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6.58 pm

Dr. Howard Stoate (Dartford): I welcome the Bill, which sets out an enormous improvement in the national health service. It goes a long way towards making the contents of the NHS plan a reality. Hon. Members have presented reasoned arguments about why they are not happy with some elements of the Bill, and why they would like the Government to look further at some others.

I share some of those concerns, especially when it comes to long-term care of the elderly and to the replacement of community health councils. Those are legitimate questions, but is extraordinary how Conservative Members pontificate about these matters and berate Ministers for their plans to make nursing care free. What did the previous Conservative Government do over 18 years? They did not make any nursing care free.

Moreover, Conservative Members seem to believe that proposals to establish a three-month disregard period, during which people will not have to sell their houses, somehow sell people short. Yet we had years and years of a Conservative Government who did nothing at all to prevent people from having to sell their homes to pay for residential care.

I am happy to listen to reasoned arguments, but I will not take lessons from Opposition Members who did nothing for so long.

Dr. Brand: I agree entirely with what the hon. Gentleman has just said. However, does he not think that the problem goes further? Did not the Conservative Government effectively privatise all long-term care? Previously, it was supplied through the national health service.

Dr. Stoate: The hon. Gentleman makes a valid point. Many homes are closing because the financial arrangements have not worked out, and because they have not met the standards demanded of them by the present Government; but it is important to bear in mind the care provided in the community for people who no longer need to go into long-term residential care homes.

I believe that, as one who still carries out a certain amount of general practice in the NHS, I am well placed to recognise the many problems faced by the NHS over a number of years. I have first-hand experience, and I understand the difficulties that have been faced by both patients and staff. This evening, however, I want to concentrate on patients, because they are what this is all about. We must focus all our plans for changes in the NHS on ensuring that they are given a better deal. Any measure that improves their lot--anything that makes the service more accessible to them, and makes that service better--must constitute a step forward, as I am sure all Members will agree.

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I want to talk not just about what is in the Bill, but about other changes that I would like the Government to consider. There are currently five pinch points, certainly from the point of view of patients. As I have said, I intend to concentrate on processes and outcomes as they affect patients, rather than on structures. Patients do not necessarily want to know who is providing care; they want to know that the care will be provided when they need it, at the standard that they require.

The first of my five pinch points concerns access to primary care. The second concerns arrangements for managing patients in accident and emergency departments. The third concerns elective surgery. The fourth concerns what is to be done about delayed discharges in hospitals dealing with acute cases. The fifth concerns the need to maximise the skills of the many different types of health specialist in the NHS, which I consider are under-used at present.

So far the Government have made good progress in regard to access to primary care, through NHS Direct, the extension of GP co-operatives, out-of-hours centres and walk-in centres, increased use of nursing practitioners and practice nurses in GPs' surgeries, and their commitment to reducing the time for which people must wait to see their GPs and nurses to 48 hours and 24 hours respectively by 2004. Those are important steps towards improving access to primary care, but I think that we could go still further. We could do more to ensure that there are more GPs, that practice premises are better resourced and that more attention is paid to how patients can have access to services out of hours. Securing appointments with GPs often presents a barrier to patients, especially in certain parts of the country. They are often forced to use other services that may not be appropriate.

That brings me to the subject of accident and emergency departments. Many people who use their services do so inappropriately. By definition, accident and emergency services should be dealing with accidents and emergencies, but many people whom I see in my local accident and emergency department, where I spend a lot of time, have not used its services appropriately. The department is being clogged up by people who could have consulted a pharmacist or GP, or telephoned NHS Direct. We must tackle the reasons for that, and the question of what happens to people when they go to accident and emergency departments.

Currently, those who go to such departments will have nurse triage. They will be categorised according to whether their problems are acute and constitute an emergency, or are more routine, and they will wait to be dealt with for a time that accords with that. The system causes huge dissatisfaction not just among patients but among accident and emergency staff, who feel overburdened and overstressed by the sheer number of patients.

Moreover, accident and emergency doctors have not always had the most appropriate training. They are often junior doctors, who have trained in, say, surgery or orthopaedics but are not general practitioners, and do not necessarily possess the required skills and years of experience. The Government should consider arrangements enabling more GPs to be stationed in accident and emergency departments at busy times of the year, and busy times of

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the week. Such arrangements have been piloted in some parts of the country, very successfully. Ministers should encourage further projects of that kind, so that more accident and emergency departments have GPs with the necessary skills and experience--and, sometimes, the necessary forcefulness--to ensure that patients are moved through the system much more quickly. I think that that would benefit everyone.

Then there is the issue of elective surgery. One of the most difficult experiences for any patient is to be teed up for an operation, only for it to be cancelled at the last minute because the bed has to be used for an emergency. Everyone understands that the NHS must deal with emergencies, but that is not much consolation to someone who has had to rearrange child care and family life. That person may have spent the past week preparing psychologically for what may constitute a major life event, only to have his or her hopes dashed. When someone is told, "I am sorry but the bed has gone; come back next week", that is not acceptable.

The Government should consider setting up dedicated elective-surgery units whose beds are not subject to emergency pressures. Those beds would be guaranteed--a cast-iron guarantee--for elective work. Providing such arrangements in general hospitals would ensure not only that all ancillary emergency services were on hand, but that patients were given the paramount attention that they needed. In the event of an emergency, the patient could still be dealt with in an acute hospital in the usual way.

Doctors and nurses could spend six months or a year in elective units as part of their training--as part of surgical rotations, perhaps. There could be dedicated units. Patients could be guaranteed beds, and it would be almost inconceivable that anyone else could use those beds. Patients would really know where they were.

Then there is the problem of delayed discharges. My local hospital in Dartford currently experiences between 40 and 50 on a given day, and I am sure that the same obtains throughout the country. The hospital has only 400 beds. If 40 are filled with people who have completed their treatment and are ready to be discharged, but cannot be discharged for a number of reasons, 10 per cent. of the hospital's capacity has been taken up. The problem is, of course, much greater for a hospital that is dealing with acute emergencies, GP admissions and elective surgery.

When the Secretary of State visited my constituency recently to open the new district hospital, he added his weight to the call for a step-down community unit in the constituency of my hon. Friend the Member for Gravesham (Mr. Pond), which would allow 24 patients to move into a nurse-led unit with much lower levels of medical cover. That would be entirely appropriate. It would be much cheaper and cost-effective, and would allow the expensive acute hospital to provide the high-tech care that is needed. The acute hospital would be able to use all its 400 beds, not just 350. By that means the Government could speed progress through the system, and give patients a far better deal.

We need to maximise the skills of all who work in the NHS. I chair the all-party group on pharmacy, and I meet many groups representing pharmacists. I meet community pharmacists; I talk to pharmacists at length. It seems to me that pharmacists can and want to do far more than they do currently, and I think that if they were able to do so it would be of enormous benefit to both the NHS and patients.

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I welcome the part of the Bill that deals with the extension of prescribing. I am glad that pharmacists will be able to prescribe drugs--that they will be able to issue not just repeat prescriptions but de novo prescriptions in the case of certain classes of drug. Where that has been tried in pilot studies involving, for example, emergency contraception, it has proved very popular and workable. It has greatly satisfied patients, who have been given much-needed access to drugs. I hope that, as the Bill progresses, we shall be given more details.

The Bill contains proposals for the remote provision of medicines through the internet, by mail order or through a delivery service to patients' homes. That, too, is a good idea. For all sorts of reasons, some patients have difficulty in getting a prescription, taking it to the pharmacy and collecting their drugs, which may cause considerable hardship. Again, I hope we shall have more details as the Bill progresses.

There is no doubt that community pharmacy contractors welcome the opportunity to broaden the range of services that they provide. They have called for such opportunities for some time. However, they have an over-arching concern. At present, community pharmacy is probably the most accessible part of the NHS. There are pharmacies all over the country, in most high streets and in all but the most remote parts of the country--in cities, towns and villages, and areas where people work.

Community pharmacists are more accessible than the majority of health professionals. Community pharmacies are normally open six days a week, sometimes seven. They are open for long hours. People do not need an appointment; they can just drop in and talk to pharmacists, who provide expert advice on medicines, medicine management, compliance issues and a range of other health-related matters. They sell "p" medicines, which are available only from pharmacies, dispense drugs and ensure that people understand how to take them. That extraordinary accessibility and flexibility is the cornerstone of what pharmacies have managed to achieve. Pharmacists welcome that advance and patients also find it useful.

I am slightly concerned about clause 31, which allows for the suspension of control of entry regulations to facilitate the provision of new services. Pharmacists have explained that suspending control of entry and establishing new premises from which pharmaceutical services, including existing services, are provided, might have a serious impact on existing pharmacy services and pharmacies in the area.

I want the Standing Committee to consider whether it would be reasonable to include a provision that allows health authorities to take account of the effects of the arrangements on existing pharmaceutical supply services. Rather than simply suspending the list and allowing new contractors to establish services, which might be in direct competition with existing contractors and might, therefore, have a destabilising effect, we should allow the authorities to take careful account of the effect of the new arrangements. We do not want to damage the fragile but essential network of community pharmacies. I would hate a brand new arrangement to be implemented that appears, on the face of it, to be a good idea, but which destabilises existing contractors and worsens the service for patients. I would be extremely happy for that to be flagged up, and perhaps the Minister will be able to comment on it.

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Men have had a bad deal from health services over many years. They suffer from far more illnesses, die much younger and contract more cancer and heart disease than women. However, they are very bad at accessing services. We do not understand why that is the case. Women have been extremely successful at improving and accessing their services. Men lag a long way behind. The Government should consider what they can do to understand why men get a bad deal, are more ill and do not access services. We need to find out what we can do to ensure that they are included in the health improvements that are needed so that the health service is fit for the 21st century.

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