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Mr. Nicholas Winterton: My hon. Friend reflects the concern of GPs throughout the country. I spoke earlier of the benefits brought by GP fundholding, but admitted that there had been abuses. My hon. Friend is outlining some of the problems with the Government's proposals, but
how would he amend GP fundholding to reduce the abuses and the problems that were created for some hospitals and hospital trusts, while preserving the many benefits that it brought for patients, putting as it did the GPs on an equal footing with the hospital consultants, who had hitherto dominated the health service?
Mr. Fabricant: I would like to extend fundholding. I would not make it compulsory and I would provide better training so that all GPs would have the ability and the financial wherewithal to manage their own practices, as happens with the 55 per cent. of practices that are currently fundholding. Eventually, by voluntary choice and ability, all practices in England and Wales would be GP fundholding practices. We should certainly not say, as the Government do, that the extraordinary budget--for emergencies, for illnesses in winter and cardiac arrests--should come out of the GPs' budgets.
Mr. Fabricant: I am coming to my conclusion, and I know that others want to speak.
The measures will not help community care. They are all about party dogma. I end not with my words, but with those of my Lichfield doctor. In an e-mail that he sent to me last night, he said:
"Like the 'new' arrangements for the House of Lords,"--
I will have to sign this doctor up to the Conservative party if, as I believe, he is not already a member; his words provide a better ending than any that I could possibly write. He said--I repeat his opening words--
"Like the 'new' arrangements for the House of Lords, the new NHS seems to be words with no substance. Sorry, that is unfair; circulars describing the new NHS arrive almost every day. The comparison is only valid as nobody seems to know how either will work!!"
6.8 pm
Dr. Howard Stoate (Dartford): As the only general practitioner on the Government Benches, it is up to me to inject some common sense into the debate, following some of the arguments that we have heard from Conservative Members. I am sorry that the right hon. Member for Maidstone and The Weald (Miss Widdecombe) is not here, because I want to take issue with much that she said. I am afraid that, as usual, she displayed a tendency not to let the facts get in the way of some damn good rhetoric. It is important to consider in more detail some of what she said.
The right hon. Lady spoke about GPs having referral rights taken away from them by primary care groups. The record will correct me if I am wrong in supposing that she said that, under the new primary care group arrangement, GPs will lose referral rights to the hospital of their choice.
Some years back, under the fundholding arrangements--I hasten to add that I have never been a fundholder or accepted the necessity for fundholding--a patient came to see me and I diagnosed a particularly rare and unpleasant form of leukaemia. I knew that there was only one hospital in the land that could offer her any hope of decent treatment; I contacted it and spoke to the consultant. I said that if the woman was to have any
chance of survival she should be in his unit. He said that he entirely agreed, that it was a very rare case and that he would like to see the patient immediately.
The consultant asked me to send the patient along, but then said, "Hang on a minute, you're a fundholder, aren't you? You do have a contract with this hospital, don't you?" Oh, dear. Of course, the whole thing then fell flat on its face and it took another 12 hours to sort out whether I could have an extra-contractual referral on an emergency basis. That was all to the great detriment of my patient, who subsequently died.
I would argue that fundholding has not been a great success because it has led to a two-tier service and undermined doctors' ability to send patients where they choose, causing great distress and difficulty.
Dr. Brand:
I am grateful to the hon. Gentleman, who has just described my fear that the new arrangements will mean that all patients will be treated in the same way as patients of non-fundholding GPs. I am sure that he has read the executive letters issued by the Department of Health and I hope that he is clear, because I am not, on how we can retain the ability to refer patients in the situation that he describes. A speedy response between clinicians is essential for an effective national health service, and managerial systems must not get in the way. Fundholders cut out a lot of the rubbish and I hope that primary care groups will be able to do the same.
Dr. Stoate:
Fundholding took out some of the nonsense, but it should not have been there in the first place. Before 1990, a GP had the right to refer a patient to any hospital in the land. The previous Government created the mess and it needs sorting out. GPs who were not members of fundholding groups did not have the right to choose to whom they referred their patients and that caused great distress and difficulty for many people.
I wish to tell the House about experiences I have had in my constituency. I take issue with the hon. Member for Lichfield (Mr. Fabricant), who seems to think that all the doctors in his area are opposed to primary care groups. He gave the game away when he said that he would send a membership form for the Conservative party to one local doctor, who seems to be a ripe candidate for joining. The hon. Gentleman's experience differs from mine.
Mr. Fabricant:
The doctor is not a member of the Conservative party. In Lichfield, every GP is a member of a fundholding practice--it works for them and, more importantly, for the patients. I do not know how the hon. Gentleman can talk about fundholders when he has never bothered to become one. Does he not think that his patients might have benefited?
Dr. Stoate:
I never bothered to become a fundholder because I was sure that it was not right for my patients. The hon. Member for Southwark, North and Bermondsey (Mr. Hughes) claimed that we would spend huge amounts on bureaucracy under the new system of primary care groups. Currently, there are 4,000 commissioning groups of varying sizes and we intend to replace them with only 600 primary care groups. Huge savings will be made in bureaucracy.
Mr. Simon Hughes:
Those two statements arenot necessarily logically connected. If fundholders
Dr. Stoate:
I shall enlighten the House on that point. As the hon. Gentleman knows, fundholding practices employ fundholding managers. They employ members of staff to shuffle bits of paper around, to sign off completed patient episodes, to sign off patient treatments and to ensure that patients have been seen by the right consultants. That involves thousands of pieces of paper. Every fundholding practice has a member of staff, sometimes several, to deal with that. A primary care group will contain an average of 50 GPs covering 100,000 patients, and one level of bureaucracy will cover all of them.
Mr. Hughes:
One member of staff?
Dr. Stoate:
No, but one level of bureaucracy. We will no longer need single pieces of paper for every completed episode of patient care. We will sweep away that nonsense of a bureaucracy that never taught anyone anything about patient management and never contributed to patient care, but snarled up the system with thousands of pieces of paper. That will lead to huge savings.
Nobody has yet put forward a sensible argument against a primary care-led NHS. Our changes will mean that local doctors, nurses, and members of social services departments who understand the local needs of local patients will set up local services to meet those needs. What could be more sensible? That has to be the way forward, not the hugely bureaucratic system we now have.
Change is threatening, and the hon. Member for Lichfield described the fears and doubts of some of his local GPs. I do not decry those fears, because they are genuine. Nobody easily votes for change--other than to get rid of the previous Government, when people voted with alacrity for change. Many GPs have expressed their concerns to me because I am the only GP who sits on the Government Benches and I tend to be the focus for GPs' concerns and anxieties. I do not wish to patronise them by saying that their doubts and fears are unfounded, because in many cases they are not.
In the interests of good debate, I wish to point out some of the genuine fears of GPs. For example, fundholders have spent much time and energy setting up new clinics and services for the benefit of their patients. Good luck to them. They have sometimes succeeded in pushing at the boundaries of medical care and making some treatments very effective. Some genuine innovation has flowed from fundholding and I do not seek to minimise that. Fundholding GPs do not want to see those benefits lost and they are anxious that the clinics they have set up continue to provide good care for their patients.
Non-fundholders are anxious to ensure that they have enough time, energy and expertise to make the new primary care groups work. I do not seek to minimise those fears, either. Other fears include overspending and what will happen if the money runs out. Some people are concerned that if they take time out of their practices to
sit on primary care boards, their partners will have to pick up the slack. If a doctor is out of the practice for half a day a week, somebody else has to see the patients and that can cause tensions in partnerships. We must face up to those problems in an adult way, instead of with rhetoric and loud voices. Those fears are not merely moaning from a privileged interest group that has always had its own way. That is a patronising and simplistic view. It is also wishful thinking, because GPs have raised real issues that will not be solved without careful consideration and thought.
This morning I contacted Dr. Alasdair Thomson, the GP chief executive of the Dartford, Gravesham and Swanley HealthCare Partnerships Project and chair elect of the new primary care group. The project was initially set up as a pilot scheme, covering 220,000 patients with 116 GPs, 70 per cent. of whom are fundholders. They have worked with non-fundholders, voluntarily, to set up the project, which is a precursor of primary care groups. The project has followed, almost exactly, the model that will be followed by all PCGs. It has blazed the trail for PCGs, faced up to the difficulties I have described and found solutions.
The project is enthusiastic about its work. I was due to meet Dr. Thomson this evening to discuss his group's plans, but I felt it was more important to take part in the debate. We intended to discuss the project's seemingly unquenchable thirst for innovation. I am sure that Ministers will be delighted to hear that the subject of tonight's meeting was whether the project should express an interest in becoming a primary care trust at the earliest opportunity. The project is convinced that it is of real benefit to the local communities.
Dr. Thomson sent me a progress report today, which explains what the group has achieved and how that has benefited its patients. The report states that the project was set up
GPs have also formed new service review groups to develop local services in conjunction with trusts. So far, there has been success in urology, anticoagulant therapy, radiology and ultrasound, and dermatology. That is
exactly in line with the Government's proposals in the new Bill. Our primary care teams--GPs, practice nurses, practice managers, district nurses and health visitors--are working together with social services care managers to develop elderly care services in the community. That way of working has been piloted at six GP sites in the district, and it is ready to be rolled out across the entire group. It has also allowed the commissioners, the health authority, social services and GPs to work together with providers to improve mental health services in the locality.
Perhaps more excitingly, the groups are also working with the health authority pharmacists and pharmaceutical advisers to draw up guidelines on the most rational and cost-effective prescribing. The report sent to me this morning asks, "What's gone well"? It responds:
"as a Locality Commissioning Group Pilot in September 1997 . . . Since the publication of the White Paper . . . the GPs have been working in partnership with West Kent Health Authority, Kent Social Services Department, Trusts, particularly Dartford and Gravesham Acute Trust and Thames Gateway NHS Community Trust and the Community Health Council to develop services which are more responsive to local needs."
The progress report continues:
"The pilot status has given us a head start in developing partnership working, bringing together organisations in Health and Social Care and in particular, tackling the 'Berlin Wall' culture.
It allows GPs to become directly involved in commissioning decisions and service development of local trusts. In particular, GPs are looking at ways in which to bridge the gap between fundholding and primary care groups. For example, equity of patient access to in-house clinics is one of the difficulties that we have considered, and they have found the way around that problem.
This has enabled . . . GPs from very different types of Practice in Dartford, Gravesham and Swanley (Urban, Single Handed, Rural) to come together in a specific forum to raise issues and solve problems which directly relate to local health needs."
"Groundswell of support from all organisations, particularly around partnerships working.
That is not a bad record for a group that set itself up voluntarily, and which is a mixture of GP fundholders and non-fundholders who have demonstrated a year ahead of everyone else that they have tackled most of the problems head-on in a way that has met local need.
A belief that we can tackle local issues better.
A head start in developing management structures to cope with the new PCG agenda.
GP involvement in the Commissioning process.
A foundation to enable us to start to tackle issues in Primary Care and the concept of Clinical Governance."
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