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Dr. Harris: I checked in the table provided by the Minister to determine whether that was the case. It states that the provision replaces schedules 10 and 11, which are, as we know from our debates on Sildenafil, infamous. Is the provision a direct translation? Sildenafil, or Viagra, probably offers a good example, although I do not want to go too far down that path.
Can the Minister tell us whether it would be a breach of contract, or a breach of the terms and conditions of a general practitioner under a GMS contract, for a GP providing primary care services under a GMS contract to prescribe something that the Secretary of State has put under schedules 10 or 11? At present, that is not a breach of terms and conditions because GPs can provide such drugs privately; indeed, they have to do so if they are not to be out of pocket, because they are not reimbursed. In effect, that is rationing. I do not object to rationing itself, but it should be explicit. Normally, if rationing is an issue, it is possible for prescribing freedoms not to be limited and the GP has to explain, within the reimbursement process, what is going on. There may be exceptions, where reimbursement for such a prescription is appropriate, but the blanket provision in the regulations that the subsection may herald could go further than schedules 10 and 11.
I accept that the matter is technical and that the Minister may not be able to address it at present. If we were in Committee, I should ask him to write to me before Report. However, perhaps he can address that point, as several practitioners have raised it.
Proposed section 28R deals with the power to set out in regulations the primary medical services that a GP must provide under a GMS contract. In the third columnheaded "replaces"of that very useful table in the explanatory notes, the Minister explains that proposed new section 28R will replace a description in section 29 of the National Health Service Act 1977. The explanatory notes do not specify any provision; they refer to the agreement on essential services in paragraph 2.8. However, among other things, section 29 of the 1977 Act states:
New clause 26 has been written in very vague terms, so it waters down the obligation in the Bill to ensure that patients can refer to something when protesting that the essential services are insufficient to fall within the remit of the primary legislation. I should be grateful to the Minister if he reassured me about the absence of any description in primary legislation in respect of what must be provided to meet reasonable needs.
Why are such things not still defined in the new arrangements? If they were defined, future negotiations could allow something that patients have a right to expect beyond the current definition of adequate personal care and attendance to be moved from paragraph 2.8 of the GP contract, which deals with essential services. Does the Minister accept that removing section 29 of the 1977 Act without replacing it with a similar duty represents a dilution, unless I have missed something? That brings me to the Government's amendments on primary dental contracts.
Dr. Harris: I have got amendments in this group, and it is reasonable to speak for 20 minutes. The hon. Gentleman made the point earlier that we did not have enough time in Committee. I will ensure that I end my speech shortly, so that he has a chance to speak, but I have a specific question on the Government's amendment on dentistry.
My last point relates to proposed new section 28U(3), where the Government's description refers to a power to make regulations setting out the relationship between contractors and their patients. Those relationships are covered in chapter 6 of the NHS Confederation/General Practitioners Committee agreement. The legislation refers to issues relating to termination of the relationship between patients and GPs. I have mentioned patients being the struck off the list. However, I am a bit concerned whether chapter 6 of that agreement is the way by which the proposals that the Government floated in the Labour party about a contract between the patient and the GP may be enforced.
I should like the Minister to clarify whether chapter 6 of that agreement could be used, if amended in future, to make patients agree to stop smoking, stop eating or start exercising before they can continue to get services. Perhaps the Minister will welcome the opportunity to put that idea to rest, because a number of people have read into the consultation that the Minister is undertaking in the Labour party that that may be the result.
We recognise that, overall, the contract represents a good deal for GPs, especially in financial and work load terms, but that is not the same as saying that it represents a good deal for patients because, especially in respect of the number of hours that GPs have to work, there is a zero sum gain. If GP work load is reduced, the services that patients can get from their GPs at a one-stop shop, holistically, are inevitably reduced.
The Government say that GPs will no longer have to provide out-of-hours services if they choose not to do so. Indeed, they will be paid for their other services even if they choose to drop that responsibility. GPs will be paid more, even if they do less, so patients will get less of a service from their own GPs. I understand that there are not enough GPs and that there are not enough hours in the day for GPs, but I hope that the Government will accept that patients would not have voted for the new contract, even if GPs thought that accepting it was the only thing that would allow them to cope with their work load. Until there is a significant number of new GPs, patients and GPs will not benefit from the new contract.
Sir Patrick Cormack: I will certainly be briefer than the hon. Member for Oxford, West and Abingdon (Dr. Harris). I do not dispute for a moment that all the points that he raised were very pertinent and should be addressed. Again, the terrible time constraints under which we have to debate this very important Bill have been underlined.
I regard the Minister as a very honourable and extremely decent man, and I know that he has the interests of patients very much at heart. That is not in dispute, but I am very concerned about one aspect of the contract in particular. I touched on it in an intervention, as did the hon. Member for Oxford, West and Abingdon towards the end of his speech. What concerns me is the service that patients will receive.
I fully understand the need for the contract. I completely support my hon. Friend the Member for West Chelmsford (Mr. Burns), who spoke eloquently from the Opposition Front Bench. He said that he supported the Minister and that he would not seek to divide the House. I am glad about that, and I certainly would not wish to do so. I hope that no one will do so on this issue. However, while it is possible to go through life without going into hospital, it is virtually impossible to go through life without needing the services of a doctor, so we are dealing with a part of the Bill that affects every man, woman and child in this country. I believe in the NHS. If we are to have a national health service worthy of the 21st century, it is crucial that the services provided by GPsfamily doctorsare of the highest possible excellence.
If there is a contractual arrangement that the practice does not provide out-of-hours services, that should be fixed up between the PCT and the practice, so that the patient has absolutely clear information. We have to remember that, although there are some hoaxers and malingerers, most patients who need a doctor out of hours are genuine people who are alarmed and need a service. The last thing that they want is a plethora of telephone numbers or a sheaf of papers. Those people are often elderly. They are sometimes old, distressed and even confused. A doctor is needed for the husband, the wife or the child in the middle of the night, but how is that doctor obtained? I should be most grateful to the Minister if he addressed that point and told us how such things will work.
I have a rural constituencynot as large as some of my colleagues' rural constituencies, but quite large. I have had experience of patients who are registered with practices that rely for virtually all their out-of-hours services on agencies. If the patient gets a doctor who has no idea of the geography of the area, who takes a long time to reach them, who does not know the patient and knows nothing of his or her medical history, it is hardly reassuring. Any agency that provides an out-of-hours service for a practice should have all their cars equipped with satellite navigation, which is simple these daysI have it myself, and I find it helpful when I am driving around an area that I do not know. It would be most reassuring if when people made a telephone call they knew that the doctor would arrive on their doorstep in pretty sharp time.
This aspect of the contract worries me. It is underlined by something that was said to me by the wife of a GP in my constituency a little while ago. I was shockedperhaps I am too old-fashionedthat she said, "Of course, medicine is not a vocation any more. It's just a job." I am naive and idealistic enough to believe that the element of vocation is terribly important and should still exist. Of course doctors deserve private lives as much as anybody else, and of course they have great pressures on themmany of them work in practices whose lists contain thousands of names. Of course it is incumbent on us to ensure that they have a contract that allows them to have decent private time and decent private lives. Nobody makes a man or woman become a doctor, however, and the element of vocation is important. When somebody has a sense of vocation, as most of us in this place do, hours sometimes have to be forgotten.
I trust that the Minister's answer will reassure me satisfactorilybecause this would also reassure my constituentsthat however the new arrangement works, the patient will still feel registered with a practice, that if illness strikes in the dark hours of a winter's night a doctor can be summoned, will be summoned and will appear in reasonable time, and that the quality of care will be commensurate with that given by the doctor who
I thank the Minister for what he has done. I appreciate the information that he got to usalbeit a little late, but that was not his faultand, I have absolutely no doubt about his personal integrity or desire to ensure that the quality of medicine is the highest possible. I have these worries, however, and I hope that he can reassure me. When he winds up this all-too-brief debate, I hope that he will be able to give me that reassurance, so that I can pass it on to my constituents.