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9 pm

Dr. Peter Brand (Isle of Wight): I shall not talk about community health councils or long-term care--not because those are not important parts of the Bill, but because that ground has been covered well in the debate, in particular by my hon. Friends the Members for North Devon (Mr. Harvey) and for Sutton and Cheam (Mr. Burstow).

A number of the issues in the Bill concern me as matters of detail, but they are best explored in Committee. I shall highlight the more philosophical issues that underpin some of the hints that the Government are giving us as they unroll their plans for the national health service.

I was intrigued to see the parts of the Bill that deal with setting up pilots, which are to be administered by the Secretary of State. I was bemused by the traffic light system, which would empower the right hon. Gentleman to reward positively or negatively the performance outcomes not of health authorities but of trusts.

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I wonder about the Government's avowed intent, because when they came to power they made it clear that they wanted to retain the commissioner-provider split. The Bill, as we will explore further in Committee, will result in direct management of NHS provider units by the imposition of particular standards, not through the commissioning bodies--health authorities--but directly through the trusts. If that is to happen, let us be open and honest about it. Let us say that the great experiment--the tension between commissioning and providing--is no longer relevant if we are not to have a managed market.

I was a big critic of the unmanaged market unleashed by the previous Government's reforms, but the managed market was working in the interests of patients. It made trusts sit up and tailor some of their activities to the communities that they serve, rather than to what suited them best.

In the Bill we see an extension of what we have seen with the special initiatives of which the Government are so fond, and the projects for bidding for extra funds, in which the delivery units are directly influenced. Once one influences, one controls what happens on the ground. That is worth exploring, and I should be grateful if the Minister could say in his reply where the Government intend to go in the long term.

I recognise that the health service evolves; it has never stood still. I think that this is the fourth or fifth reorganisation during the 30 years that I have worked in the service.

Mr. Swayne: It is what will happen on the ground that concerns me. Will the hon. Gentleman consider the case in which constituents may already be unfortunate in the service that they are receiving from a trust, then the trust gets the red light and is therefore punished by the Secretary of State in some way? Are they likely to get an improved service as a result, or is it more likely that there will be an even worse service?

Dr. Brand: The hon. Gentleman makes a valid point, and it needs to be examined in Committee. The wording in the Bill is unfortunate. It seems to imply that funding will go only to trusts that meet performance targets, whereas the Secretary of State has said that funds would be made available to other trusts, but with strings attached. That implies that a management team will emerge from Richmond house to sort things out. I wonder whether that would not be better done through health authorities, as they should be more aware of what is required in their localities.

Before I move to my next question, I have to declare an interest. I qualified as a doctor in 1971, and have worked for the national health service for 27 years as a general practitioner, largely on the Isle of Wight. I have enjoyed being an independent contractor tremendously, and I still do a little work on a part-time basis. I shall have to see what happens later this year, but I have greatly enjoyed my calling.

In previous NHS reorganisations, GPs were often asked how they would meet certain objectives, and what they were going to try to achieve. The usual answer was that GPs wanted to continue to provide a good service to patients and to be responsive to their needs, while remaining able to employ the team of people who are so vital in primary care--and to pay the mortgage. That is a small ambition, but it is amazing how inventive GPs have had to be to achieve it in the face of reorganisations.

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Two proposals in the Bill ring a small alarm bell with me. The first is the plan to scrap GPs 24-hour responsibility for their patients. I know that many of my colleagues will not be displeased by that proposal, but I may belong to the last generation of family doctors who felt that they were responsible for the total care of their communities and the individuals within them.

The proposals to allow organisations to take over some of that responsibility are much to be welcomed, but the doctors with whom patients are registered should retain a responsibility for the quality of care that an outside organisation delivers.

Mr. Denham: The Bill does not remove GPs 24-hour responsibility for patients. In practice, many GPs look to an out-of-hours provider, and the Bill clarifies the way in which a GP can delegate that responsibility to an accredited provider. That is an important distinction. We can discuss it further in Committee, but I want to clarify that very important point this evening.

Dr. Brand: I accept that distinction, but GPs will still be contracting out a responsibility. Before, we contracted out a service and retained responsibility for it. There is a difference.

My other misgiving concerns the extension of the private finance initiative into primary care. It is clearly good for GPs to have access to funding. That allows them to improve their capital stock and give a better service to patients. However, I am concerned that we will end up with a uniform pattern of one-stop shops. They might be completely suitable for cities and more densely populated areas, but it would be difficult to sustain them, and their responsiveness to patients, in more rural areas. In addition, whoever contracts with the private sector to provide the premises will also have control over who works there.

I have been very privileged. I have been answerable to my patients, the General Medical Council and God. I do not think that the Secretary of State came into it very much. One could continue to provide a service as long as one had a patient base. The introduction of clinical governance is absolutely right, as is the need to look at outcomes and to take account of all the other matters that are so important. I agree that things have changed; I may have started my career in feudal mode, but things have moved along considerably. A GP relies on team work, and patients are part of that team.

I am worried about the possible creation of a blueprint that might be too prescriptive, dictating to primary care teams not only what service they deliver, but how it is delivered. We are already seeing evidence of that in primary care groups and trusts. I suspect that I am being old-fogeyish, but I think we have done extremely well out of the dedication and initiative shown by private independent contractors. I hope that we can retain that arrangement, because I do not think that a more bureaucratic organisation will create what the hon. Member for Bedford (Mr. Hall) described as a national health service according with patients' needs.

We must have balance. It is entirely right for us to be responsive to patients' needs, but pure consumerism in health care would be very expensive. It could not be afforded, even given the Government's more relaxed attitude to funding. Patients' demand for access is almost

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infinite. It is not unusual for a doctor to be called out in the middle of the night because a shower is not working, or because someone needs a plumber. It should be possible to say no occasionally. I am sorry to say that my practice recently had to introduce an all-appointments system, because the work load could not be managed in any other way, unless people were made to wait for a very long time. We no longer deal with requests for prescriptions on the telephone, because we do not have enough staff to deal with that work load either.

I welcome some of the initiatives on prescribing. It is entirely right to enable other members of a clinical team to take responsibility for their areas of expertise. I would be foolish not to countersign prescriptions written by my practice nurse or the district nurse, but it is demeaning and stupid that I should have to do so. On the other hand, I would be very worried if there were a free-for-all allowing me to sign prescriptions for my own medication, or--this aspect was raised by the hon. Member for Woodspring (Dr. Fox)--to obtain my asthma inhalers ad lib over the counter. If that were possible, someone might be given too much of the wrong medication, which would not be in that person's interest.

A balance must be struck. Consumerism in the NHS may be good, in the sense that we must be responsive to people, but allowing patients to dictate what happens in the NHS would not be a positive development, because it might not benefit the wider community. That is why I made my point about the naming of the patients forum, and the over-dominance of direct NHS users in it. The health service should do more than just treat people who are sick. It should be there to maintain health, to promote health and to take account of the broader aspects of the community that it serves. I hope that we shall have an opportunity to explore some of those issues in Committee.

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