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Mr. Dorrell: I thought that I had answered the hon. Gentleman's question at some length and quite specifically. I gave two examples of why I am not ruling it out. I also made it clear that I do not regard general practice as the core responsibility of an acute trust. Nor, critically, do health authorities. We are talking about a pilot-based scheme, under which proposals will come from health authorities for the approval of the Secretary of State.
If the hon. Gentleman is concerned that all GPs will be subsumed into a hospital and that a patient will have to go to a hospital to see his or her primary care physician in future, I can give him an assurance that that is the policy neither of any health authority nor, certainly, of this Secretary of State. That is not what we are talking about, and the hon. Gentleman is raising an Aunt Sally.
Let us return to the real options, which are based on the listening exercise that was led by my hon. Friend the Minister for Health. My hon. Friend spent the first six months of this year going round listening to primary care practitioners, patient groups and other interested groups as well. There is broad agreement, and that has been revealed in the House. Hon. Members have questioned me on whether I plan to continue to deliver the objectives on the development of primary care, but those objectives are agreed throughout the House and in the primary care world. The questions are essentially agreed. My hon. Friend was engaged in looking at how we can address the weaknesses--the areas that need to be improved--in NHS primary care.
It is true that we have good general practice, but there is too wide a variation around the country, particularly in inner cities. It is also true that there is an unhelpfully rigid distinction between GP services and secondary services, which is preventing the development of the range of services that are available and which could be made available in the community, in the GP's surgery. It does not in every circumstance make it impossible, but it is inhibiting the development of what I might term a "super-surgery"--a surgery that can do things beyond what was imagined as a definition of GP services a decade or two ago.
Furthermore, that rigidity is inhibiting modern ideas about the distinction between the service that is delivered in the hospital and the service that is delivered in the community. It is engaging one of the more unhealthy aspects of NHS primary care, the introduction into health care of a rigid distinction between the role of the community primary care physician and the hospital doctor.
A general practitioner might want to be engaged more actively in sub-acute hospital care or in establishing hospital-at-home schemes--ensuring that there is proper support with general practitioner input--for recovery at home, to enable beds in hospital to be used for those whose needs are more acute. The development of hospital-at-home schemes is not impossible, but it is inhibited by the present rigid distinction between primary and secondary care in the contracting system. The development of primary care has been inhibited in the sense of the divide not just between primary care and hospital services, but between primary care and community health. That is particularly true in mental health.
The contract has demonstrated itself to be a powerful instrument for developing high-quality primary care, but it is rigid. That has led to another characteristic--that it has not been possible to respond as flexibly as we should to the different circumstances and different priorities of different parts of the country.
Furthermore, it is important in primary care to talk not only about general practitioner services. There is also dentistry. We need to ensure that we continue to have not just the growing NHS dentistry service that we already have, but more equitable access. We want more flexible systems to ensure that access is available to NHS dentistry around the country. Pharmacy and optometry are important parts of NHS primary care. We need to allow more flexible development of the pharmacy service and more active integration of the optometry service into the rest of the national health service.
Those are not issues that were invented by the Department of Health, still less by Conservative central office. Those are matters that are raised whenever one has intelligent discussions with practitioners about the development of NHS primary care. In June, we set out our approach in a document that details the things that we can do without legislation. It also recognised that there are key legislative bars to the development of those ideas.
The purpose of the Bill that will be introduced this Session is simply stated: to pilot different, more flexible types of GP and primary care contract, to allow us to address some of the issues in today's primary care. As the House knows, every NHS primary care principal is currently employed on a national contract. There are different national contracts with individual professions, but it is a national contract framework.
What we plan, on a pilot basis, is an opportunity to develop a more varied basis of contract between local health authorities and local primary care principals, to address more precisely the specific needs of the health service in the district for which they are responsible. The document sets out the range of options that we have in mind: practice-based contracts; contracts with organisations such as NHS trusts, which may employ GPs, in the way that we have already discussed; and contracts that target money on GP services that may be weak in a particular area, and make that possible by flexing the boundary between primary and secondary care, which is currently defined in statute. There is also development of super-fundholding, to allow fundholders the same freedoms across the primary and secondary divide as would be available for those who are not operating a fund.
The Government plan to proceed on the basis of pilots proposed from the field. We would undertake to assess and evaluate the results, which would be made available. Critically, every pilot would be voluntary. The status quo remains open to any clinician who wishes to continue to operate within the existing structure on the same terms, and any clinician who engaged in a pilot that proved not to be successful would have the opportunity to return to the existing basis of service delivery.
To describe that as a big bang is nonsense. What is true, however, is that it represents the Government's clear commitment to continue the development of NHS primary care. I regard the primary care sector as a key part of the NHS. We want high-quality NHS services to be available on an accessible basis in the community, and the primary care sector offers us the opportunity to do that.
Mr. Chris Smith (Islington, South and Finsbury):
Perhaps we can begin with what we agree on. The Government tell us that they are introducing a primary care Bill, and that is the only subject that the Secretary of State spoke about. We presume that the contents of the Bill will more or less follow the outline in the White Paper published last week.
There is much in the White Paper that the Opposition welcome. We welcome, for example, the fact that the Government now endorse the approach of piloting--the incremental approach, as the Secretary of State called it. That contrasts with the approach that they took when they brought in the internal market: the then Secretary of State for Health, now the Chancellor of the Exchequer, said then that the Government would make all the changes immediately and would not consider pilot schemes because the demands for piloting were merely an attempt to obfuscate, filibuster and delay. I am delighted that the present Secretary of State has learnt from that mistake.
In its response to the primary care White Paper, the British Medical Association said:
We welcome the idea of an enabling Bill that will permit a variety of models of progress in primary care to be developed, fostering diversity, trying out different ideas and enabling the health service to pick the best, to see what works and to develop from there. We welcome that pragmatic, commonsense approach.
The Secretary of State got rather bogged down in the part of his speech about the relatively new-found strength of primary care in its relationship with secondary care. I accept entirely that the balance has changed for the better over recent years, putting primary care in the driving seat. However, the Secretary of State claimed that that change was entirely a result of the Government's introduction of fundholding. There is a grain of truth in that; the introduction of fundholding has given some GPs extra power in their dealings with hospital providers, but the Secretary of State conveniently ignored the fact that the additional funds allocated to fundholders and the relative freedom given to both fundholders and non-fundholders, which is evident in the commissioning groups now being established, were rather more important factors.
Far from demonstrating that single-practice fundholding is the be-all and end-all, as the Secretary of State wants us to believe, the proposals in the White Paper show that there is a growing demand in primary care for a development away from that.
We support the proposal to develop super-surgeries. That will be important for the development not so much of surgical procedures by GPs but of a recuperation service for people coming out of hospital; it will offer them care and support nearer their home, in their community, so that they need no longer take up acute beds in acute hospitals.
I welcome the Government's new-found reconversion to the principle of the cottage hospital; it would have been happier for everyone if they had not closed 245 of them in the past five years. I welcome the Secretary of State's acceptance that there is a continuum between primary and secondary care, that there need not be a rigid division between two separate parts of the health service and that we need to facilitate flexibility in the system.
I welcome the proposal--the Secretary of State did not even mention it--to reform the way in which single-handed practitioners are replaced. The absurd existing rules stipulate that as long as there is a candidate, that candidate, however poor, has to be appointed; that is clearly nonsense and it will be good to do away with it.
"The voluntary nature of the proposals, which are to be piloted and evaluated,"--
I note in passing that even now the Government have conducted no proper evaluation of fundholding--
"is a welcome change from the Government's previous dogmatic initiatives which were imposed on an unwilling profession."
I am pleased that the Government have seen how wrong they were the first time round and have chosen a more incremental approach.
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