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9.14 pm
Mr. Don Touhig (Islwyn): I welcome some of the measures in the Bill, such as appointments to single-handed practices, the move towards practice-based contracts and the provision for salaried GPs. Yet I reflect that, when Aneurin Bevan founded the national health service, the guiding principle was that the health service should be available according to need and free at the point of delivery. Sadly, 18 years of Tory rule have seen the erosion of that principle, and I fear that, if the Bill is passed as it stands, it will lead to the destruction of that principle.
We have already had the introduction of individual GP fundholding, which, with the internal market, has without question brought about a two-tier health service. Many patients are no longer treated on the basis of need. Instead, other factors such as age, where they live or whether their GP is a fundholder are considered important.
Last year, I was at the European Surgical Institute in Hamburg with several British consultants. One of them told me that he had been telephoned by a GP who asked him what he charged to do a hernia operation privately. He replied: "Seven hundred pounds." The GP replied: "I will give you £10,000; do it for £300." That is not the language of health care but the language of the market trader.
Senior staff to whom I have spoken in the health service confirm that treatment is no longer available on the basis of need. I fear that, if the Bill is passed in its present form, it will accentuate the variation in the quality of services that patients receive and encourage cherry picking.
I listened to what the Secretary of State said about amendments that would be tabled in Committee, and I welcome what he said. However, the Bill as drafted offers no safeguards against the growth of a two-tier health service--a two-tier health service in which hospital services are effectively being denied patients who are not registered with a GP fundholder.
In September 1996, Derek Smith, chief executive of King's Healthcare NHS trust in south London, said:
Recently, in another place, Baroness Jay said that there is surely something wrong when Lincoln county hospital writes to all non-fundholding GPs in its area, cancelling
out-patient appointments for the rest of the financial year, although it is telling fundholding GPs that they can continue to send their patients there.
The Bill will have a significant effect on the way in which the health service operates. Pilot schemes are a key feature of the Bill, which I welcome. I also welcome the Government's change of mind on pilot schemes. It is quite a surprise to many people in the medical profession and elsewhere. My hon. Friend the Member for Islington, South and Finsbury (Mr. Smith) expressed his surprise earlier.
I recall the remarks of Dr John Marks, chairman of the BMA, at the time when the right hon. and learned Member for Rushcliffe (Mr. Clarke) was Secretary of State for Health, suggesting that we should have pilot schemes, to which the Secretary of State replied that he would not agree to them because the BMA would sabotage them.
The provision in the Bill that allows "other bodies" to become involved in the formulation of pilot schemes by sponsoring someone who has an existing NHS contract or by allowing them to apply to become health service bodies is obviously deeply worrying. We must wait until the Committee stage to discover what more the Secretary of State has to say on that point.
Supermarkets, large pharmaceutical companies and private health care companies have all been considering the feasibility of becoming involved in pilot schemes. Asda has been considering plans to provide rental space for GPs in supermarkets. Unichem has plans to build up to 20 new health centres and has suggested that it should employ GPs as part of a consortium with BUPA. PPP Healthcare proposed a pilot scheme involving provision of GP services at the company's private hospitals with referrals for hospital care to the hospital. We shall need to discover in Committee what the Secretary of State plans.
Those are significant concerns--concerns about the integrity and quality of primary health care and about the very existence of the national health service. I know that they are shared by the BMA and general practitioners. Only yesterday, I spoke to a general practitioner in my constituency, Dr. Sahni. He tells me that, to his knowledge, about 80 to 90 per cent. of GPs consider most of the proposals in the Bill to be extremely damaging. As Dr. Sahni pointed out, when a large pharmaceutical company becomes involved the emphasis is no longer on patient care. Commercial organisations would be under pressure to maximise income and it is probable that they would seek to sell a range of services and products that are not necessarily in the interests of patient care.
Some aspects of the Bill risk destabilising the general practitioner service. At the moment, patients know that the NHS family doctor has a contract with the state. The BMA has stated that the family doctor service remains, and must remain, fully within the NHS and not be open to direct or indirect privatisation. Under the Tory Government, we have seen creeping privatisation. It is no longer possible for the majority to get free eye tests, which are an essential health check, and the number of dentists offering treatment under the NHS continues to fall. That is the legacy of the Tories, and I fear that the Bill provides for more privatisation.
Doctors to whom I talk tell me that they are disillusioned and demoralised, and we must take account of what they say. They are dedicated professionals,
but they have enormous difficulty securing the best care for their patients because of the internal market and creeping privatisation.
Ms Tessa Jowell (Dulwich):
The Secretary of State's announcement on commercialisation was a huge climbdown, but it was born of coercion rather than conviction. At the launch of the White Paper "Choice and Opportunity" that preceded the Bill, the Secretary of State was glorying in headlines that heralded the "big bang" style deregulation of general practice. It was claimed that the way would be opened for supermarkets and other private companies to employ GPs. The GPs would then be accountable to their employers--a different prospect from supermarkets or any other potential landlord being able to offer premises for rent to GPs.
Before the Secretary of State's climbdown, Asda and Unichem were trailed as having an interest in employing GPs, PPP Healthcare had already submitted a bid and one central London GP claimed to have had three approaches from private companies. The future appeared to be one of American-style health maintenance organisations that could pick and choose between patients.
What has happened? We know that the Secretary of State now deals with health as his day job, while moonlighting--much to the irritation and embarrassment of his colleagues--on devolution, Europe and constitutional matters. For the benefit of the House, perhaps the Secretary of State can clear up the confusion on whether he speaks on constitutional matters--
Madam Deputy Speaker (Dame Janet Fookes):
Order. I am sorry to call the hon. Lady to order, but, however wide Second Reading debates may be, the Bill does not embrace constitutional reform.
Ms Jowell:
We are concerned to ensure that the Secretary of State is fighting for patients and not fighting to become the Leader of the Opposition after the election. The difficulty is another example of the chaos that is besetting the Government. During the Secretary of State's distractions, GPs have been standing up for the values of the national health service--hence today's climbdown.
The proposals for the privatisation of primary care have been dropped not out of conviction, but to avoid a row with the British Medical Association in the run-up to the election. If the Government thought that they could get away with it, they would go ahead.
The Secretary of State said in his opening remarks that he thought that the concern raised by Labour and the BMA about the commercialisation of general practice was misplaced. The implication was that the misunderstanding was on our part. Let me remind the right hon. Gentleman of his comment to Pulse:
The Secretary of State spoke today about
Then there is the Secretary of State's discovery of the value of GP commissioning. Welcome to Labour's cause, which appeared in the White Paper, "Choice and Opportunity". Labour's proposals will ensure equity between patients, less bureaucracy and co-operation between GPs in the procurement of patient care.
GP fundholding, however, has reinforced inequity between patients. Whether or not people have fundholding GPs has become a major and unfair determinant of whether they get hospital treatment. As the Audit Commission remarked, fundholders tend to come from suburbs and shires, rather than inner cities, and, as a natural corollary, tend to look after more affluent and less socially deprived patients.
We also welcome the Government's climbdown today on the critical role played by the Medical Practices Committee in central work force planning, and ensuring within the terms of its remit that there is an even spread of family doctors across the country. As my hon. Friends have made clear during the debate, there are parts of the country that suffer from chronic shortages of GPs. In my health authority and that of the hon. Member for Southwark and Bermondsey (Mr. Hughes), 20 GP vacancies are currently unfilled.
I pay tribute to the Medical Practices Committee for its rigour in checking the eligibility of GPs to practise. It is worth noting, and I am sure it is not accidental, that, since the NHS was created, only one bogus GP has ever entered practice. That demonstrates the rigour with which the committee applies itself to its task.
We welcome the fact that the Secretary of State was so adamant that the Bill as at present drafted does not preclude nurse-led pilots. That must be made clear to the BMA and the Royal College of Nursing, which have slightly different concerns, but are both clear that the Bill as drafted excludes that possibility. We shall return to that in Committee if the Bill secures a Second Reading, so that the position can be made absolutely clear.
As my hon. Friends have said, there are parts of the Bill that we welcome and support. We hope that the proposal to allow community trusts to employ GPs will help to address the chronic problems of GP recruitment in some areas. The move towards practice-based contracts is welcome, as are the new rules for the appointment of GPs to single-handed practices. The only question is why it did not occur many years ago. Hon. Members raised many other issues during the debate that we shall wish to pursue in Committee, if the Bill gets that far.
My hon. Friend the Member for Gower (Mr. Wardell) drew attention to the worrying decline in the number of medical trainees entering general practice. He suggested that medical students should conduct part of their training in general practice. He makes common cause with the hon. Member for Chislehurst (Sir R. Sims), and I hope that it will be possible to proceed with the proposal on the basis of cross-party support.
My hon. Friend the Member for York (Mr. Bayley) made a valuable contribution to the debate, setting out in detail the inequity in the distribution of primary care resources. He also underlined the enormous discrepancy between the number of GPs per patient in different parts of the country. The inequitable distribution of national health service resources is one of the Government's worst legacies, and will be addressed as a matter of priority by a Labour Government.
The hon. Member for Belfast, West (Dr. Hendron) raised concerns about the conflict of interest in acute trusts that employ GPs. We share his concern, but the situation was not illuminated by the Secretary of State's explanation as to why the purchaser-provider split is blurred by health authorities employing GPs, but not by acute trusts doing the same thing. My hon. Friend the Member for Halifax (Mrs. Mahon) drew attention to the threat to the doctor-patient relationship posed by the involvement of the private sector in the delivery of primary care. She gave the example of PPP Healthcare, which wants to establish a base for GP services at its private hospitals in London.
"a two-tier NHS is an everyday reality".
It is an everyday reality for those who rely on the NHS.
"If a service cannot be provided using other routes, commercial enterprise may offer a solution."
Even though the Government have backed off, there is still enormous scope, as my hon. Friend the Member for Islington, South and Finsbury (Mr. Smith) rightly pointed out, for a new relationship between the private sector and general practice--a relationship that we believe would be to the detriment of patient care. Despite the Secretary of State's climbdown, we shall use the Committee stage, if the Bill secures a Second Reading, to ensure that further avenues to privatisation and fragmentation of the national health service are closed.
"the importance of the pilot-based approach."
We welcome that change of heart, but it will surprise many in the NHS who still have the bruises to show from the previous round of Tory NHS reforms. The then Secretary of State, the right hon. and learned Member for Rushcliffe (Mr. Clarke), still speaks proudly of imposing the Government's dogmatic internal market on a reluctant health service. He said at the time:
"I was quite sure that if you isolated a few places as pilots, all the best efforts of the BMA element in the medical profession would be bent to ensure that it failed."
Had he shared the more consensual approach preferred by the current Secretary of State, we would not be saddled with a bureaucratic competitive market that is universally detested in the NHS.
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