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Mr. Rendel: Is not it the case that not only would the Liberal Democrats support it, but so would most of the best GPs?
Mr. Burstow: I am sure that is so. We need to re-examine the role of the GP and how some of the tasks hitherto undertaken by a GP can be taken on by others who have a great deal to contribute. For many years community pharmacists have felt undermined and undervalued within the system and as though they were not seen as part of the primary care team. There are now opportunities to overcome that.
It is not just the role of pharmacists that can be expanded. There is also scope, for example, to develop the role of therapists, particularly physiotherapists. I was struck by a pilot scheme undertaken in the Forth Valley primary care trust over a 30-month period, which
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looked at opportunities for self-referral to NHS physiotherapy services in a primary care-led setting. The study found that that had significantly reduced GP workloads. People were choosing to go not to the GP but to the physio, possibly to deal with problems of back pain. That had a marked impact on individuals' quality of life and reduced GPs' work load so that they could concentrate on other tasks, not least issues relating to the management of chronic disease.
Other possibilities such as nurse prescribing, nurse-led practices and therapist-led clinics are providing new career paths for professions that we need to attract into primary care, and are freeing up GP time. These changes in the roles of nurses and therapists are crucial to ensuring that we start to tackle the shortages in these professions.
What is being done with the time that GPs have? The Government's obsession with targets is of real concern to GPs. For example, follow-up appointments are delayed and deferred to ensure that first appointment waiting time targets are hit. Diseases with a target attached take priority over those without a target. GPs end up playing piggy in the middle as frustrated patients turn up at the surgery asking for their appointment with consultants and others to be expedited. It is not just targets in secondary care that need to be scrapped. The 48-hour access target is leading to all sorts of wheezes to game the system.
Sarah Teather (Brent, East) (LD): Despite repeated assurances from my local primary care trust that the 48-hour access target should have no impact on forward-planned appointments, I have had a continuous run of complaints from two groups of patients in particular. The first is those who are chronically ill and find it impossible to book repeat appointments with the same doctor, and the second is those who work and want to book an appointment for, say, next Wednesday, so that they can take a little time off work. They find that the only way they can get an appointment is by starting to jam the phones at 8.30 am, book the whole day off and hope that they can get to see the doctor by the end of the day. That has huge implications for going to see a doctor when the situation is not urgent and people simply want to talk something through.
Mr. Burstow: I thank my hon. Friend for her intervention. Those experiences are reflected in MPs' mailbags. Perhaps the good intentions behind the target are not being translated into reality. My hon. Friend's example of patients not being able to see the same GP at their next appointment raises concerns about the continuity of care, and there are increasing concerns about access to the GP by those who work away from the area where their GP surgery is located and not being able to get an appointment when they want one.
Other wheezes that are being used to game the system have been drawn to my attention by GPs, such as restricting patients to one problem per consultation. I do not know how that works in practice, but it is being tried. Another wheeze involves setting limits on times when patients can call for an appointment and, as my hon. Friend the Member for Brent, East (Sarah Teather) mentioned, rationing access because the telephone is engaged all the time. So many people are phoning in that
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they cannot get through to book an appointment. The selective release of appointment slots is a further wheeze. Appointments should be booked to meet the patient's need, not to hit an arbitrary target. All too often it seems that the target is shaping the way the system is working.
The motion refers to out-of-hours services. There is still much confusion about how such services will work after 1 January. The Select Committee on Health, whose Chairman intervened earlier, rightly raised concerns about the costs, planning and implementation of a huge change to the provision of family doctor services out of hours. I support the change. [Interruption.] If the Minister would not chunter from a sedentary position, I would be happy to outline my concerns. Hopefully, there will be a response to some of those.
It is evident from my mailbag and that of many other hon. Members that people are worried about the loss of Saturday morning surgeries and the difficulties that that will cause. How did the Government arrive at their estimate of £6,000 per GP to provide out-of-hours and Saturday morning services? According to the results of a survey by the NHS Alliance, PCTs are struggling with the logistics, staffing and finances necessary to deliver out-of-hours services. One in five PCTs say that they will restrict services on the basis of quantity or quality or both. On what basis does the Minister reject the findings of the NHS Alliance's survey? I wonder whether he has looked at it and why he does not consider it an acceptable basis on which to criticise the Government's approach to the provision of out-of-hours services in the new form under the new contract.
Where will all the extra doctors come from to staff the out-of-hours services? How much reliance will PCTs have to place on locum and overseas doctors to fill the gap? Many PCTs plan to use NHS Direct services as the front end of their out-of-hours services. However, that will need to be monitored closely in the light of recent research in the British Medical Journal. A study published on 17 September looked at the effects on consultation workload and costs of off-site triage by NHS Direct compared to on-site nurse triage in general practice. Patients in the NHS Direct group were less likely to have their call resolved by a nurse and were more likely to have an appointment with a general practitioner. In other words, it was costing more to use NHS Direct. Perhaps that explains one of the cost pressures that PCTs are grappling with. Half of PCTs have said that they will contain the extra costs by delaying investment in new services. How long will they delay investment in much-needed new services?
Ministers have said that the recent increases in accident and emergency attendances have nothing to do with the change to out-of-hours services. Certainly some of the figures suggest that the increase predates the changes. I accept that, yet reports from the front line tell another story. The Nursing Times recently quoted an accident and emergency sister at Norfolk and Norwich university hospital as saying that her department had
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seen a 13 per cent. rise in attendances since January. She is quoted as saying:
"People tell me they are here because it is convenient and because they cannot get an appointment at the GP's."
Perhaps that is another unintended consequence of the 48-hour access target. To what do the Government attribute the increase in accident and emergency attendance?
Mr. Hutton: I have tried to resist intervening on the hon. Gentleman, but it has got too much for me. He has repeatedly attacked the 48-hour target, as did the hon. Member for Brent, East (Sarah Teather). I understand the criticism, but under the hon. Gentleman's proposals, how quickly would one of his constituents be able to get an appointment to see a GP if he scrapped the target?
Mr. Burstow: I am not proposing a target. I am proposing to scrap a target, because it gets in the way of people being treated quickly. The problem is that with the target, people are not getting treatment as quickly as they need because they are unable to get an appointment when they want it. An arbitrary target misses the point. That is my criticism of the Government's target culture.
Mr. Burstow: I will not give way again, if the right hon. Gentleman does not mind. I wish to make some progress and move on to NHS IT procurement, which is mentioned in the motion. Well designed business processes delivered by well implemented systems can save GPs and other primary care professionals time previously spent on administration, but there are real concerns about how the procurement is proceeding and how the end users are being engaged in the process. What control do GPs have over the process?
Mr. Simon: Will the hon. Gentleman give way?
Mr. Burstow: No, I shall make progress, if the hon. Gentleman will forgive me. Without GPs' engagement and without their enthusiastic support, delivering a system that is fit for purpose will be a challenge. It is far from clear who in the national team is responsible for leading on this aspect of the programme's work. How will the full costs of the procurement be met? It has been reported that the total cost of IT procurement could be anything from £18 billion to £30 billion. Most of the extra costs will have to come out of existing budgets, increasing the average spend on IT; yet another cost pressure for PCTs to grapple with.
A further issue not mentioned in the motion but relevant to the working conditions of family doctors and the quality of care that patients receive is the standard of practice premises. According to a written answer that I received there are 700 GP practices operating in sub-standard accommodation; that is, accommodation below the Department's minimum standard, such as surgeries that lack sufficient consultation space, have access difficulties or pose questions about patient confidentiality. What is the timetable for tackling such sub-standard premises?
Many GPs face the serious problem of the affordability of premises, a particular concern in areas with extremely high property prices such as London. In
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some areas, GPs are retiring and selling their premises at residential rates to recover their investments, and those doctors are not being replaced because prospective GPs cannot afford to set up premises in such areas.
The hon. Member for Leigh (Andy Burnham) mentioned the difficulty of getting doctors to set up in other areas, and I sign up to his view that salaried GPs have a role to play in ensuring good primary care across the whole country.
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