Health and Social Care Bill

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Mr. Denham: I have considered that last point carefully. It is a matter of judgment for the Committee, but my view, on balance, is that quality need not be included. The Government's wish to have a contract that gives appropriate rewards for quality is shared by the profession. That is not in doubt. We have found in previous legislation that including such factors imposes constraints; it is a matter of judgment whether one should impose a further constraint, but I believe that it is unnecessary.

The hon. Gentleman is in something of a tangle with his interpretation of clause 20 and the 1977 Act. The effective interpretation of the 1977 Act has been that doctors are paid a fixed amount each year, including a sum that is based on capitation and must be more than 50 per cent. of the total remuneration. That is a restriction. The contract is to be renegotiated. I do not know whether a payment related to quality might replace it. It is conceivable that, as with some PMS contracts, a certain part of the payment should relate to maintaining a certain size of list, but one that is not related to capitation. A number of variations are possible.

Rightly or wrongly, I take reassurance from the fact that my officials have met with the General Practitioners Committee of the BMA and discussed the clause in some detail, as they have done the rest of the Bill. The GPC understands what we propose, and does not share the hon. Gentleman's concern. It is true that they would like a provision on quality to be included in the Bill, which I entirely understand. However, it has not raised with my officials the matter of remuneration being

wholly or mainly of a fixed salary.

Mr. Hammond: I do not wish to flatter him unduly, but the Minister says that the GPC has not raised those concerns with him. If he turns his mind back a couple of years, he may remember that, on more than one occasion, he got the better of the GPC in negotiations. The fact that the GPC has not expressed concerns about what the Minister intends to do does not mean that we should not probe the matter carefully. By nature, doctors tend to be trusting, and they will expect Ministers to be open and honest. I do not think that there is any misunderstanding over clause 4.

I seek a clear statement from the Minister. If he is looking to replace capitation-based remuneration with fixed remuneration, he needs to repeal section 29(4) of the 1977 Act. If he proposes that GPs should have more than 50 per cent. of their remuneration by way of a fixed salary, without reference to capitation or anything else, he needs clause 20. My understanding, from the general tone of the Government's approach to GP remuneration, was that he intends that more than 50 per cent. of GPs' remuneration should be related to the quality of the service that they provide and the outcomes that they deliver. If, therefore, the most significant part of their remuneration will be dependent on the quality of service that they deliver, he does not need clause 20.

Nothing in section 29(4) of the 1977 Act would prevent the Minister from paying a general practitioner 49 per cent. of his total remuneration as a fixed sum, by reference to nothing, and the other 51 per cent. by reference to something like quality of outcome or patients' experiences of the services delivered. Will the renegotiated GMS contract provide for the payment of a fixed salary, without reference to capitation, which constitutes more than 50 per cent. of the total remuneration? If so, the Government are missing an opportunity to do something that their propaganda suggested they would do, which is to place quality patient experience and outcomes at the top of the agenda.

Mr. Denham: In a sense, capitation payments are fixed. They are not fixed in absolute terms, because they depend on the number of people on the practitioner's list, but they are fixed in that they must be more than 50 per cent. of the total. We are trying to remove that obstacle. The provision effectively requires a GP who has twice the number of people registered on his or her list as another GP to be paid twice as much. We are trying to escape the hook of a direct link to capitation. In the future, it is likely that remuneration will be linked less directly to the number of patients on the list. In some PMS contracts, the GP is required to maintain a list of a certain size, but the contract emphasises the quality of services provided to those on the list. It is conceivable that we may wish to cap that type of contract.

In this discussion, where there is no real difference between our objectives and those of the profession, it seems pointless to try to specify what elements might or might not constitute precisely 50 per cent. of the future remuneration. When we come to negotiate, it is likely that the number of patients will be a relevant factor, but we are trying to get rid of the provision that has effectively tied us to a capitation system.

Dr. Brand: It is true that before quality can be delivered, a basic practice must be assembled, so there is still a need for a basic practice allowance of some sort. I support what the Government are trying to do, and that is not necessarily because I am so trusting. I have spent my clinical professional life with drug addicts—people who are pathological liars.

Mr. Hammond: Like politicians.

Dr. Brand: I have been anticipated. Medical negotiators can certainly cope with the average politician.

Mr. Denham: We know that, but what we want to know is what the hon. Gentleman did before he became a Member of Parliament.

We have reached the stage in the debate where I have set out my view of the legislation and the purposes that lie behind the clause, and the hon. Gentleman has set out his views. I fear that we will simply go over the same ground again and again.

Mr. Hammond: I fail to be convinced by the Minister's argument. My interpretation of section 29(4) of the 1977 Act is that it would allow for a fixed salary, without reference to capitation, equivalent to 49 per cent. of the total remuneration to be paid. I see nothing in clause 20 that would stop a further amount, linked to capitation, being paid, and a further amount beyond that, linked to the fulfilment of other criteria.

The Minister is clearly basing his remarks on the advice that he has been given. I will go away and talk to people who are better able to dissect these things than I am. I do not pretend to be a lawyer. One of the problems under which we labour in this place is that we are expected to provide interpretations and advice for which people outside the House would expect to be paid a great deal more per hour than Members of Parliament or civil servants are. However, I hope that the Minister will think again if I come back to him, before the Bill is considered on Report, with an opinion that gives credence to what I am saying. We are simply seeking to look behind what he is trying to do and find out whether he has an agenda that requires the measure. Such an agenda might give some cause for concern, whereas his stated agenda, which we do not believe requires the clause, does not. We accept that that agenda is being discussed with the profession. Our only concern is to unmask any actual or potential hidden agenda for the future.

The Committee can move on now, but I hope to revisit the issue with the Minister later. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 20 ordered to stand part of the Bill.

Clause 21

out of hours medical services

10.30 am

Mr. Desmond Swayne (New Forest, West): I beg to move amendment No. 168, in page 14, line 21, leave out `another' and insert `any other'.

The Chairman: With this it will be convenient to take amendment No. 169, in page 14, line 26, at end insert

`, including requirements as to the provision of information on services provided to the principal'.

Mr. Swayne: In view of what the Minister has told us about the disagreeable consequences of reconvening the dreaded Programming Sub-Committee, it may be for the convenience and relief of the Committee if I kept my remarks as focused as possible. That will be my endeavour.

Amendment No. 168 attempts to remedy the lack of clarity in the clause. What was meant was not entirely clear to us. The explanatory notes state:

The body to be regulated is any body or organisation providing out-of-hours cover to GPs that will have to be accredited by a Health Authority.

Does that mean that the body will have to be accredited by any health authority, not necessarily by every health authority, to which it provides an out-of-hours service? That is our understanding of what the clause means, so we are trying to make it more explicit. After all, we are here to help. The spirit of the amendment follows Oliver Cromwell when he said that no real reform could be achieved unless the whole law was reduced to the bigness of a pocket book, intelligible to all men.

Having said that, and believing that the clause has precisely that meaning, I understand the attractions of its having an interpretation under which a provider would have to be accredited and be on the list of every health authority to which it provided a service. If a complaint were to arise against such a provider, the health authority that received the complaint might be unable to seek redress by taking proceedings against that provider, with a view to removing it from its list. The health authority would have to initiate those proceedings with another health authority that had the provider on its list.

It may be administratively convenient for a provider to be on every health authority's list to which it makes provision. However, that administrative convenience must be set against the huge bureaucratic burden that would be placed on the provider of having to register to be accredited by every health authority to which it provided a service. We tabled the amendment in the understanding that the clause means that once a provider has secured access to the system by gaining accreditation from a health authority, that body can provide those services to all health authorities. We seek to make that explicit in the Bill.

Amendment No. 169 is intended to make one of our principal concerns explicit. We fear that access to NHS services may be becoming fragmented. That concern for continuity of care is not restricted to Conservative Members, but is also a concern among medical professionals. In an article in Doctor on 21 January 2000, Dr. Gillam, the Luton general practitioner who is also a director of the primary care programme at the King's Fund, commented that NHS Direct was part of what he saw as an agenda of fragmenting access to the national health service and that it could destroy continuity of care.

That fear has been echoed in a survey of doctors published in GP Magazine on 25 February 2000, which revealed that 81 per cent. of doctors questioned felt that continuity of care was being jeopardised by NHS Direct and walk-in centres. That concern for continuity of care was expressed in the independent report that was commissioned by the Department of Health ``Raising New Standards for Patients—New Partnerships in Out-of-Hours Care.'' I draw the Committee's attention specifically to recommendation 4 of that report, which states that

all providers should report all out-of-hours consultations to GPs by 9.00 am the next normal working day.

Clearly, the authors of the report share the concern that there should be continuity of care and that that information should be provided. However, even that was only an interim measure and very much a second best, because the ideal solution is the provision of electronic systems. The electronic health record will provide a three-way exchange of data between NHS Direct, the out-of-hours providers and general practitioners. It would assist us if the Minister could say precisely what stage has been reached in the provision of the electronic record and what prospect there is of its delivery in the medium term.

I have a wider concern about the clause, which is not germane to these two rather focused amendments. I am inclined to leave that matter to a stand part debate, but if you decide that there will not be a stand part debate, Mr. Maxton, I shall seek to catch your eye a second time.

 

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Prepared 25 January 2001