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Ms Harman: Hospitals, not GP fundholders, carry out operations. The document also deals with hip replacements in Sheffield. It no longer matters who is in greatest pain and needs a hip replacement and who finds it most difficult to get upstairs and has to sleep on the sofa on the ground floor because they cannot get to the bedroom. What matters is whether or not the patient's GP is a fundholder. In Sheffield hospitals, patients of non-fundholders have to wait up to 52 weeks for hip replacements, but patients of fundholding GPs, even if their condition is less serious, have to wait only three months.
The Secretary of State said that he wanted to know what was wrong. I shall tell him: it is the unfairness of a two-tier system. We are not talking about advantages won by GP fundholders; they are not carrying out the hip operations. The system simply provides unfair access to our hospitals.
Did the Secretary of State know about the position in Sheffield? Did he know about the two-tier bulletin for waiting times in Sheffield? Does he defend it?
Unfairness is built into the heart of the system of GP fundholding because the advantages of the patients of fundholding GPs--
Mr. D. N. Campbell-Savours (Workington):
On a point of order, Mr. Deputy Speaker. Will you ensure that Hansard shows that the Secretary of State said, from a sedentary position, "Yes, I do defend it"?
Mr. Deputy Speaker:
It is not for the occupant of the Chair to determine what Hansard reporters record.
Mr. Alan W. Williams (Carmarthen):
On a point of order, Mr. Deputy Speaker. My concentration during the debate has been badly upset by the hon. Member for Hayes and Harlington (Mr. Dicks), who at no stage has tried to intervene, but continually barracks from a sedentary position. Will you call him to order?
Mr. Deputy Speaker:
In an ideal world, there would be less barracking from both sides of the Chamber, from both the Back and Front Benches. It has been a lively debate so far.
Ms Harman:
My hon. Friend the Member for Workington (Mr. Campbell-Savours) is absolutely right.
It is the same story across the country. In Scotland, the Glasgow royal infirmary issued a letter proposing to give priority to the patients of GP fundholders. In King's College hospital in my constituency in London, there are extra surgery sessions for fundholding patients only. As my hon. Friend the Member for Halifax (Mrs. Mahon) said, it is the same in Halifax. I have a letter that was sent to a GP in her constituency from St. Luke's hospital.It states that
When the Secretary of State responded to one of my hon. Friends, he tried to say that a new system was being developed. What is being developed is not a new system, but unequal access to an existing system. It is not just that the internal market is unfair; it is too expensive to run and it piles bureaucracy on to bureaucracy. Every GP fundholder has to have his own set of contracts and has to have a business manager in the practice. Each fundholding practice now employs a business manager who is paid twice as much--if not three times as much--as the practice nurse. The hospitals have to employ more managers to negotiate with the fundholder managers and the bill is huge--at least £80,000 extra in administration costs for each fundholding practice. With the current number of fundholders, that amounts to an extra£212 million a year on bureaucracy. There is no contribution to patient care, just more bureaucracy.
With the multiplicity of GP fundholders, there is no chance of developing what we want to see: an overall strategy for health services in each area. It is impossible for hospitals to plan from one year to the next. Like unfairness, instability is driven into the system byGP fundholding. We do not criticise the patients ofGP fundholding; we do not criticise the fundholders.GP fundholding was not the idea of doctors; it was forced on them by the Government and there is still widespread opposition to it among GPs.
The Secretary of State misrepresented GPs' views.A survey in 1995 by Pulse magazine found that more than three quarters of GPs wanted fundholding abolished; half of all the fundholders wanted the scheme abolished. The GPs joining the fundholding scheme are not giving a vote of confidence to the fundholding scheme; many are simply trying to do the best for their patients in an unfair system. Unless GPs become fundholders, they have no right to choose where patients go for treatment; unless GPs become fundholders, they have no say in the planning of local services. Two thirds of GPs object to fundholding in principle, but half of them said that if other practices in their area started to become fundholders, they would have to apply too.
Because the fundholding scheme is fundamentally flawed, many doctors across the country are working together to remedy its defects. They are trying to make fairness in an unfair system; they are trying to make sense out of a senseless system. They are struggling to overcome bureaucracy.
In Hertfordshire, GP fundholders have tried to instil some strategy into the fragmentation of the NHS market. A joint strategy working group there incorporates
fundholders and non-fundholding GPs, public health, Hertfordshire health agency and the local medical committee. The group has created a Hertfordshire-wide policy where the fundholders agree to purchase within the policy.
In Winchester, an attempt has been made to mitigate the two-tier system by using fundholders' budgets to pay for operations for the patients of non-fundholders, who would otherwise have to wait until after April for their operations. In Newham, GPs have tried, single-handed, to influence the purchasing decisions of the health authority by combining to create the Newham Innercity Multifund.
The Minister for Health (Mr. Gerald Malone):
I am grateful that the hon. Lady has at last decided to give way on a constituency point. Does she not understand that if the fundholders had not been in a position to manage their budgets to make savings, the money would not have been available for health care in my constituency? That is the point.
Ms Harman:
No, that is not the point. The situation was unfair: neither the GP fundholders nor the non-fundholders found it acceptable, so they all got together to pool their resources so that the fundholders could help out the non-fundholders in an unfair system. That is an example not of the system working, but of good people on the ground trying to mitigate the unfairness of the Tory system, and I applaud them for that.
All the examples that I have given show GPs struggling to improve their care for patients despite the problems of fundholding. The Labour party will build on their work and will replace fundholding with GP commissioning--a framework for primary care that will allow all GPs to have a role in shaping local health services.
All GPs will have substantial new powers and opportunities under Labour's scheme for GP commissioning. First, all GPs will be able to refer their patients to the hospital or specialist they want so that GPs can ensure that their patients are in the right hands without the tangle of red tape. Secondly, Labour offers all GPs an enhanced role in the planning and public health functions of the health authorities. GPs and the health authority will team up to commission health care. There are a number of models, so the relationship between the two can be flexible. But, under our system, health authority commissioning decisions will have genuinely to reflect the views and experiences of local GPs. GPs will have the chance to innovate, while bureaucracy can be cut and strategic planning maintained.
GP commissioning is, as the Secretary of State acknowledged, already evolving throughout the country: more than 60 commissioning groups are in operation, representing more than 5,000 GPs and covering 11 million patients. The range of commissioning models is still developing. In Nottinghamshire, a commissioning group has been established by 200 GPs, caring for nearly 400,000 patients. They have achieved many improvements in patient care. In Tamworth, first-wave fundholders frustrated with the limitations of fundholding have taken up commissioning instead. Working with non-fundholders and the South Staffordshire health commission, they have created a health commissioning group. They say that commissioning is the way in which the NHS should work in the future.
The Tory internal market in the NHS creates division. It sets patient against patient, doctor against doctor and hospital against hospital. Today, the Secretary of State has sought to manufacture further division with his motion. He has tried to play fundholding GPs against non-fundholding GPs. He realised that it did not workand so he backed off. His strategy, however, iswidely understood. One fundholding GP, Dr. Marcoolyn, observed that the Government
When they cannot find those situations, they create them.
"we are not able to respond to your recent request to provide a psychology assessment/treatment service for your patient, and I am, therefore returning your letter of referral . . . We are only able to provide services . . . where we have contracts with fundholding practices".
"are never happier than with divide and rule situations."
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