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Mr. Spearing: My hon. Friend has raised an important procedural issue. Would it not be reasonable to assume that, if the Government oppose the motion of which he has given notice, they have something to hide which so far they have not made clear?
Mr. Smith: An impartial observer might, of course, place such an interpretation on any such action by the Government. It is also possible that the Prime Minister has a secret plan to call an early general election--in which case I think that we would be pleased enough by his decision to forgive the Government for opposing the motion.
Primary care is, of course, crucial. Many provisions in the Bill are welcome, but in some cases we feel that the Government have simply got it wrong. The process that has brought the Bill to the House has been cack-handed
from the start, and there are ominous signs that the commercialisation of GP services will remain on the Government's agenda.
Sir Roger Sims (Chislehurst):
The Bill is about the provision of primary care to patients by doctors and nurses, and I want to deal briefly with each of those three groups.
First, let me say something about patients. It is clearly desirable for GP services to be convenient and easily accessible. I commend the idea of pilot schemes, and the flexibility foreshadowed in the White Paper and the Bill. The Opposition seem to be raising a hare in regard to commercialisation, but my right hon. Friend the Secretary of State dealt with it very effectively. It is unfortunate that, having said that there are many good things in the Bill, the Opposition still appear determined to oppose it--although the main ground on which they seem to be doing so no longer exists.
I see no objection to the idea of general practices' being available in the most convenient sites for patients. Why not site them at railway stations, for instance? It is interesting to note that a private practice has been successfully established at Victoria station in the past few months. I also think that there should be far more practices in shopping centres: offering such facilities at Boots, for example, would accord very sensibly with the overall concept. I can imagine eyebrows being raised at the idea of siting a general practice at the back of a supermarket, but it would surely be convenient to have one immediately next to the largest supermarket in the district. Let us try out those ideas, by means of the pilot schemes referred to by my right hon. Friend the Secretary of State.
However, I hope that we shall not lose the principle whereby patients are registered with GPs. In some countries, patients can go to any doctor they like, and, if they are not happy with the treatment that they receive from the doctor down the road, they can go to another doctor next time. Indeed, sometimes patients "shop around". Although I think that we should retain the system that allows a patient who is not happy with the doctor with whom he is registered, and who feels that the doctor-patient relationship is breaking down, to change to another doctor, I also think it important to retain the principle of registration. The practice should have all the records of the patient who is registered with it, and, if the patient transfers to another doctor, the records should be transferred as well. We should not discard that procedure lightly.
The Bill is about the provision of services by GPs. It is important for us to have enough GPs, for them to be trained to high standards and for those standards to be maintained. It is worrying to note that the number of
trainees entering general practice has been falling steadily: between 1985 and 1995, there was a reduction of20 per cent.
Mr. Charles Hendry (High Peak):
In fact, the fall has been even greater. A number of trainees come from overseas, and, having completed their training, return to the country from which they came.
Sir Roger Sims:
My hon. Friend makes a valid point.
I was pleased that the hon. Member for Islington, South and Finsbury (Mr. Smith) raised a specific aspect of medical graduate training. As he explained, new medical graduates must spend 12 months as provisionally registered doctors before obtaining full registration. Their training must include a minimum of four months in medicine and four in surgery, but they are allowed to spend up to four months in general practice. Most pre-registration house officers divide their year between medicine and surgery, spending six months in each. At present, only one university--London--has approved a general practice for pre-registration house officer service, although a number of others are keen to make such experience available to their graduates.
As the hon. Gentleman said, section 12 of the Medical Act 1983 restricts the experience of general practice that may be counted towards the 12 months of general clinical training needed for full registration to that obtained in practices based in publicly owned premises. The fact is that very few general practitioners operate from publicly owned premises. The House may be surprised to learn that, of 3,800 new doctor graduates each year, only three spend part of their pre-registration time in general practice.
Obviously, during their pre-registration year, graduate doctors will be considering how their medical careers are to develop, and deciding on which branch of medicine to concentrate. It is clearly desirable for them to spend part of the time in a general practice, and to see what goes on there. I suggest to my right hon. Friend that that merits consideration. All that is needed is the repeal or the amendment of section 12 of the Medical Act to remove the legal restriction with regard to the premises in which a pre-registration year can be spent.
The House will be aware that I am a lay member of the General Medical Council. As the hon. Member for Islington, South and Finsbury said, the GMC has asked my hon. Friend the Minister for Health to consider taking the steps that I have mentioned. I know that he is not unsympathetic, but he has said that he is not minded to use the Bill as a means of making my amendment. I invite him to reconsider that and I hope that, perhaps in Committee, the opportunity will be taken to amend the Bill, which, after all, is about the provision of primary care services by general practitioners. I hope that he will take the opportunity to discuss the matter further.
There is also the issue of maintaining standards. The House will recall that it passed the Medical (Professional Performance) Act 1995, since when the GMC has been doing a lot of work on the mechanics of implementing those proposals. Tomorrow, it will hold a conference to take the matter further, with a view to implementation later in the year.
Under the performance review proposals, doctors who have not necessarily done something that merits the label of serious professional misconduct, but whose general performance standards have fallen below that which one would reasonably expect, can be assisted by the GMC to come back up to the standard that they should be at. It will be not a punitive procedure, but one to assist and to help bring doctors up to the standard that one would reasonably expect.
Of course, that will apply only to those doctors about whom complaints have been made. Perhaps in passing I could comment that all nurse have to renew their registration with the United Kingdom Central Council for Nursing, Midwifery and Health Visiting every three years and, when they do so, they have to satisfy the council that they have kept abreast of medical knowledge and development. There is nothing comparable in relation to doctors. Having completed his training and been registered as a doctor with the GMC, a doctor can remain on the register and, although he may go for years without practising, he can come back and practise without having had anything by way of refreshers.
I am not suggesting that that happens; nor am I trying to raise a scare about this. I know that much work is being done by the royal colleges with regard to accreditation. It seems that there is scope for steps to be taken to ensure not only that doctors are trained, as they are, to high standards--people would not come from all over the world to train here as doctors if we did not have such fine training facilities--but that they should maintain them and keep abreast of developments in the medical sector throughout their working life.
In 1986, a report was published by the then Mrs. Cumberlege, which recommended that the Department of Health should agree a limited list of items and simple agents that may be prescribed by nurses. In 1989, the Crown report put more detail on the proposal and made the point that enabling nurses to prescribe would benefit doctors, nurses and patients. The Government subsequently made sympathetic noises about the idea, but seemed reluctant to act, so, in 1991, when I was successful in the ballot for private Members' Bills, I introduced a Bill to enable nurses to prescribe.
After an initial lack of enthusiasm, the Department of Health embraced the proposal and assisted me in getting the legislation safely through the House, after which it was assisted in its passage through another place by the same author of the original 1986 report, who was by then Baroness Cumberlege, sitting on the Back Benches. It was just before the 1992 general election that I went to the other place and saw the Queen's Assent being given to several Bills, including my own, immediately followed by the order for the dissolution of Parliament to precipitate the general election, so I only just made it, but the Bill did get on to the statute book.
Progress since has been disappointingly slow. We have had eight pilot sites on nurse prescribing, but we still await the results of those. I am pleased, however, that, on what appears to be the eve of another general election, the Government plan to extend prescribing to a further seven trusts and their White Paper refers to full implementation by 1998. I hope that that will be adhered to.
Originally, the proposal was that only a limited range of drugs and dressings could be prescribed by nurses, and that nurse prescription should be restricted to district
nurses and health visitors. I believe that the pilots have shown that the range could be extended and certainly that the ability to prescribe could be given to more nurses. Practice nurses are an obvious example. Nurses in cottage hospitals and hospices where there are no doctors in constant attendance are another group that could be considered for prescribing powers.
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