ready and available to receive those patients. Other innovative work has been done there in bringing community midwifery forward. By ensuring that private nursing homes can be used to deliver respite care for their patients, GPs have helped to resolve many of the problems that the hospital had with beds being inappropriately used. Likewise, GPs in Runcorn have contracted for the secondment of midwives from provider units to their practice, to set up team midwifery and thus bring services far closer to patients.

All those projects are demonstrating how GPs involved in the direct total purchasing of care for their patients can help to introduce a radical culture change within a health authority. Under the old system, although there were committees that presided over all such matters, they probably gave more lip service than real attention to the needs of patients.

It was said that GPs were involved in purchasing under the old procedures, but if that was so, why is a system such as total purchasing, in which GPs have control, suddenly producing demonstrably better innovative services that under the old schemes were never thought possible?

That is a culture change of the most extraordinary and innovative sort. We seek to spread such culture across all health authorities, and when the new health authorities are up and running on 1 April next year we expect the new chairmen and chief executives to rank it among their top priorities.

The development of a primary care led NHS throughout the country means improving the links between primary and secondary care, and increasing the influence that GPs and their teams exercise over those services. It means giving GPs real power to influence the way in which services can best be shaped to benefit patients. It is about trusting GPs to listen to and reflect the wishes of the patients whom they see daily, rather than paying lip service to their good work and then depriving them of the means of carrying it out, as the Labour party wants to do.

That means real power, with real responsibilities and real money, not notional power, notional budgets and notional accountability. Only the Labour party would wish to

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reintroduce the endless committees, the centralised bureaucracy and the abrogation of decision making that was rife in the health service that we inherited in 1979.

What are Labour's plans for GPs and the primary health care led service that we want? What is its policy for primary care? What are Labour spokesmen saying when they tell GPs that they want to end fundholding? The truth is that they have no policies for primary care and no plans to use GPs' skills and abilities. Their message is a simple one: "Let's turn the clock back. GPs, go straight back into the box that you used to occupy. Stop fighting for what is best for your patients." In effect, Labour says, "Trust us, we know what's best; the old committees know what's best. We recognise that you GPs happen to have been developing services in a way that nobody could have anticipated--but too bad, we want you to stop, and we want to go back to the bad old ways."

I suspect that one reason why the Labour party is so determined to scrap fundholding is that it could not think of a way to rename it, as it has renamed the rest of the NHS. It will be interesting for my hon. Friends to hear how Labour has redefined the health service and its language, because the definitions are strange and marginal. With some of the jargon words, Labour has made some really fundamental progress. What is now commonly known among professionals as the internal market, or the purchaser-provider split, Labour has heroically decided to rename; it is now called the "planner-provider split". What a difference that will make. Trusts will be changed fundamentally from their roots up; they will be called "local hospital services"--although I understand that trusts will not change their signs or letterheads.

Instead of the vile marketplace, which uses such disgustingly hard-edged words as "contracts", there would be "health care agreements". Labour strategists' problem is that they cannot find another word for fundholding, so it rather looks as though they are obliged to scrap it.

The difference between our parties is clear. GP fundholding and the move towards a primary health care led NHS have brought improvements in the provision of care, made services more accessible and provided a means by which GPs and their primary health care teams can have real power and responsibility, and can change the pattern of local health services to meet the individual needs of their patients. I take the opportunity now to thank all those who have been involved in the pioneering of fundholder practices, including the health care professionals that GPs have brought into their practices, for the work that my colleagues and I--and, if they were honest and admitted it, Labour Members--see when we visit fundholders all over the country. The success of fundholding has exceeded the Government's expectations, and the people involved should be thanked for that. Our policy is about levelling up; Labour's policy is about levelling down. Our policy is about giving doctors control over funds for patient care; Labour's is to patronise them and take that real power away. We have built an NHS that will meet the challenges of the 21st century, and today we have an excellent opportunity to debate the policies of the Labour party, which seems determined to destroy it.

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10.15 am

Mr. Henry McLeish (Fife, Central): I am pleased that the Government have selected fundholding to debate today.

Mr. Keith Mans (Wyre): Delighted.

Mr. McLeish: We shall wait and see the delight develop in the next few minutes.

It is important to accept the fact that a primary care-led health service is what Labour wants and supports. There is no distinction between us and the Government there. GPs' role in that process is, of course, vital, but it is also important that we register our support for and applaud the work of every person who works in the NHS. Far too often in the House we have a knockabout over issues, principles or structures, but we in Britain are fortunate in having some of the most dedicated and skilled personnel working in all aspects of the health service. [Hon. Members:-- "Hear, hear."] That, at least, is a point that unites the House at this early stage in my speech. It is important to talk about the political context of the Government's approach to health care. I do not want to destroy the morale of Conservative Members, but I hope that most of them have read The Daily Telegraph this morning. Probably because the Government do not listen, do not evaluate and do not care much what ordinary people think, the Conservatives are now 40 points behind in The Daily Telegraph poll.

I am quite happy for the Conservatives to plummet to historical new depths of unpopularity, but there must be a link between the unpopular policies for which the Government are famed, and electoral support. It is instructive that Tory party strategists in Smith square want to bury the issue of health. It is a weak issue for the Government. [Hon. Members:-- "Why are we here, then?"] That is what I want to find out. It is important to know, because it may represent a change of tactic by the Government. They are 40 points behind in the opinion polls, but now they think that health may be a winner. Is that right?

Mr. Malone: I am delighted that the hon. Gentleman has given way to me. The sort of news that we do not want to hear about the health service is the false news peddled by the Labour party. That is what John Maples, my successor as deputy chairman of the Conservative party, was talking about. Conservatives want to hear the truth about the new NHS that is delivering proper health care. On that issue we can be strong.

I had hoped that the arrival of a new health team on the Labour Front Bench would stop the peddling of untruths about the health service. However, the first instance arose at Question Time earlier this week, when the hon. Member for Peckham (Ms Harman), in order to make a clear political point, made the accusation that people in Winchester--my constituency--were having to wait more than 18 months for admission to hospital for orthopaedic surgery. After Question Time, I checked and found that that was simply untrue. I have written to the hon. Lady to ask her to withdraw her allegations, but I have yet to receive a reply. We do not want to hear untruths about the health service. We want to hear about what is happening.

Mr. McLeish: I am delighted that the Government are to engage in discussions on the NHS in the run-up to the general election. If they do so, I am convinced that the Opposition's 40-point lead will be increased.

Column 511

The Government do not like certain concepts being discussed in their presence--for example, the two-tier health service that they have dismissed in relation to fundholding. In The Independent on 19 October, the new Secretary of State for Health said:

"fundholding certainly empowers the GPs in a way that makes it easier for them to improve services available to their patients." If that is not a comment about a two-tier health service, what is? [Interruption.] The Minister may mumble, but even the Secretary of State has acknowledged that GP fundholders who receive preferential contributions will inevitably and instinctively use them for the benefit of patients. That is not the issue, however. The issue is whether this country should have a two-tier health service.

Mr. Malone: The clear implication of the hon. Gentleman's argument on two-tierism is that all GPs should become fundholders and share the same benefits. That would get rid of the problem by levelling up, and not levelling down as the hon. Gentleman wants.

Mr. McLeish: I am happy to engage in discussions on levelling up, and the Opposition will give more detail on that in our commissioning proposals. But the Government cannot wriggle off the hook. The Secretary of State for Health acknowledges that the current system empowers GP fundholders to get a better service than non-fundholders.

It was instructive that the Minister did not spend more time in his speech on other activities in primary care, despite the fact that I asked him to do so. He did make a grudging and passing reference to those involved in commissioning, but we should not have a particularised view on what is good for primary health care. It is evident that the Government are obsessed with GP fundholding virtually to the exclusion of anything else that is happening in primary health care, especially in the multiplicity of commissioning options.

Mr. Mans: Does the hon. Gentleman agree that the present system also empowers health authorities--as well as GP fundholders--to get a better deal for their patients?

Mr. McLeish: That is a fair point, and I shall discuss that issue in detail shortly.

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