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Mr. Peter Bottomley: That is not what he said.
Mr. Hughes: I heard the interview. The Prime Minister certainly said that it would not be later than 1 May and he indicated general support for the idea that it might be 1 May. Of course he did not commit himself, but I think that we can all work on the assumption that if it were after 1 May it would be a disaster for the Tories because of the local government elections on 1 May, and they would not want that as a trailer to their general election.
There was not much in the Queen's Speech that was controversial, although we will give all the Bills proper scrutiny. As the hon. Member for Islington, South and Finsbury said, often it is what is not in the Queen's Speech that is equally the subject of debate. I shall briefly identify the missing issues that for us need to be flagged up. The Secretary of State for Health heard my question and understood it, but failed on three occasions to answer it. What does he intend to do about removing the two-tier consequence of fundholding in the health service? He must be honest with the House and accept that, as evidenced in the example that I gave him from the Exeter
and Devon Health Care trust document, which was sent on official paper, someone who is a patient of a fundholding practice will get non-emergency treatment more quickly than the patient of a non-fundholding practice. There is a two-tier health service for many non-fundholding practice patients. The Government could and should change that.
The health service does not treat people equally in all parts of the country. We sometimes have much better service in some parts than in others. Of course, to a degree, that will always be the case, but there is a serious issue about ensuring that the allocation of moneys is fair if we are to avoid significantly different waiting times in different parts of the country.
The health service is clearly also not properly co-ordinated. It is not only me who says that. It is the answer given to the hon. Member for Newham, South (Mr. Spearing), who asked a question about what the deficits are this year and was told that no information was suitable for publication. The reason why it was not suitable for publication was that it showed the fact that there is a large deficit. My colleagues and I calculated it at £133 million. The Government have conceded that it is £122 million. There is a significant shortfall of money this year.
The third special report of the Select Committee on the Parliamentary Commissioner for Administration--as objective a body as any--was published yesterday. On the responsibilities of the NHS executive, it said:
My office and I undertook a wild paper chase in September to try to obtain information about health authority deficits. The Secretary of State said, "Don't ask me"; the NHS executive said, "Don't ask us"; the local NHS regional chairman--such chairmen chair nothing these days--said, "We don't know"; and in the end we had to collect the information ourselves. Having telephoned six different ports of call we had collected two horrifying quotations. A fax from one regional office said:
Mr. Malcolm Wicks (Croydon, North-West):
Safe in their hands.
Mr. Hughes:
Indeed. It is hardly evidence of a health service safe in their hands.
It is some consolation that the Government have now seen fit to publish the deficit figures, even though the figures that we have are for only the first three months of this year. They confirm that some authorities are in deficit by up to £10 million and that co-ordination and control in the health service are not working. We do not have a national health service in the true sense, because nobody is properly nationally responsible for it any more.
Leaving aside the questions of health promotion, improving public health, restoring free dental and eye checks, banning advertising and sports promotion of tobacco and ensuring that we have properly independent health education authorities and public health commissions, all of which should be covered in the Queen's Speech but are not, there are two other specific matters that have not been addressed.
The first is the removal of unnecessary bureaucracy. I will defend NHS managers, but not a system that requires annual contracts and forces people to renegotiate every year or a system whereby people in 488 different places have to negotiate their own pay. Even now, six months into the financial year, people are being called away from looking after their patients to attend pay negotiation meetings. The sooner we get back to nationally negotiated NHS pay, the better.
The second question that was not addressed--the Secretary of State may say that it is a matter for the Budget, but all legislation has implications to do with money--is where the resources are to come from. There is no guarantee that the primary care part of the NHS will have the resources that it needs and that they will not be taken away from the acute and hospital sector.
These concerns about the Queen's Speech come not only from politicians but from professional bodies, including the British Medical Association, the Royal College of Nursing and the National Association of Health Authorities and Trusts. They are all concerned about the resources.
The Prime Minister made a commitment at his party conference that if the Tories are re-elected--I hope that they will not be--they will provide at least enough money for the NHS to keep pace with inflation for the next five years. A sub-question arises about how inflation is defined and whether it is NHS inflation--which is higher--or general inflation, but, assuming that we are talking about NHS inflation, the health service is still in deficit already. To make up for last year's funding shortfall, £178 million
was taken out of this year's money, and there are already projections of big deficits for this year and the year to come.
The health service needs catch-up money to enable it to do its job. That means extra money: much more than the £100 million to which the Labour party is committed and much more than the Government have committed. There was silence on that in the Queen's Speech, in the Prime Minister's speech and in the speech made by the Secretary of State today. Unless we find more resources, the closures and the reduction of services that we are experiencing will not be stopped, the new staff that we need will not be recruited, the increasing waiting lists will not start to decrease, necessary health promotion initiatives such as free dental and eye checks will not be restored and the unnecessary bureaucracy will not be cut.
Mr. Piers Merchant (Beckenham):
I listened to the Gracious Speech with some surprise and much satisfaction. I certainly did not recognise the description of it given by the hon. Member for Islington, South and Finsbury (Mr. Smith) because I consider that there is a great deal in it.
It would not be surprising, in the last six months before a general election, if a Queen's Speech was thin and offered no more than some tidying up legislation, but that was not the case: it was large in quantity and in substance. That is welcome and demonstrates the Government's commitment to continuing in their clear direction for as long as possible. That is true on health, with which we have been concerned today, and it is excellent that there is a commitment to legislation on extending primary health care reform.
The commitment reflects two important principles that have powered Government policy on health. First, there is an unshakeable commitment to the national health service and to the provision of free basic health care facilities for all. Secondly, there is a continued attempt to improve quality as well as quantity of provision, with an important emphasis on achieving better value for money. Those reforms have involved an emphasis on primary health care. I very much welcome that, because primary health care is the pivotal point of a good national health service.
Why is a greater concentration on primary care so important? First, because it emphasises--this is an emphasis that most people want--the role of the patient's own doctor and the personal relationship between the patient and their general practitioner, providing choices that may be impossible at other levels of the national health service. Secondly, it reflects a welcome development in health treatment: the availability of ever more forms of treatment from the GP--the lowest possible level closest to the patient. Thirdly, primary health care offers a flexibility and efficiency that is more difficult to achieve at other levels.
For all those reasons, I welcome the greater emphasis being placed on primary health care. It has been an important part of the reforms and the success of widening
the base of primary health care has been evident. It is certainly evident in my constituency, where many more services can be provided than was possible five years ago. Of course, that is possible for non-fundholding GP surgeries and for fundholding surgeries, but it is clear that the fundholders have set the pace and led the way.
One surgery in my constituency--the Elm Road surgery, to which I have referred before in the House--has provided a massive extension of services. I am glad to say that I recently gave successful support to the surgery's plan for a physical extension to its health centre, which has made the provision of even more services possible. The former--now retired--principal partner of the practice, Dr. Ken Scott, was one of the first and leading advocates of GP fundholding. He is now the president of the National Association of Fund Holding Practices. I compliment him on the great work that he has done on the principle and the practice of GP fundholding.
All those advances are very welcome, but there are still several severe problems linked with primary care, particularly in inner-city areas. The Government's attempt to tackle those problems in the new Bill is therefore welcome. From what my right hon. Friend the Secretary of State for Health said this morning, it seems that the Bill will cover all the issues that I intend to raise, but if, when all the details of the Bill emerge, any of those issues are not covered, I hope that means can be found to tackle them.
The first difficulty is faced by single-handed practices, particularly those in inner-city areas. For historical reasons and reasons relating to premises, the proportion of single-handed practices in inner-city areas tends to be greater than that in outer areas. That is so in my constituency, with the practices in the less urban area to the south and east tending to have more doctors--sometimes a large number--attached to them, whereas in Penge and Anerley, which abut inner London and where there is much greater deprivation, with properties built closer together and a higher population density, the majority of practices are single-handed.
I have nothing against single-handed practices, which can often provide a worthwhile and efficient service, but if we are to expand primary health care in the direction in which I believe it should be expanded, inner-city areas need more health centres of the sort seen elsewhere. Such centres can provide a continuity of service--with longer opening hours--and a breadth of provision that single-handed practices find it difficult to provide.
I hope that creative means will be found to encourage the development of multi-doctor health centres in such areas. Bromley health authority has led the way in the creation of what are called multifunds. I also strongly support the prospect of bringing together single-handed practices to share some services in the smaller local hospitals. I will return to that in a few minutes.
A second concern is the level of liaison between health authorities and newly set up practices. There is an anomaly in that, when the ratio of population to GPs rises above a certain level, it is possible for any GP to go into an area and, after going through the appropriate application process, more or less set up a practice straight away, without the local health authority even knowing and without its say-so. That does not make for good and efficient co-ordination. It would be wise to amend
practices to involve the health authority more and, where necessary, to give it a more proactive role in ensuring that there is adequate provision.
Linked with that is the fraught issue of the doctor-population ratio itself. It is a set ratio throughout the country. Consideration should be given to adjusting it to take into account some of the greater pressures that increasingly come to the fore, particularly in deprived and urban areas. For example, in fixing the regulations, the additional services that doctors have increasingly provided since the 1990 contract should be taken into account. At a certain trip point, as it were, practices can take on assistance or part-time assistance. I believe that the figure is around 2,500 patients per GP. Perhaps it would be wiser, certainly in some regions, for that figure to be lower to take into account the extra strain on some GPs, particularly single-handed ones.
In the Bromley region, only 78p per patient is allowed to follow a patient to a GP if his existing GP retires. That needs to be adjusted to enable quick and adequate provision to be given to patients if they have, sadly, lost their GP's services and until such time as they can find a new and permanent practice.
No locum payments are permissible in an urban area such as the one covered by my constituency. They are possible in rural areas. Some attention needs to be given to making the regulations more flexible in relation to that matter. All those suggestions will, I hope, help to deal with the rigidity and perhaps the now outdated regulations that govern the way in which GPs can set up and operate.
Recruitment is the fourth well known concern. It is especially difficult in some parts of London and in the Bromley region. Just in the past few months, doctors' practices have raised two cases with me about the difficulty of obtaining new GPs to replace ones that have either retired or moved on for other reasons.
I took up those cases with my hon. Friend the Minister for Health, who told me that the Government had launched initiatives, which I welcome, to deal with the matter. They include the London initiative zone, which has enabled extra payments to be made where flexibility allowances are needed and encourages medical schools to take on new students to train as GPs to increase the flow. It also encourages people who have left the profession to return--they are described by that awful word "returnees"--so that the NHS benefits from people who were trained, who still have much to offer and who could be encouraged, if conditions were right, to return to the profession. There is also a role for salaried GPs, particularly when a health authority identifies a problem and urgently needs a solution that is easy to implement, and which may be temporary or not because of traditional recruitment pattern difficulties. I welcome that additional flexibility.
I mentioned my keenness for linking single-handed practices and others with local secondary facilities, particularly small hospitals, where no health centre exists. Beckenham hospital is an excellent example. My right hon. Friend the Prime Minister mentioned that he would like to see the encouragement of cottage hospitals in Bournemouth. Beckenham hospital meets that description, although health professionals do not like to use the phrase any longer. Three or four years ago, Beckenham hospital appeared to have no future. There was grave concern about its likely closure and the suggestion that all
secondary health facilities would be concentrated on one central location in Bromley borough. I am glad that that did not happen, but the reverse.
After a while, the health authority recognised that such hospitals have an important role, for which there is a strong demand in the community. The authority adjusted its plans and made a long-term commitment to Beckenham hospital's future. Over the past 18 months, that has produced investment of £1 million, new diagnostic facilities, out-patient facilities and a range of specialist clinics, a new pharmacy, a range of health education facilities, minor treatment suites and other facilities best provided in the community but not always available at a surgery--an intermediate stage. That innovation has proved extremely popular. The number of people using the hospital has increased dramatically, with a 5 per cent. jump in the number of out-patients over the past two quarters. A new stroke clinic has also been opened.
Doctors unable to provide at their surgeries the range of facilities available at larger fundholding practices could collaborate and use the services available at hospitals such as Beckenham. Day surgeries, and even short-term overnight stays for patients who could benefit from them, could be supervised by the GPs--an arrangement that both they and their patients would probably prefer.
I am keen to see the provision in Beckenham and elsewhere of a minor injuries unit, which would take the pressure off larger, centralised accident and emergency units and those GPs unable to offer an appropriate service. Constituents with a minor injury often feel aggrieved when immediate treatment is not available from their GP and they are referred to an accident and emergency unit. It would be better if they could receive attention at the minor injuries unit of a smaller hospital, possibly at the hands of a duty GP. Such provision presents great possibilities in primary care, and I should very much like to see it implemented in my constituency.
I end my speech by moving on to issues other than primary care, because primary care can hope to work only if we know its limits and if it is backed up by good hospital facilities. Clearly, GPs cannot be expected to deal with the entire range of health problems, and they must have back-up when necessary.
There is a desperate need in my constituency for a new district hospital to provide such facilities. The need arises not because the Bromley hospital system is not manfully trying to provide the best possible level of support to the local population--it does--but because, for historic reasons, provision is split between four sites in the borough, which is inefficient and means that running the system is more expensive and difficult. The current system creates unnecessary duplication and overheads, and makes it difficult--in some cases impossible--for a patient's entire treatment to be conducted at one hospital. A patient may present at the accident and emergency department, but after stabilisation will probably have to be moved to another hospital across the borough to receive specialist or long-term care.
The local hospital structure has been working very hard to overcome that problem, and it now has a clear plan in place. Only yesterday, it announced its private finance initiative preferred bidder--a group called United
Healthcare, which is an equal partnership between Taylor Woodrow and the Healthcare Group. That group will provide a new £120 million hospital, which will overcome all the problems that I have described.
I urge my right hon. Friend the Secretary of State for Health and Ministers in his Department, in co-ordination with the Treasury, to reach as hasty a decision as possible on that hospital's future. I very much hope to see--and I am reasonably confident that I will see--bricks and mortar in place in the near future, which will help to complete the balance that the reforms have brought in my constituency.
"We are concerned that public and parliamentary accountability are being ignored. If management is being devolved locally, we believe that one of the prime duties of the NHS Executive is to ensure that Parliament is not thus deprived of information by which it can judge the overall performance of the Health Service."
The King's Fund annual health care report contains a significant and weighty article by Sean Boyle and Anthony Harrison, who conclude that there should be much greater clarity and that
"current national policy is inadequate because it fails to state clear primary targets . . . and to monitor policies in a way which would allow swift, effective reactions in order to avoid crisis management."
The article continues:
"Nationally there has been no clear responsibility for ensuring that there are sufficient intensive care facilities to meet the needs of the whole population."
There will be a crisis in the health service this winter, partly because the left hand does not know what the right hand is doing, and the Secretary of State and the NHS executive do not seem to know what people are doing either. There are endless examples of hon. Members being told in response to parliamentary questions that information is not available or is not held centrally.
"Please be advised that you should address this query to the Minister."
25 Oct 1996 : Column 273
When we did so, the Minister of course said, "Don't ask me." The second response was extraordinarily direct and honest. It said:
"There is actually no one collecting that sort of information at the moment. At the end of the day it will hopefully all get sorted out. God knows how."
If that is all the information that a health service official can provide, we are at a pretty sorry pass.
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