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Mr. David Drew (Stroud) (Lab/Co-op): I have some concerns about how the out-of-hours service operates, but I am not sure that GPs would want to turn the clock back. Part of the reality of the new contract was that GPs wanted a new environment to work in. I would prefer it if GPs volunteered to join the out-of-hours services. Some will, but some have chosen not to do so. What would the hon. Gentleman do in the circumstances to try to encourage them to do so?
Mr. Lansley: I shall deal with the issue of out-of-hours services in some detail later in my speech, but the short answer is that where the PCT continues to have a contract with a GP-led co-op that continues to have the support of local practitioners—as is happily the case in my area—much better results are seen than in other areas. That distinction points us in the right direction.
Despite the fact that a million patients visit their local family doctor practice each day—a far greater number than access NHS services by any other means—GPs see their service being diminished in importance. For example, I was on a bus in London recently—such is the nature of opposition that we cannot just get into the back of a car and hope that it moves. I saw an advert placed by a strategic health authority advertising options for care. The list included self-care, visiting a pharmacist, going to an NHS walk-in centre,calling NHS Direct, attending a minor injuries unit, going to accident and emergency or dialling 999 in an emergency. At the end of the list it said:
Is it any wonder that GPs feel devalued?
Increasing numbers of GPs are becoming salaried and controlled by their PCTs, and all GPs are being inspected, validated, performance-managed and target-driven to the point where they are concerned about their continuing clinical freedom. As Dr. Mayur Lakhani, the new chairman of the Royal College of General
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Practitioners, said in the most recent edition of the BMA News:
"I feel general practice is under threat—it is not valued . . . I want doctors to look forward to going to work in the morning. At the moment, people seem browbeaten."
Dr. Lakhani also suggested that the greatest threat to the profession—and this point is relevant to the intervention by the hon. Member for Bury, North (Mr. Chaytor)—is the
"I do not buy this idea that others can do the work of GPs. GPs cannot be replaced. We cannot take the role of the GP and break it up into bits and say let provider X do that, provider Y do this and provider Z something else. You lose the essence."
Chris Bryant (Rhondda) (Lab): The hon. Gentleman may think it odd that a Welsh Member of Parliament should intervene on this point, although much of what he has been talking about applies equally to Wales as it does to England, even though some of what he says applies only in England. He said that many more GPs are now salaried and he suggested that that was a problem. I represent a valleys constituency that has found it very difficult to recruit traditional-style GPs, so the advent of the salaried GP has led to a dramatic improvement in provision locally.
Mr. Lansley: Far be it from me ever to think that what the hon. Gentleman says is odd. However, to introduce salaried GPs in circumstances in which it is difficult to recruit self-employed practitioners is very different from trying deliberately to introduce salaried GPs in place of self-employed practitioners, as PCTs are attempting to do in many areas.
Dr. Lakhani is right in what he says and right to say it. The Government cannot have it both ways. If, as I suspect, they know that they will achieve their aims only through recreating the innovation, energy and responsiveness of GP fundholding, they cannot at the same time put GPs on to a treadmill of providing services as dictated by the Department of Health. The Government cannot seek to recreate the benefits of fundholding and, at the same time, devalue the leading role of family doctor services in primary care.
Mr. Chaytor: Does the hon. Gentleman accept that one of the by-products of the introduction of GP fundholding by the previous Government was that it encouraged many GPs to devolve responsibilities to nursing staff for the first time ever? With no disrespect to Dr. Lakhani, there are many GPs who have actively argued for that to happen for many years. Does the hon. Gentleman seriously object to initiatives such as NHS Direct, which gives ordinary patients faster access to the health service?
Mr. Lansley:
The point is not that NHS Direct is undesirable as a means of accessing NHS services, nor that walk-in centres are undesirable as a means of improving diversity of provision. We are in favour of diversity of provision. I have spoken about the importance of extending the role of nurses, for example. However, it is important for GPs to be focused on the things that they do best, such as diagnosis and the
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management of chronic disease. My objection was—and the hon. Gentleman will recall that this was the subject of his first intervention—that the Secretary of State announces that, for example, the NHS will recruit community matrons who will be responsible for the provision of services to the most elderly, who have a range of co-morbidities and who suffer from chronic diseases. Those are precisely the patients whose care GPs, as family doctors, are best equipped to manage. The relationship between community nursing and GPs is at the heart of the issue, but that is not what the Secretary of State said. It is not that diversity of provision is wrong—far from it—but we need to understand the central role of the GP and family doctor service.
We saw another example last week when the Minister of State, the right hon. Member for Barrow and Furness (Mr. Hutton) announced the establishment of seven walk-in centres for commuters. Fine. Okay. By all means, let us offer access to health care services. But that is the same Government who eroded the very access to family doctors that people who commute to city centres need. Commuters and office workers want to be able to visit their own GP practice in the evening or on Saturday morning, but those opportunities have gone. The consequence of the contract and the unwillingness of PCTs to commission those services from GPs has meant the abandonment of Saturday morning surgeries across the country.
The Minister of State, Department of Health (Mr. John Hutton): The hon. Gentleman is being generous in giving way and I am extremely grateful to him. May I take him back to the question put by my hon. Friend the Member for Stroud (Mr. Drew)? The hon. Gentleman has again raised concerns about the new GP contract and criticised those aspects that relate to the definition of out-of-hours services. Would he go back on the contract?
Mr. Lansley: What GPs want—[Interruption.] Do Labour Members want an answer? I am not sure. Let me give the Minister an example. As the Under-Secretary of State for Health, the hon. Member for Welwyn Hatfield (Miss Johnson), knows, I recently met GPs in Welwyn Garden City. They want their PCT to commission them to provide Saturday morning surgeries, but they are not being given the commission, so they have been forced to cancel Saturday morning surgeries. They regard that service as valuable and explained to me at considerable length the benefits it provides and the difficulties that will ensue in accessing services in its absence— the number of patients fetching up at surgeries on Monday mornings or going to accident and emergency departments or elsewhere. No doubt the hon. Lady knows about that.
It is not me who is saying that we want Saturday morning surgeries; it is general practitioners. They are not saying, "Scrap the contract", but, "Enable us to continue to provide the Saturday morning surgery that our patients want and that we are prepared to offer".
Mr. Hutton:
I will be well behaved, Mr. Deputy Speaker. This is the last time that I shall intervene on the hon. Gentleman.
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It is fundamentally untrue to say that GPs have been forced to do any of those things. The GPs were offered a contract and negotiated it. They wanted to be relieved of those responsibilities and chose to be relieved of them.
Mr. Lansley: The Minister knows perfectly well that, under the terms of the contract, out of hours was defined such that if a continuing level of access to service was required it would have to be commissioned as a locally enhanced service. That is all we seek—a locally enhanced service. We discussed the GP contract on 8 July 2003 for the sum total of one and a half hours—such is the nature of parliamentary proceedings. On that occasion, the Minister said:
"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. I can give the hon. Member for South Staffordshire the assurances he seeks: we will implement the agreement to ensure that there is no loss of access to out-of-hours services."—[Official Report, 8 July 2003; Vol. 408, c. 1050.]
He said that there would be no loss of access to out-of-hours services, but the agreement was not implemented on that basis, as I shall explain later.
For the reasons I have given, we need to be clear about the future of the family doctor service. My colleagues and I are clear. We believe that the relationship between patient and doctor is vital. That does not mean that a patient should necessarily see their own GP every time they visit a practice; nor does it mean that they have to see a doctor if that is not necessary, as the hon. Member for Bury, North pointed out in his intervention. The role of nurses and other health professionals is expanding and it makes good sense to focus scarce medical time on the tasks for which medics are actually needed. However, what that relationship means is that patients want to know that their health needs are understood, seen in context and that one illness is not treated without an understanding of the range of further illnesses and complications that they may experience. That is what patients are concerned about. It is clear that patients value knowing, and being known by, their GP.
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