all PCTs will complete procurements...for new GP-led health centres
One would have hoped that the Department and Ministers might have learned lessons from the debacle that was the Medical Training Application Service and from the whole business of modernising medical careers. We saw the consequences of imposing an entirely new system across the whole country, without proper piloting, and it ended in disaster, causing many problems for junior doctors. Did the Government learn their lesson from that gross error? No, they did not.
Here we are again, imposing a system from the centre despite all the evidence, which I shall come on to, from the Kings Fund and many others, which ought to be enough to make the Government stop and think, and learn lessons before proceeding further. In future years, this case will provide us with yet another perfect case study of how rushed central imposition fails, with the waste of resources that always happens when attempts are made to impose a measure from Whitehall, with the failure to develop policy based on evidence, and, critically, with the alienation of professionals and communities.
Let me deal with the subject of the alienation of professionals. The Government have decided to pick a fight with the BMA, and with GPs in general. They quickly dismiss the BMA, accusing it of being luddite and resistant to any change, and saying that it always has been like that and always will be. That view results in the Government closing their mind to legitimate concerns from many doctors about the implications of the proposals. It also closes their mind to the risks of undermining what is already very good in our primary care system. Primary care in this country is the envy of much of the rest of the world. We must never be complacent about the need to improve primary care
when it fails, but there is a real risk that the proposals will undermine much of what is so good about the system that we have.
Alienating communities is not the way to empower communities or local commissioners. The primary care trust in Birmingham mentioned by the hon. Member for Birmingham, Selly Oak might well have its own plans about how it wants to develop services in that community. In my county of Norfolk, the primary care trust has not even finished a review of its estate since it was created in the autumn of 2006, yet this change is being forced on it.
These decisions should surely be made locally, and should be based on what works best in the area. They should be based on what services are being developed to provide the services talked about in the proposalsuch as the community hospitals, which are so critical in serving rural areas. They should be based on the quality of primary care. It is variable; surely that points to a need for local solutions, rather than having Whitehall simply impose its proposals. Surely local commissioners should make such decisions. What are the important principles that should apply, and what evidence is there that existing provision is failing? What evidence is there that polyclinics will provide solutions to any of the failures that we identify?
The principles behind the proposal are important. First, clearly there are real issues to be addressed in connection with the concept of breaking down the divide between primary and secondary care. The case for providing care closer to home is an important principle, as is the quality of care provided to the patient. As for whether there is a need to improve what we already have, as I have said, we must not be complacent. There is a divide between primary and secondary care, and we should consider all ways of reducing that divide, to ensure that there are better working arrangements between consultants in hospitals and GPs working in the community.
The quality of primary care is generally, but not universally, excellent. The Royal College of General Practitioners is aware of that; it recognises the variability of care across the country, and the fact that in deprived areas there are fewer GPs. There are concerns that some single-GP practices do not provide the quality of care available elsewhere. Some are very good, but others do not offer care of a sufficient quality. There are financial incentives that encourage GPs to work in the leafy suburbs, but not to workor stayin the poorest communities. Those financial incentives need to change.
There are also concerns about the patient experience. The Secretary of State made the point that if a person has to visit a GP, then a pharmacy elsewhere, and then a hospital for a further check-up, perhaps after an operation, they may make many long journeys. That can be extremely onerous for the elderly and people who live in rural areas. At the beginning of the week, I spoke to a constituent who described making a 60-mile round trip to the acute hospital in Norwich for what turned out to be a two-minute check-up appointment following an operation. None of us can be happy with that situation, so we must have open minds and be willing to consider ways of improving the patient experience.
It is worth while considering new models of care, looking at what works in other countries, and trying to learn the lessons. Last summer, I visited the Arches health centre in a poor, inner-city part of Belfast. It is, in essence, a polyclinic. It brings together health and
social care, and there is a citizens advice bureau in there, too. To all intents and purposes, it looked like an incredibly impressive facility, so I am certainly not dismissive of the concepts potential to work in certain defined conditions, but when the Kings Fund looked at the evidence, it raised serious concerns.
The Kings Fund first looked at other countries. There is some bizarre cross-dressing going on; it talked about the original concept coming from the Soviet Union and being developed in many eastern European countries that were part of the Soviet bloc, yet those countries are now moving away from that model, and towards a much more open primary care market. Meanwhile the United States, Germany and Canada are very much moving in the direction of the polyclinic model. As two groups of countries are moving in diametrically opposite directions, the changing enthusiasm for polyclinics surely ought to make us wary.
The Kings Fund also warns that what might look very attractive and work effectively in the States or Germany cannot be translated to this country. It makes the point that there are far more doctors per 1,000 people in Germany, for example, than in this country. So caution is required about simply adopting something that looks good elsewhere.
The Kings Fund clearly recognised the potential for such new concepts of delivering care, but it found no systematic evaluations of polyclinic models in other countries. The Government, however, appear determined to proceed without that evidential base. The Kings Fund had real concerns about what it saw overseas. It saw that, in many cases, the fact that professionals were working together under one roof did not automatically lead to integrated care; it saw a lack of integration between polyclinics and hospitals. It raised concerns about a lack of continuity of care, whereby the patient did not see the same doctor every time. That is one of the issues that cause elderly people a lot of concern.
The Kings Fund found concerns about a decline in professional motivation and development, where consultants who might previously have been based in hospital centres of excellence end up in more remote settings away from professional colleagues.
Bizarrely, given the Governments claims, the Kings Fund identified a lack of patient choice. Given some of the concerns that have been raised by the BMA and others about the ultimate position with small GP practices closing, the result could be that people in a local area end up with less choice about their primary care centre. They might have no choice but to go to the local polyclinic. That looks very likely to be the case in London.
The Kings Fund also looked specifically at the local improvement finance trust schemes already operating in this country. It specifically examined 12 LIFT schemes that it considered bore all the hallmarks of the polyclinic model that the Government seek to pursue. It said:
If anything were to demonstrate the benefits of the polyclinic model in England, it should in theory be evident in LIFT schemes.
What did the Kings Fund find? Its conclusions should worry the Government. It found little evidence of innovation in this countrys existing polyclinic model. It found that local authority social services, which were supposed to
be integral to those centres, had fallen by the wayside and were not continuing to participate in them because of tight local funding streams.
Crucially, the Kings Fund found a lack of clarity about responsibility for strategic developmentno one in charge, determining the strategic development of those centres. It found a lack of clarity about who was responsible for overall clinical governance in those facilities. Surely that should disturb the Government. It found that payment by resultsthe Governments mechanism for funding care, which is a blunt instrumentis causing acute hospitals to have their funding streams undermined where such centres exist, because the polyclinics do the more routine procedures, thus leaving the acute hospitals to do the more expensive procedures, while receiving the same tariff. They are losing income for the simple procedures and receiving too low a tariff for the more complex procedures. All that is swept aside in the Governments determination to rush headlong down this route.
The Kings Fund also found that none of the 12 existing schemes demonstrated savings or improvements in costs compared with previous models of care. They had struggled to persuade GPs to relocate, and had been developed because of a political imperative to introduce them, rather than being based on patient need. The report raised the specific fear that polyclinics would, in effect, become white elephants. It also noted the concern about access. It drew specific attention to the fact that if people have to travel further and for a longer time to their primary care centreparticularly in the more deprived communities, where people might not have access to carsthey are less likely to use that facility. Surely, again, that should be a concern in London, given the proposals that the Government are intent on pursuing.
When the Kings Fund examined the 12 existing cases, it identified a failure to shift any care from remote acute hospitals to polyclinic settings. It is essential to secure local leadership and a shared ambition, which is usually lacking when a model is imposed on an area by Whitehall.
The Kings Fund has stated that, critically, the Government have not answered the question about who will lead on either strategic direction or clinical governance. Until the Government clearly indicate their intentions on centrally imposed GP-led health centres, there will be massive concern that the fears identified by the Kings Fund in the existing centres will be realised right across the country, because we have not learned the lessons from the pilots. Foreign evidence also points to the central importance of leadership in such centres. The existing LIFT schemes and the foreign experience should be enough to persuade the Government to pause for thought.
My plea to the Government is to develop pilots with proper investment. The Kings Fund has stated that the focus is often on simply creating the building within which services are provided, without investing in change management, which involves changing services and the way in which patients are treated. We should develop those models, extend the evidence base, sort out the question of leadership and explore the range of models, which include hub and spoke, and locating all GPs in the same building.
The Minister of State, Department of Health (Mr. Ben Bradshaw): The hon. Gentleman is discussing pilots and polyclinics. He may be interested to know, if he does not know already, that the only part of the country that currently proposes to develop polyclinics is London, where 10 pilots have been proposed.
Mr. Goodwill: I have the minutes of the North Yorkshire and York primary care trust clinical executive meeting in February, which considered a proposal for a polyclinic in Scarborough. The PCT thinks that it is going to have a polyclinic, even if the Minister does not.
Norman Lamb: I am grateful to the hon. Gentleman for that intervention. Everyone outside this place uses the terms interchangeablyfor example, the Kings Fund, the independent research body, uses the terms interchangeably. Everybody understands that what is happening is the introduction of something that looks very similar to a polyclinic: it may be embryonic, if that is the right way to describe it, but it has many of the characteristics of what the Government describe as a polyclinic.
We should watch the evidence develop and allow experiments with community hospitals to develop services in rural areas. We should listen to the warnings from the Kings Fund and many others rather than the warnings from the BMA. Many independent bodies have expressed concern and oppose the central imposition of a new model of primary care. Even at this late stage, given all the evidence out there, the Government should make it clear to PCTs and to strategic health authorities which quietly do the Governments bidding, that PCTs are free to say that they will not introduce polyclinics, that PCTs can develop their own mechanisms for delivering care within the community, and that PCTs will not be disadvantaged as a result of taking such decisions. We should learn the lessons first, and allow locally accountable commissioners to make such decisions.
Mr. Deputy Speaker: Order. Mr. Speaker placed a time limit of 12 minutes on Back-Bench speeches in this debate. It is now apparent that if that is maintained throughout the period, not everyone will be able to take part. I propose that the first two such speeches will be subject to the 12-minute limit, and then I shall review the situation in light of how much time we have left at that stage.
Frank Dobson (Holborn and St. Pancras) (Lab):
I am in no position to comment on the appropriateness or otherwise of polyclinicsor whatever the Governments term is in relation to other parts of the country. Polyclinics may turn out to be useful, successful and helpful, but I am here to speak up on behalf of patients and professionals in my constituency who are expressing a great deal of concern about our primary care trusts proposals. Most people in the locality approach the issue with great distrust, because they feel that our area has been used as
a testing ground and my constituents as guinea pigs in new approaches to general practice and primary care.
Until now, our area has been well served with effective and very popular GP services, but it is being subjected to changes that, from the point of view of local people, are unasked for and untried. Recently, three GP practices were privatisedthere is no other way to describe it. Three popular practices were required to bid to continue their existence. They met all the quality requirements, and in the assessment they did better than the private sector bidder on all of them, but the private sector bidder put in a lower bid in terms of costs. The bid was never quite clear, because when people inquired into how the situation had come about, they were told that the matter was commercial and in confidence.
UnitedHealthcare, a subsidiary of an American outfit, secured the contract. I expectedperhaps rather cynicallythat it would put on an absolutely wondrous show in the three practices that it had taken over, so that they would serve as loss leaders and as an example of what a good job it could do. My cynicism was not justified, because although a man called Neil Bentley from the CBI has declared them to be a success, he obviously lives in an evidence-free zone. Since the new company took over, appointment times for each patient have been reduced from 15 minutes to 10. If the visit or appointment is unscheduled, people get only 5 minutes and are told that they can talk about only one problem, even if they have more. The new company has not complied with the extra opening hours that the contract specified, and which it undertook to deliver. It closed a baby clinic and then had to reopen it in response to a public outcry. There are rumoursalthough they are deniedthat the company is in the process of going back to the primary care trust to ask for more money.
That is what has been happening in my constituency, and now we have proposals for polyclinics. These, we are told, will provide community-based diagnostics. There are apparently three proposals for polyclinics in my constituency, and as part of the move to community-based diagnostics, one will be at University College London hospital and another will be at the Royal Free hospital, so we will actually have hospital-based diagnostics andthis will be a noveltyhospital-based community and GP services. Originally, polyclinics were to be targeted at under-doctored areas and populations, which might be worth while if it were the only way to secure the extra doctors and better services required to meet peoples needs. But those needs vary from place to place, depending on the geography and on the nature of the population. I have always believed in horses for courses, but I do not think that the Government do. In London, it is certainly not horses for courses but Thou shalt have a polyclinic. I also believe that it would be a good idea for these things to be tried out in pilot schemes in various parts of the country.
I must remind Ministers that, generally speaking, GP services are very cost-effective, particularly in their role as gatekeeper for the rest of the national health service. I am sure that the Minister would have to confirm that when he talks to Health Ministers from abroad they are envious of the impact of GP services on keeping down costs. It looks, from such evidence as is available, as though where polyclinics, or something like them, exist, more investigations and tests are prescribed, often wastefully, as in the United Statesperhaps less so in Germanyand
more people are referred to hospital as in-patients. Both those developments may be a good thing from the point of view of patients, but they may also be on the excessive side.
I have some questions, to which I have not managed to get answers, about the proposed polyclinic at University College hospital. It appears that that scheme will involve everybody who goes there for GP services, as well as everybody who goes to accident and emergency and can walk into the place, as opposed to arriving by ambulance. In effect, far from there being a shift to community services, we are moving towards provision being increasingly concentrated in the hospital. Will the doctors there be able to refer people to other hospitals instead of University College hospital, where the polyclinic will be located?
Then there is the question of the impact on the areas existing GP services, which are convenient and familiartwo things that appeal particularly to older people, disabled people and families with children. It is also the case that nearly everyone looks for some continuity of care by seeing the same doctor, if at all possible.
Ministers have said that no one will be forced to join a polyclinic, but when the companies contracts come up for renewal, will they get them renewed, will the same terms be available to them, and, more importantly, will they be entitled to apply to some of the practices outside the polyclinic? That is not clear at the moment.
That brings me to the question of who will own the polyclinic. Will it be a private sector outfit? Will UnitedHealthcare, which has already taken over the three GP practices in the area, be able to bid for and take over the polyclinic? If so, that will be despite the fact that its owners have been indicted for fraud and every form of swindling of taxpayers, patients and doctors in the United States. If it gets the polyclinic contract, will it also get the out-of-hours contract, for which it is believed to be bidding? If so, we would end up with a US company having something approaching a local monopoly in part of my area. I remind Ministers that the first priority and statutory duty of the people running a private sector company is to put the interests and needs of shareholders first. It is not just me who says that. Mr. David Worskett, director of the self-styled NHS Partners Network, which is in the private sector, has said:
The independent sector has to protect shareholders interests.