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Mr. David Faber (Westbury) indicated dissent.
Mr. Bayley: I can see the hon. Gentleman shaking his head--he or any other hon. Member is welcome to intervene, but those are the figures prepared by the Library, whose staff will dig out the same information for him if he wants it. [Interruption.] I cannot hear what he is saying, but he should either get up and contribute to the debate or keep quiet.
In my intervention on the Secretary of State's speech, I made it clear that I welcome the fact that the cash limits exposition booklet, which sets out for next year the basis on which the Government intend to fund the NHS for both secondary and primary care, will start to redistribute resources for primary care more equitably around the country. The effect, over time, may be that the Cornwall and Isles of Scilly health authority, as a result of Government policy, gets relatively fewer GPs per head of population and that Wigan and Rotherham get relatively more. I was, however, pleased to hear the Secretary of State's commitment that there would be no cut in absolute terms to GP provision in any part of the country and that growth money should be used to iron out the inequalities.
In October 1995, the Centre for Health Economics at the university of York produced a report on the issue of equity in primary care. It concluded that the allocation of funding and the distribution of the work force in primary care is extremely unequal in England and suggested that the Government should introduce an allocation based on the population served and its health needs. The centre estimated at that time--some two years ago--that, if resources were allocated according to population and need, the North West region would receive 447 additional GPs and the Northern and Yorkshire region would receive 311, while the South and West region had, according to the centre's calculations, 356 more GPs than its fair allocation.
In May 1996, a private sector company, North-West Surveys and Research, produced a similar piece of work, which estimated that an equitable distribution of resources for primary care would shift 700 GPs from the area south of a line drawn between the Wash and the Severn to the
area north of that line. However, I stress that it is a question not only of shifting resources from north to south, but of shifting resources within health authorities and regions in the south and north, so that the provision of primary health care in every locality and community meets the needs of the population.
The introduction of a needs-based allocation for primary care is, as I said, a welcome development. The principle is right, although I believe that the methodology that the Government have adopted is wrong. The initial targets set for allocations in years to come in the cash limits exposition booklet produced for next year's allocations show that the historical allocation, which was based on demand for and utilisation of services in the past, reveals a sharp mismatch with need. For example, the two health regions with the poorest financial allocation in years past--indeed, next year as well, because they still lag behind and will not catch up in one year--are the two health regions with the highest score for "underprivileged area status" in the public health common data set; and the two best funded regions are the two with the lowest score for underprivilege.
The figures also show that the two regions that are the most poorly funded for primary care have stillbirth rates that are higher than the national average; and the two regions that are best funded per head of population for primary care have a lower stillbirth rate than the national average. It is a case of those who have will receive more and those who have not will receive less.
That has been the historical situation, but the Government have addressed the problem and have taken a small, but welcome, step in next year's allocation, to move towards an equitable distribution of resources. As I said, the principle is right, but the methodology is wrong--perhaps not entirely wrong, but wrong in significant respects. For example, the actual cash allocation next year for non-cash-limited general medical services per patient--or, to be strictly accurate, per resident--in the Kensington, Chelsea and Westminster health authority area is £21.49, which is the highest cash amount for any health authority; whereas the lowest cash amount for any health authority is in South Staffordshire, where residents receive £13.69 per head.
One would think therefore that, when a needs-based allocation was introduced, Kensington, Chelsea and Westminster health authority, over time, would receive less per patient for primary care and that South Staffordshire health authority would get more. That assumption, however, could not be more wrong. Under the Government's needs-based allocation formula, Kensington, Chelsea and Westminster, despite the fact that it already gets more per resident than any other health authority in the country, is deemed to be the most underfunded health authority in the country. When it finally reaches its target, it will receive, at current prices, £5.36 per patient on top of the £21 or so that it already receives--20 per cent. more in real terms--whereas South Staffordshire health authority, currently receiving the lowest funding per resident of any health authority, will receive only 92p per patient more.
The principal reason for that anomaly--and it is an anomaly, which needs to be corrected--is the way in which the Government have applied what they call their market forces factor. The principle of reflecting wage costs in inner London and the south-east and the cost of premises in inner London and the south-east in the
funding formula is right, but I do not accept that the gearing--the amount of extra weighting--that Kensington, Chelsea and Westminster gets, which is 36 per cent. extra money under the market forces factor part of the formula, is appropriate to its needs. Its funding for primary care, already the highest of any health authority, will increase by a larger percentage than will the funding of any other health authority. The needs-based capitation formula for cash-limited general medical services should be revised to reflect need more sharply.
I want to discuss not only the quantity of resources available for primary care, but the quality of primary care. The hon. Member for High Peak spoke about the importance of the NHS efficiency index, but the efficiency index measures the quantity of care provided, whereas we need instead a quality index--perhaps we should call it an effectiveness index. Little or nothing in the Bill will address the issue of clinical outcomes: the extent to which primary care treatments work--the extent to which they make patients better, or better able to live with a disease or the disability that they have.
It is essential for us to develop measures to address issues that are being debated in the health service, such as skill mix--arguments about which clinical activities should appropriately be done by GPs and which by practice nurses. Should nurses prescribe? Should they do an initial screening and consult patients before patients see a doctor in general practice?
There are arguments for and against, but we should take decisions on the basis of the clinical effectiveness of a nurse intervention or a GP intervention in similar situations. One will find that in some cases a nurse can provide as good a clinical outcome as a GP and, if that is the case, one should redraw the boundary and allow a nurse to undertake that primary care activity. However, we need evidence of the effect on the patient--of the clinical outcome.
Most of the work on outcomes has been done in secondary care. In some ways, it is easier to do it there because, as doctors and other clinical workers in secondary care are direct employees of the NHS, one can to a limited extent require them to do clinical audit. That is much harder in primary care, where primary care practitioners are currently independent contractors, and it may become harder still if the job of providing primary care services and GP services as envisaged in the Bill is contracted out to private, commercial operations.
Nine out of 10 consultations between doctor and patient take place within primary care, so we need a great deal more work on the effectiveness of those consultations, and we need to establish lines of accountability that will allow the NHS, which is buying the care, to ensure that high-quality care is provided by primary care clinicians.
Mr. Tim Devlin (Stockton, South):
I am interested to hear what the hon. Gentleman says. People in secondary care have not been compelled to audit their care outcomes--far from it. The royal colleges have of their own volition gone into the field very heavily. The hon. Gentleman probably knows that my father is involved in the biggest project: the confidential inquiry into perioperative death. That was a voluntary activity; it has been enormously successful.
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