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9.3 pm

Mr. John Randall (Uxbridge): The hon. Member for South Swindon (Ms Drown) mentioned a problem with the terminology of chairmen and chairs. I have spent most of my adult working life selling chairs, and that is where they should remain.

The Bill gives effect to the legislative requirements laid out in the Government's three health White Papers. The Government are presenting it as the centrepiece of an ambitious health reform programme. Ministers have heralded it as offering a radical future for the NHS, promising to improve the quality of health care across the country, eradicating unfairness and reducing bureaucracy. Rather than fulfilling the Government's ambitious rhetoric for the NHS, the Bill will make the health service more inflexible and inefficient, reduce choice and, regrettably, centralise decision making.

I shall concentrate my remarks on the issue of fundholding and the new primary care groups. As we have heard repeatedly this evening, it was the previous Government who introduced GP fundholding. It has been a focus of particular hostility from the Labour party since its introduction in 1990. Fundholding offered doctors greater financial and clinical autonomy, while allowing improvements in patient care. It enabled efficiency savings to be reinvested in the system, resulting in shorter waiting times and the development of new specialist services. Even the Government have come round to acknowledging that. Their White Paper stated that the introduction of fundholding had enabled doctors to

As we have heard this evening, fundholding received the support of many groups, including the British Medical Association and the Organisation for Economic Co-operation and Development. GP fundholding encompassed 60 per cent. of NHS patients. Sadly, the Government have now killed off fundholding despite acknowledging its success, and in the face of widespread support.

The Bill proposes instead to create primary care groups and primary care trusts, leading to the biggest change in the family doctor service since the creation of the NHS. That is despite the promise of the Prime Minister before the election that there would be no great upheavals in the service. The Bill will coerce GPs into the new primary groups whether or not they want to join them. There is the question of the costs associated with these new structures. Initial estimates vary from £150 million per year to more than £300 million per year, without accounting for the new structures start-up costs--at a time when the

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Government want to save money on bureaucracy and have budgeted for savings. Under fundholding, any extra administrative costs were more than offset by efficiency savings. The new system will be more costly and less efficient.

The Office of Health Economics has predicted that the organisational costs of delivering health care are likely to increase. The Institute of Child Health stated that the cost of developing three to five-year health improvement programmes will more than offset even the most generous assessment of savings made by cutting the number of commissioning bodies. With that background, it is difficult to work out how the Government can claim that their reforms will make substantial savings that will be directed to front-line patient care.

The BMA found that fundholding encouraged accountability and that GPs were truly willing to share the decision-making process. The Audit Commission said that fundholders introduced more services to patients, improved communications with hospitals and were more cost effective in their drug prescribing. The main criticism of fundholding was that it was a two-tier service, but the Government propose to introduce a four-tier service. If two tiers were bad, how can four be good?

The Government's answer to GP fundholding is to have a compulsory system whereby between 50 and 100 GPs are forced into the same group. Under the old arrangements, patients were usually able to choose the fundholding GP, but under the primary care group system, patients will be assigned to a primary care group on the basis of where they live. That contradicts one of the central points of criticism that the Labour Opposition used to make about the operation of the NHS internal market.

The primary care groups became active on 1 April this year and replace the voluntary nature of fundholding with a compulsory approach. GPs will remain able to commission services from hospitals for their patients, but will not be able to act individually as in fundholding. The White Paper stated that PCGs should develop around natural communities, but the boundaries have been fixed by the Department of Health and GPs have consequently been coerced into a designated geographical area. A BMA poll published on 4 February showed that 55 per cent. of GPs would not be willing to take an active role in their local primary care group. It bodes ill for the future of primary care group management if GPs prove to be unwilling to sacrifice time to serve on their boards.

In addition to the lack of enthusiasm for the new PCGs among GPs, the fact that groups, rather than individual fundholders, will make service agreements with trusts means that individual practices will lose the flexibility that previously existed. The Government's hostility to individual practices retaining their autonomy could lead to a loss of the specialist services that many fundholders have developed for their patients.

Under the new resource allocation formula, there will be little incentive for practices to make savings because the bulk of efficiency gains will be made by the whole PCG, not the individual practice. The inefficient will be carried by the group, with the result that the entire group will suffer financially. The direct incentives, which existed under fundholding, to be as efficient and effective as possible will simply disappear.

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The abolition of GP fundholding will not lead only to financial inefficiencies--according to the BMA, it will lead to substantial regional variations in care depending on where a patient lives. Under fundholding, patients were almost always able to choose a fundholding GP if they believed that they would therefore receive a better service. Under PCGs, that will no longer be possible.

PCGs and PCTs will reduce the freedom of individual doctors to run their own affairs. They are compulsory bodies, and GPs must join them. They will control contracts, and prescribing budgets for individual GPs will be at the mercy of collective decisions. Flexibility will be reduced, with GPs unable to switch patients from one hospital to another without protracted negotiation. That will add pressure to waiting lists and waiting times. There will no longer be the same drive to improve hospital services.

The Bill will result in a far less efficient, more centralised system of health care. It will reverse the shift in the balance of power from the health bureaucracy to the GP that fundholding made possible. It is a very bad Bill, and I shall oppose it.

9.12 pm

Laura Moffatt (Crawley): I have waited a long time to stand here tonight, both during the years that I spent in the health service dying to have a Government who really cared about the NHS, and during this evening's interesting debate. I have waited for change not only as a nurse, but as a patient.

As a nurse, I found it abhorrent to have to tick forms saying that some people had the advantage of being GP fundholder patients for whom there would be extra care and would be able to rise up the waiting list. I deplored that practice deeply, and I did not want to have to do it.

As a patient, I have the common nurse's complaint of varicose veins, and have waited for two years for treatment. When I rang the hospital to ask what my chances were of being treated soon, I was told that there had been a huge mistake and that, because I came from a GP fundholding practice, I should have been treated a year earlier. When faced with that sort of thing, I realise how important it is to be here today.

I was interested to hear a former Secretary of State for Health, the right hon. Member for Charnwood(Mr. Dorrell), say that the only way in which to judge who held the balance of power in the health service was by seeing who sent Christmas cards to whom. The concept that we might hold each other in mutual respect--that we might want to send Christmas cards to each other because we value the contribution that each of our colleagues makes to the health service--is completely alien to the Conservatives. They are unable even to contemplate it, but the Bill does so, valuing equally the contributions of everyone in the health service and ensuring that we can all work together.

Goodness knows that difficult decisions must be made to balance the needs of the community against the desire to ensure that we have the best service and to ensure the clinical excellence of services provided. The National Institute for Clinical Excellence and the Commission for Health Improvement are our best opportunity to ensure that we work together.

The duty of co-operation excites me because of my local government background. Was it not local authorities that made sure that we had clean water and that people

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lived in decent housing? Now, after all the wasted years not being consulted by those involved in health services, they are back next door to their colleagues in the health service, making sure that they are able to contribute to the improvement of the health of all our people. That is the flavour of the Bill.

The Bill is designed to create a new confidence in the NHS, a confidence that we are beginning to build with the staff. We now talk to NHS staff. There was a huge consultation process involving nurses, who were asked what they thought. I have here a fax from just one nurse in my constituency who said, "I want to contribute and write five pages to Frank Dobson about the way that we should move forward." It is crucial that we listen to those people who are committed to the service.

Staff are the health service's greatest asset. As a former nurse who was pleased about the recognition that nurses have just received--a recognition not only of their contribution to the service but in terms of their pay packets--I cannot forget other members of staff who work in the service. I could not have done my job without the people in the laboratories who helped me to get the results of blood tests as quickly as possible so that we could do our work on the wards. We must think about those people now.

It was bad enough when I had to collect a particularly disgusting specimen--I am sorry; I am a nurse, and I always get down to this sort of talk--but I would often think of the poor person who had to open and test it the next day. Some of those people could be earning just £8,000 a year, so I hope that some can be included in a pay review, just as nurses have been. Nurses are very pleased with their recognition, but we cannot forget some of the other NHS staff.

The Bill is about confidence, about how we recognise the value of NHS staff and about how we communicate and work with them. That is why there should be a duty to communicate with the voluntary sector as well as all the other people involved. They understand what is going on, and this is our best opportunity.

I greatly welcome the new regulatory systems and the new systems of self-regulation of many professions allied to nursing. Some are incredibly invasive--for example, chiropody involves many sharp instruments and even anaesthetics. Many are not registered or regulated, and I want them all brought into a regulatory system.

It is 20 years this month since I joined the Labour party. I joined because I wanted a Labour Government to do what this Labour Government are doing. I am extremely proud that this new Labour Government have the guts to deal with the issues that we think they should, bringing the NHS back to the people and ensuring that the staff work together, instead of fighting among themselves. We want people to be able to say that we have an NHS of which we can be extremely proud.

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