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Mr. Mark Francois (Rayleigh) (Con): My hon. Friend referred to the debate on 24 March in the European Standing Committee. I was present and, as the Minister will recall, he and I crossed swords quite actively over this issue. He admitted that it did not apply solely to doctors, but would require additional staff in other categories. As can be seen in column 13 of the Hansard report, he acknowledged that extra nurses in a number of categories would be needed. However, the £780 million figure that he gave the Committee was only the NHS estimate of the additional cost for doctors. When other staff are included, the estimate will be even greater. The Minister promised to provide the figure on the day, but failed to do so. Does my hon. Friend agree that it would be helpful if the Minister honoured that commitment today and gave us the total figure?

Mr. Lansley: Perhaps the Minister will take up that question. The estimates have indeed related to doctors. My personal view is that the scope of "Agenda for Change" should enable the nursing profession to be compliant with the working time directive without substantial additional costs. My argument rests on the implications for doctors' hours and the costs to the NHS.

The Minister of State, Department of Health (Mr. John Hutton): I am interested in what the hon. Gentleman said about "Agenda for Change", which he prayed in aid in relation to supporting the NHS in meeting our obligations under the working time directive—but is not his party opposed to "Agenda for Change"? Did not the hon. Member for West Suffolk (Mr. Spring) make it clear when he was appointed as shadow spokesman that he was against national pay bargaining for the NHS?
 
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Mr. Lansley: No, he did not say that. He is in favour of NHS trusts and foundation trusts having the freedom to respond locally—through pay, if necessary, as well as other conditions of service—to their particular needs. Is it the Minister's view that hospitals should not have that freedom? If so, let him say so. I said to him in the Standing Committee that considered the Health and Social Care Bill last year that we support "Agenda for Change" and the ability of nurses, in particular, to be supported in extending their role and to have their work reflected in their rewards, and it is entirely appropriate for that to be negotiated. Review bodies provide a national pay framework, and it is in the interest of NHS trusts that they should do so, but that is a framework, not a straitjacket. Is the Minister saying that the Government want to put the NHS in a national pay straitjacket?

Mr. Hutton: The hon. Gentleman knows, because he does his homework, that "Agenda for Change" incorporates an element of flexibility in meeting local pay terms. That has always been the case. The Government have always supported "Agenda for Change". The issue is whether the Opposition do. The hon. Member for West Suffolk made it clear in his first interview as shadow public services spokesman that the Conservative Opposition are against "Agenda for Change" precisely because it is a national pay agreement and he would prefer to revert to local trust contracts. If the hon. Gentleman is saying that this is one further aspect of his health policy reforms that he has abandoned, we would welcome that news.

Mr. Lansley: I am not having any of that. We have made it clear throughout that we favour hospitals having the freedom to manage themselves and respond to their particular needs. If the Minister is against that, let us put that on the record. I am not having the suggestion that by allowing that freedom we necessarily abandon either pay review bodies or "Agenda for Change". There is nothing that my hon. Friend or I have said that would suggest that an incoming Conservative Government—before too long, we hope—will abandon or reverse "Agenda for Change", but it must be regarded as a framework rather than a straitjacket.

There are practical implications. Managers at a district general hospital told my hon. Friend the Member for Westbury (Dr. Murrison)—he may refer to this in more detail later—that, being in deficit, they cannot afford to pay staff to be treated as working while they are sleeping, so they have to move to full shift working, and to some extent from doctors to nurse practitioners. That may be entirely acceptable, but if staff on full shifts are not then fully employed, the activity needs to be increased to ensure that they are.

The hospital managers said:

"this may require the closure of some units and the transfer of work to units with spare capacity. This will affect many of the medical low volume specialties where there is a requirement to have residential specialist staff".

Hospital at night can achieve many things, but there cannot necessarily be cross-cover, for example between non-paediatric and paediatric staff. Cross-cover is not possible on obstetrics, if people are not obstetric-trained and experienced, or on anaesthetics. Some rotas simply have to be staffed with those specialists. If the hospital
 
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cannot scale up from the five doctors that it has now to the arguably nine or 10 that will be required for a full shift a few years hence, those units will close.

Mr. Andrew Turner (Isle of Wight) (Con) rose—

Mr. Lansley : I see that someone who may have direct experience of this in his constituency would like to intervene.

Mr. Turner : There are some hospitals that cannot attract greater volume because the distances or the means of travel are too difficult, but for the very same reason cannot be closed. How are they supposed to survive within the same budget and yet meet "Agenda for Change"?

Mr. Lansley: That is an important point. The directive will bear harshly on some specialties and in some remote areas. The Isle of Wight has special problems that will have to be managed.

Our prospective parliamentary candidate in Southport, Mark Bigley, reports:

"The Hospital Trust says they cannot run A&E services at Southport due to the impact of the EWTD on junior doctors' hours."

There may be a complementarity between what local people want there and what my hon. Friend wants on the Isle of Wight. They know that centres of excellence and major specialties may have to be concentrated—perhaps in Southampton, in my hon. Friend's case—but they want access to stabilisation and treatment more locally and accessibly, so that large numbers of people do not have to be referred a great distance away for routine treatment.

My colleague in Enfield, North referred me to the health hospitals review document of Barnet and Chase Farm hospitals, which says:

"Neither the doctors nor the funding is available for the hospitals simply to 'grow' their teams out of this problem."

That may bear on maternity, for example, or obstetrics.

I do not know the precise circumstances, because it is in Scotland, but even today The Herald reports:

"New rules cutting the number of hours worked by junior doctors and consultants, which make staffing multiple maternity hospitals more difficult are threatening units across Scotland."

Mr. Stephen McCabe (Birmingham, Hall Green) (Lab): Before the hon. Gentleman goes through the complete list of prospective Conservative parliamentary candidates—at least some of them know where the constituency is, which is not the case in Hall Green, as I noticed from a recent visit—can he tell us how he will square these demands for additional funding with the fact that his party voted against the 1 per cent. national insurance increase? How can he reconcile that? It is a fundamental question.

Mr. Lansley: With respect, it is not fundamental to the implementation of the working time directive. We have committed ourselves to the resources for the NHS, to support not only reform but the additional transitional costs, which the Government are clearly not
 
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doing, when one compares the costs that they anticipate for the working time directive with the £46 million that the Minister has promised.

When we had a modest one-and-a-half hour debate on GP contracts—one of the major changes in the NHS—on the back of the Health and Social Care Bill last July, the Minister made a statement in response to my hon. Friend the Member for South Staffordshire (Sir Patrick Cormack), who told me that he wished to be here today but had to attend an important meeting with a constituent and so sends his apologies. The Minister said to my hon. Friend:

"I know from my work as a constituency MP that our constituents place a high premium on around-the-clock access to a GP, 24 hours a day, seven days a week. It is a defining characteristic of our primary care services."—[Official Report, 8 July 2003; Vol. 408, c. 1050.]

That is the promise from this Government, but what is the reality? A shift to emergency nurse practitioners and paramedics. Perhaps that is acceptable, because it is appropriate care. A shift to NHS Direct's handling the calls. Perhaps that is fine too, although it turns out that the Minister of State, the hon. Member for Doncaster, Central (Ms Winterton) said in a reply to me that she had no estimate of how many primary care trusts were going to ask NHS Direct to handle their calls for out-of-hours services, so quite how NHS Direct will be able to staff up to provide that service, I do not know. However, as a consequence of a shift to NHS Direct's handling the calls, do we shift from risk management by GPs to risk management by the NHS Direct clinical assessment software? That is not the same GP service that people thought that they had before.

Everywhere that I have gone around the country, people have told me that they expect that their GP out-of-hours service will be run with fewer GPs. In one place that I visited recently, I was told that roughly speaking, the point would come where a GP sat in a centre and never really went out on call because there would not be enough GPs available in the service to enable them to travel around the country; they would have to sit in one place. Will this be a GP-led service? That is the issue.

What do GPs themselves say? In January, the health journal Pulse surveyed 1,168—

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