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Mr. Dorrell: I shall give way once more, but then I must get on. I am still on my introduction to the terms of the Bill.
Mr. Hughes: This is a long warm-up. I still agree with everything that the Secretary of State has said and he is bright enough to understand that he has not yet answered the question. If I exercise my right in Exeter or in that part of Devon to be on a doctor's list and that doctor chooses not to be a fundholder, is it not the case that today, in October 1996, I shall be at a disadvantage in receiving non-emergency treatment from the local NHS trust as opposed to those who are the patients of fundholding practices? That is a two-tier system, to the disadvantage of patients of non-fundholding practices.
Ms Harriet Harman (Peckham): If it is a two-tier system, why do the Liberal Democrats support it?
Mr. Dorrell: The hon. Lady has always made it clear that she would abolish fundholding. It is nice to hear her being so clear and direct on the subject. She always sought to persuade me previously that abolishing fundholding was different from the concept of replacing fundholding. I never quite understood the difference, and I am glad to hear confirmation from the hon. Lady that she never really understood the difference either.
Ms Harman: That is sexism. The right hon. Gentleman thinks that women do not understand anything because they are stupid.
Mr. Dorrell: No. I am merely picking--
Madam Deputy Speaker: Order. It does not make for good debate if there are sotto voce comments, especially from a seated position.
Mr. Dorrell: I resent the proposition that, because I pick up a comment that the hon. Member for Peckham (Ms Harman) lets slip, which everyone knows to be her view, that makes me sexist. The hon. Lady is claiming a protection from normal and legitimate debate which anyone who wants to see equality of the sexes would not wish to claim on her behalf.
I have twice answered the question posed by the hon. Member for Southwark and Bermondsey (Mr. Hughes). The hon. Gentleman is focusing on one specific aspect of patient care. It is my case that we provide resources on the same formula to both fundholder and non-fundholder patients. Every practice has a different experience, of
course, of the NHS. I am not talking about 42 per cent. or 58 per cent. The purpose of the scheme is to create pressure for improvement.
Mr. Frank Field:
I am grateful to the Secretary of State for giving way.
Mr. Dorrell:
The only trouble with that is that I am not going to give way, but I am always happy to accept the hon. Gentleman's gratitude. I wish to make progress, or we shall spend the whole morning on fundholding. I have been on my feet for more than 20 minutes and it is probably time that I moved on to the Bill that we intend to put before the House.
I wished to stress by way of introduction to the Bill that the fundholding scheme--more than half the doctors have chosen to be part of it, and it was based on the introduction of an idea by means of a pilot scheme--has delivered significant change and benefit to the NHS. The hon. Member for Islington, South and Finsbury (Mr. Smith) will have to avoid the fudge that has recently been revealed by the hon. Member for Peckham. There is no fudging possible of the Labour party's policy on fundholding. Those interested in primary care will want to hear from the Labour party whether the hon. Gentleman agrees that replace and abolish in these terms amount to precisely the same policy.
The Bill that we propose to introduce will build on the success of the fundholding scheme and primary health care more generally. I shall outline the objectives that lie behind the Bill, but I shall begin by making two points about what it is not. First, there is speculation in some parts of the professional press that the Bill will constitute big bang in the primary health care sector. I have made it clear repeatedly, and I do so again, that the Government's approach to the implementation of new bases of contract is explicitly a pilot-based approach. It is an incremental approach to change in the primary health care sector.
I do not understand how a big bang can be piloted. We have either a big bang policy or a pilot incremental policy. I have made it explicitly clear that we have a pilot incremental policy. It has not yet been explained to me how I can pilot a big bang. That is the first thing that the Bill will not be.
Secondly, the Bill will not represent a policy for introducing a huge range of new general practitioners based on supermarkets. I have made it clear already that I am in favour of NHS primary care, by which I mean a service delivered by NHS practitioners, NHS staff and the NHS generally. I set out the principles at the beginning of my speech. The patient chooses the general practitioner. Critically, the patient then goes on the GP's register. It is not a reactive service. The GP delivers the range of care that we expect of the modern NHS primary care GP. General practitioners act as the gateway and as the patient's advocate for the rest of the NHS. I am not interested in developing a new competitor idea of what general practice means. Instead, I am interested in developing the present system, which in the sector that we are discussing I believe to be the best in the world.
So far as I know, no supermarket operator has evinced the slightest interest in developing his own primary care sector. I find it difficult to understand why much of the commentary so far has concentrated on those who have never expressed any discernible interest in primary care.
That commentary has avoided discussing the group for which there is real interest in extending opportunities for developing primary care, which is NHS community trusts.
Having made those comments by way of introduction, I come to the real options that we shall be introducing in the Bill.
Mr. Richard Burden (Birmingham, Northfield):
I imagine that the Secretary of State is aware of Mr. Roy Lilley, a former Conservative councillor and currently the chair of the Homewood NHS trust. The right hon. Gentleman may be aware also that in 1994 Mr. Lilley said that general practitioners had three duties. One was to themselves, one was to the organisation within which they worked and the third--it was interesting that it took third place--was to their patients. The right hon. Gentleman is suggesting that GPs could become the employees of trusts, including, I assume, acute trusts--
Mr. Dorrell:
That is unlikely.
Mr. Burden:
If the Secretary of State is saying that the suggestion is ruled out, that is fine.
Mr. Burden:
If he is not saying that it is ruled out, how can it be said that there will be a primary health care-led NHS if the GP--as the right hon. Gentleman said, the gatekeeper--is employed by the secondary sector?
Mr. Dorrell:
The secondary sector includes community trusts. My sedentary reaction to the hon. Gentleman's proposition that acute trusts could be included was that it was unlikely but possible. There are two reasons why I am not ruling it out. First, there are many trusts that are both acute and community in a single trust. In that instance, it would be the community sector typically that would be most likely to be the employer of a salaried GP.
Secondly, if we reflect on some of the ways in which we manage pressure on an accident and emergency department, for example, some acute trusts are providing a proper, high-quality GP-based primary care sector as a front-line service, close to where the acute trust is. That is already being done within the existing contract scheme. It has been widely recognised as an improvement in the quality of care and in the management of the work load in inner-city accident and emergency departments. It may be that some trusts will find that approach--the salaried option--a more efficient means of delivery. For both reasons, I am not ruling out the proposition that an acute trust could put forward a suitable proposal.
There is no point in our constantly being taken down a cul-de-sac. As far as I know, Sainsbury, for example, has never expressed an interest in those matters. When we ask, "How do we address the failures of general practice in areas such as east London?" the answer, repeatedly, turns on the inability of the community trust to employ salaried GPs. It is thought that that is a significant difficulty in the development of NHS primary care.
If a young GP is contemplating going into NHS general practice on the basis of the present national contract, he is in reality required to make a substantial commitment, if not a lifetime commitment, to the area in which he
wishes to practise. That has led to NHS GPs gravitating away from the most difficult areas. As Secretary of State, I regard it as part of my responsibility to set up systems that allow us to create a countervailing pressure against that tendency.
Mr. Burden:
Again, the Secretary of State is not answering the question. If he does not rule out a GP being employed by an acute trust that is a secondary care organisation, how is that GP, being responsible to the acute trust, to act in the gatekeeper-advocate role, which the right hon. Gentleman said was perhaps the most important role of the GP?
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