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Mr. Yeo: Is the Minister suggesting that merely because a commitment has been contained in a manifesto, the need for subsequent parliamentary scrutiny and consultation about the details of implementing the proposal is removed? If that is the case, it is a very serious threat to this country.

Mr. Kilfoyle: I am not saying that at all. First, we are a responsible Government who want to bring the procedures of this House up to speed with the demands of the 21st century rather than the 19th. Secondly, it is self-evident that the Prime Minister and the Government were given solid support by the electorate on 1 May for making those necessary changes.

I assure the right hon. Member for East Devon that the Prime Minister is just as accountable to the House as he was before; that he answers questions for as long now as he did before; that a question which could have been put to the Prime Minister before can be put to the Prime Minister now; and that all the new arrangements can be reviewed by a Select Committee of this House. I am sure that the new format for Prime Minister's Question Time is a considerable improvement on the old. I believe that this view will be shared by right hon. and hon. Members of all parties in increasing numbers.

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GPs (Sunderland)

12.59 pm

Mr. Bill Etherington (Sunderland, North): I congratulate you, Mr. Deputy Speaker, on your appointment. I have already done so privately, but I take the opportunity to do so formally, on the record, and I wish you all the best in the years ahead.

I am pleased to get the chance to have this debate today, because it is no exaggeration to say that the subject is the most important one that I have dealt with in my five years in the House. It is the cause of considerable concern to my constituents and to various people in the medical profession.

I have a little difficulty, because I must praise both the British Medical Association, in the form of Dr. Patnaik, who has sent me quite a lot of information, and Clare Dodgson, the chief executive of Sunderland health authority, who has done likewise. The trouble is that their figures do not quite coincide.

The one thing that is certain is that the average number of patients registered with a general practitioner in the country as a whole is about 1,800. In Sunderland, the worst figure suggested by the BMA is an average of 2,400 patients. That is a long way above the national average--one third or 33 1/3 per cent. extra. Even the lower figure suggested by Sunderland health authority, 2,200, is about 22 or 23 per cent. above the national average.

The position is exacerbated by the fact that, according to the last survey that I read about the general health of the nation, Sunderland was in the bottom five health authorities for the state of the public's health. A GP in Sunderland has many more patients than he or she should have, and those patients are generally in a poorer condition. That term may sound impersonal, which I do not mean it to be, but that is the reality.

The problem is not new. It has been known about since the early 1990s. Indeed, in 1994, when the health authority published its services review, the whole thrust was to take work away from the secondary sector and put it back into the primary sector. In other words, everyone seemed to think that it was a good idea to try to reduce the work load at hospitals and pass it back to GPs.

At that time, many people warned the health authority that doctors could only just manage with the work load that they had then, let alone an increased load. At that time, the local medical committee, general practitioners, consultants, Sunderland community health council, local Members of Parliament--including my hon. Friend the Member for Sunderland, South (Mr. Mullin), who has been vociferous on the issue--patients and many individuals expressed concerns and proposed alternative views but, unfortunately, as probably happened in many other areas, the health authority chose to ignore them.

We warned at the time that crisis point would be reached in the service if something dramatic was not done to address the problem. Unfortunately, the resources that were supposed to be made available to augment and strengthen the primary sector relied on diverting money saved by a reduction in costs in the secondary sector. Three years on, we find that no resources have been moved from one sector to the other. Indeed, Sunderland health authority has stated publicly that the rundown in hospital facilities will, if necessary, be reduced until such time as the primary sector can deal with its problems.

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In their manifesto, the Government stated that there would be a Minister responsible for equalising the service that people can expect from the health service regardless of what part of the country they live in. It is not my intention to deliver a long tirade about what might or might not have been done. I am sure that everyone in the health sector recognises the problem, and endeavours have been made to improve the situation, but I am concerned when I hear about trying to take work away from GPs and give it to nurse practitioners, because I have not met a single member of the public who is in favour of that. If we want nurse practitioners to do doctors' work, they should be properly trained and paid as GPs.

I must give credit to the GPs in Sunderland. The burden that they have and the disadvantages that they are working under are such that they must be really good people, or the service would have collapsed long ago. I know of no place in Britain where the GP:patient ratio is worse than in Sunderland.

The health authority thinks that it has done all that it can. We might disagree at times about the best way forward--for example, I should like the career start scheme, allowing a young doctor to work in the area without the financial obligations of having to buy into a practice, which has been successful in Durham, to be tried in Sunderland.

In addition to the current shortfall, there is not a single GP under 30 years of age working in Sunderland. The average age is almost 48, and the preponderance of people working in the service are in the 50 to 55, or 55 to 60 range. We even have four doctors who are between 65 and 70. With no disrespect to them, it should not be necessary for doctors to work after they are 65; there should be enough young doctors coming in to allow them to retire while they are still in reasonable health themselves.

I want the Minister to contact the people on Sunderland health authority, try to come up with some new ideas, and perhaps appoint someone independent to consider the problem. No matter how hard the health authority is trying--and I give it its due--it is not having any effect and the situation is not improving. The citizens have a right to say that it is a Government responsibility to take the necessary action, to ensure that all areas have an equal health service.

For me, the problem is the No. 1 priority in the health care sector in my constituency and in the Sunderland area as a whole. I get a little depressed when I find that the health authority intends to spend scarce resources on litigation to try to force Northumbrian Water to put fluoride in the water, when the vast majority of the public do not want that.

It is even more depressing that the local hospital, which for many years--most of the century, as far as I am aware--was called Sunderland district general hospital, decided a few weeks ago to change its name to Sunderland Royal hospital, which will no doubt lead to extraordinary costs and will not result in one more patient receiving treatment or any improvement whatever for health service patients.

I know that the Minister knows the Sunderland area well, and worked there at one time, and I wish him well in his new post. I hope that he will be able to see his way clear to trying to bring some relief to my fellow citizens

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in Sunderland, because the situation is extremely worrying; from being manageable, it could suddenly become completely unmanageable.

When a couple of doctors retired in the middle of 1985, more than 1,000 of my constituents were struck off from the practice and had to find somewhere else. People have to travel all over the town. People are now only rarely able to go to surgeries within walking distance of where they live. So bad is the situation that the health authority employs someone full time to find places for citizens on doctors' panels. That cannot be a satisfactory situation. We need something doing, and urgently. Whatever measures are required to bring it about must be taken. It does not matter who takes them.

I hope that the Minister will be more effective than his predecessors over the past four or five years. My hon. Friend the Member for Sunderland, South and I twice met Ministers in the previous Government. We have had numerous meetings with the local health authority; we have met the regional health authority. I do not doubt that there is plenty of good will, but we are not getting any movement. This is going to be a good test of our new Government in view of our commitment to improving the health service and reducing bureaucracy to get more patients treated.

1.10 pm

The Minister of State, Department of Health (Mr. Alan Milburn): I am glad to have the opportunity to reply to this debate, which I congratulate my hon. Friend the Member for Sunderland, North (Mr. Etherington) on securing and which is important to his constituents. I know that my hon. Friend the Member for Sunderland, South (Mr. Mullin) also takes an active interest in the recruitment and retention of general practitioners in the city.

As my hon. Friend the Member for Sunderland, North rightly said, he and I have a great affinity for Sunderland, which is a great city. I spent two years working to keep the Sunderland shipyards open. I therefore have a great deal of sympathy with the points that he raised, and I thank him for raising them in such a considered way. I listened carefully to what he said about his and his constituents' concerns about the situation in Sunderland. Those concerns are shared by the Government. I especially realise that Sunderland has faced considerable challenges in relation to the high work load on existing GPs and the problems of recruiting new doctors.

People in Sunderland deserve the best possible primary care services. Sunderland needs such services because of the situation that my hon. Friend described. There are high levels of mortality and morbidity, and real problems of social deprivation and poverty that have wholesale health implications. In that respect, I understand that Sunderland is engaged in a programme of urban regeneration and that the health authority is actively involved in a range of partnership initiatives with the city council and other organisations in an effort to promote healthier life styles, create job opportunities, improve housing and so on. I hope that my hon. Friend agrees that those engaged in such activities are to be congratulated on their efforts; we wish them well. I hope that he also agrees that the new Government's approach on job creation, housing and public health will be of direct benefit to those local efforts.

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In addition to that general activity, Sunderland health authority, which is responsible for providing services in the area, is actively trying to redress the situation. It has taken several positive steps to promote recruitment and retention of GPs. I know that my hon. Friend recognises the commitment of the health authority chairman, the chief executive, to whom he paid tribute, and their colleagues on the ground to doing what they can. I was also pleased that Sunderland has at least made some efforts to listen to the views of the local community using the King's Fund citizens jury initiative, which highlighted several issues including making greater use of multidisciplinary teams working in primary care.

I have read carefully the information that has been supplied to me about the progress that has been made in Sunderland, in trying to address some of the problems that my hon. Friend described. I was particularly struck by one initiative, the new out-of-hours emergency centre in the city, which is staffed by the deputising service and tries to relieve the out-of-hours work load on GPs. As my hon. Friend knows, that service became fully operational on 1 March last year. I understand that a recently completed evaluation by Sunderland's local medical committee showed it to be a great success. Patient satisfaction with the service was high, and a further survey of GPs in Sunderland has shown that a significant number of doctors would be willing to work sessions in a modern primary care centre. In the light of that progress, two further such centres are being opened in the city. I hope that those developments will make Sunderland more attractive to young doctors.

My hon. Friend knows that there have been other initiatives, and highlighted one that he would like to be imported from a neighbouring area. I shall ask Sunderland health authority to explore that possibility. I want to build on those local efforts by pursuing policies nationally that I believe will help tackle Sunderland's GP recruitment problems. As my hon. Friend knows, Sunderland is an extreme case, but there are pockets of similar problems in other parts of the country. We intend to do what we can to take action to resolve them. I shall briefly describe some of the measures that are in hand.

In the short time that we have been in government, I have, precisely because of the concerns that have been expressed by my hon. Friend and others, begun to consider in detail recruitment and retention issues in general practice. Family doctor services are the bedrock of the national health service. The Government believe that there is a need for overall work force policies that will attract high-calibre students into general practice. In the light of that view, I was concerned, as I said last week, by recently published figures that show that the number of GP trainees fell by more than one fifth over the decade between 1986 and 1996.

While the falling number of GP trainees is a cause for concern, the issue cannot be seen in isolation. My hon. Friend made some important points about the relationship between the primary and secondary care sectors. We must ensure that we do not consider such issues in isolation, but take a holistic view of the national health service and the range of services that it provides. I intend to look carefully at how primary care is provided, how to get the balance right between secondary and primary care and how to encourage the work force to reflect that balance. We are aiming to integrate medical work force planning more closely across the primary and secondary sectors,

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so that in future the number of GPs and the number of hospital doctors will be considered together rather than in isolation. We shall talk to the medical profession about all those issues.

We want to consider flexible working patterns to provide opportunities for change that address the needs of the work force while providing high-quality services for patients. We shall seek the views of the profession on what employment opportunities would better suit their needs and how any such needs could be addressed.

We shall also consider opportunities under the National Health Service Primary Care Act 1997 for health authorities to improve the level and types of services that family doctors may provide. We shall also look at other options within the existing national contract, such as whether a salaried doctors scheme within the existing framework might provide some answers, particularly in areas with recruitment difficulties, such as Sunderland. I know that many health authorities have already explored that option, but have found several legal obstacles to its implementation. I shall consider ways in which we might move forward as soon as possible.

We also realise the importance of retaining GPs and attracting back into practice qualified practitioners, especially the increasing proportion of female GPs. My view is extremely straightforward. The health service needs to develop much more family-friendly policies, if we are to recruit people into medical practice and retain them. The world has moved on and the medical profession is no longer a male bastion. With an increasing number of women GPs and doctors comes a need to consider flexibility so that their careers are no longer artificially moulded by outdated practices. I shall look carefully at that.

I shall also examine how general practice retains its work force. We need policies that provide sufficient opportunities for doctors who wish to take career breaks but to retain skills so that they can re-enter general practice at a later date. In considering the needs of the work force, we shall also consider the effect on services. We need to ensure that we continue to build a strong family doctor service in which quality is the watchword.

I believe that access to primary care services is a patient's fundamental right in the NHS. At the risk of repeating a point that was made by my hon. Friend, it may be worth giving just one statistic that will help to put the position in Sunderland into the national context. Average GP list sizes have been falling throughout the country, in some cases dramatically--by about 9 per cent. They stand now at an average of about 1,800 per doctor. The average list size in Sunderland is at least 2,200. I know that there are arguments about whether the health authority and the British Medical Association have got the figure right, but as my hon. Friend says, there is real anxiety that list sizes in Sunderland are much greater than in other parts of the country. Sunderland is working hard to improve that ratio while not compromising quality.

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I know that there have been discussions with the Medical Practices Committee of the BMA, which controls the distribution of GPs throughout England and Wales, to ensure that entry into general practice in Sunderland is planned to give the best services possible in the areas of greatest need. If my hon. Friend the Member for Sunderland, North would like to submit evidence to me about the extent of the problem, if he thinks that the health authority has not quite got the measure of the problem, or if my hon. Friend the Member for Sunderland, South would like to do so, I shall take a personal interest in what they have to say.

I shall ask Sunderland health authority to identify the steps that it considers necessary to tackle the problems that my hon. Friend the Member for Sunderland, North described. I shall take a personal interest in its response. I do not think that the problem persists for lack of trying to deal with it on the part of Sunderland health authority. It has embarked on a wide and impressive range of initiatives. My hon. Friend says that it has not cracked the problem. That may be true, but it has operated in a national environment that has not been conducive to attracting doctors into general practice or retaining them.

It has become crystal clear to me in the past few weeks that there is real concern among GPs about their work load and the continual public pressures that they face. We shall have to deal with that. I know that there is particular stress and pressure in Sunderland, but it is fair to say that GP morale in the country as a whole is not what it was or should be.

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