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4.55 pm

Ms Harriet Harman (Peckham): I beg to move, to leave out from "House" to the end of the Question, and to add instead thereof:

"pays tribute to the role all GPs have played in developing innovative practice in both primary care and the acute sector; regrets that the system of GP fundholding leads to two-tier health care and a massive increase in bureaucracy; believes that the unfairness of the internal market should be ended and GP fundholding replaced by GP commissioning in which all patients get excellent primary care, access to hospitals on the basis of clinical need, and in which all GPs have a say in the planning and development of primary and hospital care.".

I welcome the debate and the chance that it gives us to talk about what is really happening in primary care. The Secretary of State has clearly forgotten the advice of the Maples memorandum. He has proved again today that no news about the NHS is good news for the Tories. Any time that he wants to use Government time to debate the NHS and our policies, we shall be happy to oblige.

The Government motion is a disgrace. It congratulates only fundholding GPs; it has nothing to say about all the other GPs who are working hard for their patients. Our amendment, which I commend to the House, pays tribute to the efforts of all GPs who are struggling, despite this Government, to improve patient care.

Mr. Jacques Arnold (Gravesham): Was the hon. Lady aware, before my right hon. Friend the Secretary of State made his speech, that the Government motion, almost in its entirety, was drawn from three quotations from a speech by the right hon. Member for Derby, South(Mrs. Beckett), her predecessor? Was she aware of that, yes or no? If she was not, that is incompetent; if she was, how can she and her colleagues oppose the motion? If they oppose it, it is clear that Labour spokesmen say one thing, but vote in exactly the opposite direction.

Ms Harman: It is clear, from the speech that the Secretary of State quoted, that my right hon. Friend the Member for Derby, South (Mrs. Beckett) was proposing all the points that we make in our amendment. I quote from the press release that went with the speech. My right hon. Friend said:

"Labour's proposals are to end a two-tier system of primary health-care provision . . . Fundholding"--

hon. Members should listen to this point--

"has improved GP services for some, but at the expense of others."

That is our case.

I am glad that the Secretary of State mentioned the points that I made in 1990 because we warned then that the Tory internal market in the NHS would lead to unfairness for patients. We said that it would lead to costly bureaucracy for doctors and fragmentation ofNHS provision. The experience of patients and doctors has borne out our warnings. Labour rejects the internal market now as we did in 1990, and we will end it.

Mr. Keith Mans (Wyre): The hon. Lady keeps making the point about the so-called two-tier service that

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she believes fundholding to be. Will she confirm, in that case, that she believes that before fundholding was introduced, there was a single-tier service throughout the health service, despite the fact that across the country, people were waiting different times for the same operation?

Ms Harman: Later in my speech I shall give examples illustrating that there are different waiting times at one hospital because of the two-tier system that has been driven into the NHS.

Mr. Mans: There always were.

Ms Harman: No, there were not. Clinical need determined priority before the internal market, but now it is cash before care. The hon. Gentleman is wrong.

We shall replace GP fundholding by GP commissioning--a system that will benefit all patients, not just a few, and will give all GPs the opportunity to commission care.

Ms Jean Corston (Bristol, East): Is my hon. Friend aware that last week I met a member of the Avon fundholders group? I asked him what innovations he could provide under fundholding that he could not have made available before. He told me that his practice now offered psychological counselling two nights a week and that that would have been impossible before he was a fundholder. However, locality commissioning in south London has enabled non-fundholding surgeries to provide psychological counselling five days a week between10 am and 3 pm. So fundholding allowed that GP to provide a service that must surely be available to non-fundholding GPs.

Ms Harman: My hon. Friend is absolutely right. In his speech today, the Secretary of State sought to perpetuate the idea that innovation takes place only in fundholding practices and that all other GPs are letting their patients down. We reject that and GPs are right to be angry.

The Tories want GPs to compete. They want to be divisive, but Labour wants GPs to work together in the interests of their patients. I shall set out four principles, and the primary care system should measure up to them. We heard nothing about the principles and objectives for primary care from the Secretary of State, so we shall hear whether he agrees with these. The system should provide equal access for all patients; it should make the best use of NHS resources; it should help to provide stability within the NHS so that it can grow; and it should play a part in local health strategies to improve the health of local people.

The Government's policy of fundholding fails on all those counts. It has created a two-tier service; it has added to the mountain of management bureaucracy and red tape; it prevents hospitals from planning for their services; and it cuts across any chance of strategic planning for health gain.

The Secretary of State claimed that fundholding is the fount of innovation in primary care. That is a sectarian and partial view. The Government see no merit whatsoever in the work of non-fundholders. There are hundreds of examples, but I shall mention just a few.Dr. Helen Groom, a GP in Gateshead, has set up a nurse

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assessment unit for men with prostate problems. That is innovative and the Secretary of State should welcome it. Dr. Robin Singer, a GP in Enfield, has set up a new service to treat cataracts and a twilight nursing service. The Secretary of State should welcome that. Why has he not done so?

Mr. Dorrell: I did. I said in my speech that there was no difference between the hon. Lady and myself on the benefits that commissioning GPs have brought to their patients. However, the hon. Lady has to explain how that would have been possible had the relationship within the health service not been changed by fundholding.

Ms Harman: We are talking about GPs innovating within their own practices. That has nothing to do with GPs buying hospital care and managing their budgets. Non-fundholding GPs do not control their budgets; they are simply improving primary care in their surgeries. However, we have had some success today because we have forced the Secretary of State, against his motion, to recognise that all GPs are doing a good job, whereas previously he wanted to concentrate on fundholders--to divide and rule.

The Government's claims for fundholders do not stand up. They claim that fundholders improve efficiency, responsiveness and quality of care. Angela Coulter, director of the independent King's Fund centre, says that those claims

"are in general not supported by the evidence."

The Tories claim that fundholding has been the mechanism for reducing prescribing costs, but the British Medical Journal says:

"Early reports of the effectiveness of fundholding in curbing prescribing costs has not been confirmed in its longer term study.".

There is one thing about GP fundholding on which the Government like to stay silent and everyone else agrees. A two-tier system is an inevitable part of GP fundholding. Some patients are fast-tracked for hospital appointments, while others have to wait longer.

The Secretary of State for Health has always denied that unfairness. This afternoon, it was not clear whether he was denying it or admitting it as his line of argument was somewhat confused, but in the past he has denied the unfairness. He said:

"The role of fundholding is not to allow a two-tier service",

but the evidence tells another story.

I have here a bulletin sent out by the hospitals in Sheffield. It shows the two-tier service in action. The first column reveals that cardiology patients of non-fundholders wait 26 weeks for an out-patient appointment, and the second column sets out the waiting time for patients of fundholders. Instead of waiting26 weeks, patients of fundholders wait only 12 weeks. Dermatology patients of non-fundholders wait 26 weeks, while patients of fundholding GPs wait only nine weeks. [Interruption.]

Mr. Dorrell: Perhaps the hon. Lady would prefer to make her own speech in her own way, but she is illustrating the force of my argument. Is it wrong to improve the service available to the patients of fundholders? If it is not wrong to improve the service to the patients of fundholders, is it then wrong to apply

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pressure, as the hon. Lady and many others will do,to improve the service available to all patients of the health service? The hon. Lady is highlighting how fundholders are improving standards and that leads to pressure for improvement across the board. While she is talking about waiting times, she might also recount to the House how waiting times for out-patient and in-patient care have tumbled over the past five years, not least under the pressure created by fundholders.

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