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The Prime Minister: Perhaps I could remind the hon. Gentleman that it was a Conservative Government who abolished the earnings link for pensions. Perhaps I could also remind him that it is a Labour Government who are committed to restoring it. The reason for that is that we take seriously our responsibility to the dignity and security of everyone in retirement. We will restore the earnings link for pensions.
Stephen Pound (Ealing, North) (Lab): On a point of order, Mr. Speaker. On Monday, the House heard a savage attack on Mr. Mohamed al-Fayed, made under parliamentary privilege. Can you tell me whether any redress at all exists for people who are traduced, even under parliamentary privilege?
That this House supports the family doctor service, and recognises that it is the first point of contact for the majority of patients; further recognises the invaluable role that GPs have in the NHS; regrets the undermining and undervaluing of GPs by the Government; is concerned about the lack of empirical and clinical evidence for the establishment of polyclinics in every primary care trust; opposes the central imposition of polyclinics against local health needs and requirements; is further concerned about the delay in publishing evidence on the cost-effectiveness of walk-in centres; believes that patients should be able to choose the most convenient GP practice, whether close to home or work; calls for GPs to be given real budgets, incentives to make savings, the freedom to re-invest for their patients and the ability to innovate in contracts with healthcare providers; supports rewarding GPs who choose to provide services in deprived areas or areas of expanding population; and further supports the incorporation of patient-reported outcome measures into the Quality and Outcomes framework and the development of structures and services in general practice that are designed by GPs and primary care providers in response to patients needs and choice.
The purpose of the motion is straightforward. Through the new contract with general practitioners, the Government had a major opportunity to revive general practice in this country, and to rebase the NHS in patient-centred care and primary care-led services. They failed to do that; by contrast, they have entered into a conflict with general practitioners that will undermine the service. The Government are taking an approach to the reconfiguration of primary care services that matches the dangers of the approach that they took to reconfiguration of secondary care. The progressive centralisation of services, the progressive undermining of access to care, the progressive undermining of the ability of clinicians across the NHS to determine what is best for their patientsthose are the tragic consequences of the Governments failure to negotiate the GP contract successfully. Their mean-minded approach is not to negotiate in partnership with general practitioners, but to try to arrive at a solution that cuts costs and centralises services, while undermining the independence and clinical effectiveness of general practice.
Robert Key (Salisbury) (Con): Does my hon. Friend agree that perhaps the single most popular feature of the national health service is the trust that patients have in their family practitioner, but that the Government are absolutely determined to prove that they do not trust family doctors any more? We have to rebuild that trust.
Mr. Lansley: My hon. Friend is right. I have heard exactly that from GPs in his constituency, who fear that a polyclinic will be established in or near Salisbury, the effect of which will be to force the closure of other GP practices and undermine the relationship with patients.
Let me remind the House what the evidence tells us about the benefits of a strong primary care system. In the context of examining why the American health care system did not deliver successfully for Americans, which is an interesting subject, given the nature of the current debate on health care in the United States, Barbara Starfield, who is the professor of health care management at Johns Hopkins university in America, concluded:
There is no single or simple answer, but a large part of the storyand a part that is commonly overlookedis precisely the predominance of specialist care over primary care.
Primary care deals with most health problems for most people most of the time. Its priorities are to be accessible as health needs arise; to focus on individuals over the long term; to offer comprehensive care for all common problems; and to coordinate services when care from elsewhere is needed.
There is lots of evidence
that a good relationship with a freely chosen primary-care doctor, preferably over several years, is associated with better care, more appropriate care, better health, and much lower health costs.
In light of that evidence, which demonstrates how successful primary care can be, I find it utterly astonishing that today, when we tabled a motion whose purpose is to support general practice and the family doctor service and to stress the importance of the relationship between patients and their doctor and the importance of continuity of care, which is so lacking in other parts of the health care system, the Governments amendment fails to support the family doctor service and focuses on their current ideological fixation in favour of large polyclinics, and in the process undermines precisely the continuity of care and the relationship between doctor and patient that the evidence suggests is so integral to the successful delivery of services.
Mr. Stewart Jackson (Peterborough) (Con): Does my hon. Friend share my concern that the Governments proposals represent a national template to be imposed on primary care trusts, with no thought given to social inequalities and need at the local level, or to the need to open more GP surgeries in areas of deprivation in our constituencies, rather than the Governments one-size-fits-all approach?
Mr. Lansley: My hon. Friend raises an important point. In the course of the GP contract negotiations, the move towards a quality and outcomes framework had real potential, but as the National Audit Office report published earlier this year set out starkly, in order to try to secure agreement with general practitioners the Government took a large amount of that money out of the pot and put it into the minimum practice income guarantee. Over the intervening years, the system of remuneration for GPs has not impacted on list size and need as it should have done, which would have helped the most deprived areas; nor has it incentivised more doctors to come into those areas.
The Governments and everyone elses purpose in starting to negotiate the new GP contract back in 2002 was to deal with problems of recruitment and retention. Recruitment in deprived areas was most difficult and it remains difficult. The Governments response should have been to deal with that problem, not to try to impose a solution everywhere else. By encouraging PCTs to offer new practices in under-doctored areas, the Government are saying now the same thing as they said in 2006 in the community White Paper, which we supported throughout. However, it is wholly wrong for them to seek to impose a polyclinic system in London and across the country, including in the most under-doctored areas, which would deprive many people of access to GP surgeries in their local neighbourhood.
David Tredinnick (Bosworth) (Con): Does my hon. Friend agree that there is a danger that if patients do not have a named doctoran individual doctor to whom they can relatethey may not report illnesses as soon as they should, which will add to the burden of costs to the health service?
Mr. Lansley: My hon. Friend is right. In an article in the British Medical Journal on 22 March 2008, Martin Roland, professor of health care at the university of Manchester and director of the National Primary Care Research and Development Centre, said:
The UK system of universal registration with a single general practice promotes equity, provides a medical home for coordinating care, and is an effective mechanism for holding providers to account for the quality of care provided.
That is where my hon. Friend is coming from. That relationship between patients and their doctor is instrumental in delivering effective care, but the Government are determined to undermine it. [Interruption.] The Secretary of State says Rubbish, but he should look at what his own PCT is proposing in Hull. In a document, which I have seen, the purpose of which it acknowledges is to reconfigure GP care in the area, it says that its objective is to have fewer GP sitesby which I think it means practicesand to put polyclinics down in Hull. Hull is an under-doctored area, as the Secretary of State knows perfectly well. Of course there is a case for additional practices, but the consequence of the polyclinic plan will be that some of the existing practices will be shut down, and that will not enable services to be delivered more effectively in the area.
Mr. Graham Stuart (Beverley and Holderness) (Con): My constituency is in a rural area outside Hull, and it is rural areas that are particularly concerned about the proposals. They suffered when the Government tinkered with dentistry and my constituency has seen a major loss of dentistry services. The idea that the Secretary of State and the Government will now be tinkering with GP services horrifies my constituents.
I agree with my hon. Friend. The impact on rural areas is one of the most significant and worrying aspects of the way in which the Government are going about this. I have been to many places throughout the country. Not so long ago I was talking to GPs in Worcester and to the local medical committee in Cornwall. One can imagine the situation: there are practices throughout Cornwall and the Department of Health tells the local PCT that it must have a polyclinic, but
there is no obvious place for it, so it is just popped down next to a GP practice somewhere and practices in many neighbouring areas close down as a consequence.
There are different models of care in different parts of the country. Interestingly, the south-west has some of the largest practices in the countryfor example, I went to Fromefor the simple reason that sometimes a network system between a large GP practice and satellites is one of the most effective ways of ensuring access to neighbouring villages. But scrapping all that and not having an organic system that is developed by GPs themselves, in favour of the polyclinic system where GPs do not have independent contractor status and can no longer design services for their areas needs, will undermine access in rural areas at precisely the moment that towns and villages throughout the country are losing their post offices, shops, pubs and public services. Their GP surgery is one of the critical elements that they now perceive is under threat.
Tony Baldry (Banbury) (Con): They are also losing their dispensaries. Is my hon. Friend aware that 8.5 million patients are in GP practices that dispense drugs? Under the Governments White Paper on the future of pharmacy services it will be almost impossible for GPs to dispense drugs in the future. Why on earth remove patient choice in this way? This is yet another service that will be lost in villages in my constituency and colleagues constituencies.
Mr. Lansley: Yes, I am interested in what my hon. Friend says because in one particular respect the effect of the pharmacy White Paper, which was published during the recess, may well be to undermine dispensing by dispensing doctors, and it may all be part of a common process by the Government. The polyclinics are expensive beasts; they cost about £800,000 each, so money has to be raised for them. I suspect that in many cases the Government intend to ensure that they have a large pharmacy, which will take the pharmacy profits, and the dispensing doctors in local surgeries will lose out and shut down as a consequence.
Rob Marris (Wolverhampton, South-West) (Lab): I caution the hon. Gentleman to go a little further down the line of variation around the country. Wolverhampton is one of the most deprived cities in the country. We have the excellent Phoenix medical centre, which might be termed a polyclinic, which is expanding its hours because it is so popular, and many of the services that it offers have been taken from the acute hospital, not from GPs. Correspondingly, the Castlecroft medical centre, with which I am registered, is building a brand new GPs surgery, and the Mayfields medical centre, which opened recently, has a pharmacy alongside. The configuration in different parts of the country is different, and in Wolverhampton we will have three new GP practices from the Government, which are welcome because we are under-doctored.
The hon. Gentleman has not been listening carefully, and he cannot have read the speech by my right hon. Friend the Member for Witney (Mr. Cameron) to the Kings Fund on Monday. My right hon. Friend made it clear that we do not oppose change in general practice, but it must be driven by GPs themselves. [Hon. Members: Why?] It must be driven
by GPs in response to the needs of patientsit would be useful if the Secretary of State were to read the Opposition motion. The Government amendment does not provide any evidence that the Secretary of State sees any role for GPs or clinicians in interpreting the needs of patients, so I do not know how he thinks that patients needs will be met.
For the PCT to contract with additional practices to provide additional services in under-doctored areas is finewe have always said that, and there is no reason why it should not go ahead. There is no reason why services that can be delivered more effectively in the community should not be delivered in the community, and there is no reason why GPs should not be able to commission services from a hospital or a community provider transferring services into the community. Sometimes, the hospital itself can provide those services, which certainly can involve diagnostic and treatment services. There will even be places where GP practices conclude that their premises are so poor that they need to come together in larger practices and premises. None of that causes me any problem at all.
As the hon. Member for Wolverhampton, South-West (Rob Marris) represents a constituency in Wolverhampton, perhaps he has not carefully examined the Darzi plan in London and what is being rolled out in every PCT across the country in a one-size-fits-all fashion: the creation of polyclinics. The Darzi plan in London makes it clear that a polyclinic is 25 GPs occupying 16,000 sq ft costing £800,000 a year with all the services in that place. Where are those polyclinics being put? Last week, I was in Bexley, where a polyclinic is being located on the site of Queen Marys hospital, Sidcup. In Epsom, a polyclinic has been proposed for the site of St. Helier hospital. That is not taking care closer to home; that is centralising primary care, which will take it further away from the people whom it is meant to serve.
Sandra Gidley (Romsey) (LD): The hon. Gentleman seems to regard GPs as being at the centre of the infrastructure. How can we ensure that the best interests of patients are represented? What assessment has he made of the fact that GPs are most likely to commission services from themselves in areas in which they have a specialist interest? Is there not a conflict of interest, and where is the scrutiny when we discuss the best use of taxpayers money?
Mr. Lansley: Last October, we published our document, The patient will see you now doctor, which the hon. Lady has probably read. In that document, we made it clear that there must be a mechanism by which, beyond the boundary of the primary medical services contract, GPs can commission services from connected providers or providers that they control only in circumstances in which there has been a tendering process controlled by the PCT, which would prevent them from handing business to themselves. That is one of the problems with GP fundholding that needed to be sorted out. The Government have not sorted it out because the same problem is occurring in places where there has been any progress on practice-based commissioning.
The hon. Lady also raised the issue of a voice for patients. We have repeatedly made it clear in this House that we need a strong voice for patients. We need health watch locally and nationally to make that
happen, but where general practitioners are concerned, we also need the exercise of patient choice. Again, it is interesting to quote Martin Roland from Manchester:
The NHS goal of providing patient choice in primary care is not realised in many parts of the country where patients have little real choice of practice. Increased patient choice requires more high quality practices, not the small number of large practices that some polyclinic models suggest. We know that patients in small practices rate their care more highly in terms of both access and continuity. Indeed, although small practices show more variation in quality, on average, they achieved slightly higher levels of clinical quality than larger practices in the quality and outcomes framework.
So having more high-quality practices, which include many smaller practices, is the route down which to go. Our patient choice proposals are similar to some that the Government made in the community White Paper of 2006. They are about making sure that when patients move from one practice to another, proper capitation follows them and to ensure that practices with open lists cannot be declared full when there is no justification for that.
Those proposals are precisely the mechanisms to make sure that general practice, although integral to service delivery and commissioning, is none the less increasingly accountable to patients. At the moment, the Government seem to be moving to a world in which the only customer to matter is the primary care trust. To whom is the primary care trust accountable? The experience of everybodyincluding, I suspect, most of my hon. Friends across the countryis that primary care trusts are accountable only to the Department of Health and Ministers, who are the only people they ever listen to. At the moment, patients get no look in at all.
Mr. Gray: I am most grateful to my hon. Friend for giving way; he is being very generous. What he describes has particular resonance in Wiltshire, where the PCT seems to be giving GPs incentives to move towards a polyclinic system. For example, a polyclinic is being proposed for halfway between the town of Corsham and the nearby village of Box. That would be convenient for neither place, but the PCT appears to be giving GPs in both places financial incentives to move towards it, even if that is not in patients best interests.
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