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Mr. Paul Burstow (Sutton and Cheam) (LD): As I listened to the exchanges across the Dispatch Box, it occurred to me that the proposition is either GP family services on the Finlay model or primary care services on the "Peak Practice" model, as favoured by the Government. The Minister was a little hard on Dr. Finlay, but perhaps he needed to make those points because the hon. Member for South Cambridgeshire (Mr. Lansley) sounded like an advocate not so much of the consumer of health care, but of producer interests in the health care system. It is essential that the patient be kept at the forefront of our minds and at the heart of our thinking. It was not clear from some of the points about the GP contract whether that was the key consideration.

There can be no doubt that GPs are the backbone of the primary care system. It is right that we are debating the state of family doctor services and their pivotal role. It is also right to acknowledge that there have been improvements. The extra investment is beginning to give us additional capacity. I hasten to add that Liberal Democrats were happy to go through the Lobby in support of that extra investment. Changes such as the new GP contract and the development of practitioners with specialist interests are rightly placing even greater emphasis on the role of primary care in general and GPs in particular. As the Conservative motion and the unselected amendment standing in my name and those of my right hon. and hon. Friends rightly document, areas of concern remain. It is not my job—or any Opposition Member's—to act as cheerleaders for the Government's record. Our role is to analyse, criticise
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and point out areas of concern, which there are in relation to the development of primary care services in this country.

Mr. Lansley: The hon. Gentleman talked about investment in national health services, but can he clear up a point about which I am slightly confused? The Liberal Democrats appear to be proposing hypothecation to the NHS of the proceeds of national insurance, but the relationship between the two in the coming financial year would result in NHS expenditure having to be reduced by £4 billion if one simply did that hypothecation. I do not understand from where that £4 billion would come if not from national insurance, and it is not hypothecation if money is brought in from elsewhere.

Mr. Burstow: The hon. Gentleman was right to say, "if one simply" hypothecated. I shall happily send him the working paper on which the policy is based, so that he can read it in detail. The paper makes it clear that the hypothecation is spread over an economic cycle, not done one year to the next. That is how the policy would work. It seems an appropriate way to ensure that people see far more clearly how much they pay in taxes for the NHS. I would be surprised if the hon. Gentleman did not want to sign up to that, given that people would understand better how much they were paying into the health service and therefore would be more likely to engage at local level and question whether priorities were correct and whether resources were going to the right areas.

The most recent staffing figures available— I understand that new ones are due to be published fairly soon—suggest that there were 3,435 GP vacancies, a 31 per cent. increase on the previous year. The Minister said that that was no longer the case but did not quote any figure, so I hope that he can tell us today what the most up-to-date survey reveals the number of GP vacancies to be. More telling than the vacancy rate is the fall in each of the last three years for which figures are available in the number of applicants for GP posts. In 2001, there were 6.9 applicants for every vacancy, but that number had more than halved, to 3.3 applicants, by 2003.

Furthermore, the position will worsen before it improves. There is a demographic time bomb ticking away under the NHS work force; the number of GPs who will reach the mandatory retirement age—70— in the next five years will increase rapidly, especially in London and the west midlands. It is clear that there are recruitment and retention issues to be addressed. A change in working patterns has also been noted. Many more GPs are choosing to work part time. As a result, although the headcount of GPs has increased by 4,237 since 1997—a welcome increase—the full-time equivalent has increased by only 2,913.

One of the pressures on the system is the number of people who do not get a choice in which GP they sign up to. Patients in many areas struggle to get easy access to a local GP. Many GPs have lists much larger than the national average, which is about 1,850 per GP; for example, the average Westminster GP is coping with 2,500 patients, and areas such as Barking, Newham and
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Birmingham also have among the busiest GPs in terms of the number of people on their lists. No wonder many GPs are having to close their lists to new patients and patients are finding it ever harder to register with or change their GP.

Earlier this year, in its "Transforming Primary Care" report, the Audit Commission found that 0.5 per cent. of people every year are assigned to a GP. That might not sound like a large number when described as a percentage, but a significant number of people are affected; about 250,000 people each year are unable to find a GP because of list closures and other difficulties and are assigned to a GP by their primary care trust. The Audit Commission rightly said that this

Of course it can. People should be able to choose their GP and get care closer to their home; they should not be allocated a GP, which might entail longer journeys away from where they live. Where is the choice for those 250,000 people every year?

Such shortages give cause for concern about how patient choice will work in practice, especially in the "choose and book" programme. I have no problem with patients having more choice and more control over their health care, but I am concerned about the Government's choice agenda being too narrow and its basis being on rather over-optimistic assessments of the capacity available to introduce choice. We believe that patients need to have more control over their health care; they should not just be faced with an array of choices—a choice of five hospitals, say, or—

Mr. Hutton rose—

Mr. Burstow: I give way to the Minister, who seems to have perked up.

Mr. Hutton: I am confused by what the hon. Gentleman just said. He said that our choice agenda is too narrow, but then described it as over-optimistic. Will he explain?

Mr. Burstow: I described as over-optimistic the assessment of the capacity available to make the policy a reality in practice.

Mr. Siôn Simon (Birmingham, Erdington) (Lab): Will the hon. Gentleman give way?

Mr. Burstow: I ask the hon. Gentleman to allow me to develop my point before intervening. In my view, patients should be regarded as partners in their care and involved in decision making about their treatment. If that is to become a reality, it must be not be something that is available only to the articulate few. When the NHS improvement plan was published earlier this year, the way in which PCTs and primary care professionals provided support to everyone in their community in exercising choice was left as a matter of local detail, so although the Government have targets for the implementation of the choice programme, there will be variations throughout the country in the support available to make choice a reality for everyone, not just for the articulate few.
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The argument about choice between the Government and the Opposition is advanced in terms of, "My choice is bigger than your choice," but Ministers must give serious consideration to the extra time that GPs will have to take to make choice a reality for all patients. I wonder whether Ministers have undertaken any assessment or evaluation of how much additional time GPs will require to support patients in making choices at the point of referral.

Mr. Simon: As one of the inarticulate many on this side of the Chamber, and bowing as we do to the articulate few on the other, I have to say that I am not following the hon. Gentleman's argument. It sounds articulate, but I am not getting the details. For the benefit of those of us who are finding his speech baffling, will he speak more slowly and even more articulately?

Mr. Burstow: I am grateful to the hon. Gentleman for his constructive criticism of my remarks so far. He has clearly been struggling, but I shall endeavour to improve my performance, so that he can follow the rest of the argument.

I was exploring whether the patient choice programme will have an impact on GP consultation times and what assessment the Government have made of how much extra time GPs will need to provide the advice and support necessary to make that choice a reality. It is essential that the best use is made of GPs' time, so the roles of other members of the primary care team will have to be expanded. I do not buy the argument advanced by the hon. Member for South Cambridgeshire, that it is not possible to examine critically the range of tasks for which GPs have historically been responsible and determine whether some might more appropriately be discharged by others in the primary care team. I do not know whether that is his view or whether he was quoting the view of others, but my impression was that it is his own view.

It is estimated that one fifth of GP appointments are made in relation to minor ailments that could be handled by pharmacists. The development of minor ailment services in high street-based community pharmacists could help to ease the pressure on GP surgeries. That is a sensible proposal and one that I think will emerge from the new pharmacy contract. The Liberal Democrats would support such a move.

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