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8.34 pm

Mr. Richard Burden (Birmingham, Northfield): I should say in response to the hon. and learned Member for Harborough (Mr. Garnier) that I have no difficulty at all in defending, and, indeed, supporting the reasoned amendment tabled by my right hon. and hon. Friends. It is constructive. All Labour Members have made it very clear that the principle of a discussion of primary care is to be welcomed. Indeed, we have been calling for it for some considerable time.

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Parts of the Bill are to be welcomed, too, but since other hon. Members want to speak I shall not dwell on those aspects, save to say that the principle of piloting is a very good idea and is being welcomed around the country. I know that in Birmingham, which has been at the forefront of developing ideas for local commissioning of the kind that Labour Members have been suggesting, people are coming up with some fairly imaginative ideas for pilots that the Government could take up if the Bill is enacted.

There are nevertheless significant weaknesses in the Bill, which so far the Government have not addressed. The first is one of principle. I still fail to see--I mentioned this the last time that I contributed to a debate on the health service--how the Government can think that an effective primary care strategy can work, with the co-operation that it involves between different parts of the health service, if it is grafted on to a market mechanism whose ethos is splitting up the health service into different units and making them compete with each other.

That is very different from saying that there is anything wrong with separating the commissioning from the providing of health care, which makes a good deal of sense. For the health service to function effectively as a national service--whether that be nationally or in the locality--co-operation and team work of the kind mentioned by my hon. Friend the Member for Cannock and Burntwood (Dr. Wright) is required, not competition.

Mr. Spring: Will the hon. Gentleman give way?

Mr. Burden: With respect, a number of hon. Members want to speak, so I will make progress. I will not be able to take any interventions. If the hon. Gentleman wants to know how the system to which I referred can work and focus more on quality, I could do worse than refer him to the speech on quality in health care and the building of a co-operative ethos in the health service made by my hon. Friend the Member for Islington, South and Finsbury (Mr. Smith), the shadow Secretary of State for Health, only last week.

I should like to address the problems in the Bill and I hope that, in winding up, the Minister will clear up some points on which I at least am still a little hazy. The Government have said that they have listened to the criticism about what has been described as the supermarket surgery--the commercialisation aspects of the Bill--and that they will table an amendment to address them. I am still rather confused about what the Government intend to do.

It has been said--I think that the Secretary of State indicated it when he opened the debate--that the question of direct employment of general practitioners by commercial enterprises will not be acceptable under the proposed amendment. Will the Minister clarify exactly what is meant by direct employment? Perhaps more to the point, does he envisage indirect employment, and what might the consequences be for commercialisation of the health service?

I put to the Secretary of State earlier a problem that already exists when there is a commercial relationship between a patient and an outside body, and the impact that it can have on GP referral patterns. Such a problem is equally relevant when the relationship is between the GP and commercial areas. GPs are telling me that, if a

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patient comes to see them under the health service but is a member of a private health insurance scheme and a referral is needed, there can be pressure on the GP--if the referral is to be through the private insurance scheme--to refer to the preferred provider. So the GP's role as a purchaser of health care can be compromised.

If it can happen that way round, it can also happen if the GP is tied into a commercial firm outside. I ask the Minister to define exactly what the Government mean when they talk about employment, and where the boundaries are. There is also a question relating to acute trusts. The Minister said in the last debate on this matter, and the Secretary of State mentioned it again today, that while it is unlikely that acute trusts would employ salaried GPs, the Government were not prepared to rule it out. They said that it would be ruled out only where there is a conflict of interest. When the Minister winds up, I want him to talk about where he thinks that there would be a conflict of interest, and equally important where he thinks that there would not.

My hon. Friend the Member for Islington, South and Finsbury mentioned earlier that if a local acute trust employed a salaried GP, that might create a problem in that it would be cornering the market for referrals, which would put pressure on the GP. I also see a problem if the acute trust was not in a local area and was trying to attract business--to use the market term--for its own hospital by employing a GP in another area. I ask the Minister to clarify how he will guard against those problems.

If commercial enterprises can have a role in this, and if acute trusts can employ GPs, why cannot health authorities? The Secretary of State said earlier today that it would compromise the purchaser-provider split, but the GP's role is one of both purchaser and provider. The Government are saying that a health authority cannot employ a GP because the GP is a provider of health care, but what about the fact that a GP is also a purchaser of health care? If the GP is employed by an acute trust, that compromises the purchaser-provider split. If a health authority is to fulfil the role of identifying health needs in an area and enable the development of primary health care, what reason is there for preventing it from employing GPs?

There are flaws in the Bill, but that does not remove the value of discussing primary care and having new legislation on that. There is a shortage of GPs. There are recruitment problems, and they must be addressed. The boundaries that used to exist between secondary and primary care are becoming fuzzy and in many places are breaking down. It is no longer easy to determine exactly what should take place in a hospital and what should take place in a local health centre, but the structure of NHS finance still maintains that division, which is not there in reality.

I give just one example. If a patient on a low income needs to get to a hospital that is not nearby, it is likely that he or she will get financial assistance for transport, but if the same patient needs the same treatment and instead gets it at the local health centre, he or she cannot get financial assistance to get there because it is not funded in the same way. Those anomalies need to be addressed. I welcome the Bill in so far that it has started the discussion, but without the reasoned amendment tabled by the Labour party it is flawed.

If a primary health care strategy is to be developed and is to mean what it says in developing a national health service that prevents ill health as well as treating the

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consequences of ill health, it needs to look beyond the boundaries of the health service. It is a fact that the life expectancy of somebody in the lowest income tenth of the population is eight years less than that of somebody in the highest income tenth of the population. Unless we as a society address the problems of poor housing, of the benefit system and the poverty trap, of the availability of work and of low pay, a primary health care strategy will not work. A multi-disciplinary approach is needed to tackle the problem, not just within the health service but between the health service and our economic policies.

Sadly, from "The Health of the Nation" White Paper onwards, the Government have not shown themselves willing to acknowledge the huge link between poverty and ill health. Until the Government address that issue, we shall not have an effective primary health care strategy in this country.

8.44 pm

Lady Olga Maitland (Sutton and Cheam): I give a very warm welcome to the Bill. It is fundamental and is a natural development of the way in which health care is going. This afternoon, however, I appeared on a television programme with the hon. Member for Dulwich (Ms Jowell). I think that she will recall that our conversations appeared at complete odds. She talked about "crisis in the health service", constantly running the health service down, somehow suggesting that GPs are to be in the pay of unscrupulous commercial organisations.

Ms Jowell: Rubbish.

Lady Olga Maitland: It is all very well for the hon. Lady to say, "Rubbish," but that is the truth.

What worries me is that such a performance is deeply damaging. It does not enhance her own cause and it worries the patients outside. The hon. Lady carries a grave responsibility when people then ring up believing the erroneous and totally inaccurate information fed to them by the Labour party. On the one hand, the Labour party says that it is all for the national health service, but on the other it bashes it down, runs it down and denigrates all the work that we have done.

It is a curious fact that when I talk to people in their own homes and we discuss the health service, they say, "I'm very worried." When I ask them why they are worried, they tell me that they are worried because of what the Labour party says--that the health service is in crisis. It is in no crisis at all. Indeed, when we discuss the situation a bit more, people tell me that they understand that the Conservatives have put more money than ever before into health care.

It is important that we try to brush away the cobwebs and confusion put about by the Labour party and look more positively at what the Government are trying to do. We are trying to move ahead with the times. We have recognised that we have reached a stage where GPs are able to provide a service that is second to none. Give them their freedom, allow them to become fundholders--as more than half the country's GPs are--and it is excellence that they provide. I have seen the differences for myself in a fundholding practice, which now carries out minor surgery. It has consulting rooms where people are given counselling about various problems. People come in to give physiotherapy. It has employed nurses. It links up with osteopaths. There is no end to the services that an effective GP fundholding practice can provide.

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There is another side to the coin, however. While such practices are going full blast in perhaps the more prosperous areas--in my constituency they are a wonderful showcase of modern medicine--I am aware that there are GPs working on their own, particularly in the inner cities, which are less attractive to GPs, who badly need to expand the services that they would like to provide.

Would it not make marvellous sense for such a GP to branch out and set up a relationship, say, with the local supermarket or shopping centre to bring in private finance, like the private finance initiative, which the Labour party is not a bit against, as I understand it, to bring in fresh money and fresh enterprise and thus be able to provide the services that they are not able to provide on their own? That is known as flexibility and moving with the times; it will certainly respond to patients' needs, and I believe that it will be greatly appreciated.

I am worried about the Labour party's allegation that there will be unscrupulous behaviour and that doctors will be in hock to companies which will insist on selling only those drugs and treatments that generate a profit to themselves. That allegation totally ignores all the safeguards which are built into the Bill to ensure that the health service continues to provide the excellence, honesty and integrity that it has always provided.

It is reassuring that in another place a number of their Lordships conceded that the Bill would provide services that will be much appreciated. The fact that the pilot schemes have to be referred to the health authority and then to the Secretary of State, and that he can veto unsuitable schemes, shows that we are not allowing unscrupulous people to get through. I would be more worried about too much red tape and bureaucracy slowing up a jolly good idea, which would spoil what we are trying to do. We could be almost too careful. I hope that my hon. Friend the Minister will address that point.

We have moved into an age in which we should be expanding and taking advantage of all the outside interests which could benefit patient care. That is the name of the game, and I give the Bill a warm welcome and wish it a safe passage.


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