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Dr. Evan Harris: I begin by offering my apologies to you, Madam Deputy Speaker, and to the Minister, for my slightly delayed arrival. There was a lobby of social services users—appropriately enough—from my county this afternoon. They are waiting for me to lodge a petition this evening, which I shall do if I am able to catch your eye when the time comes. I was detained with them, and I regret missing the beginning of the Minister's speech. However, I understand that, in the bit I missed, he set out in general terms the issues relating to the background of the new clauses.
I am keen to speak to amendment (a), tabled in my name. The Minister began to deal with that, and the hon. Member for South Cambridgeshire (Mr. Lansley), in his perceptive style, also made a substantial part of the contribution that I was going to make. However, I also have a number of questions with which I hope that the Minister will deal, given the Committee style of our proceedings today. I should be grateful if he ensures that he is able to cover them. By way of advance notice, I can tell him that he will find some of the matters that I want to raise among the questions that I placed on the Order Paper yesterday. They were not selected for debate, but I am grateful that a starred amendment was selected, given its late submission.
I share the gratitude expressed by the hon. Member for West Chelmsford (Mr. Burns) for the fact that we have some explanatory notes, even if we did not get much warning that they were coming and had little time to read them before the deadline for tabling amendments. As I said in respect of the programme motion, it is not very satisfactory that a large chunk of new clauses and amendments should be presented with so little time to consider them before the debate. Even so, like the hon. Gentleman, we must do what we can with what we are given.
With regard to amendment (a), the Minister rightly recognised that it raises concerns about incentive payments in general terms. However, he—and the hon. Member for South Cambridgeshire—were both right to recognise that it relates specifically to incentive payments for vaccinations and immunisations, especially childhood immunisations.
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The problem is that, if the system works, it will be of questionable ethics. If it does not work, it will be unnecessary. The Minister has argued that, if GPs were not paid to meet a target, some people would not receive the vaccination that they needed, even after a
consultation. Effectively, therefore, there is a third person in the consultation room with the doctor and the patient, or the patient's parents. That third person is the doctor's accountant.In general terms, I do not think that that is how a doctor-patient relationship should be conducted. It seems to me entirely wrong that GPs should entertain the notion that, if seven out of the next 10 patients do not end up with being immunised after their consultation, they—the GPs—will miss out on a significant amount of money. It is not an item of service payment, or a payment per immunisation, as the payment kicks in once a threshold is reached. If a doctor is on the cusp of achieving that incentive, the risk is that that factor will creep into the consultation.
The Minister would consider that to be a success. Like me, he believes that immunisation, where clinically inappropriate and in the absence of contraindications, is a good thing. Even so, it is not appropriate for a GP's recommendation to be backed up—in force or in any other way—by the promise of payment for reaching a particular target. That is not the relationship of equipoise that ought to exist. Doctors and patients should not have these incentive payments and targets in mind.
If the Minister is arguing that the system works and that doctors are right to chase payment in the consultations, that is not an ethical basis for giving treatment. If the system does not work—if it is not a relevant factor in increasing the number of immunisations—then what is the point in having it? Indeed, I would go further and state that not only is the system pointless, it is damaging. Even if a GP is not influenced by the equation that states that, to reach the threshold, he needs to get seven of the next 10 patients immunised, the perception that he is being influenced still exists. To a great extent, that will undermine the doctor-patient relationship.
Informed patients—and patients in general—may well be concerned that their doctors will be influenced by the incentive payment. That is especially the case in an area such as immunisation, where the recommendation is being given not to a competent patient—that is a patient with capacity—or even to a Gillick-competent patient, but to a patient without capacity, whose parents must make a decision.
That is an especially sensitive area. We are talking about treatments that are given to healthy people, and it is understandable that some parents may feel that an unnecessary intervention is being made in respect of a healthy child. It is always more difficult to see the need for such an intervention than for treatment for a person who is symptomatic.
In addition, many parents and patients may be aware that they benefit from herd immunity and consider that they do not need the immunisation because they can rely on others. That is not an approach that I recommend, but it is a serious concern.
Mr. Lansley: Before the hon. Gentleman moves off this point, does he share my concern about the incentive payment mechanism? The mechanism is not specified in the contract, which states only that it will be the subject of further discussion and that exception reporting does not apply. Moreover, under the new contract, GP
practices will be able to opt out from providing additional services, at a cost of just over £1,000 of the global sum. Does the hon. Gentleman agree that there is a risk that practices that are unhappy with the ethical position presented in the contract may simply choose to opt out of the arrangement? Would not that undermine our ability to deliver this additional service?
Dr. Harris: Quite so. Immunisation levels are so marginal that we cannot run that risk. The Minister may say that he cannot run the risk of removing incentive payments, but I hope that he will give me some comfort by assuring us that if the system is pursued, it will be changed. There is less of an argument against having a threshold for the number of consultations, so that GPs will be incentivised to consult patients. However, if patients refuse or reject standard immunisation, even with no good clinical reason, that should not penalise the doctor. The Minister could achieve the improvement of access to immunisation that he wants and ensure that there is a proper call and recall system by setting incentive payments—if they have to happen—at a proportion of the eligible population receiving those consultations.
In fact, that should be the default position and the Minister should have to justify his current position on two grounds. First, there should be clear evidence that a threshold for immunisation payments given works. It is not good enough to look at trends without having an adequate control group to determine what would happen over time if the threshold payment system did not apply. Indeed, the Minister might consider a test whereby in some parts of the country some practices did not operate an incentive scheme for immunisations given, so they would not be penalised when people without good clinical reasons refused immunisation. Simply to cite trends coincident with the introduction of incentive payments is the same sort of logic as he and I both reject when people cite increases in the incidence of autism at the time the MMR vaccine was introduced. If the test is not controlled, such arguments do not have a rational scientific basis. Where there is better evidence—as there was in that case—it should be cited. I urge the Government to show convincingly that there is evidence that the scheme works.
Secondly, the Minister needs to show that he can overcome the ethical objection that I identified and the public relations problem—people who have lost confidence in the system—before he proceeds with the incentive scheme.
In Committee, the Minister said that it would be unwise to try to amend these provisions because GPs had just come to an agreement, so any amendments would undermine that agreement. That cannot be right. First, it is the right of the House to make amendments to legislation. Secondly, GPs are still not happy about some aspects. As we know from the recent BMA meeting, incentive payments are one such matter. I should be grateful if the Minister provided some explanation and a defence of his position in response to those charges.
I have a few more questions that relate to the Liberal Democrat amendments that were not selected. Can the Minister explain why subsection 28U (2) of the new clause states "may" rather than "must"? One would have thought that regulations were definitely needed to
make provision for all the points listed under subsection (2). Indeed, a series of questions flows from that and we should try to deal with them if we had time.Subsection (3) refers to regulation of the circumstances in which a contractor or contractors
- "may decline to accept a person as such a patient; or . . . may terminate his or their responsibility for a patient".
Often the reason is that the patient has made a complaint. The Minister knows that that is an unacceptable basis for striking off. He knows that the BMA guidelines sent out by family health services authorities, health authorities or whatever they are called nowadays make it clear that the practice is unacceptable. I have an example from my constituency. In a conciliation meeting, a GP told a patient that they should not have complained to their GP if they wanted to stay in the practice. That is unacceptable.
The Minister has an opportunity to toughen up the regulations. There is an argument that the reasons for which patients can have their relationship with their GP terminated should be limited. That is not just on the ground of natural justice but because it can be so damaging for a patient to be treated in that way, especially when they do not receive a good reason or even any reason at all. Unfortunately, that is a problem in the culture—I speak as someone who has practised as a doctor. It is on the wane, but it still exists; GPs and other doctors still find it hard to adjust to having their treatments questioned. However, that is part and parcel of a modern NHS with empowered patients, and the regulations must keep pace.
Will there be provision for an appeals process that is open and transparent? It should allow the patient to be reinstated in the practice without GPs automatically saying that they cannot possibly have the patient back because the termination process means that the GP-patient relationship is irrevocably broken. That is a circular argument and such a fallback position cannot be right. I should be grateful if the Minister explained his thinking about that.
Subsection 28U (6) states that a GMS contract
- "must contain provision requiring the contractor or contractors to comply with any directions given by the appropriate authority"—
- "for the purposes of this section as to the drugs, medicines or other substances which may or may not be ordered for patients in the provision of medical services under the contract".
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