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Andrew Selous (South-West Bedfordshire) (Con): My hon. Friend mentioned practice nurses. Is it not rather extraordinary that the Government's definition of those eligible for key worker housing does not include practice nurses in GP surgeries? They may have been in the NHS pension scheme for 35 years, yet because some of their salary is paid directly by the GP they are not included.

Mr. Lansley: I do find that strange. Our constituencies are almost neighbouring, so my hon. Friend and I are both aware of the pressures on health workers and of their need to access affordable housing. I was not previously aware of that exclusion, but the Minister will know of it and I hope that he will take note of my hon. Friend's point and perhaps discuss it with the Office of the Deputy Prime Minister. In the past, I have had occasion to press for the extension of the definition of key workers, and my hon. Friend makes a good case in that regard.
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Andy Burnham (Leigh) (Lab): I am listening to the argument that the hon. Gentleman is developing. He has mounted a critique in opposition to the concept of salaried GPs. He seems to want to uphold the principle that GPs are independent contractors. What would he say to deprived communities, such as the one I represent, where for many years GPs have not wanted to invest their capital and commit themselves? Consequently, GP vacancies are higher in such areas. If he is denying us the right to salaried GPs, what will the Conservative party do for communities such as Leigh?

Mr. Lansley: It will come as a surprise to some of my colleagues—for example, in Hertfordshire—to hear that significant numbers of GP vacancies are experienced only in urban areas. In fact, they occur in many areas.

The hon. Gentleman asked what we would do. Of course, we need measures to try to support GPs. I have held discussions with GPs, so I know of the difficulties for a young GP, especially in some urban areas, of taking on the necessary mortgage not only to live in the area, but to buy practice premises. That is not easy as it once was, so of course support is needed. There could be a range of options, such as the PCT purchasing the premises and, in some cases, as I acknowledged to the hon. Member for Rhondda (Chris Bryant), it will be right to employ salaried GPs. I do not dispute that. My point is about the desirability of creating opportunities for GPs actually to be independent contractors. That is the best basis on which to establish the service.

The relationship between GPs and patients is one of the benefits that small practices offer patients, but which well-run practices of all sizes can achieve. It is more than simply a matter of service standards; it has a positive impact on the treatment of patients. We should not underestimate the need for effective management of co-morbidities or the benefits that flow from giving patients a framework of information and advice in the management of chronic disease. In both respects, the patient-GP relationship may be instrumental.

We should also be aware that every GP is an advocate for public health promotion and has the opportunity to make early interventions to combat disease. That will be maximised if GPs know their patients, take responsibility for their patients, assist them in exercising choice and influencing the management of their care, and are progressively able to commission services on their behalf.

The value of GPs and the family doctor service in terms of health benefits is clear. As Dr. John Chisholm, a former chairman of the BMA's GP committee, said in his speech to local medical committees in June:

Central to the role of family doctors should be the opportunity for practices to commission services on behalf of patients. Fundholding was taken up by many GPs and we should look to all practices progressively to take responsibility for commissioning decisions on behalf of their patients. Whenever possible, patients should exercise choice. All patients should have
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influence and a voice in the management of their care, but we should never underestimate the value of GPs as advisers and commissioners on behalf of patients.

Mr. Drew : Will the hon. Gentleman give way?

Mr. Lansley: No.

If we can be clear about the central role of GPs, why cannot the Government also be clear? In part, of course, it is because their focus is elsewhere. They have talked of hospitals and waiting list targets to the exclusion of all else. It is a condemnation of the Government that it is only now that they are acknowledging the need for the NHS to focus on improved chronic disease management.

Another reason is that the Government cannot let go of central control. Let us take that example of out-of-hours services, which we have discussed briefly. Eighteen months ago, I and my Opposition colleagues sought certain assurances. The Minister, as I quoted earlier, said that there would be no loss of access to out-of-hours services. What did we get? In seven areas, with a population totalling 1.2 million, including South Lincolnshire, we got a service with no GPs at all, and the Minister had to be brought to the House by my hon. Friend the Member for Grantham and Stamford (Mr. Davies) to answer that point. Saturday morning surgeries have gone. MedEconomics reported recently that the bill for new out-of-hours services is likely to reveal a frightening level of underfunding, which will have a detrimental effect on the quality of out-of-hours services. We were promised that more would be spent and access would be maintained.

Mr. David Hinchliffe (Wakefield) (Lab): I am grateful to the hon. Gentleman for giving way and I apologise for not being present for the first few minutes of his speech. I am particularly interested in the points that he is making about out-of-hours services and I have noted that the Conservative motion talks about deploring

I do not know whether he has had the opportunity to study the Health Committee's report on out-of-hours provision, published as recently as July, in which we actually said:

which we thought was a very important development. That report was signed up to by the entire Committee, which of course includes colleagues on his own Front Bench who agree with that particular point.

The hon. Gentleman seems to be harking back to a golden age of out-of-hours cover, which, in my experience, never existed. I worked alongside GPs in an out-of-hours service on mental health care; frankly, many of them were knackered—if that is not an unparliamentary term—and should not have been practising because they were exhausted. The hon. Gentleman really needs to address that point.

Mr. Deputy Speaker (Sir Alan Haselhurst): Order. The distinguished Member, the Chairman of the Select Committee, has a lot of knowledge on these matters, but we do not want it all at once.
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Mr. Lansley: You are absolutely right, Mr. Deputy Speaker, but as a former member of the Select Committee under the hon. Gentleman's chairmanship, I would not diminish the value that we can get from hearing from him. I would sign up to what he says and I am not surprised that my hon. Friend the Member for West Chelmsford (Mr. Burns) did as a Member of the Committee, because there are some models from which we can learn.

In my region, the ambulance trust has taken responsibility for the provision of out-of-hours services in Norfolk. However I know—because it has been recruiting doctors from Germany to meet its requirements—that it is having difficulty in getting GPs involved. Among the things that we need to be clear about is the fact that GPs in particular will subscribe to an out-of-hours service if they feel that it is structured around their needs, that it will manage risk and take clinical judgments on a basis with which they are happy, and that it will provide a service that is complementary to them. Of course, it must be seen as part of a more integrated service of unscheduled, unplanned care, but that does not mean that it becomes part of a bureaucracy that is no longer accountable to GPs. It is the out-of-hours GP service and it must be seen as such.

NHS Direct was mentioned. It is important to understand how this will work because NHS Direct is gearing up to take over call handling nationally, and that could undermine GP out-of-hours providers locally. It could substitute clinical assessment software for GPs' management and judgment and it could mean handling calls at centres where staff simply do not know local services.

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