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Mr. Simon Hughes: The hon. Gentleman referred to the reasoned amendment. The Minister will no doubt deal with this later, but unless I misunderstand, under clause 2(5), there must be consultation about pilot schemes before they are submitted. I think that that is important. The hon. Gentleman will have to persuade his colleagues as well as the Opposition if he wants to remove
consultation. I urge him to think again. Involving patients and the public in decisions is a hugely important way of developing primary care.
Mr. Hendry: I understand the hon. Gentleman's point. I was quoting from the reasoned amendment one of the Opposition's reasons for objecting to the Bill.
One can push consultation too far and stifle enthusiasm so that GPs do not go ahead with some of their more exciting and dramatic ideas because they lack general support. It would be a tragedy if such enthusiasm were stifled because of the consultation process.
It is also unfortunate that the reasoned amendment states that the Bill
Four key principles that underlie the Bill should be put on record. Patients must continue to have the right to be registered with a GP. A disadvantage of some overseas systems is the lack of registration with a particular GP. Such systems involve additional bureaucracy and mean that records cannot be so readily brought to hand.
Concern has been expressed about the involvement of GPs within shopping centres. I do not believe that people trundling a shopping trolley round Tesco would want to visit a GP by going through a little door between the frozen peas and the band-aids. If I were shopping in Tesco and there was something wrong with me, the last thing that I would want is for my constituents to see me popping in to see the GP there. Many people would feel like that. That is why some of the more extravagant schemes dreamed up by the Opposition would not be put forward. GPs may wish to open centres where people are at work, in stations and in shopping centres but they would be wary of being brought under the direct control of a supermarket or similar organisation.
Mr. Simon Hughes:
I want to reinforce an important point which was implicit in what the hon. Gentleman said. There are many services that it is hugely important to keep confidential, such as family planning and sex advice to young people. In such cases, people would not want to be seen popping in to see GPs in a supermarket. A range of things will be needed. For well women or well men services, or blood pressure checks, the nearer the service is to where hundreds of people shop, the better. No one would be embarrassed by such check-ups.
Mr. Hendry:
The hon. Gentleman makes a valid point. We must remember that the people who will be pushing the schemes and developing the ideas are those who are most sensitive to patients' needs: the GPs. The more extravagant schemes would not be put forward.
I said that there were four principles. The second is that legislation should ensure that there are national safeguards for both practitioners and patients. Thirdly, there must be public accountability for the use of funds. Fourthly--this is vital--if pilots are unsuccessful, it must be possible to
revert to the previous arrangement. If a pilot scheme did not work and GPs could not go back to their earlier arrangements, many GPs would be reluctant to try the scheme.
I hope that the Minister will be able to reassure us, here or in Committee, that pilot schemes can be worked up free from the stifling intervention of health authorities that do not like the proposals. Clause 2(2) states:
I am concerned that it should not be possible for a health authority to stifle go-ahead, dynamic GPs who have ideas that are not entirely in keeping with those of the health authority. Even if health authorities do not believe that such ideas are the best way forward, I hope that the Secretary of State will continue to bear in mind the fact that there should be a wide cross-section of projects so that the best proposals can be developed.
Mr. Bayley:
Inevitably, there are good and bad general practitioners and practices. That is recognised by the provision in the Bill that a GP does not automatically have to be appointed if he is deemed to be unsuitable. If a health authority is not to sort out the good pilot projects put up by GPs from the bad, who will?
Mr. Hendry:
There are different grounds whereby a health authority may raise concerns. If an authority says that a GP is an alcoholic or has something fundamentally wrong with him, that would be relevant and should be taken into account. But the fact that a pilot scheme proposes something that is not immediately in tune with what the health authority thinks is the way forward should not rule it out. If the health authority is to be directly involved, there needs to be a right of appeal directly to the Secretary of State, so that good, exciting and innovative projects are not knocked on the head early in the consultation process.
I hope that the Bill receives cross-party support. It is encouraging that Labour is, lately, agreeing that fundholding has been beneficial, but its proposals for locality-based commissioning are not what fundholding or non-fundholding doctors want. In my constituency, GP fundholders can cover between 3,000 and 10,000 people. To suggest that GPs should cover areas of between 50,000 to 150,000 people is to be out of touch.
It is strange to hear Labour talking as if pilots were its idea and that there should have been pilots when fundholding was introduced. I was working at the Department of Health as a special adviser at that time, and we knew why Labour wanted pilot schemes--it wanted to kill off the idea of fundholding at birth. Labour did not
want the system to have time to grow, and it wanted to make sure that the system moved at a snail's pace so it would not be a success.
Mr. Hugh Bayley (York):
I should like to start by responding to one of the arguments made by the hon. Member for High Peak (Mr. Hendry). He sought to convince the House that the Opposition parties argued for pilot studies rather than for a leap in the dark at the time of the "Working for Patients" reforms, because we wanted to frustrate their implementation. He said that that was perfectly clear to him when he worked at the Department of Health. I suggest that that shows how out of touch those involved in developing the project in government were with the mood within the health service.
At the time, I was working in a university as a health economist on contract to health authorities, and people in the health service and academic commentators said time and again that it was necessary to set clear standards, to evaluate whether the health reforms were both effective in terms of improving patient care and cost-effective. Those in government who were driving the "Working for Patients" project stood in the way of evaluation because they felt that it might reveal that the proposed reforms were not in the best interests of patients. The same lobby of NHS staff and commentators had argued for years that there should be a thorough and independent analysis of the benefits, as well as the disadvantages, of GP fundholding. The Government resisted that.
Finally, the Audit Commission carried out such an assessment in a report--I understand that the Department of Health used every trick in the book to try to persuade it not to undertake it. Yet last year the report was published, and what did it find? It found that some benefits had come from fundholding, and some costs. It quantified the benefits and costs, and found that benefits for patients worth £202 million had been achieved at a cost to the NHS of £236 million. In other words, the benefits were less than the costs.
Mr. Andrew Robathan (Blaby):
Will the hon. Gentleman make it plain whether those costs were one-off and whether the benefits were annual? Is he comparing like with like?
Mr. Bayley:
That is a good point. The report looked at the cumulative costs and benefits of the fundholding scheme. One could certainly re-examine the system were it to continue for another five years, but that is unlikely--even if there is no change in Government. The Bill demonstrates to the House and to the country that fundholding has not been the panacea that it was originally supposed to be, and that it is not enough to ensure that high-quality primary health care is provided for everybody. But if fundholding were to continue, we could review it.
It is important to draw on the independent analysis, to pick out the benefits that have come from fundholding and to retain them, while chucking into the dustbin of NHS history the disadvantages--the inequity, the creation of a two-tier system and the high administrative costs of running purchasing on a practice-by-practice basis.
Primary care is the jewel in the crown of the NHS. It is what enables us to achieve a relatively high health status for the population at a lower cost than any other advanced industrial country. That was brought home to me vividly after the previous election, when I visited Washington DC. I visited a number of private and public--in US terms, state-funded--hospitals, one of which was the notorious DC general hospital, a public hospital dealing with patients who did not have the money or the insurance cover to go for private care. In some ways, I was surprised by what I saw, because it looked very much like a workaday NHS district general hospital. The level and quality of care seemed similar. It was not as plush as the private hospitals, but it provided a high quality of clinical care.
The difference between the United States system and the United Kingdom system was brought home to me starkly when I was shown the maternity ward. I was staggered that the majority of patients in the ward--who had given birth a day or two before--had received no antenatal care whatever. They had simply gone into labour and gone to the public hospital. Inevitably, that results in the United States having higher perinatal and infant mortality rates, despite spending more than twice as much of its national wealth on health care as we do. We have achieved more with the primary-care-supported NHS than the US has been able to achieve.
It was equally shocking and surprising that the only patients discharged from that maternity ward with any post-natal health care provided by the public system were mothers who were deemed to be "at risk". "At risk mothers" in Washington DC fell largely into two categories--homeless parents and drug addict parents. Almost by definition, those two groups, although entitled to post-natal health services, would not get them because nobody could trace where they had gone following their discharge.
When the Secretary of State and my hon. Friend the Member for Islington, South and Finsbury (Mr. Smith) opened the debate, it was clear that--although there are some sharp differences between the two main parties--there is substantial agreement on much in the Bill. My hon. Friends and I support the measures that seek to improve the distribution and quality of primary health care services.
I ask the House to consider this: we all talk and have done for a number of years about the importance of a primary-care-led national health service, but we need to be clear what we mean by that. We need to be clear about who does the leading--is it GPs or is it nurses? Who, in primary care, are the leaders? By what means do they lead? Do they lead solely by placing contracts and by controlling the money for primary and secondary care, or by using the research base of effective innovation and clinical practice? Above all, where are they leading the NHS?
"fails to establish criteria by which the success of pilot projects can be evaluated".
I do not understand how that can be done in advance. If we say that GPs should be encouraged to produce ideas for pilots and think widely, we cannot now establish the criteria for all circumstances because we do not know what the pilots will be. It is in the light of the proposals that are made that we will best be able to judge how the pilots should be evaluated.
"Subject to any directions given to them by the Secretary of State, an authority must--
Clause 2(3) states:
(a) prepare proposals for a pilot scheme, and
(b) submit them to the Secretary of State,
if asked to do so by a qualified person who wishes to provide piloted services."
"A request to an authority under subsection (2) must--
I hear a little alarm bell in respect of what may be prescribed under the final section about what requirements may be set down.
(a) be made in writing; and,
(b) comply with such requirements (if any) as may be prescribed."
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