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Westminster Hall

Tuesday 10 July 2001

[Sir Michael Lord in the Chair]

GPs (Sussex)

Motion made, and Question proposed, That the sitting be now adjourned.—[Mr. Sutcliffe.]

9.30 am

Tim Loughton (East Worthing and Shoreham): I am delighted to have secured this debate so early in the new Parliament. I welcome the new Under-Secretary of State for Health, the hon. Member for Salford (Ms Blears), to her first outing in such circumstances. We will be gentle with her. I am pleased to see so many colleagues from West Sussex. They, too, have encountered the problems that I am about to recount; my comments will relate mostly to Worthing, but the problems are found throughout the two counties that comprise Sussex.

I hope that I do not gain a reputation for whinging on behalf of my constituents if I claim that we in Sussex—especially in Worthing—have special problems. I have initiated several Adjournment debates on the problems facing the elderly in West Sussex, the enormous pressures that are put on social services by the high population of elderly people, and the great pressures put on the health service generally in the county. Much of what I say will strike a chord with other hon. Members but, as they would expect me to say, the situation in Worthing is far more acute.

That severity is the result of a cocktail of contributory factors, not least the fact that the population of the borough of Worthing is the oldest in the entire country: 48 per cent. of the electorate in the constituency of my hon. Friend the Member for Worthing, West (Mr. Bottomley) are of pensionable age, making the population there by far the oldest in the country. The knock-on effect is felt in many of the other Sussex constituencies where the proportion of elderly in the population is nearly as high. That is why I broadened the debate to include the whole of Sussex, even though I shall concentrate on Worthing.

Worthing has more than double the national average of over-65s and more than treble the national average of over-85s. Of the 211 hospital trusts in England, Worthing hospital now has the ninth longest waiting times; they have been gradually worsening for the past four years. Hospitals with even longer waiting times include those of the neighbouring Mid Sussex national health service trust and the Royal Surrey County Hospital NHS trust, which is not far away. My hon. Friend the Member for Runnymede and Weybridge (Mr. Hammond) knows of that problem.

A great deal of work caring for patients who wait inordinately long times falls back on GPs. Patients whose operations are cancelled need some form of ameliorative treatment while they wait. The enormous pressure on social services—I introduced a debate on

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that subject some months ago—leads to significant problems of bed blocking. All those factors result in increased fallback on GPs, particularly in Worthing. One Worthing GP says,

I do not mean to be alarmist or scaremongering, and I am not trying to score party political points. What I am about to describe is based on facts and the experiences of several GPs in Worthing and elsewhere in my constituency who are at their wits' end.

Mr. Nick Gibb (Bognor Regis and Littlehampton): We in Bognor Regis have the same problems. The Bognor Regis health centre has cut 1,000 patients from its list. This morning, I received a letter from a doctor saying that there is simply no leeway—he cannot accept more patients. Grove House in Pagham is full and not taking more patients, Maywood and West Meads surgeries are full, and Feltham and Middleton have recently discarded patients. The doctor points out that there might well be 2,000 patients in Bognor Regis who have no GP at all.

Tim Loughton : I thoroughly understand the problems in my hon. Friend's constituency, just along the coast from my own. The situation in Worthing is rather more alarming, although that does not improve the situation affecting him and his constituents.

My comments stem from a meeting that I had just before the election with a couple of dozen GPs, at their behest, and from a letter sent to patients of one surgery in Worthing that has had to close its list. Virtually all the GP surgeries in Worthing have now closed their lists to new patients. My argument also stems from the anger that that engenders in many patients, even though they understand the pressures that their doctors are under. Usually mild-mannered doctors have gone public to give details of their plight to patients, not least in a series of articles run by the Worthing Herald, a local paper to which I pay tribute for the work that it has done on the issue. In an article entitled "Why your doctor fears for your health", one doctor is quoted saying:

A letter from Shelley road surgery in the centre of Worthing—it lies in the constituency of my hon. Friend the Member for Worthing, West but caters for many of my constituents in East Worthing—informed patients that it was about to close its list. In it, the doctors stated:

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I pay tribute to the doctors who, although they are working under enormous pressures, have, both on and off record, contributed to my speech. In particular, I thank the Shelley road surgery and Dr. Bruce Allen, who has taken the decision to speak out on behalf of his patients and colleagues because the local GP service is at breaking point. He sent me some comments for the debate, which I received yesterday; he apologised for having taken so long to get back to me after learning that I had secured the debate. His excuse—

Mr. Peter Bottomley (Worthing, West): His reason.

Tim Loughton : Indeed. His reason for taking so long was that on Thursday he had worked solidly between 8 am and 11.30 pm, on Friday he worked solidly between 8 am and 8 pm and on Saturday he worked solidly between 7 am and 10 pm. He typically works between 60 and 65 hours per week. It is not a question of being on call or waiting for something to happen—all the work involves intensive patient contact.

The surgery deals with 11,400 patients and has a full-time equivalent of 5.7 doctors, which means that each doctor has about 2,000 patients. Doctors live in fear of falling ill themselves because of the problems that that would cause in terms of getting cover for patients, and because of the pressure that it would put on other doctors in the practice. On top of those working hours, in the past few weeks Dr. Allen has had his face spat at, been threatened with violence and sworn at profusely, and has had paint stripper poured over his car; one of his partners has had two tyres slashed and another a knife scraped down the side of his car. That has happened in cushy, affluent, south-coast Worthing.

The statistics are clear. In Worthing, 14 per cent. of the patients on a typical GP list are aged over 75; that is more than double the national average of 6.9 per cent. On the list of one surgery in Worthing, 22 per cent. of patients are aged over 75; that proportion is thought to be the highest in the country. The proportion of over-85s on patient lists in Worthing is 5.1 per cent.—more than three times the national average of 1.6 per cent. Worthing primary care group has 30 nursing homes caring for 778 people and 78 residential homes caring for 1,515 people. The Shelley surgery has 125 nursing home patients and 190 residential home patients on its list. That works out at an average of 55 per GP, whereas the UK average is five per GP. That surgery copes with 11 times the national average of patients from care homes.

The British Medical Journal states that nursing home patients require just over two times the number of visits required by patients of equivalent age who live in their own home. The home visit rate for over-85s is double that for over-75s, and we know the additional requirements that over-75s bring. However, no additional capitation is available for over-85s. That problem is not unique to Worthing, but many people like to retire to Worthing and, because of the general niceness of the place, they tend to live a very long time. We are delighted that they do, but local GPs face an inordinate amount of extra pressure as a result.

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There are many other factors involved. Many people in our town live alone, which is a known cause of increased demand on GP services. In the Central Worthing ward, 16 per cent. of the population are aged over 65 and live alone; the figure is more than 21 per cent. in another ward. That compares to only 5 per cent. of the population in "younger" Sussex towns. Despite those extra pressures, Worthing does not have more district nursing services available than any other area of Sussex.

We have a serious problem with nursing recruitment. There have been 70 vacancies at Worthing hospital for more than five years. There is a particular problem with recruiting practice nurses to help with the work load: they simply do not apply for the jobs. Worthing also has a serious shortage of health visitors to deal with the under-fours. The absence of those extra staff creates additional pressure that falls back on to GPs.

Worthing has more than its fair share of deprivation. Of 155 wards in West Sussex, Nos. 1, 11 and 16 in the rank of deprivation are in Worthing, but local GPs describe the deprivation payments that come within the national health budget as very inadequate. In addition, there are enormous pressures in the mental health sector. We have three homes in the centre of Worthing for long-term psychiatric patients. Many patients have recently moved to the Shelley road surgery area following the closure of Graylingwell psychiatric hospital further to the west: the capitation fee to the GP is much lower, but the patients' problems are not diminished. I remind hon. Members of the tragic case of Sarah Lawson, who was killed by her father while she was in a desperate mental state. He is a constituent of mine and the tragic incident took place in Worthing, although I am sure that the report on it will show that local GPs and the staff of the local care trust offered a great deal of support and performed very professionally.

Extra local pressure is caused by four homeless hostels that contain potentially high demand patients, including people with serious alcohol and drug misuse problems and are therefore susceptible to hepatitis and HIV. There are two local homes for disturbed children, including one for mentally disturbed adolescents from Southwark in London. It is cheaper to house them in Worthing than in London, but they are far removed from their social care workers. A doctor told me that a youngster from one of the homes recently ran amok through the streets of Worthing brandishing a knife. To section him, the doctor had to locate and contact the social worker and psychiatrist in London. In addition, the Shelley Road surgery runs fortnightly methadone clinics on a shoestring budget and meets demands from three local hostels for asylum seekers, with the extra pressure and costs that that involves.

Things are not easy in Worthing and the situation is getting worse. At the Shelley road surgery, each doctor sees an average of 58 patient contacts in a working day: that is one every 8.27 minutes, including home visits and telephone consultations. Those figures represent a 21 per cent. increase during the past six years. The doctors have also to deal with referrals, incoming paperwork, letters and test results that require action. They must also run practice premises, achieve national service framework targets, attend primary care group meetings and postgraduate education meetings, run

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audits, participate in local development schemes, hold weekly practice meetings, monitor prescribing patterns and keep within their budget.

An enormous extra work load has been placed on general practitioners across the country. They now must administer drugs to deal with cholesterol levels, monitor more blood pressures and achieve blood pressure reduction targets, which involves administering more drugs. Forty per cent. of patients being monitored for blood pressure typically require three drugs to achieve targets, and those drugs must be administered by the GP. They are also administering more antidepressants and treatments for osteoporosis. They, rather than hospital out-patient departments, now give prostate injections, and there have been further shifts from hospitals to primary care in dealing with routine diabetic care and coronary heart disease follow-ups. In addition, the closure of long-stay geriatric and psychiatric hospitals has given greater responsibilities to GPs. Those may be progressive developments, but they were usually made without consultation as to their likely impact on GPs and without proper additional resources accompanying the patients. As one Worthing GP puts it,

The funding model for GP surgery staff is 30 years out of date. Many GPs have to subsidise from their own pocket the necessary extra staff. It has been estimated that GPs in West Sussex subsidise the staff model by between £750,000 and £1 million a year. There has been an alarming rise in resignations among practice staff: one surgery in Southwick in my constituency has lost five out of its 16 members of staff in the past six months. Losing experienced staff means that it will have to increase the number of new staff, if it can find and recruit them. As a consequence, the staff budget will be overspent by £20,000, which will cost each partner £4,000 from his or her own pocket. As one said,

GPs are having to pay to move to new premises in Worthing because the old ones are bulging at the seams; they are not getting the necessary support from the local health authority. There should be sporadic reimbursement for computer equipment, but the total budget for computers in Worthing in the current financial year is, in effect, zero. How are surgeries supposed to modernise? New local development schemes, which the Minister might mention as bringing extra funding, provide only 20p per patient per annum, and practice development money amounts to only £1 per patient per annum—and both have been described as hopeless. Worthing GPs are particularly annoyed to have received no fees from the Government for flu jabs for the over-65s, despite the Government claiming success for averting a flu crisis.

The situation is not a happy one. At the Shelley road surgery, there is a two-week routine wait to see a GP and a one-week routine wait to see a nurse. Out of 48 GP positions in Worthing, there are four full-time

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equivalent vacancies. The last three advertised posts attracted zero applications, and the health authority acknowledges the problem. As one GP put it, new GPs consider working in Worthing, but decide to move elsewhere because resources do not flow there proportionately. Although nearly all the surgeries in Worthing have closed their lists, the lists continue to increase because the health authority compulsorily allocates additional patients.

The closure letter sent by the Shelley surgery said:

There is a crisis not only in recruitment of new GPs, but in retention of experienced GPs. A recent survey in West Sussex showed the age at which GPs hope to retire: 30 per cent. hope to retire between the ages of 52 and 55, and 60 per cent. before they are 60, whereas only 4 per cent. want to retire aged between 60 and 64, and 6 per cent. want to retire as soon as possible. Experienced GPs are talking about leaving an already demoralised service. They cannot be replaced by going to a shop and buying a new packet of seeds to grow some more.

The health authority knows about the problems, but the glossy, professionally assembled briefing pack full of wonderful brochures with which general election candidates were provided may have led one to think that the health service in West Sussex is flourishing. It was difficult to find much discussion of the problems that I have recounted today. The community health council—long may it remain in Worthing, but if the Government revisit their previous intention, it will not last much longer—flagged up four problems: retaining GPs other than those retiring and recruiting new GPs; appointment times for non-emergency conditions extending in many practices; GP contracts being renegotiated with an adverse effect on morale; and the acute need for more nurses to lighten the load, but severe difficulties in recruiting them.

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We hear a great deal from the Government about their plans for NHS hospitals in terms of hospital waiting lists and recruitment of doctors, but GPs account for only 3 per cent. of the entire NHS budget. Small wonder they feel that they get a raw deal. In 1990 there were 27,523 GPs and by 2000 their number had increased to 30,252, which is a 6 per cent. increase in working time equivalent GPs, whereas there were 15,520 consultants in 1990, compared with 23,045 last year, which is a 45 per cent. increase. No wonder GPs feel that theirs is the Cinderella service in the NHS. The statistics on GPs are confused by the full-time working equivalent figures: a truer estimate of the increase in the GP work force is probably no more than 1 per cent.

When international comparisons our made, the figures in this country are woeful. There are 554 doctors per 100,000 patients in Italy, 350 in Germany and 303 in France. In the United Kingdom, there are 164 GPs per 100,000 patients; the next lowest figure in the European Union is Ireland's, where there are 219 GPs per 100,000 patients. In the whole of Europe, only Turkey and Albania have a worse ratio than the UK. The future is worrying. According to the British Medical Association,

No doubt the Minister will say that the Government are doing their best to retain doctors by offering £10,000 golden handcuffs. It seems amazing that doctors are not interested, but behind the figures is the fact that a GP who retires at the age of 60 in West Sussex has an average life expectancy of 14 years, whereas a GP who retires at the age of 65 has an average life expectancy of only two years. That is a no-brainer—£10,000 in exchange for 12 years of life in retirement is hardly an attractive proposition. The Government need to look beyond that gimmick, because it has not been well received.

We worry, too, about the increase in clinical requirements in the NHS plan, as they will require longer patient consultation times even though doctors' schedules are already tight. An increase of one minute in the average patient consultation time is an increase of just under 10 per cent.; that will require a corresponding increase of more than 3,300 GPs. The BMA notes:

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All those factors, and more, are concentrated in and around my constituency, especially in Worthing. The risk is that doctors will leave the NHS en masse, and perhaps leave the country or leave the profession when we can least afford it. Help is needed before something breaks. The current situation is not fair to our doctors or our constituents, nor is it safe.

I ask the Minister to have a close look at the problems in West Sussex and Worthing, which have a high concentration of elderly people and problem patients. Sussex and the coastal strip are not wealthy, cushy areas, but the Minister's colleagues have dismissed them as such. We desperately need help. I implore the Minister urgently to consider the matter in the light of the alarming statistics and case studies that I have presented to her. I hope she will agree to meet GPs in my constituency to see what can be done to help them before things really snap.

9.59 am

Mr. Peter Bottomley (Worthing, West): I congratulate my hon. Friend the Member for East Worthing and Shoreham (Tim Loughton) on initiating the debate. I welcome the presence of Conservative Members of Parliament from Sussex. The issue clearly matters to Labour Members as well, and I am glad that they are so well represented—[Laughter.] I would like especially to pay tribute to the Whip for his contribution to our debate.

My hon. Friend's speech was far better than any of the rest of us could have delivered. He brought together the points that matter, and I will not repeat them in any detail. I invite the Minister not just to respond to the debate, but to give a lot of thought to how to respond to the issues that have been spelled out.

In Worthing, West Sussex, Sussex as a whole and in the country, great efforts are being made, and I pay tribute to the efforts of the auxiliary staff, support staff, nurses, doctors, managers and administrators across all the health services. However, it is also true that more could be done but is not being done. Many people's experience of the national health service is that it has become a national waiting service. Some things can be put right. There was a time in Worthing when the wait for a 20-minute hearing test at the hospital on the NHS was a year; once the assessment had been made and the hearing aid had been ordered, it took five months to have it fitted—six weeks for it to arrive and three and a half months to get an appointment to be shown where the on-off switch was. However, that temporary problem has been resolved.

Many other waits have not been resolved. Worthing and Southlands hospitals have reduced some of their waiting times, which is welcome, but they remain far too long. My hon. Friend mentioned the situation in Surrey: one in 10 of those waiting for more than a year in Surrey

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are waiting for in-patient treatment, and the Sussex figures are not that different. However, it is instructive to contrast those figures with those for Durham health authority area that covers the Prime Minister's constituency: there, the rate is one in 100 or one in 200. There may have been reasons why that disparity arose, but there is no reason for it to persist four years after we were told the NHS was going to be saved.

Hon. Members and their GPs all know people who have died because they have had to wait. The debate is not about hospital services, but I do not want to focus solely on GPs and not mention the efforts being made by people working in hospitals. Some complaints are unjustified, others are justified, but all need investigation and consideration. In GP services, complaints about what doctors do are far fewer, but the concerns about things going wrong have been well spelled out by my hon. Friend the Member for East Worthing and Shoreham. GPs hours are far in excess of those agreed for junior hospital doctors, and at least junior hospital doctors are trying to get experience of new sorts of cases.

GPs working 60, 70 or 80 hours a week is not the same as a Member of Parliament working those hours. Much of our work consists of going to parties or listening to our colleagues speaking: we do not hold people's lives immediately in our hands. Every time a GP examines someone he has to ask serious questions—for example, he might have to determine whether a baby has meningitis, which requires him to be alert to symptoms that are not obvious. I pay tribute to a GP who diagnosed an ectopic pregnancy in someone who matters a lot to me. He dropped his surgery commitments and came round after hearing a couple of sentences on the telephone through his receptionist. That is the kind of skill that GPs exercise all the time.

The underlying point—the challenge for the health authority and the Government—is the special position of Sussex, West Sussex and Worthing in particular. The issues that my hon. Friend the Member for East Worthing and Shoreham spoke about—people with special needs who are in their middle years or younger—do not apply only in inner cities. People with such problems live in many different areas—they include troubled teenagers and people who need to escape addiction to illegal drugs or legal ones, for example, alcohol. However, the real problem locally is the population of over-85s. Thirty years ago, health policy administrators understood the extra loads that the over-75s brought, but the over-75s of that era are the over-85s today.

Three years ago, West Sussex health authority carried out a pilot study to find out how to analyse the needs of the over-85s. The study was not continued, in my view because the cost or resources implications were unsustainable at local level, and because the health authority could not justify using the extra resources that would otherwise help family doctors to meet their patients' needs in a humane way if they could not find the cash.

I shall not say how the resource allocation model penalises places like Sussex. We could start a debate about morbidity and mortality rates, but I am sure that the Minister will become familiar with those and many other figures. Instead, I want to talk about what Worthing is showing the rest of the country. My hon.

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Friend the Member for East Worthing and Shoreham pointed out that the proportion of over-85s in Worthing is five times higher than in the rest of the country. What is happening now in Worthing will be happening everywhere in 20 years' time. The actuaries can tell us how such things happen.

The spread of the over-85s will come about as did the spread of the over-75s. If we had had this debate 20 years ago, and if I were making the same point about the over-75s, people would have nodded and said that I was right. That is certainly what has happened. It will now happen with the over-85s, but the average person of that age will give doctors almost twice the work load of someone aged over 75, which is many times the load imposed by a person of my age. I am 56 and I see a doctor every two or three years for trivial complaints; I am lucky, but it is a function of my age. However, when I am 75, I am likely to need to see a doctor once a month, and when I am 85 I might have to see a doctor once a week.

That acceleration puts an extra burden on GP services and on their staff and surgeries. The doctors do not mind doing the work—in fact, most of them go into medicine, and most of their nursing contemporaries go into nursing, to help people avoid illness and disease, to help cure those who can be cured and to care for those who cannot be cured. The question is how much of that burden each of them has to shoulder. The fact that 11 per cent. of patients in West Sussex are over 85—the national average is 5 per cent.—has an impact on doctors' surgeries. That should be recognised; an extra doctor, or even an extra half doctor, would make a difference to the work load. It would also allow a bit more room in what I think of as the concertina.

None the less, the problem remains of what happens when a doctor retires, or is sick, or is called away to help run the local primary care trust. This may be the right place, but it is not the right time to rerun the argument on GP fundholding. There are some excellent GP fundholding practices in my constituency, which includes Rustington, but we are now to have primary care trusts. I shall not argue about that today. However, I strongly support what my hon. Friend the Member for East Worthing and Shoreham said in connection with the community health council, and I plead with the Minister to ask her colleagues not to abolish CHCs.

The work of Trevor Richards, chief officer of Worthing and district CHC, and his colleagues has been important and I pay tribute to them. It was their asking whether the Association of Community Health Councils opposed the Government's determination to abolish the councils that began to make the difference, and the timing of the election has made it possible for the Government to think again. I ask them to do so. I ask them not to abolish community health councils. CHCs' work can be expanded into the family doctor field, but the experience that they bring to the job cannot be supplied by reconfiguration, patients' advocates or the other arrangements that the Government have in mind. I do not ask the Minister to say this morning that Government policy will be changed, but I ask her to present our plea to the Secretary of State and the Prime Minister.

I also ask the Minister to request that the Secretary of State and the Prime Minister visit the coastal area of Sussex, together or separately, for a private meeting. I would suggest that the doctors came to No. 10 or to

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Richmond house in Whitehall, but the travelling time would result in their being unable to see 30 or 40 patients. If the Secretary of State or the Prime Minister could spare the time, they should come to Sussex to meet the doctors, nurses, support staff and local managers and administrators. By all means, let the meeting be private—there is no need for cameras to be present—but it is important that they hear directly from those who can reflect upon today's conditions in Sussex, which will spread around the country over the next 10, 20 or 30 years as the benefits of old age and the consequent burdens on the health service extend.

I pay tribute to the doctors who raised this issue in a responsible manner. The headlines said that no more patients would be accepted south of the railway line in Worthing, but the doctors knew that if a practice kept its list open while others closed theirs, it would get all the new patients. By closing their lists, practices required the health authority to make allocations, but that does not solve the underlying problem of the excessive burden. If the Government could see a way forward through the health authority and implemented a plan to get resources through—rather than relying only on words and charm—doctors would notice the difference, and patients would, too.

I have been a Member of Parliament for quite some time, although not for as long as you, Mr. Winterton. I have had experience of GP services in depressed areas of Victoria, in Stockwell in south London, and in my previous constituency in south-east London. I am now watching GPs in my Worthing constituency. Partly because of conditions there and partly because of the age of the people and the burdens involved, the stress and strain in Worthing are greater than any I have known during 26 years as a Member of Parliament.

I plead with the Minister to ensure that resources can flow and that the approach to the problem can be modified, so that GPs can do their work and meet our constituents' medical need.

10.10 am

Mr. Howard Flight (Arundel and South Downs): I congratulate my hon. Friend the Member for East Worthing and Shoreham (Tim Loughton) on his excellent speech and my hon. Friend the Member for Worthing, West (Mr. Bottomley) on reiterating the points that it raised. I also congratulate and welcome the Minister. The spirit of today's debate is non-partisan—it is about solving practical problems.

I cannot add to the well researched presentation of my hon. Friend the Member for East Worthing and Shoreham, which dealt with problems along the Sussex coast. If I may, however, I want to discuss an instance involving GPs slightly to the north, in my part of Sussex. I, too, plead for the Minister's help to solve a fairly simple problem—it will involve no cost to the Government—that illustrates some of the problems that GPs elsewhere encounter.

In Pulborough, we have outstanding doctors. Two fundholder practices came together to create a bunch of incredibly hard-working and innovative doctors who serve their community well. For two years, they have been working on plans for a remarkable new centre,

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which was to have been a model for the country and to have received a beacon award. To get the necessary funding, they used local help to put together a scheme with the Dunhill trust. At the time, they had the support of Horsham district council.

The scheme addresses several problems constructively and collectively. First, the new medical centre would provide nursing care facilities, operation facilities and convalescent facilities—services that a rural community needs. Secondly, by moving into the Horsham and Chanctonbury GP group area, the scheme would gather 140,000 patients who would render the future of St. Richard's hospital much more secure. One of our problems is whether hospitals have enough patients to guarantee their futures; the scheme would indirectly address that and enable consultants to come out and do a lot of operations on the spot. Clearly, the doctors could not finance such a scheme by themselves, so it was a blessing when a charity was brought in to put up the finance and combined the scheme with the provision of a modest retirement village. That would also meet a need, as that part of the world has nowhere of a sheltered nature for elderly people to go, which presents other social problems.

The scheme was worked out over two years. The district council identified the Oddstones site as suitable and suggested that those involved apply for it. Then planning policy guidance note 3 was introduced. At the last minute, the head of planning took the view—wrongly; the note contains certain qualifications— that he could not recommend the site after all because the majority of it was greenfield land. As a result, the planning committee, doing what it thought was its duty, turned the application down. The doctors have spent £100,000 out of their own pockets on planning costs. The district council, trying to be constructive, has made some alternative suggestions but, for a variety of reasons, those will not work.

I was in contact with the Minister's predecessor, the hon. Member for Birmingham, Edgbaston (Ms Stuart), about the scheme, because it would have been a model for the country. West Sussex health authority and the national health service had offered tremendous help, but the rather unhelpful letter that I received—I am sure that it was not written by the former Minister herself—said that the health authority could not be involved in planning issues. That illustrates the precise point that the Chancellor of the Exchequer has endeavoured to address. We have held huge public meetings—attracting 10 times as many people as any political meeting—as the community is genuinely furious that a project that everyone wants is being frustrated.

The community does not want any more housing than it needs, nor does the problem involve choosing one section of the community over another. There is a cast-iron case for using a bit of greenfield land because that is the only land that would meet the criteria for the site. I have written to the Secretary of State asking for help because there is no point in having a public appeal to finance a planning appeal unless such a planning appeal has a chance of success; otherwise we would be misleading citizens. The doctors cannot be expected to finance that, given what they have already spent to no avail. The issue is bipartisan, involving health and the environment, and the essence of the decision to be made is political: is there a possibility of PPG3 being

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interpreted in a different way? The question is then whether the health case for the total combined package and the model that it represents are sufficiently deserving to warrant such an interpretation.

I warmly invite the Minister to come and look at what is being planned at the same time as she looks at the more acute problems in coastal West Sussex. It is an example of doctors, on their own initiative, seeking to solve several major problems of the community. They have constructively found the resources to address the problems yet—incredibly frustratingly—they have been blocked by what is perceived locally as narrow-minded pedantry arising from a different issue, that of excessive housebuilding in the area.

We all face the problem of an ageing population. The question in West Sussex is what is the right level of resources for both GPs and hospitals in a community that has both a high average age and an increasing number of people aged over 85. The problems of GPs differ between rural areas and the south-coast urban area. The pressing need in rural areas is for the type of centre that I have described. A lot of beds will be released if there are local convalescent facilities, and a great deal of time and expense will be saved if many minor operations and nursing care can be undertaken in a local centre. For a group of doctors who have come up with the answer to be frustrated in such a way is not only a shame, but a disgrace. I plead for the Minister's help.

Mr. Nicholas Winterton (in the Chair): Before I call the hon. Member for Romsey (Sandra Gidley) to speak for the Liberal Democrats, I remind the Chamber that the debate is fairly narrow, relating to NHS GPs in Sussex. I shall be generous in showing discretion, and no doubt hon. Members will want to draw comparisons, but I urge them to note the narrowness of the debate.

10.20 am

Sandra Gidley (Romsey): I congratulate the hon. Member for East Worthing and Shoreham (Tim Loughton). I could not disagree with anything he said—he may find that unusual coming from a Liberal Democrat. The hon. Members for Arundel and South Downs (Mr. Flight) and for Worthing, West (Mr. Bottomley) also raised pertinent points. I understand your warning, Mr. Winterton, but the speeches that we have heard not only describe problems in Sussex, but tell of events around the country. From Sussex to Sunderland, from Cumbria to Cornwall, the problems highlighted are present in varying degrees. The hon. Member for East Worthing and Shoreham referred to GPs as normally mild-mannered individuals. I agree. Most people share that perception of their family doctors. However, when I was at the BMA conference last week, I realised that the people in the hall were angry—they had had enough.

Before I turn to more general points, I should talk about the specific problem of an ageing population, which has been identified in Sussex. GPs receive more money for elderly patients, but the way in which contracts have developed has shown a sticking-plaster approach. GPs realise that they have more work to do for elderly patients, they negotiate a little more money, and on the system goes, but as the needs of the elderly become more complex, they require a lot more time, and

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time is money. There is a balance to be struck. Even if a GP has plenty of work, his patient numbers remain the same, which is a problem. A GP from the north of the country told me that things balance out somehow, but that is clearly not the case. It was said that what is happening in Sussex will happen throughout the United Kingdom in 10 or 20 years. GPs in other parts of the country do not face the problem so acutely, so I thank the hon. Member for East Worthing and Shoreham for making that good point.

GPs want increased time for consultations and are scathing about the 48-hour target that the Government have set for appointments. Some people can wait: those having routine appointments do not need to see a doctor within 48 hours, so it is patently ridiculous to set a target for them, whereas people who require urgent help need to receive it within 24 or 12 hours. We have set a target without thinking about what we need to achieve for the benefit of the patient.

The GP's job has changed. Thirty years ago, GPs referred tonsillitis to specialists, but they would be laughed at if they did so today. There has been a shift from treatment in hospitals: there are no general physicians in our hospitals now; everyone is a specialist. Conditions such as asthma and diabetes are managed in the surgery, which takes an increasing share of the time of doctors and other staff.

It is frustrating for doctors that to an increasing extent they have to manage patients who are on a waiting list. In many areas—I suspect that it is so in Sussex—there is a wait of 18 months for an orthopaedic appointment. In that time the burden of managing the patient's pain and expectations falls on the GP, who probably in the end prescribes antidepressants—after all, it is pretty miserable to wait 18 months for an appointment. More multi-agency working is also taking place. Often funding must come from health, education or social services, so more GP time is taken up in meetings. We all know how frustrating and time-wasting those can be.

Computerisation has been mentioned, but no one pointed out that, because most computers are surgery based, GPs who previously took notes home to work on them must arrive at work an hour or two early to update records on the computer.

The Parliamentary Under-Secretary of State for Health (Ms Blears ) indicated dissent.

Sandra Gidley : That is not just my view. If the Minister does not agree, perhaps she would like to look at a series of press cuttings compiled under the heading "A time for general practice". There are many quotations from GPs telling how it is.

The stress of being on call has increased. The requirement has grown over the years as many GPs—especially older ones—decide to sacrifice income and pay to have a good night's sleep. GP morale is at an all-time low, and not just in Sussex. Dr. John Chisholm, who chairs the BMA's general practitioners committee, has said:

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There are also problems of recruitment. I have talked to a local GP about this and we have heard about a similar state of affairs in Sussex. Twenty years ago there would be 30 applicants for a job in a certain practice; four years ago there were three applicants for a job in the same practice; another vacancy arose recently and not a single person applied for the job. If our doctors do not want to become GPs, we shall face a crisis. There was a crisis of GP provision in the late 1960s. Reference has been made to the Asian work force. In the 1960s efforts were made to find GPs abroad, but most of those GPs work in the more difficult practices and are approaching retirement age. We desperately need ways to tackle the problem that will probably hit us in about six years.

A recent survey showed that about 80 per cent. of family doctors will consider resigning their NHS contracts next spring if the BMA's GP committee is not able to secure a new and acceptable contract. Negotiations are under way. A public perception survey showed that 72 per cent. of people thought their GP was either fairly overworked or very overworked. If the people whose views were sought heard today's debate, the percentage would probably increase.

We have heard about the rise in the number of consultations per GP, which is contributing to the problem, and about the number of additional GPs announced under the NHS plan—not 2,000 but 900, and it is not even certain that those are to be full-time equivalents. The BMA has calculated that an extra 10,000 GPs are needed to meet increased patient expectations and to cope with the demands of the national service frameworks. However, the Government appear to have developed an ostrich approach to the problem. A BMA briefing states:

The doctors speak for themselves more eloquently than I can. The final comment that I want to use comes from someone in Cumbria; I apologise for the fact that it is not from Sussex, but the problem is nationwide. The person states:

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Mr. Nicholas Winterton (in the Chair): Order. Is the hon. Lady going to mention Sussex?

Sandra Gidley : I am sorry, Mr. Chairman. To keep you happy, I will substitute Sussex for Cumbria.

Mr. Philip Hammond (Runnymede and Weybridge): On a point of order, Mr. Winterton. Who is the Chairman to whom the hon. Lady keeps referring?

Mr. Nicholas Winterton (in the Chair): I am being very tolerant today. I am not yet an additional Deputy Speaker for sittings in Westminster Hall. The hon. Lady can call me Mr. Chairman or Mr. Winterton. I accept either.

Sandra Gidley : Now, back to Sussex.

Mr. Peter Bottomley : If we were on the radio I should press the button to challenge for hesitation.

Sandra Gidley : I have already been accused of deviation for not speaking on Sussex, but I shall carry on and finish the quotation. It continues:

10.32 am

Mr. Philip Hammond (Runnymede and Weybridge): I congratulate my hon. Friend the Member for East Worthing and Shoreham (Tim Loughton) on securing this debate and raising important issues. I also congratulate and welcome the new Under-Secretary of State for Health, the hon. Member for Salford (Ms Blears), to her important job.

What has been said this morning about West Sussex is to a great extent true of the whole country, although my hon. Friends have raised an important point about the mechanism for allocating funding to health authorities and the system's apparent failure to recognise the severe problems caused in some areas by increases in the elderly population. However, that is a matter for another debate. The Government are examining the allocation mechanisms for health service spending, so no doubt we shall return to the subject.

More than nine out of 10 patient contacts in the national health service are at primary care level, and the majority of those will be with GPs or their staff. The family practitioner service is the jewel in the crown of the NHS. On the whole, it has served the NHS extremely well and provided an efficient, relatively low cost and high quality service. It is apparent to us all that that jewel is under severe threat, and I am amazed that the Government appear to be willing to tolerate that threat to a service that is the core of the NHS, especially in view

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of the fact that the NHS plan states that development of primary care services is to be the key to the modernisation of the NHS.

I would like to take hon. Members back to before 1997, to fundholding. I shall not argue the merits of fundholding. It had its faults and never covered a sufficient percentage of practices to be evaluated fully. However, from the fundholding experience, I want to draw out a fact that the Government now recognise, which is that entrepreneurial spirit can be unleashed in the delivery of public services. When it is unleashed, it is a powerful force that empowers GPs to develop their practices and find best practice solutions for their patients. The primary interest of the vast majority of GPs is to serve their patients and develop professional services for them, and they can do that enthusiastically using their undoubted skills and imagination. Fundholding certainly stimulated something in the GP population.

Mr. Nicholas Winterton (in the Chair): Order. Will the hon. Gentleman refer to fundholding in Sussex?

Mr. Hammond : I am grateful to you, Mr. Winterton, for reminding me that fundholding practices in Sussex made an important contribution to the delivery of services in that area. By contrast, GPs in Sussex have found the Government's reforms prescriptive in nature and bureaucratic in structure. The reforms have created significant additional bureaucratic work that has undermined Sussex GPs' ability to use their professional judgment in the interests of their patients. The Government's attacks on the medical profession in Sussex and their sometimes unwise inflation of patient expectation in Sussex and elsewhere have caused morale in general practice to fall to an all time low ebb. No one can doubt that, so I shall not quote from the report of the BMA conference with which we are all familiar.

The Government's agenda is to shift the emphasis of service delivery to the primary care sector and to propose better quality GP services. Most GPs think that that should involve spending a longer time with their patients, but the Government focused on the time before access to a GP is achieved and set a 48-hour target. Additional pressures arise from the Government's programme. I accept that some of the measures are entirely necessary and inevitable, for example, revalidation and continuing professional development, but they must be seen against the demographic background that we have heard described, which will place incredible pressures on the service in future.

My concern is with the Government's response to the problem. In the national plan, they set out several outcome targets including a target for access to GPs. They underpinned those with some input targets that they must know will not deliver the output targets in the plan—the former Minister of State, the right hon. Member for Southampton, Itchen (Mr. Denham), came close to admitting that. The Government have raised public expectations that cannot and will not be met. That places GPs in Sussex and elsewhere under extreme stress and pressure. Day in, day out, they face patients whose expectations have been raised, but the GPs do not have the wherewithal or resources to fulfil those expectations.

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The hon. Member for Romsey (Sandra Gidley) spoke about the GP numbers in the national plan. The Government have set a figure of 2,000 additional GPs by 2004, but the BMA says that 900 of them are already in the system, so the figure represents only 1,100 genuinely additional GPs. I do not want to get into an argument about that, but I am concerned that the figure of 2,000—as against the BMA's figure of 10,000—does not represent whole-time equivalent GPs.

I should tell the Under-Secretary of State that there is no doubt about that. I asked the former Minister of State an explicit question and his answer was explicit: it is a head-count figure. That means that if 2,000 full-time GPs retire or leave the service and 4,000 half-time GPs are recruited, the Secretary of State will be able to say correctly, arithmetically speaking, that he has met the target of delivering an additional 2,000 GPs. However, not one additional doctor-hour of patient service will be available.

That problem must be seen against the backdrop of the changing profile of the medical profession and the increasing feminisation of the medical work force. Across the nation, 34 per cent. of GPs are female; that is a fair reflection of the position in Sussex. Last year, the majority of entrants to medical schools—58 per cent.—were female. Our medical work force will, therefore, become increasingly feminised. That is a good thing, but the Government must recognise the fact that female doctors, because of family responsibilities and a greater predilection for part-time working during at least part of their careers, contribute fewer working hours on average over their careers than their male colleagues. That means that, as the medical work force is feminised, it will have to get larger to keep the service at a standstill.

The figures in the NHS plan, which are not whole-time equivalents, take no account of such factors. There is a real probability that the Government will meet the target that they have set themselves in the NHS plan in technical terms, but deliver fewer general practice doctor-hours in total. I challenge the Minister to explain why the Government do not express their targets in whole-time equivalent GPs. That would be a meaningful figure and would underpin, in a way that could be understood across parties and in the community, the Government's laudable strategy to increase the number of part-time workers in the NHS by luring back into the service people who, for various reasons, including family responsibilities, are unable to give a full-time commitment.

There is another problem. The Minister will no doubt tell us about the increased numbers of training places. The Government have committed themselves to creating 450 additional GP training places by 2004, but training GPs is not enough: we must get them to join the service once they have completed their training. However, conversion rates are falling: in 1996-97, 1,029 doctors joined general practice; in 1999-2000, the figure fell to 958. Whether we like it or not, GPs are among the best educated and best trained members of our work force and they are generally endowed with some of the best interpersonal skills. They are therefore much in demand outside medicine. I am sure that other hon. Members know many GPs who have been recruited away from medicine to other careers.

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We must recognise those competing demands. The NHS will never be able to compete simply by offering GPs financial incentives, and I do not think that it should. Obviously, money is important, but it is not the whole game and is probably not the most important factor. GPs want the freedom to exercise their professional discretion in the interests of their patients. They want freedom from scapegoating by the Government. Of course there are a few rotten apples in the barrel, as there are in any barrel. Even in so joyous a place as Sussex, we find the odd GP who falls short of the standards that we all expect. However, the vast majority have, as their primary and overriding concern, the ability to deliver, with the benefit of their extraordinary skills and professional training, the best possible services for their patients. To do that, they need not only the resources and the support of Government combined with freedom from scapegoating and the blame culture, but the liberty to exercise their professional judgment locally in the interests of their patients.

The Government must recognise that the primary care group-primary care trust experiment, whatever else it may bring or has brought, has not engaged GPs at the grass roots as was anticipated. It has not provided an alternative mechanism to fundholding for unleashing the entrepreneurial spirit among GPs. The Government must recognise that the practice is the fundamental unit for general practitioners. They need to enthuse and inspire GPs at that level if the services that the public expect and the Government want are to be delivered.

That brings me to my final point about the delivery of first-class general practice services in Sussex. During the general election campaign, the Labour party and the Prime Minister offered the British people world-class public services—not just good or better, but world-class. The ball is now firmly in the Government's court: they have been given a clear mandate to deliver those world-class public services. The Minister must know that the public will be watching. In this Parliament, the Government will be judged by their success or otherwise in delivering world-class public services. They cannot do that in relation to health care unless they win over the GPs in Sussex and elsewhere by inspiring them and empowering them to deliver and develop their professional practice for the benefit of their patients. Unless they have the freedom to do that, we will never restore general practice to what it was and should be—the jewel in the crown of our national health service.

Mr. Nicholas Winterton (in the Chair): In calling the Minister to reply to the debate, I, too, congratulate her on her appointment.

10.47 am

The Parliamentary Under-Secretary of State for Health (Ms Hazel Blears) : I congratulate the hon. Member for East Worthing and Shoreham (Tim Loughton) on securing this important debate. I have welcomed the atmosphere and tone in which it has been conducted and have learned a great deal, particularly about the hon. Gentleman's constituency and the specific problems there. I would also like to thank all

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hon. Members for their kind words of congratulation. I will do my best to address my comments to Sussex and Worthing and to be as direct and focused as I can.

I represent an inner-city constituency that has many problems of deprivation, but that does not mean that I do not recognise that there are sometimes real pockets of hardship, poverty and deprivation in seemingly affluent areas, especially in many of our coastal towns. There are particular problems associated with the structure of the population in such places, and the hon. Gentleman has highlighted the issue of NHS care for the elderly. About 75 per cent. of the NHS centres on care for older people; it is a fundamental part of the service and we need to take it into account.

The hon. Gentleman raised the issue of the combination of services. Older people are not the only ones involved. His area has four hostels for the homeless and a number of institutions looking after vulnerable children. I have been made aware of that combination—he referred to it as a cocktail of ingredients—and I will take it seriously.

Several hon. Members asked if I could arrange for my right hon. Friend the Secretary of State or the Prime Minister to visit the area and talk to GPs and listen to their problems. I cannot promise the Secretary of State, and I certainly cannot promise the Prime Minister, but I can promise myself. I have regional responsibility for the area and I intend to get to know my areas in detail. I want to listen to the GPs and the nurses, the people working at the front end of our services, to find out what it is like on the ground. There is nothing more valuable than hearing people speak in their own voices, rather than reading official documents. Much to the disquiet of some of my officials, I intend to go out during the recess on a tour of the areas for which I am responsible. I shall do my best to visit the areas that are represented by hon. Members who have spoken today.

Let me start my first debate as Minister by paying tribute to all who work in the national health service. They have changed the landscape of the NHS in recent years, and have a key role to play in its future. The hon. Member for Runnymede and Weybridge (Mr. Hammond) referred to public sector entrepreneurs—a phrase that was, I think, first used by my right hon. Friend the Secretary of State. It is good to find that we share a view. In my constituency, a school for social entrepreneurs is developing the imagination, creativity and innovation of people in the public sector. Staff are the key to developing different ways of working.

However, today's debate is about GPs in Sussex. We owe GPs a great debt. I acknowledge the energy that they put in day in, day out, week in, week out. We have heard about their long working hours and their tremendous amount of patient contact. Their commitment is resulting in improved services in all communities. Because the Government recognise the pressures on GPs, we made a commitment in the NHS plan to help to develop primary care services. The hon. Member for Runnymede and Weybridge told us that 90 per cent. of patient contacts in the NHS are at primary care level. That is why the development of primary care is the key to modernising and improving

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services. One of the things that we have constantly emphasised is our desire to give people in the front line the power, the resources, the money and the decision-making opportunities to change the services that we provide.

Let me run through a few of the things that the Government are doing. I shall not have time to tell hon. Members about everything in the NHS in 10 minutes, but I hope to expand on some issues in future. We are investing £100 million over the next three years to encourage the recruitment and retention of GPs. Some of that will be spent in Sussex. Although new GPs receive £5,000 to enter general practice, I acknowledge that financial incentives are not the be-all and end-all. People work in public service because they believe in it and they want to provide services to their communities. However, financial incentives can help when they are deciding where to practise and what kind of work to take up. It is important that the Government acknowledge the need to attract more people to general practice by providing extra incentives.

We are also trying to provide extra incentives for women returners. The point was well made about the increasing feminisation of the service and the need to ensure that women can continue to practise and that their skills remain up to date while they are at home caring for relatives or on maternity leave. We have introduced a scheme under which women work for four sessions a week in the NHS to maintain their contact and to continue their professional development, so that when they are ready to return, they constitute another pool of workers from which to draw.

We are investing £100 million to support service development. Sussex received £3 million this year—that is about £10,000 per practice, half of which can be spent entirely as the practice wishes. It is important for creative and innovative GPs to be given the resources to change their practices. We recognise the personal strains on GPs, which is why we are setting up the first ever occupational health service for GPs. If we do not look after their health, their ability to care for others may be impaired. In addition, we are trying to reduce the administrative burden on GPs, although there remains a lot more to do. We have saved them from having to sign applications for passports and driving licences, and all the extraneous things that people ask doctors to do. Doctors should be doing what they do best: seeing patients, providing consultations and working out care plans.

We are also modernising the surgeries of 3,000 GPs. It is important that GPs, like Members of Parliament, work in a decent environment, because people's working environment affects the quality of their work.

Mr. Nicholas Winterton (in the Chair): Order. Is the Minister going to advise us how many surgeries in Sussex have been modernised? It would be helpful if she directed more of her remarks to Sussex.

Ms Blears : I am grateful for that comment, Mr. Winterton. I am sure that at least a proportionate amount is being spent on modernising GP practices in Sussex—[Laughter.] When I visit the area, I shall have the opportunity to see for myself the improvements that are being made. I look forward to it.

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We are also increasing the number of GPs, although it is a slow process. The target in the NHS plan of 2,000 extra doctors is a floor, not a ceiling. We would like more GPs—indeed, we have asked the BMA to suggest ways in which we might increase the number of doctors. The BMA has not yet responded, but I hope that it will. In fact, the number of GPs in Sussex has increased from 802 in 1997 to 835 in 2001. It is not a huge increase, but it is going in the right direction.

Mr. Hammond : Will the Minister say whether that number is a whole-time equivalent, or whether it is a simple head count that conceals an actual reduction in whole-time equivalents?

Ms Blears : I do not have that information with me today, but I shall find out and let the hon. Gentleman know.

We are moving in the right direction. I remind the Opposition that GP numbers began to fall in 1991 and continued to fall for the next five or six years; only now are we beginning to solve the problems caused by the massive reduction in training places that took place under the Conservative Government. I appreciate that we are not here today to make party political points, but we should remember that the GP training places and GP numbers fell dramatically under the Conservative Government.

Mr. Peter Bottomley : If the Minister cannot cover the subject in the remaining few minutes—I realise that we do not have much time—would she write to my hon. Friend the Member for East Worthing and Shoreham, sending copies of the letter to the rest of us, saying how she plans to analyse the additional burdens imposed by the over-85s? My hon. Friend and I both spoke about the need to look forward. It may not be possible to answer that question today, but we should be grateful if she would to write to us.

Ms Blears : I certainly shall. In the few remaining moments, I shall try to give some pertinent examples of how GPs are being helped to look after elderly people in Worthing.

First, local primary care groups are considering how to use nurse practitioners to provide general medical care in nursing homes. They are already running clinics that deal with coronary heart disease and high blood pressure, which relieves the burden on GPs. Three GP practices in the area now have a dedicated health adviser for the elderly, providing support especially for the over-85s. Under a local scheme, the scoring assessment for those who need cataract operations is now being made when they visit the optician, so that they do not have to return to their GP; that innovation, too, is relieving pressure on general practitioners in the area.

Many general practitioners in Worthing and in Sussex generally are embracing change and innovation. They are looking to the future and are prepared to consider new solutions. We have heard a great deal today about the problems of general practice. The challenge for the Government and for Parliament is to try to come up with long-term, sustainable solutions so that GPs feel really valued and know that they are an important part of the health service. The innovations that we are introducing in Worthing, Sussex and elsewhere help to support GPs in their work.

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I must also mention the work of NHS Direct. That service takes thousands of calls a month. It refers people to different kinds of care, gives them advice on how to look after themselves, and refers them to pharmacists, midwives and a range of other services.

If long-term sustainable solutions to the pressures that GPs undoubtedly face are to be found, we politicians must be more creative and more imaginative—we must work smarter and not simply work harder. We need to achieve investment at the front end, so that we can provide patients with appropriate care. It is not always right to visit the general practitioner; patients can often receive care in other ways and in places that are quicker, more appropriate, and that better meet their needs.

We have a responsibility to look creatively at the whole of the health service. We value general practitioners enormously, but we must not forget that the NHS comprises a range of primary care workers, whose contribution I acknowledge. Nurses, advisers and community-based workers are doing a marvellous job in supporting patients and providing services. We rely on them. I want to ensure that they find their working lives enjoyable and satisfying, rather than consisting wholly of pressure and overwork.

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