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Mr. Deputy Speaker: Order. The hon. Gentleman's time is up.
6 pm
Mr. Kenneth Clarke (Rushcliffe): The Secretary of State for Health attracted to the Chamber three Conservative Members who are former Secretaries of State for Health. We should all have come here out of sympathy with the Secretary of State because his task is very hard, if it is done properly: to prioritise the service and to produce steady development within finite means when demands are ever burgeoning. I regret to say that we were all drawn here by the fact that, in tackling his task, the Secretary of State is getting into a bigger and bigger mess. We all fear that, in relation to how the health service will perform, he is building up for himself considerable problems in the medium term. Our constituents will all feel that winter by winter, as the crises start to reoccur in the system.
In 10 minutes, I have no time to answer all the points in the Secretary of State's speech, but I do not wish to do so; he sacrificed any sympathy that he might have had from me. He has a standard Opposition-based rant on what the health service was like when he took over. On every occasion he gives an extremely clever, partial and disingenuous presentation of the money that he says that he has, and what he is doing. On each occasion he produces an announcement--today, it was on NHS Direct--to distract the journalists from what the Government are doing. He made only partial references to the Bill.
The reason why the Secretary of State is getting into a mess is that, as he will discover, however skilful the rhetoric, however good the special advisers and press presentation, he may fool people for a bit, but it is what he does to the health service that will come back to live with him. He will find that the Bill will do considerable harm.
I anticipate my criticisms by stating what I welcome about the Bill. It does not reverse the reforms of the previous Government. It does not repeal the internal market or anything like it, although that is not a phrase that I would ever use to describe it. I am glad that the purchaser-provider divide is kept completely intact. No doubt it is regarded as clever that contracts are now described as "collaborative understandings", but they are
still there between purchasers and providers. The Secretary of State is even extending the number of NHS trusts on the provider side.
The Bill alters what we used to call in the jargon--it is only jargon--the purchasing side: the commissioning of health care on behalf of the patient. The Secretary of State is moving away from fundholding into new primary care groups, which, as I hope to show, are a wholly undesirable change in the system and will, in the long run, have only adverse effects.
I say in passing--I have no time to say more--that I welcome the fact that elements of quality control are built into the Bill. We began that when we introduced clinical audit into our reforms. When we were in office, we spent our whole time trying to build a more patient-oriented service, and better management of clinical practice and quality, with the support of the best people in the profession.
An attempt is being made to produce further improvement in performance management, although it is being done in an odd way. We have new acronyms and we have new quangos in the acronym-ridden national health service--CHIMP will now join NICE. My right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) is right to say that we are not sure what NICE and CHIMP will wind up doing, but they at least are commendable.
Overall, my judgment of the Bill is that it is centralising in its ambitions, which is a serious mistake in such a giant service: the biggest employer and the biggest public service in western Europe. In its changes to the purchaser-provider divide, the Bill is bureaucratic in the extreme. As the hon. Member for Rother Valley (Mr. Barron) said, that will lead to cultural change on the ground. That change will be a stifling of individual initiative by the best go-ahead general practitioners, because that practice will be made more difficult because those GPs will be locked into a group with people who will not want to be as innovative as them.
The best general practitioners will have to proceed at the pace of the slowest as they try to develop the primary care system. The decision-making provisions in the Bill go back to the worst of the old NHS. Slow, expensive decision making will be conducted by the large committees that are being re-established. I fear that they will not function well.
Primary care must continue to develop. Every Minister with responsibility for health knows that developing primary services continues to be one of the major priorities in trying to solve the conundrum of how to meet rising demand out of finite resources. However, like my right hon. Friend the Member for Maidstone and The Weald, I fear that primary care will go through a process of levelling down, rather than levelling up, for quite a period once the primary care groups come in.
I concentrate on the new primary care groups and the end of fundholding; there are other important parts of the Bill about which I have not time to talk. I will not express an opinion on the parts of the Bill that concern the PPRS--the pharmaceutical price regulation scheme--and drug cost provisions. If I did so, I would have to declare an outside interest as chairman of a pharmaceutical wholesale company. I make only one comment, which is faintly relevant. One detailed aspect of the primary care groups has been sadly neglected: the role of the
pharmacists as a profession. The fact that they will have no real involvement in the new groups is not to the advantage of patients.
Primary care groups are based on the abolition of general practice fundholding. Fundholding was a success. One of the key things that the Secretary of State tried to deny was that we worked to ensure--the best reforms do it--that those who carried out the reforms had ownership of the reforms themselves. The fundholders were volunteers and they were largely enthusiasts.
Almost 60 per cent. of GPs wished to become fundholders. If we had achieved 100 per cent. GP fundholding, as we did with NHS trusts, the Government would never have dared to reverse the policy. They are going to great and unnecessary lengths to reverse it now. It put family doctors in the driving seat in raising the standard of care in their locality. It gave them new and unprecedented influence over the quality of and access to hospital-based services. It enabled them to concentrate on the needs of their own patients. The benefits from the growing number of fundholders were spreading to the rest of the service.
In the short time I have left, I mention specifically what I think are the dangers of the new primary care groups. First, they will level the service down. I will not repeat what my right hon. Friend the Member for Maidstone and The Weald has said. The best fundholders developed set-ups in their practices that were unprecedented in the NHS: physiotherapy in the practice, consultants coming in for special in-house sessions to deal with people in the surgery, better facilities than ever before for minor surgery by GPs. In many cases, after the Bill, those things will be squeezed out in some practices by constraints on the budget of the primary care group as a whole.
A second thing will be lost. Compared with the old fundholders, GPs in the new groups will lack the clout and influence over colleagues in hospital-based and community-based NHS services; those fundholders were such a beneficial influence on behalf of patients.
Practitioners' incentive to achieve efficient practice will be lost in a particular practice because money will be distributed according to historic spending patterns--to practices as a whole. Indeed, the way in which the money is being distributed to the groups rewards the more inefficient practitioners. They will get their historic level of spending, and some more efficient practitioners will be penalised. Under the system, every practitioner will be handicapped by the most difficult GPs in the slowest practices.
The biggest problem in some primary care groups will be that some GPs will simply not be interested in being involved in such management and development of the service. Keen GPs will probably get themselves elected on to the boards, but they will have no way in which to stop the less keen from inhibiting what they can do. That is a serious problem. The cash-limited budgets that will be imposed on those large, almost unmanageable blocks of GP practices will give rise to particular difficulties, especially as prescribing costs will be imposed on the groups, which will have no ability to hold to account those whose prescribing habits start to exceed the budget.
My biggest sadness is that GPs will lose that commitment to their own patients and practice and the incentive to drive improvements, which led to benefits on the ground.
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