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Mr. Deputy Speaker (Sir Geoffrey Lofthouse): Order.
Mr. Devlin: --that the problem will be solved.
Mr. Deputy Speaker: Order. The hon. Gentleman should have finished a while ago. He is fully aware, with his experience in the House, that interventions should be brief and to the point.
Mr. Deputy Speaker: Order. The Chair did not think it was; otherwise it would not have intervened.
Mr. Bayley: Although it is true that clinical audit has been driven by the royal colleges, the thing that made it take off was the fact that the NHS agreed to provide a certain proportion of paid clinical time--I believe a session a month--to enable it to happen. It was possible for the NHS to do that in relation to secondary care. It is much harder to do it in relation to primary care.
Admittedly, as information technology becomes increasingly available in primary care, the capture of the data needed for a clinical audit will be easier, but I do not agree with the hon. Member for Stockton, South (Mr. Devlin) that that has come about as a result of GP fundholding. It has come about as a result of Government investment in information technology in primary care. We need to ensure that that provision is made equally and fairly in all general practices, irrespective of status.
I have received complaints from non-fundholding practices in my constituency not only that they are unable to obtain as much grant as is given to fundholders, but that they are unable to obtain support for the information technology that they need to improve and develop their clinical practice. That is wrong. The technology is needed in all practices.
Technology used in different practices should be compatible, because data collected using incompatible systems are impossible to audit across the locality. To me at least, that emphasises the need to ensure that the NHS, albeit without heavy central direction, is driving forward the audit process in primary care. If it does not, dozens of different computer systems will be used among the various practices, and it will be impossible to assess the effect of clinical interventions across localities and from one health authority or region to another. We need to be able to do so if we are to drive up standards of clinical care.
The amount of good, solid information about effective clinical practice in primary care is pretty small compared with secondary care. Through their NHS research and
development programme, the Government are supporting the centre for reviews and dissemination at the university of York. It has produced a number of clinical practice guidelines, only three of which relate to practice in primary care--the guidelines on cholesterol screening and on the prescription of anti-depressants, and the controversial guidelines on prostate cancer screening, which were published last week. Most of the guidance on good clinical practice relates to secondary care, and we need to develop a greater emphasis on evidence-based medicine in primary care.
The Select Committee on Health, in its report on purchasing, recommended that GP fundholders should be required to submit a clinical practice plan to their health authority each year before receiving their budget. I am sad to say that that recommendation was rejected out of hand by the Government. The Labour party addressed the Select Committee's proposal in its policy on commissioning.
I presume that the Bill, if enacted, will require quality thresholds and outcomes to be built into contracts for bought-in primary care services, otherwise the purchaser would be buying a pig in a poke. When a health authority is purchasing care from a secondary care provider, it establishes standards and quality thresholds in the contract. If that is to apply to contracted-in primary care services, the Government will have to develop mechanisms to ensure quality control. Such mechanisms should be applied throughout primary care, whether provided by traditional, non-fundholding practices, fundholding practices or the new contracted-in practices.
Dame Elaine Kellett-Bowman (Lancaster):
I especially like the Bill's flexibility and its imaginative approach to pilot schemes, which those at the sharp end of health care may wish to adopt. I am, as the House is possibly tired of hearing, fortunate in my constituency in having forward-looking GPs. In fact, I cannot think offhand of any aspect of health care in which Lancaster does not excel. I may be biased, but our new premises mean that it is getting better all the time. Many of my local GPs, who were among the first fundholders, have extended the services they offer their patients almost beyond belief. I am sure that they will be happy to introduce pilot schemes to extend their services still further, because that is especially important in a country area.
Not all new ideas, which seem fine on paper or in the first flush of enthusiasm, will work in practice. One of the strengths of the Bill is that if a pilot scheme is not as good as first hoped, it can be terminated and the practice involved can return to the status quo without penalty or humiliation. That means that practices will be more willing to start pilot schemes than if they thought they could not get out of them.
The elderly often look back longingly at the old cottage hospitals. Time lends enchantment, but they were delightful places. I vividly remember that we used to hold sewing bees for the hospitals and mend all the sheets. We put our hearts and souls into those hospitals, but nobody could pretend that they were high-tech. They were supported by the whole community, but they could not supply the sophisticated care that is now required.
The rapidly expanding health centres that are springing up all around the country are able to provide a range of services. They are, in effect, modern versions of the cottage hospital. The pilot schemes will enable health centres to extend the range of services that they provide, which is very important in an isolated rural area. The speed of the changes in the primary care sector is astonishing. Only a few years ago, it was unheard of for consultants to stray from their hospitals and leave the barrier of their entourages and consulting rooms. Now, many consultants attend doctors' surgeries, to the great benefit of patients. Again, that innovation is especially important in scattered areas where not everybody has a car. It is marvellous that people can go to their local health centres and be seen by a consultant; it also cuts waiting times.
Another strength of the Bill is that the pilot schemes will not be able to drag on. They will be carefully assessed within a time limit of three years. Nothing is worse than a pilot scheme that drags on and on, with nobody knowing whether it is a success or when it will end.
Not every area is as fortunate as mine. Inner cities still face severe problems. Sometimes I have to remind my constituents that the Government run services not only for Lancaster but for the whole country, and the Bill will provide for less fortunate areas. It will enable medical practices and community trusts to employ doctors in salaried posts. Many young single doctors may be willing--as a social service, to repay the training they have had and to do their duty by those less fortunate than themselves--to serve in a difficult inner-city area, but the need to invest in premises and to enter a long-term commitment to a partnership can be a frightening deterrent. Doctors who have worked for only four or five years may be able to fill a serious gap in areas that are now almost barren of doctors.
The pilot projects may also push forward the boundaries of the care and advice that can be given by nurses and trained pharmacists. The way in which we use our pharmacists is a scandalous waste of talent and training. On the continent, pharmacists provide advice: they are almost as good as doctors and, in many ways, are better. That does not happen in this country and it must be very frustrating for highly trained pharmacists to spend so much of their lives just dishing out pills. They are capable of giving a wide range of advice and the pilot projects should take advantage of their expertise.
Dr. Joe Hendron (Belfast, West):
I have spent the past 35 years in medical practice in inner-city west Belfast, so I have listened carefully to the debate this afternoon, especially to the hon. Member for Lancaster(Dame E. Kellett-Bowman). More and more people in the higher income brackets are turning to private medicine, whether we like it or not.
If the Bill becomes law and eventually, by Order in Council, applies to Northern Ireland, the important question for me and for those I represent will be how it
applies to people in inner-city areas and to people who are deprived. We all remember the Black report a few years ago on inequalities in health care. It was an important report, but it was shelved. People refer to it from time to time, but it was not taken seriously by the Government at the time.
I pay tribute to all those involved in primary health care. As every hon. Member accepts, it is a magnificent service provided by well trained people. The standard among general practitioners today is probably the highest in the history of medicine. I pay tribute to all members of the primary care team. Much has been said about community nurses. The Bill refers to nurse-led pilot schemes, and I would certainly support them.
For years, nurses in the United States have played an important role. I accept what the hon. Member for Lancaster said about wasted talent, referring to nurses and pharmacists. They are highly trained people. In the United States, nurses have the authority to give out certain drugs. There is no reason why that should not apply in the United Kingdom.
That is equally true of pharmacists. People in deprived and inner-city areas ask the pharmacist for advice, but that should be put on a proper footing. I know that the Bill deals with that.
Social workers and health visitors are all worth their weight in gold. I want to say a special word about the psychiatric nurse. In the communities, the community psychiatrist plays an important role, but the pivotal role is played by the psychiatric nurse. That is the person to whom a GP would first refer a patient with a mental health problem, and later perhaps to the psychiatrist.
No hon. Member has referred to the role of occupational therapists. If the Bill becomes law, its application in inner-city areas could give rise to a major problem in regard to occupational therapists and housing. The GP or the primary care team may be concerned about a patient with disabilities, but there may be a waiting list of six months or a year for recommended modifications to be made to the patient's home, such as the installation of a stair lift. I also find that what the patient wants, and what the occupational therapist and housing executive agree, sometimes differ widely.
I listened carefully to the Secretary of State's speech. He spoke about the flexible approach to contracts. No one would disagree with that. I accept the general principle of pilot schemes. We are tied down by day-to-day work in general practice, but the biggest handicap for general medical practitioners is the increased administrative work that they have to do. They are trained to treat patients. I shall not go into the question of fundholders versus non-fundholders, but administration and administrative staff seem to be increasing, not decreasing.
The Secretary of State spoke about the evaluation of pilot schemes, which is essential. There are many aspects to pilot schemes. Although I have studied the Bill carefully, there are many aspects that I do not fully comprehend. I appreciate that regulations will be issued after the Bill becomes law.
The Secretary of State said that the Medical Practices Committee would be given a statutory right to be consulted. I hope that that will be meaningful consultation.
Many Opposition Members are concerned about commercialisation, and I share their concern. When we talk about flexibility, do we also mean privatisation? I would be worried about that.
The question of health authorities employing a GP has been discussed. Earlier we heard reference to a hospital trust employing a GP. If that GP is a fundholder, a distinct conflict of interests could arise.
When the time comes, I will judge the Bill in relation to inner-city and deprived areas. I hope that it will be amended to build in certain safeguards to protect the quality of primary care. Mention has been made of the quality of primary care, as opposed to the extent or the cost of the care. The quality of the care is important.
The family doctor service must remain fully within the national health service, and not be open to direct or indirect privatisation. GPs will oppose provisions in the Bill that would allow private companies to be involved in running the family doctor service. GPs must be free to be advocates on behalf of their patients and to exercise independent clinical judgment. The Secretary of State, I think, quoted Dr. Bogle of the British Medical Association, who said that there must be no third party in the consulting room. No one would argue with that.
I have read the Labour amendment with care and would accept its main points--that the Bill
I have some criticism of certain bodies--GPs are no more perfect than anyone else. In some cases, doctors from other practices sit on the committee and decide who should or should not be appointed to the single-handed practice. It might be in the interest of those doctors that no one was appointed, so that the patients would go on to other doctors' lists. The question of viability arises; the practice might simply disappear. I do not know the position in Great Britain, but that has happened many times in Northern Ireland. Many things happen in Northern Ireland, however.
Independent monitoring schemes are important, as is the training of young doctors. I see the GPs of today as the best ever. I was a trainer myself in medical practice, and I had nothing but admiration for the young doctors who came into our health centre--extremely able young men and women. Standards are rising all the time. The problem is that as the administrative arrangements increase, doctors must spend more and more time on administration, and therefore less time with patients.
We can all pay tribute to paramedics, especially anyone who has been at the scene of a road traffic accident and seen the efficiency of paramedics in action. However, it must be said that some are not trained in such matters. It seems that, if anyone puts on a big coat with something written on the back to the effect that he is a paramedic, everyone steps aside to let him in. There must be protection for the public in that regard.
The Government must consult every member of the primary care team--not just general practitioners, but nurses, social workers and health visitors or their representatives. I am not sure how the Government will do that, but it is obviously extremely important. I have read the British Medical Association briefing document for today's debate and, like that organisation, I would be concerned about the involvement of private companies in the running of the NHS family doctor service.
The criteria for assessing the value of pilot schemes must be clearly defined. GPs working on pilot schemes should be represented through their recognised local medical committees. Such committees are statutory bodies, and therefore proper, full and meaningful consultation should take place with them. We have already referred to the fact that pilot schemes would be voluntary, so I shall not re-examine the issues involved.
The question of salaried GPs has arisen many times over the years. Doctors have different views on the subject, but the Bill puts the case for salaried general practitioners. I mentioned the problem of replacing doctors in inner-city areas while patient numbers remain viable. In such circumstances, salaried positions might appeal to some doctors who would like to be freed from the administrative detail associated with running a business. Doctors are not trained in business, and many would like to concentrate solely on patient care. There is a role for a salaried service, but it should not be introduced across the board.
"fails to require health authorities to consult with patients and professional groups on pilot projects"
and that it
"fails to provide for nurses and other primary care professionals to participate fully in pilot projects".
Reference was made earlier to pilot schemes and the single-handed doctor, and the quality of such a doctor. I would support that approach. We heard that, if an advertisement had been placed three times and no suitable candidate found, the post would be frozen. If a practice became available, perhaps because a single-handed doctor had died, the local authority would advertise for a doctor, but the committee might not think that the quality of an applicant was good enough, so that person would not be appointed. I point out that the practice size would dwindle day by day, as people went to other doctors. I have seen many examples of that. It is important that a proper doctor is appointed and that there are incentives for such a person to go into that area.
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