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Mr. Philip Hollobone (Kettering) (Con):
One big concern in the opposition to the proposals was the cost per patient visit of the new centres. My own GP, Dr. John Fitton of the Dryland surgery in Kettering, has produced
evidence that that cost in his surgery is far less than in the new Darzi centre that might be established in the town. Will the Minister satisfy the House that the cost per patient visit in the new centres will not be far larger than in current GP surgeries?
Mr. Bradshaw: I shall be happy to look at the figures if the hon. Gentleman would like to provide them, but it will be the responsibility of his local PCT to ensure that the services are provided effectively and efficiently, and that they represent good value for the taxpayer.
Mr. Stewart Jackson: Will the Minister give way?
Mr. Bradshaw: I will, but then I really must make some progress.
Mr. Jackson: The Minister is being very generous, but is he aware of the survey done last month by the company CACI, which helps big commercial organisations with mapping their retail operations across the country? It found that a significant number of PCTs do not have suitable sites for Darzi centres, and many PCTs were quoted as saying that the centres would lead to an “inefficient and overlapping network” of services. The lack of a major centre plan from the centre means that a lot of public money would surely be wasted if the Darzi centres were imposed on PCTs.
Mr. Bradshaw: One moment we are criticised for having too much of a strategic plan from the centre, and the next for not having one at all. By referring to Darzi centres, the hon. Gentleman is confusing his terminology in the same way that the hon. Member for Banbury did. He may be thinking of the polyclinic model, which is certainly part of the likely emerging health landscape in London but which I suspect is not something that most areas of the country will pursue.
The new centres will give people the flexibility to visit a doctor at almost any time of the week, at a time that is convenient to them, while remaining registered with their own GP. The benefits will be immense, especially for people who commute or spend long periods away from home, for students who want to remain registered with their doctor at home but who want access to health care where they are studying, or simply for people whose own GP does not open in the evenings or at weekends.
As well as the new GP-led health centres in every area, and in order to help tackle further health inequalities, the NHS is establishing 112 new GP practices in the areas of greatest need and where there are fewest GPs per head of population. The Jubilee line heads from here in Westminster to Canning Town in east London, and the average life expectancy of people whose homes pass overhead along the line falls by a year for each of the seven stops along the way. The ratio of GPs to population also falls dramatically. Based in the community, the GP’s surgery is in the front line in improving health and tackling inequalities.
Increasing the number of primary care clinicians in an area can therefore be the single most cost-effective way of improving the health of that population. Yet the most deprived areas—those most affected by poverty, an ageing population and rising levels of obesity—are usually the very ones that have the fewest GPs, so
funding new practices in the areas of greatest need will have a decisive impact. They will help remove long-standing inequities in health provision in England and improve health outcomes for the local population. More practices will also mean greater choice for local people.
I mentioned earlier that we were always looking for ways of improving GP services. One of the aspects of the existing contract that has come in for criticism, in my view justifiably, has been the minimum practice income guarantee. It has protected the historic income of GP practices that would otherwise have lost out when the new contract was introduced in 2004. It was right for that time, but as GP pay and conditions have improved, we believe that it has outlived its purpose. It reduces the incentives for popular GPs to take on more patients, thus constraining real patient choice, and it is not closely enough related to GP performance.
We are very pleased that earlier this week the British Medical Association agreed that the time had come to end GPs’ reliance on that source of income. On Tuesday we announced that in 2009-10 we would take the first step towards abolishing the MPIG.
Mr. Lansley: Will the Minister give way?
Mr. Bradshaw: I will just finish the point. As we take those steps, practices will be able to offer improved services to their patients. This includes better access to those services. I give way to the right hon. Gentleman.
Mr. Lansley: Not right honourable.
Mr. Lansley: Well, sometimes right, sometimes honourable.
We have discussed the MPIG in the past. As the Minister says, it was always intended that it would disappear over time as the award to GPs was focused on the quality and outcomes framework and weighted capitation. Given that we are moving in that direction, does it not also make sense to ensure that as GP practices lose income guarantees, so the GP-led health centres that he is talking about should not have income guarantees built into their contracts? Then at least whoever wishes to provide a new practice in the form that he describes does so on the same basis as existing GPs.
Mr. Bradshaw: I certainly agree with the hon. Gentleman that there should be a level playing field throughout primary care. That is what the phasing out of the MPIG will at long last help us deliver.
The reform of the MPIG will, as I have already said, help improve patient choice. Everyone in England can now choose which hospital to go to for their operation. We want people to have the same level of choice when it comes to their GP. The NHS Choices website provides patients with ever-more detailed information about their local GP practice, the services that it provides and its opening hours, and even what fellow patients think of the practice. With these important reforms and with people exercising choice, GPs will be more accurately rewarded for providing top-quality services, and that will help drive up standards even further.
The quality and outcomes framework, which links GPs’ pay to the health outcomes that they deliver, has also brought major benefits for patients. It has significantly improved the way in which GP practices record risk factors such as high blood pressure or smoking. This focuses attention not just on helping the sick to get well but on how to help people lead a more healthy lifestyle. This week we also agreed improvements with the BMA to the quality and outcomes framework. The new agreement will see £80 million relocated to reward practices delivering a range of new services for their patients, including helping to prevent cardiovascular disease in people with high blood pressure, improving advice and choice on contraception, a new indicator for depression to make sure that treatment is not stopped too soon, improvements for chronic kidney diseases, diabetes and chronic lung disease and improved drug treatment for people with heart failure.
Norman Lamb: In its report a week ago, the Public Accounts Committee indicated that there was not yet much evidence of any significant improvement in health inequalities as a result of the use of the QOF. When does the Minister think that evidence will be available that will demonstrate that the QOF is working to create a healthier population?
Mr. Bradshaw: Given the time lag in terms of the impacts on health outcomes, it is inevitable that the evidence will take some time to come through, but the hon. Gentleman might note the advances we are already making on mortality rates for some of the long-term conditions and killer diseases that have disproportionately affected people from the lower socio-economic groups. We are already making progress in that regard and GPs are firmly convinced that the QOF has helped. The more we change and reform the framework in the way I have just outlined, the more we will tackle the inequalities that he and I and all Members want tackled.
The new agreement also introduces valuable improvements to the framework. It recognises and rewards high-quality patient care and has a stronger focus on health outcomes. As well as rewarding and providing incentives for good clinical outcomes, we want to ensure that patients feel they have been treated with courtesy and respect. That is why, earlier this year, we announced in the next stage review that a greater proportion of the incentive payments made to GPs in the future will be based on how good the public feel the service provided was, based on our comprehensive annual patient survey. The 2008-09 patient survey will provide even more information about whether practices are getting the basics right. Do patients have the option of a telephone consultation? Are they listened to and treated with respect? What is their experience of out-of-hours services? What GPs are paid will directly reflect the standard of accessibility and convenience that they offer.
The Government are overseeing the greatest expansion in primary care since the creation of the health service 60 years ago. We are investing in new practices and new services. We are putting patients at the centre of health care planning. We are giving patients a greater choice of when and how they see a GP. That is not an alternative to existing primary care provision, and it will not undermine GP practices; it is an addition to existing services. Patients now enjoy an unprecedented quality of service.
Their views are translated into local action and their desire for a more convenient and accessible high-quality NHS is being brought to life.
Primary care is the cornerstone of the national health service. It is where we all turn first when we or our families need help. I am pleased to report that in its 60th year primary care is in excellent health. With continued investment and reform under this Government, it will get better still.
3.37 pm
Mr. Andrew Lansley (South Cambridgeshire) (Con): I am glad that the Government have chosen to discuss access to primary care this afternoon. It was timely given that the Healthcare Commission reported this morning, although from the Government’s point of view they might have checked what the commission said before choosing to hold a debate on the day it reported. However, from our point of view we are pleased that they did.
The debate follows two debates in Opposition time during this Session—on family doctor services and on the Government’s polyclinic plans—both of which gave us substantial opportunities to set out how we feel about general practice’s central contribution to health care, how we value general practice and how we hope to support and develop it in the future. I shall not take up as much time as the Minister, and will try to limit my speech, as this was the chance for him to set out some things in detail.
Mr. Lansley: The Minister generously gave way often, so I shall of course give way to him.
Mr. Bradshaw: That is the very point I wanted to make: half my time was taken by interventions.
Mr. Lansley: I did not mean to be critical. The Minister took many interventions, which allows me to avoid having to say some things I would otherwise have had to say.
Anne Moffat (East Lothian) (Lab): I have to get a flight to Scotland tonight.
Mr. Lansley: The hon. Lady is in the hands of the Chair, who determines matters such as the timing of debates. If the Chair felt that I were being excessive in the use of time, I have no doubt that he would stop me.
I have never seen a better description of the central role of primary care than that offered by Barbara Starfield, professor of health care management at Johns Hopkins university in America. In one way, it is surprising that an American academic can understand it, but I suspect that she can see it, not least because there is often a lack of such primary care infrastructure in America compared with the UK, and there is envy of our primary care system, particularly our family community physician service. She said:
“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.”
All those things are true, but as hon. Members will recall from previous debates, defining primary care in those terms also helps us to identify some of the central problems of the Government’s approach to primary care.
Primary and secondary care are too often separated from each other. Family doctors—community physicians—have too little control over care. They do not have enough ability to manage the care for their patients, so the thing we are all looking for—more integrated care, focused on the needs of patients—cannot be delivered.
People’s relationship with their GP is being undermined by the Government’s Martini strategy—“Any time, any place, anywhere”. From the Government’s point of view, it is good enough that the patient is seen by somebody, whereas from the public’s point of view, it often matters a great deal who one is seen by. Awareness of that seems to have disappeared. The atomisation of primary care in the Government’s hands is one of the central problems. It is not that the Government think primary care access unimportant, but the way they are going about it is undermining one of the most important aspects of primary care.
The Minister raised a number of subjects, and I shall mention one at the outset. He said at the start that he would illustrate how, in primary care, the patient voice was being listened to, but I did not detect that in anything that he subsequently said. Apart from the fact that a lot of the Government’s thinking seems to have been dictated by some of the results from the GP patient survey, the patient voice as such, in any qualitative sense, seems to have disappeared from primary care. Patients are supposed to be able to exercise choice. If the Minister really wants to know what we most want to achieve, we want to achieve a situation where patients have choice and voice, which has not happened.
I have been at this Dispatch Box talking about health for my party long enough to recall responding to a statement by the Secretary of State in January 2006 on the community White Paper called “Our health, our care, our say”. One of the things in that document, which we supported, was the intention that patients should be able to exercise greater choice about their general practitioner; but it has not happened.
For example, where is the incentive to take on new patients? This week, the Minister said for the first time that the announcement about increasing the global sum in relation to the correction factor means that there should be a greater incentive to take on new patients, but it has taken nearly three years to get to that point. In January 2006, it was stated that we could expect something on the expanding practice allowance, but it has not happened. The same promise was repeated in the next stages review published in June 2008, as though two and a half years had just passed by and nothing had been done inside Government.
The Government promised, in January 2006, that they would stop general practices being “open but full”. It did not happen. What happened? The promise was repeated in the next stages review: “We are going to do it now”. Well, two and half years have gone by.
The Government said, in January 2006, that walk-in centres would be reviewed. I was listening out for walk-in centres. They were not mentioned. If you had asked me, Mr. Deputy Speaker, before the Government went down the route of polyclinics, “What actually should Government be doing?” this is what we would have said—I think that the Liberal Democrats probably agree with this. First, encourage and incentivise more practices in under-doctored areas, and make sure that practices working in the most deprived communities have genuine incentives, rather than perverse incentives, to do so. Across the country, ensure that people can maintain their registration with the practice of their choice—and that they have greater choice. There is a need and a wish for patients to be able to access care on a more discretionary basis, not always having to go to their own practice. Actually, that was what walk-in centres were all about.
The logical thing to do is not to set up new polyclinics, the purpose of which is not to be open from 8 am to 8 pm seven days a week, but to look at the walk-in centre pilots and ask how we can make walk-in centres do that job in the places where they are necessary. My hon. Friend the Member for Banbury (Tony Baldry) has left the Chamber, but he made a good point. The Government have told primary care trusts to do it, and they are doing so in places, mostly of their choosing, that do not necessarily relate to that need.
There may well be a need for a walk-in centre in Oxford—perhaps there is such a centre—but in that city as, for my part, in Cambridge, where there are lots of tourists, students and people who, because they are commuters, sometimes find it difficult to access their local GP, the idea of a walk-in centre is a perfectly reasonable one. In 2006, the Government said that they would review walk-in centres and create the right incentives across primary care to look after unregistered patients, but they did not conduct such a review. They said that they would allow people to register near their work, rather than their home, but they have not done so. I am afraid that the things that the Government said that they would do have not been done, so the House will forgive us if we are less than confident about the Government’s intentions.
None of this has allowed patient choice to occur, but neither has patient voice had an impact on primary care. Community health councils have been abolished in England. Patients forums have been abolished in England, and it is very difficult to establish what is happening on local involvement networks in many places. The people who are most able and willing to support serious qualitative input by the public and patients who wish to engage with the quality of their health care have found that their contribution has been so disparaged and undermined by constant Government changes that they have walked away. We have to change that.
Mr. Lansley: I hope that the hon. Lady will say that she will support Conservative proposals for an independent, empowered health watch in every part of the country, including a national consumer voice in health care.
Anne Moffat: Is my right, or not, hon. Friend—[Hon. Members: “He is not the hon. Lady’s friend.”] Is the hon. Gentleman stating that his party’s manifesto will reintroduce all those quangos?
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