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Mr. David Ashby (North-West Leicestershire): Will my hon. Friend give way?
Mrs. Roe: I am told that a number of otherhon. Members wish to speak. I have already given way twice; my hon. Friend will be able to catch your eye later,Mr. Deputy Speaker.
Through an innovative and flexible approach to health care, GP fundholders in my constituency have now made available an extensive range of diagnostic investigations and screening including blood tests, electrocardiograms, audiology screening before referral to an ear, nose and throat surgeon and ultrasound screening. They are working increasingly closely with hospital colleagues in developing protocols for referrals, treatment and discharge. They have increased the number of community and practice nursing staff to cope with the increased work load as hospital lengths of stay shorten, more day-case surgery is undertaken and the move from secondary to primary care settings accelerates.
Most GP fundholders place contracts with trusts on a "cost per case" basis, which has led to improved procedure-based costing by trusts and to more timely
communications. That is very important. Fundholders are also working closely with the Hertfordshire health agency in developing joint approaches to contracting, and in reviewing the appropriateness and effectiveness of different treatments.
Those of us who represent Hertfordshire constituencies are proud of the way in which the whole local medical profession is delivering health services to our constituents. I assure the hon. Member for Workington that no two-tier system operates in my area: equity of service for all patients is an acknowledged priority. Moreover, there are four total-purchasing pilot projects in the county, which will begin purchasing all health services in April.
Mr. David Hinchliffe (Wakefield):
Will the hon. Lady give way?
Mrs. Roe:
No. I want to finish my speech.
Mr. Alan Simpson (Nottingham, South):
I feel very privileged to speak in the debate, mainly because I have done what the Secretary of State suggested and listened to some of the comments of GPs who are members of the non-fundholding consortium that operates in Nottingham. On the basis of those comments, I shall address the seven deadly simplicities offered by the Government in defence of their policy on fundholding, and the four more sensible options that might result from adopting the same course as the non-fundholding group in Nottingham. It may help hon. Members to know about the non-fundholding consortium's structure. It has an elected committee of 13 general practitioners, who represent more than 200 GPs in the city. Between them, they cover more than 400,000 patients. The consortium has proved so successful that it is contracted to advise Nottingham health authority on its purchasing policies.
The consortium's objectives were set out about a year ago by Dr. Doug Black, Dr. Alan Birchall andDr. Ian Trimble in the British Medical Journal. They said that they could
It is in that context that I shall deal with the first of the simplicities and inaccuracies that the Government offer us.
The Minister for Health recently said thatGP fundholders' savings far outweighed their administrative costs. It was on that basis, he said, that fundholding saves money. Let me refer him and hon. Members to last year's Audit Commission report. Paragraph 37 pointed out that, of the £19 million-worth of savings that had been made by fundholders,
35 per cent. had been spent on premises and 25 per cent. on office furnishings. One Nottingham GP pointed out in Pulse that the report showed that
That is a pattern not of value for money spending, but of a profligate waste of money. In Nottingham, 75 per cent. of general practitioners are non-fundholders. The administrative costs in Nottingham are the lowest in the Trent region. That achievement is a direct result of the non-fundholding consortium's role and contribution.
The second magical myth that the Government have peddled is that fundholding reduces drug spending.A recently completed study in Nottingham shows, however, that, over a four-year period, fundholding GPs' prescribing bills have been rising faster than those of non-fundholding GPs. It is an objective fact that, in Nottingham, non-fundholding GPs' cost for drugsper prescribing unit is almost £3 less than that of fundholders. Although non-fundholders lay claim to that and view it as a virtue, they also point out that, if the House genuinely wanted to understand the key issues in prescribing costs, it should not simply compare fundholders with non-fundholders but should consider the extent to which any savings are dwarfed by the power and pressure exerted by the pharmaceutical companies in relation to the total drugs bill. A different way of pursuing substantial savings on the drugs bill would be to link hospital and prescribing budgets at district level. That would offer direct incentives for consultants to work alongside their GP colleagues to promote more effective use of budgets.
The third fantasy that we were offered is that fundholding is popular with GPs. Last year in Nottingham, however, not a single GP moved from non-fundholding to fundholding. A meeting that was scheduled to be held on the invitation of the Health and Safety Executive, to promote fundholding, had to be cancelled because it could not attract GPs to attend--such is the measure of fundholding's popularity. All that must be viewed against the backcloth of nearly five years of direct financial incentives to GPs to opt out of non-fundholding status.
I did not understand the Secretary of State for Health when he said that the funding arrangements for fundholder GPs did not differ from those for non-fundholder GPs. The consortium in Nottingham tells me clearly that fundholders are paid on an activity basis, that non-fundholders are paid on a capitation basis and that Government rules restrict the way in which non-fundholders can use any savings that they make collectively. The aim of the unequal approach to funding is to drive GPs out of the non-fundholding sector.
The fourth Government myth is the notion that fundholding is popular with patients. A Which? report last year pointed out that about 59 per cent. of patients did not know whether or not their GP was a fundholder. We can all understand and excuse that: it will not necessarily be
the biggest issue in a person's life. What was more significant was that the survey accepted that lack of knowledge and asked patients whether they were getting better or worse access to their GP. It found that morefundholding GP patients were having difficulty in gaining such access than non-fundholding GP patients. So the claim that fundholding is popular is itself somewhat dubious and does not stand up.
The Government then tell us that fundholders influence service provision. In some cases, they do--evidence of a two-tier system can be seen in the Sheffield list--but they do so at the cost of other patients. Ironically, some of this is beginning to boomerang on Government policy. The National Association of Fund Holding Practices recently surveyed its members and found that a high proportion of them were experiencing increasing prices because of demands by trusts, after purchasing budgets had been set. Their members were having to pay increased moneys to purchase the extra services that they wanted. That is hardly a sensible way of dealing with serious, overall reductions in patient waiting lists.
Again, in Nottingham, the non-fundholding consortium's role has been precisely what the Secretary of State wished: to exercise a collective role in reducing patient waiting lists. It has been astonishingly successful. I identify just three of the sectors where there have been amazing results. At the Queen's medical centre, a teaching hospital in my constituency, the waiting lists for non-urgent, out-patient operations went down considerably. For example, the waiting list for ear, nose and throat operations went down by 30 per cent., in the ophthalmology department it went down by 48 per cent. and in the orthopaedics department it went down by15 per cent. Overall, waiting lists have gone down by14 per cent. That is what can be achieved by GPs acting collectively in non-fundholding consortiums.
The sixth claim that the Government make is that fundholding promotes change through market forces. Again, the evidence from fundholders is that it takes a huge amount of time to negotiate contracts. Many of them are simply signing copycat contracts that have been written by the hospital trust. Fundholding has not shifted the basis of leverage in terms of innovation. GPs tell me that, although they have a sense of what they can do in terms of patient care and meeting patient needs, if they are drawn into individual contract negotiations, they do not have the time or expertise to view the broader picture and to assimilate epidemiological evidence. That task must be done at a collective level.
The seventh, and the last, of the fabulous myths and simplicities that we have been offered is that fundholding ensures that the NHS is primary care led. The simple fact is that, in negotiations between a GP and a hospital, an individual practice is dwarfed by the power of the large providers, and their ability to set the agenda.
In Nottingham, the non-fundholding consortium proposes that an elected group of GPs should share the responsibility for Nottingham's budget with the executive of Nottingham health commission. That would give an innovative, primary-care edge to the whole purchasing process.
The real excitement about the debate that we should be having lies in the possibilities beyond the fundholding absurdity. Again, Nottingham has come up with an exciting idea--that of a total commissioning project based
on four assumptions. The first is the shared fiscal responsibility that I have already mentioned. That would be not an abrogation of responsibility, not a "grab it for yourself and run as far as you can" notion of responsibility, but the establishment of a common and collective responsibility for commissioning, in the interests of all patients.
The second requirement is that the absurdities and inconsistencies between the funding offered to different GPs should be removed. The consortium wants us to understand the need to accelerate the move towards capitation-based budgets at regional, district and practice level.
Thirdly, the House should acknowledge the value of allowing for virement between budgets at a district level. If drug budgets are overspent, money now automatically comes out of next year's health service allocation. There is already a direct linkage, but virement at a local level would offer incentives for consultants to work with GPs to get the maximum out of the budget, in the interests of all their patients.
Finally, the group asks for funding for information technology advances. It is a recognition of the fact that if the different elements can act collectively, they can get far more out of the system, in the interests of patients, than if they all set off down separate paths.
The group has carried out costings for the project, showing that there would be an overall saving of£3 million, compared with any equivalent move to push an extension of fundholding. That is the local Nottingham advantage that would arise simply from any such approach. If we extended the idea across the country, to the 60 or more commissioning units set up by non-fundholding practices, the benefits would be spread even more widely.
"collectively offer more time and knowledge to the contracting process while minimising the impact on clinical workload. As a large purchaser with low management costs the group has secured access to quality secondary care which is equitably available to all patients, preventing the development of a local two tier service."
"of the £19 million of fundholders' savings actually spent by 1993/4, less than 20 per cent. was spent directly on patient care. If this pattern continues, fundholders will re-invest less than £13 million of the 1993/4 savings on patient care."
He added that, if that trend continues
"fundholding will have resulted in nearly £90 million . . . being withdrawn from patient care in a single year."
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