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Mr. Piers Merchant (Beckenham): Absolute nonsense. We do not want privatisation. It is not a possibility.
Mr. McLeish: To use a phrase much quoted this morning, the hon. Gentleman's response is very predictable. The Government are very uncomfortable when one says something that they want to keep hidden. Is not that true? It is true. As far as I am concerned, the partisan approach that they have adopted this morning to primary health care merely reinforces our belief that the Government do not care about the national health service but do care about that four-step process towards the marketplace.
Mr. Jenkin: It is evident that the hon. Gentleman and the Labour party do not want to campaign on the issue of what we have achieved in the health service. They want to campaign on what they pretend that we might do in future, which they know to be untrue.
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Mr. McLeish: I have heard much better interventions from the hon. Gentleman. Perhaps, because I am reaching the end of my speech, Conservative Members are reaching the end of their concentration. I do not believe that that comment required a response.The exclusivity of the Government's approach will be evident to all who witness the debate. However, the Government are failing to tackle other problems, which we cannot go into today. Morale in the primary health care service is not good. There are major problems with recruitment and work loads and problems with early discharges and emergency admissions.
We are in the ludicrous position, which affects the Minister's constituency among others, where nearly £100 million of surpluses from GP fundholders is sitting in the health authorities' bank. I cannot believe that we have a million people on waiting lists and we have £100 million sitting there. The Minister should take seriously the issue of whether that will be ploughed back over four years into GP fundholding. Or is it the Government's tactic to dip into that bank budget and spend it on reducing waiting lists? People will find extraordinary that conflict between a million people on waiting lists and £100 million stored in a bank and not being used. It is a scandal.
We shall be in government within 18 months. We now have an important task to speak to GPs and to consider the new era that will open up for them. We shall start doing so early in the new year. I am confident that the policies being proposed by Labour will mean one national health service, a policy for all patients and a policy for all doctors. We shall reduce that partisanship, that
particularisation of GP fundholding, by building on the best and taking the whole system forward.
Ms Hodge: On a point of order, Mr. Deputy Speaker. Have you heard whether the hon. Member for Dover (Mr. Shaw) is intending to make a personal statement on the Government's decision not to privatise the harbour at Dover, especially because he appears to be the only person in Dover who supports such a privatisation?
Mr. Deputy Speaker (Sir Geoffrey Lofthouse): I have no such information whatever, and it is not a matter for the Chair. 11.4 am
Mr. David Congdon (Croydon, North-East): I listened carefully to the speech of the hon. Member for Fife, Central (Mr. McLeish). Initially, he tried to make a thoughtful speech and I believed that he would avoid the temptation to engage in party political banter. However, my hopes were not fulfilled, especially near the end of his speech, when we had the usual canard that the Conservative party, which has invested so much in the national health service and been responsible for its stewardship during most of its time since 1948, has a hidden agenda of privatisation.
If there is a hidden agenda, it must be well hidden. If the Government were intent on privatising the health service, why have they invested 22 per cent. extra in real terms in the national health service since 1990--an enormous sum? Many commentators say that not even a Labour Government would have had the ability to deliver such an excellent amount of extra resources to the NHS. That canard should be dismissed for what it is. It does not help the debate. We also had the usual canard about
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morale being bad. Someone said recently that morale has always been bad in the national health service. I do not accept that it is any worse now than it has ever been.First, I should like to place the debate in context. Debates about the NHS have usually been about hospitals and there have been four or five debates in the past year or so about the health service in London. One of the reasons why debates have tended to focus on hospitals is that that is the glamorous side of the NHS, where doctors carry out high-tech interventions and receive much publicity when they do a heart and lung transplants and the like. As a result, the opportunity to debate the importance of primary care is lost. Undoubtedly, primary care is becoming much more important because of the changes in secondary care--changes in the way that hospitals work. There is much less invasive surgery and much more day surgery. There is much more surgery which does not involve surgeons having to open up a person to find what is wrong, discover that there is nothing wrong and stitch them up again, having done a great deal of damage in the process. They are now able to find out what is wrong without doing that.
That leads to much shorter stays in hospital. It also leads to people who have had operations being discharged much earlier, which places more pressure on primary care services. That is why primary care services have rightly been forced to change, and will have to change much more during the next decade and as we enter the next century.
We are also witnessing the proper implementation of community care, which is leading to much more long-term care in the community, which also places pressure on those primary care services. However, significant changes to the configuration of hospitals, especially in London, have provided the opportunity for £85 million to be invested in primary care developments in London. Many have been in the north of the borough of Croydon. I am privileged to represent one of the constituencies in Croydon. There has been significant investment in GP surgeries in the north of our borough, providing much better care and facilities for the people of Croydon than in the past. I note that yesterday a further £35 million was announced for various initiatives to help single-practice GPs in London. I am sure that other London Members will join me in welcoming the Government's initiative in that respect.
Mr. Malone: Does it not shoot down the Opposition's case that the Government are interested only in developing fundholding practices when, as recently as yesterday, I made that announcement, which means that single- handed practitioners, most of whom are not fundholders in London, will receive the benefit of flexibility payments to improve services for their patients, too? On equity, of course we are sensitive about allowing other services to develop where possible.
Mr. Congdon: My hon. Friend is absolutely right. I should say at this point, in case I create a different impression later, that I am primarily interested in primary care services delivered by GPs and their staff. I do not care whether they are fundholders or non-fundholders, but I do care that they should have the opportunity to deliver the best possible care for their patients. I happen to believe--in my view the evidence is strong--that when one gives the budget to GPs they are better able to decide where the money should be spent.
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We should put the issue of GPs in context. I mentioned the extra pressure that GPs are under. There have been changes in the way that they work. There has been a significant growth in the number of GPs since we came to power in 1979. The numbers have risen from 21,000 to 26,000--an increase of 22 per cent. Doctors often say that they have a heavy work load, and I do not dispute that. But their list sizes have decreased from 2,300 to 1,900--a drop of 16 per cent.Perhaps the most incredible change is in the number of practice staff. How many of us remember when we used to go to our GP and were lucky to find anyone else on the premises? The number of GP practice staff has risen from 20,000 to 54,000, which means that we can receive many more treatments at our GP surgeries without having to go to the local hospital for tests. That is why a primary care-led NHS is so exciting.
According to a recent MORI poll, nine tenths of patients are satisfied with the services provided by their GPs. GPs have always been the gatekeepers to other health services: they decide whether a patient should go to the hospital for a test or to see a consultant for further investigation. But until the reforms that introduced fundholding, GPs were gatekeepers with little power to exercise on behalf of their patients. They used to have to try to negotiate with consultants at the hospital, and it was a matter of which consultants they knew best, and perhaps even whether they went to the same golf club. That was not a transparent system of negotiating health care on behalf of patients.
Mr. Malone: The relationship between GPs and consultants can perhaps be encapsulated in a remark that I heard from a GP fundholder in London recently. He said that, five years ago, he used to send a Christmas card to a hospital consultant, but now the consultant sends him one.
Mr. Congdon: I congratulate my hon. Friend on that remark--he must be telepathic and is perhaps in the wrong occupation, as that was my next point. There has been a significant change in the relationship between GPs and consultants which has fundamentally changed the balance of power in the health service for the good of GPs and, more importantly, for the good of their patients. GPs now negotiate on behalf of their patients; they are not negotiating on their own behalf to protect or spend their budget. They use the power that their budgets give them to negotiate on behalf of their patients to obtain the best possible care for them.
The evidence is clear: GPs are able to negotiate better care for their patients. They have also been able to negotiate to ensure that more treatments are carried out in their surgeries. There are cases of GP fundholders negotiating with consultants and persuading them to come to their surgeries to carry out a clinic. What better way is there to run a health service?
It was alleged that GP fundholders would spend far less on drugs because they had control of the budget. The hon. Member for Fife, Central did not refer to the Select Committee on Health in his speech, but it carried out an investigation into the drugs budget. GP fundholders spend less per capita on drugs than non-fundholder GPs. More interestingly, the average value of the prescriptions that they give is higher than for non- fundholders. Significantly, they issue fewer prescriptions. The inference to be drawn must be that they prescribe more effectively.
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Many doubts have been expressed and there have been many debates on the effectiveness of GP fundholders, as we heard some from the hon. Member for Fife, Central today. One source that has not always been a friend of the Conservative Government--the King's Fund--has acknowledged GP fundholding as one of the major successes of the health service reforms. We should give weight to its views. The evidence is that fundholders manage to buy care far more effectively than health authorities. The question for Opposition Members to ask is why. There is no evidence that fundholders have been given more money for patient care than non-fundholders, but because they are much closer to their patients they manage their budgets more effectively. In many respects, that is not surprising. We all believe that we manage our financial affairs much better than the Government do on behalf of taxpayers. Large organisations do not necessarily manage budgets and other matters better than at local level. The challenge now is to put pressure on health authorities to exercise their purchasing power more effectively and to bring themselves up to the standard achieved by fundholders.I wish to deal head on with the question of a two-tier service. Before fundholding was introduced, the charge from the Labour party was that it would lead to a two-tier service--but not the two-tier service that the Labour party describes today. The Labour party's idea of a two-tier service was that GP fundholders would have a pot of gold, which they would be so determined not to spend that they would deny services to their patients. The net effect would be that fundholder patients would receive poorer quality patient care than non-fundholder patients.
Mr. Rendel: The hon. Gentleman has just told us proudly that GP fundholders make fewer prescriptions for their patients than other GPs. He used that argument to show that they were more efficient. He now tells us that it is not true that fundholders provide less for their patients, and that they in fact provide better care. I cannot see how the two arguments fit together.
Mr. Congdon: I am sorry that the hon. Gentleman cannot understand the subtleties of the important point that I am making. Fundholders are given the same pot of gold as the health authority on a per capita basis; the important question is what they do with that money. Health authorities spend the money on behalf of GPs; fundholders spend it on their own. Fundholders spend less money on drugs than non-fundholders. They undoubtedly spend more money on some things than non-fundholders, and less on others. The net result is that there will be differences in the care provided.
It is my contention, and that of many others, that fundholders buy care more effectively. As a result, fundholders' patients are sometimes seen earlier than those of non-fundholders. That does not mean that there is a two-tier service, but that the fundholders buy a different pattern of care. The question that the hon. Member for Newbury (Mr. Rendel) must ask is what the health authorities are spending the money on and why they are not achieving the same success as fundholders.
The Opposition cannot have it both ways. If they say that there is a two- tier service, the logic of their argument must be--I make no apology for repeating it--that all GPs
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should be encouraged to become fundholders. The argument involving a two-tier service--if it is valid--would then disappear. There would still be differences within the service, because different GP fundholder practices would buy different patterns of care to meet their patients' needs.The important question is whether we level up or down. Conservatives believe that, by introducing fundholders, we have improved standards, and we want all GPs' standards to be levelled up to the standard of the best. Opposition Members believe that there is a two-tier service and that the only way to achieve the end that they desire is to level down. I am sure that hon. Members will join me in rejecting that.
I am pleased that fundholding is spreading at a fast rate. Some 41 per cent. of GPs are now in fundholding practices and next year the figure is likely to be more than 50 per cent. To date, the figures in my borough have been disappointing, but I am pleased to learn that many practices are to become fundholders from next April. I am confident that they will reap the benefits of fundholding. I have never been particularly wedded to one standard model. I accept that the needs of one group of GPs can differ from those of another. I therefore welcome the fact that we now have three possible varieties of fundholding: community fundholding for small practices which do not have the ability to buy a wide range of services; standard fundholding, which is being extended to include most elective surgery, out-patient services and specialist nursing services and--perhaps the most exciting development--total fundholding, where fundholders are responsible for buying all care.
I understand that emergency services are also included. There is a need to ensure that there are no gaps in the loop. There have been allegations that fundholders could have an incentive to delay treatment so that patients present themselves at accident and emergency units. There is no evidence to support that, but one solution is to give fundholders total responsibility for all aspects of their patients' care.
In developing and extending fundholding, we need carefully to examine transaction costs in the NHS. In that context, I welcome the publication in June by the NHS executive of the efficiency scrutiny into bureaucracy in general practice. I hope that all the proposals in that document are implemented. I shall mention one or two that are particularly important.
The implementation of the new NHS number is crucial in terms of being allocating costs back to fundholding and non-fundholding practices. That must go ahead quickly. The report states on page 14 of the summary:
"On present plans the software specification for standard fundholding does not cater for electronic data interchange.". I urge my hon. Friend to address that aspect, as it could play a key part in reducing the volume of paperwork which flows between fundholders and providers.
There is also a proposal to implement an NHS-wide clearing system from April 1996. At present, there is a big invoicing process between providers and fundholders. Unfortunately, on current plans, fundholders will not be included from April 1996. Will my hon. Friend address that, as it is important to reduce the need for paperwork going backwards and forwards in this age of modern
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technology. I could raise other points, but I simply urge my hon. Friend to ensure that the recommendations in that report are dealt with properly.Let me turn briefly to Labour's so-called joint commissioning. I listened carefully in order to understand exactly what that would involve, and I have to confess that I am none the wiser. I know that it will not be real fundholding because the GPs will not have funds, so what is the difference between what the Labour party is proposing and what exists today for non- fundholders?
Health authorities are empowered and cajoled to engage GPs and GP fundholders in dialogue about what should be in their purchasing plans. There are collaborative plans, but how much say do GPs have in that process and how much say would they have in the joint commissioning process? Professor Howard Glennester says:
"Many GPs that have participated in that sort of activity get very frustrated by it . . . they are asked their views and then nothing happens and it just causes frustration and irritation." In other words, there is consultation and collaboration and then the bureaucrats in the health authority do what they thought of in the first place. That is why the proposal for joint commissioning is no more than a half-baked idea.
Another alternative that the Labour party thought up, but did not mention this morning, is shadow budgets. I am not sure what a shadow budget is. Presumably GPs would not actually have the money, but there would be a notional account and if they were lucky the right amounts might be credited or debited. We would need more details before we could consider such half- baked proposals.
Labour's arguments for joint commissioning do not stand up. There have been a variety of allegations about what is wrong with fundholding and mention has been made of two-tier services here and there, but when the allegations have been investigated, most of them have been proved false.
In future, of course, the links between doctors--fundholders and non- fundholders--and health authorities have to be very good and clear, but when I listened to the speech of the hon. Member for Fife, Central I was struck by the fact that he was living in a time warp. He implied that fundholders were given a pot of gold and could do exactly what they liked with it regardless of the strategy of the health authority and the needs of the locality.
The reality is quite different. My hon. Friend the Minister referred to the framework document, which sets out the role of the health authority. The health authority has to assess the health needs of the population in its area. It has to prepare a strategy in line with the overall objectives of the national health service. It then has to purchase care for GPs who are not fundholders in line with that strategy. It also has to ensure that the plans of fundholders are in line with that strategy.
It is not a matter of GP fundholders getting together on a rainy afternoon to cobble together some plan that threatens their local general hospital and suddenly implementing it without anyone knowing about it. If they wish to make significant changes to their purchasing plans, they have to submit them six months in advance to the health authority which has a clear and direct role in the strategy, albeit that it does not purchase health care directly for fundholders. Opposition Members too often neglect that point.
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I am firmly convinced that fundholding is the right way ahead for the health service. At last it has put the money close to the patient. Ideally, the money should be in the hands of the patient, but that is not realistic. Fundholding is a good second best and is achieving excellent results. I hope that we can build on those results because the system is so responsive to patient needs. If all GPs cannot become fundholders--there will be problems in that respect, for reasons that we all understand--or at least community fundholders, we must find ways of giving a surrogate power to the residue of GPs unable to participate fully in the scheme. I want all GPs to benefit from the advantages of GP fundholding. I certainly do not want to turn back the clock, as advocated by the Labour party. 11.28 amMr. David Hinchliffe (Wakefield): I am grateful for the opportunity to participate in the important debate this morning. I begin by commenting on the excellent speech by my hon. Friend the Member for Fife, Central (Mr. McLeish) from the Opposition Front Bench. It was his debut at the Dispatch Box, and he made a commendable speech that clarified Labour's position on GP fundholding while totally exposing the Government's current position. All hon. Members will agree that my hon. Friend courageously raised certain points that were drawn from personal experiences.
One reason why I decided to return to the Back Benches is that, over the past three years or more, I have felt somewhat inhibited in raising detailed concerns about specific developments in my constituency in debates on the health service. When I was at the Dispatch Box, the last thing Back Benchers wanted to hear was detailed concerns from a Front-Bench spokesman about his own constituency.
As the Minister is well aware, I want to spend some time today on the detailed implications of GP fundholding for my constituents in Wakefield.-- [Interruption.] If the hon. Member for Croydon, North-East (Mr. Congdon) cares to listen, he will hear evidence that clearly shows that some people are deeply concerned that fundholding has created a two-tier system. I shall not only give examples, I shall name names. I can show Conservative Members letters that I have received--I have already shown the Minister some--that demonstrate clearly the effects of a two-tier system on my constituents.
Mr. Congdon: I am happy to accept the hon. Gentleman's examples in the spirit that they are given. If what he says is true, is not that evidence of the health authority not exercising its purchasing function as well as GP fundholders exercise it?
Mr. Hinchliffe: If the health authority was here, I think it would say that we should be examining the money available to fundholders compared with that available to non-fundholders and the health authority. The hon. Gentleman points a finger at the health authority, but it was set up by the Government, and its chairman was appointed by the Government. They cannot blame the very people whom they put in place. It is the system that is wrong, as I shall show throughout my speech.
Mr. Malone: Before the hon. Gentleman does that, we must be clear that the implication in what he has already
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said, and in what the hon. Member for Fife, Central said, is that there is some huge disparity in funding for patient care. I want to put the basis of funding for patient care clearly on the record. Fundholders get a fair share of NHS resources, which is calculated by the historic use of services that their patients made of them before they became fundholders, and which is now modified by movement to a local capitation benchmark. It is a fair allocation system. I hope that the hon. Gentleman will distinguish between the funds that are allocated fairly for patient care, which fundholders manage, and the funds allocated to carry out the management function of fundholders. It is clear from what Labour Members have said so far that the two points are being thoroughly confused.Mr. Hinchliffe: I shall give way to the Minister later if he will put on his thinking cap and find a reason for underspent resources within fundholding practices in Sheffield, while non-fundholding practices are unable directly to obtain health care purchased by the health authority in exactly the same specialisms in the same hospital. The two-tier system is not just between different areas: it is within the same district general hospital.
Before going into detail about local issues, I want to make one or two broader points of relevance to the debate and to reinforce the eloquent comments of my hon. Friend the Member for Fife, Central, who outlined the Labour party's belief in primary care. I have been very closely involved with the health service at local level over many years. I worked in local authority social services and therefore dealt with GPs and hospitals on a day-by-day basis. In fact, at one point I was practice based with a GP, so I worked very closely with a primary care team.
I recall a time before 1974 when I worked in the same building as district nurses, health visitors and midwives. The model that operated then, especially in respect of collaboration with child protection services and community care, was fundamentally better than the present model. That much better system was scrapped by a Conservative Government in the early 1970s. The Minister talks about looking forward to this or that development. I look back on the many positive elements that existed some time ago, which his party wrecked in the 1970s.
For many years, the power in the NHS has been primarily in the hands of hospital consultants. I do not think that there is any difference between me and Conservative Members on that point. I accept that moves have been made to enhance the power and status of general practitioners. That is simple common sense; anybody wanting to develop an effective primary care system would do that. I also accept that fundholding has enhanced the powers of certain GPs. Indeed, I have personal friends who are fundholding GPs. I also know some local GPs who became fundholders not because they believed in the system, but because they saw it as a way to obtain more money and to queue-jump their patients--something that many people find unacceptable. I do not blame them for fighting for their patients; I blame a system that has created two-tier health care.
I accept that effective general practice is fundamental to a properly run health service. As has been said, it is the linchpin, and has been from the word go. However, we
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have never facilitated general practice in a way that would allow it to play that crucial pivotal role, so obviously I welcome any moves in that direction. My party recognises the need increasingly to examine ways to improve primary care because that is fundamental to improving the health of the nation.I served on the 1990 Standing Committee that considered the National Health Service and Community Care Bill. I privately felt that we had failed to understand that fundholding was potentially a greater threat to the central principles of the NHS than the purchaser-provider split and trust status. I felt strongly that the Government were taking a huge leap in the dark by introducing fundholding without any attempt at a pilot scheme, any sort of experimentation or any evaluation of different models. Instead, they went straight in at the deep end. Now, unfortunately, in my area and other areas, including the Minister's constituency, we are having to pick up the pieces of the Government's failure to consider the possible results of fundholding.
We could all describe personal and practical experiences. My hon. Friend the Member for Fife, Central mentioned a few. The hon. Member for Croydon, North-East referred to equal funding. The Minister, when he intervened, made it clear that a great deal of money is thrown at GPs to encourage them to become fundholders. Many of them have spent lavishly on their premises-- money that some might argue could have been better spent on patient care. We could argue all day about equality of funding, but the simple question is whether the system for allocating funds is the best use of scarce public resources. I am not the only one to ask that question.
Mr. Malone: Before the hon. Gentleman goes too far in denigrating doctors and the way in which they spend any savings, I want him to understand that the savings that fundholders make have to be audited and schemes upon which they spend any savings must be approved. The hon. Gentleman referred to improvements in surgery premises. Surely he should welcome those improvements, which often mean that other health professionals can be included in new premises, thereby giving standards of patient care that are not available in the old-fashioned, clapped-out premises that are being replaced.
Mr. Hinchliffe: If the Minister cares to visit God's own county of Yorkshire, I will take him to a city not far from where I live, where there are some very innovative uses of fundholding money. One practice--the hon. Gentleman probably realises that I am talking about Sheffield--set up a private hospital and referred patients from its practice to its hospital. The doctors were making a large amount of money.
I am sure that the Minister will accept that, in many areas, an objective analysis of fundholding has raised serious questions. I am not denigrating fundholding GPs who have genuinely attempted to improve their service at practice level. I do not suggest that all fundholders are necessarily bad. As I said, I know a number of fundholders and, as a shadow Minister, I recently addressed the Yorkshire fundholding group. We had a very interesting dialogue. The group understood where I and my party were coming from and some of our reservations about a system that creates the anomalies that I shall describe in a moment.
Ms Judith Church (Dagenham): Like my hon. Friend, I represent an area in which there is great inequality in
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health care. I have met local fundholding and non-fundholding GPs to discuss the effect of fundholding on inequality. Do GPs in my hon. Friend's area think that fundholding is doing anything to reduce inequality? In Dagenham, they think that it serves merely to widen inequality in health care.Mr. Hinchliffe: I shall outline in a moment exactly what non- fundholding GPs think that fundholding has done. They think that it has increased the inequality that already exists. I shall illustrate my point with reference not to my views but to those of GPs who have set out in their own words what they think about the current position.
I have listened many times to Conservative Members saying that the market will resolve any problem. With the National Health Service and Community Care Act 1990, we introduced the market into primary care. The idea that competing, thrusting GPs would fight on behalf of their patients, and that practice would fight against practice, to get what is best for their patients is absolute nonsense.
As the Minister knows, right from the word go fundholder cartels were established. The Wakefield metropolitan district fundholders immediately appointed someone to work on their behalf and block contract purchase. Straight away, there was a complete monopoly of purchasing. I heard in Committee and in the Second Reading debate on the 1990 Act that the competitive, thrusting market would somehow enhance patients' rights and their access to treatment, but from the start we saw the establishment of block collaborative purchasing by fundholders. That happened not only in my area but across the country. Block purchasing is worth examining in its own right, because it has implications for the planning of health care.
Mr. Malone: The hon. Gentleman mentioned what is happening in his area. In fact, 81 per cent. of the population there are now covered by fundholding practices. A large fundholding project has resulted in savings of £820,000 to be spent on patient care. Those uncaring fundholders have also returned to the health authority £217,000 worth of savings for general spending. I should have thought that the hon. Gentleman's own area is an ideal example of the benefits that fundholding has provided.
Mr. Hinchliffe: The Minister used the term "uncaring fundholders". That is his term, not mine. I hope that he will be as happy to intervene when I have spelt out my concerns about what is happening in Wakefield. I have already raised my concerns with him and the Secretary of State, and did so with him again this morning. I am getting a little impatient because I am not getting answers to questions that are directly relevant to the meat of this debate. Before I go into detail about my locality, I shall make one or two further points on the wider issues that need to be examined. I have mentioned the collective purchasing by fundholders. Important questions need to be asked about what collective, collaborative block purchasing means for local health planning.
Mr. Stephen: Will the hon. Gentleman give way?
Mr. Hinchliffe: With respect, I have taken a number of interventions and still have some very important points to make.
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I believe that local health planning is being wholly undermined by the collective purchasing power of fundholders. It is a simple fact that their collective purchasing power increasingly renders the planning role of local health authorities redundant. Fundholders have the power to shift contracts and, effectively, to close hospitals. They have the power to close key local services. To whom are they accountable?Health authorities and trusts at least have a token accountability. If one looks through one's local newspaper, one might, if one is lucky, find a notice stating that the local trust or health authority is having a public meeting. Usually, only about three people turn up, because few know about it or know what the trust or health authority does these days. However, there are at least token meetings. Who can influence the decisions of fundholding blocks? Where is the public accountability? Where can my constituents go to ask why fundholders have decided to shift a contract from hospital A to hospital B, with the resulting implications for services at hospital A? Such issues are fundamental to our belief in a national health service that offers people equality of treatment. Frankly, that framework has gone by the board. The Government did not think through these issues, which are increasingly coming home to roost in areas such as mine. People who can spend millions of pounds are completely unaccountable to the public. How can my constituents influence fundholding practices?
Mr. Malone: Before the hon. Gentleman accuses me of not rising to deal with that point, I should point out that I shall deal in great detail with the accountability framework and what it implies when I wind up the debate.
Mr. Hinchliffe: The hon. Member for Croydon, North-East mentioned the tie-in between general practice and community care, which is an important point. I had Front-Bench responsibility for community care policy and travelled around the country, talking to many people about the implications of fundholding on community care, child protection and the services that work alongside general practice.
I hear worrying tales from people working in mental health who are responsible for implementing the new supervised discharge order. They say that it is nonsensical that local GPs are bringing in community psychiatric nurses from outside the area who are not involved in the local collaboration process. GPs are also purchasing health visitors and midwives, people directly involved with the nitty-gritty of child protection. Those people have no relationship with local social services.
That undermines completely collaboration on key issues such as child protection. I fear that, before very long, when something has gone badly wrong, we shall be hearing of yet another inquiry into child abuse. I predict that one issue that will arise from that will be the fact that fundholders are buying services from outside their immediate area and that that undermines proper local collaboration.
Mr. Merchant: The hon. Gentleman referred to the buying-in of services by GP fundholding practices. Surely GPs take decisions in the interests of their patients. He betrays a lack of faith in GPs if he believes that they cannot make the best choice for their patients in these circumstances.
Mr. Hinchliffe: I have a great deal of faith in GPs. The essence of what I am saying is that I want them to be
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given more power. General practice has a crucial role to play, but we need to think through the consequences of fundholding for community care and personal social services.I am told by community psychiatric nurses that fundholders do not understand their role. One CPN told me recently that it was sad that, instead of being brought in to deal with seriously mentally ill people, CPNs were being asked to deal with those described as the worried well, people who have various neuroses of a not very serious nature and do not need the skills that CPNs have. The Government have not even started thinking about such problems.
I focus now on an issue that I mentioned in an intervention on the Minister and which has been bandied across the Chamber--the two-tier system created by fundholding. My fundamental objection to fundholding is that it completely undermines what I felt was a cross-party belief in the equity principle of the national health service, which has been there right through from the 1940s: the belief that if people pay into a system, they have a right to expect equal access to that system and that they can get the same treatment as others in an area. That has been blown out of the window by general practice fundholding.
Mr. Mans: Does the hon. Gentleman believe that that equity principle applied in practice during the past two periods in which there was a Labour Government? Was there equal access across the country to medical facilities, as was suggested in 1948 when the NHS was founded?
Mr. Hinchliffe: One of the issues that we have had to address right through from the very brave decision of the Labour Government in the 1940s has been that of equity across the country. Of course I concede that there is different access in different parts of the country. I understand that. Indeed, Government after Government have had to address such issues. We had the Resource Allocation Working Group. Now there is the reverse of RAWG, whereby inner-city areas in the north of England have been robbed of funding to shunt it to the opulent south of England where there is less pressure on the health service.
I travel around the country and see many people. I accept the fact that there have always been differences, and successive Governments have attempted in their own ways to address them. But there have not in my experience been differences in the same hospital between patients living in the same community, served by that hospital. That scenario has arisen, and I shall spell out in some detail how it applies in Wakefield. The equity issue has been raised with me by my constituents who want to know why they are denied treatment that their next-door neighbours can get on the basis of which practice they happen to be registered with.
Over considerable time, anecdotal evidence of the two-tier system operating in my constituency--it depends on the status of a person's GP--has been given to me. In July, a constituent came to see me. All the constituents whom I am about to identify have given me their permission to mention their names and their circumstances. If the Minister wants, I will show him the correspondence in each case--it is with me today--which spells out their feelings in their words.
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In my surgery in July, I saw a Mrs. Doreen Armitage, who lives in Alverthorpe, Wakefield. She is a 65-year-old widow who, along with her late husband, spent many hours raising thousands of pounds for Pinderfields hospital from charity work. Some time ago, that lady was injured in a road accident. She broke her neck and fractured her femur and, as a consequence, needs a hip operation. She was told after an X -ray at Pinderfields hospital on 15 December 1994 that her operation would take place between four and six weeks later and that she would be "admitted on a phone call". That was later amended to four to six months and, later still, her daughter was told that the operation would be at the end of June or in July.Mrs. Armitage rang the hospital again in mid-July and was told that the operation would definitely take place in August. That was amended again because--she was quite clearly told this--her GP was not a fundholder. She was told that the operation would take place in December at the earliest. That lady is in acute pain to the extent that she cannot function on her own and has had to leave her home in Wakefield to live with her daughter in Scunthorpe.
In September, I had a letter from a Mrs. Mary Parkin of Thornes, Wakefield. This lady is a 79-year old widow and happens to be the mother of somebody who was in the same class as me at school. I have known her for many years. She is of my parents' generation. She is awaiting a hip operation in pain and discomfort. She is also a patient of a non-fundholding GP. After writing to the chief executive of the Pinderfields hospital trust, she received a letter from the chief executive dated 15 September, which said:
"Pinderfields is in negotiation with Wakefield Healthcare over the funding of operations from non-funding GPs in Wakefield. Problems have arisen in recent months as the hospital has carried out all the operations it has been contracted for".
That is no real comfort to Mrs. Parkin, who is in great pain. In October, I was contacted on behalf of a constituent, Mr. Robert English, who lives in Eastmoor, Wakefield. He is a 54-year-old man who has been suffering from a painful hip condition for more than a year. It was initially diagnosed as arthritis, and because of his concern, he ended up, as so many people have to nowadays, paying privately to see a consultant, who diagnosed a fractured hip. That man has been in considerable pain while waiting for the operation that he requires. When he rang the secretary of the hospital consultant concerned, he was asked whether he was the patient of a fundholding GP.
This week, I was contacted on behalf of a Mr. David Garlick, a 77-year-old man who lives in Wakefield. He has been treated since 1991 for a painful hip condition. His GP told him in 1991 that he required a hip replacement operation. His consultant told him in December last year that he was on the waiting list, and that an operation would be carried out before May 1995. He was told in July that the operation would go ahead in August. In late August, Mr. Garlick was told that the operation could not go ahead until after Christmas due to a shortage of funds. His GP is not a fundholder. Mr. Reynolds, from Flanshaw, Wakefield, was a miner for 28 years and after that worked as a hospital worker. He is suffering from osteoarthritis of the hip. He was referred to hospital in October 1994. He was seen by the consultant after that referral on 19 April 1995, told that a hip replacement operation was needed and that he would
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have to wait two months. He is still waiting. He has been told by his own GP that the delay is because his general practice is non-fundholding.Mr. Stephen: Will the hon. Gentleman give way?
Mr. Hinchliffe: If the hon. Gentleman would let me finish my point, I will give way later.
I would like to finish the point by giving my opinions. This morning I received a copy of a letter sent on 31 October by the Wakefield non- fundholding practices, representing the various surgeries in Alverthorpe, Chapelthorpe, Church street in Ossett, and Grove and Kirkgate in Wakefield. Most of them are in my constituency and represent 36,370 patients--most of whom live in my
constituency--including, by the way, myself, my wife and my children, because we are very happy with the service provided by our non-fundholding general practice.
The letter sent to the chief executive of Wakefield health authority is quite lengthy and asks a number of important questions. It makes the following point:
"We understand that our patients who are already on Waiting Lists will not receive Elective Surgery in ANY speciality, because the budget has been spent. We also understand that the Budget was £2 million less than the last financial year.
We are very concerned that our patients are not receiving the same standard of care from Pinderfields Hospital Trust as patient from Fund-holding Practices."
The letter goes on to ask eight questions, and I shall mention one. It said:
"We have been led to believe that the Fund-holding Practices are financed to the same level as the Non-Fund-holding Practices. If this is so, why have the Fund-holders not run out of money?"
I have raised the matter with the Secretary of State in writing. I have a letter sent to me by the Minister on 16 October, in which he says--he probably has a copy of it with him which he might be able to fish out--that he was sorry to learn that my constituent, Mrs. Armitage, the first one who came to my notice, has been asked to wait. He said that he understands that, in relation to the case, Wakefield Healthcare issued a statement confirming its policies to treat patients according to clinical priorities and that that is in line with national policy. He mentions joint guidance and also says that the statement
"refers to additional funding, which I understand amounts to £800, 000 for Wakefield, made available to reduce the length of time which people have to wait."
I welcome that additional funding; I am not grumbling about that. I am asking why some people can get treated and some cannot; that seems fundamentally wrong.
The Minister writes:
"I understand also that in mid-September the Wakefield Fundholders' Group, which represents a number of local GP fundholders, wrote to Pinderfields Hospital NHS Trust reaffirming that treatment should be given to their patients and others on the basis of clinical need."
I am not arguing that the fundholders in Wakefield want a two-tier system; I do not believe that they think it acceptable that some people are winners and some are losers, any more than I do. I do not blame the fundholders; I blame the system, and the Minister will have to respond to that point.
The Minister writes:
"I hope this information helps to reassure you that both Wakefield Health Authority and GP fundholders in the Wakefield area aim to ensure equitable treatment for all patients based on clinical need and clinical priority."
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