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Mr. Lansley: I am grateful for the opportunity to contribute to this short debate on an important subject. I feel confident that the Minister will have a few minutes in which to reply fully to the points raised. I thought that my hon. Friend the Member for West Chelmsford (Mr. Burns) was generous to the Minister in contemplating that he might respond to some of the questions asked subsequently. It seems to me that the Minister has lived with the subject of the general medical services contract for some time, and I would be surprised were we to raise issues to which it was not within his competence to reply. I hope that he will reply in substance to our points.

My purpose is not to speak about the construction of the legislation and the new clauses and amendments, but about what lies beneath them: the new contract and how that it is to be framed. The debate gives us an opportunity for such discussion. It does not depend on the documents sent to us by the Minister, which I received on Friday in the House, but on the "Investing in General Practice" document, which, as the Minister rightly told us, was published in February. There has therefore been scope to think about these issues, but none to raise them. That is why I am disappointed that we did not get an opportunity prior to this to do so. It seems rather last-minute.

7.15 pm

Let me run through my points, some of which have already been mentioned. The first was rightly raised by my hon. Friend the Member for South Staffordshire (Sir Patrick Cormack). Much as we might be putting into legislative effect the framework for the contract negotiated between the NHS Confederation on the one hand and the GPs committee of the British Medical Association on the other, we are the guardians of the interests of the public, and, in that respect, of the interests of patients. I hope that my remarks will not be interpreted wrongly—both those organisations have the interests of patients at heart, too, but the final responsibility rests with us.

My hon. Friend expressed the concerns that have been raised in the right way, and I do not want to add to them, except to say that this is not simply about out-of-hours cover. The out-of-hours issue is terribly important, and I know that the Government will have thought long and hard about the extent to which practices can opt out of it; offering a timetable of 31 December 2004 for opting out is bold. I hope, however, that we will not find in the latter stages of next year or the early part of 2005 that, in practice, primary care

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organisations are seeking to provide out-of-hours cover for a high proportion of practices that are not willing to take it up, or a high proportion in rural areas in particular that are not willing to take it up, and that the alternative service models that are being developed simply cannot cope. I hope that we do not arrive at that, and I am sure that the Minister will give us some comfort that he feels confident about the scale—and the relative modesty of the scale—of opting out by practices, as it will be very difficult if it is much more than Ministers anticipate.

The second point, particularly in relation to rural areas, is the patient services guarantee. The patient services guarantee to which the Minister referred, I understand, is a guarantee for the primary care organisation to have a continuing responsibility for the provision of services under the existing contract. It is not, however, a guarantee that those services will be provided by the existing practice, because, of course, the practice in question has the ability to opt out of additional services. Therefore—this is particularly relevant in rural areas—if the service is being provided by other practices, other primary care providers or by the primary care organisation itself, provision may be in a number of different places. A considerable difference of substance exists between receiving one's essential services from a single practice, and, in respect of additional services, perhaps having to go to a more remote town or city to access a range of different services. In relation to provision for rurality, sparsity and special allocations of funds to reflect the costs of travel and the like in rural areas, I hope that the Minister will think hard and keep a weather eye on the extent to which the patient services guarantee leads to deterioration in the level of service or access to service for patients, whether in rural areas or anywhere else, and that he will be willing to intervene if necessary to boost some of the enhancements to practices, particularly in rural areas, if it proves that the incentives are not sufficient.

I want to echo two points made by the hon. Member for Oxford, West and Abingdon (Dr. Harris). I have been concerned about a case in my constituency, as other Members will be, involving the circumstances under which practices have the right to remove patients from their lists. He referred to that in the text of new clauses, but, of course, it reflects paragraph 6.29 in the contract. Of course, we know that patients may be removed if they are violent and that primary care organisations have to take responsibility in such circumstances. Paragraph 6.29 clearly says:

"Removal from a list will follow a transparent process that normally would include a warning to the patient before removal".

That is quite right. The subsequent sentence is less clear and gives rise to a specific concern. It says:

"When a patient is removed, practices will be required to give specific reasons to the patient as to why the removal has occurred, though it is accepted that, in certain specific circumstances, a statement to the effect that the relationship between the patient and the practice has irrevocably broken down will suffice."

What are the "certain specific circumstances" in which such a situation could occur? I suspect that they applied when my constituent was removed from a list. That process affected not only him but his wife and family because the practice's decision that the relationship with him had broken down meant that the

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whole family were effectively treated as though their relationship had broken down. The family live in a rural area, so the distance that they must travel to an alternative practice is substantial. My constituent believed that there was no underlying reason behind his removal from the practice. I suspect that it happened because he made a complaint, as the hon. Member for Oxford, West and Abingdon mentioned. That should not be sufficient to allow removal because there should be a formal and transparent process. I want to know the specific circumstances in which patients may be removed.

On immunisation, I have said that it is surprising that exception reporting for informed dissent will not be applied to the target payments. I have a technical question. Amendment No. 299 will disapply section 53 of the National Health Service Act 1977 under which every practitioner who is under contract to provide personal medical services should be enabled to offer child vaccination and immunisation services. Will the Minister explain why that provision must be removed?

I want to make a further point about the structure of the contract itself, although perhaps I should have raised it with the British Medical Association because it worries about such things. I earlier expressed concern about the extent to which information technology systems in the NHS are being centralised and said that the responsiveness of the IT system to individual customers was being removed. I fear that the same will be true of information management and technology systems for practices. The BMA and general practitioners might feel comfortable at the moment that they will enjoy the benefits of centralised standardisation, purchasing and funding for the provision of IT systems and the telecommunications to support that, but GPs will not be the customers. I wonder whether the BMA is entirely confident that GP practices will be able to exercise the same control over their service providers that they do at present. They currently spend their own money and obtain their systems from a range of competing providers that meet the necessary protocols of standardisation—the systems need to be able to talk to each other. There should be a customer-contractor relationship between a practice and its service provider, but that will not exist in future.

I am worried by paragraph 5.16 of the contract. It is an obtuse, yet important, part of the structure of remuneration and it relates to the adjustment of the list size for list inflation. Up until now, the registered population has tended to exceed the population estimates of the Office for National Statistics. In future, primary care organisations will rely on new census population estimates. It will come as no surprise to the Minister that there are places throughout the country—the most prominent are Westminster and central London, but the same can be said of the city of Cambridge—in which there are significant discrepancies between population estimates from the 2001 census and the figures anticipated. If those statistics affect the allocation of resources to primary care organisations and their practices under the contract, I am worried that structural problems with census population data will lead to problems with the contract. I hope that the Minister understands that caveats might need to be entered against that.

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I asked the Minister earlier about order-making powers. He said that the negative procedure would be used; I assume that he meant in all cases. I imagine that many orders that arise from the Bill would not need to be considered using the affirmative procedure, but I urge the Government and those in another place who care deeply about the structure of legislation to look hard at Government new clause 26. It contains order-making powers to prescribe services that

"are, or are not, to be regarded as primary medical services"

and to define how they should be delivered. That is one of the central issues behind the new structure of contracts for personal medical services and general medical services. It would not be excessive for Ministers to give an undertaking that such orders at least would be considered under affirmative resolution. It would be undesirable if Opposition parties had to pray against orders so that something so central to the contract's structure could be debated.

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