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16 Oct 2008 : Column 997

Mr. Lansley: Just a few weeks ago, I published a summary of our health care policies, and it is clear that LINks should be converted to health watch locally. Local authorities, such as Kent county council, have set out to create precisely that kind of powerful consumer voice in England, embracing health and social care. A previous Secretary of State commissioned a review of regulation in the health care sector from Lord Currie of Marylebone, who as the hon. Lady will know, was previously a Labour Member in the House of Lords. He recommended to the Government that there should be a national consumer voice in health care, but the Government have effectively abolished that voice, and it has disappeared.

Instead of talking about patients very much, the Minister talked about the GP survey, which led Ministers to the conclusion that, because just less than 10 per cent. of respondents were dissatisfied with their surgery’s opening hours, because their surgery did not open in the evening or on Saturday, they needed to tell GPs what to do. The Minister keeps asking whether we are going to reverse his policy, and the answer is yes, we are going to do so. We are not going to tell GPs what to do. We are going to make them far more accountable to patients, and to give patients much greater power. We are going to hold GPs to account for the quality and outcomes that they deliver. There is something utterly perverse about the Government’s belief that quality and outcomes are the basis on which GPs should be measured and rewarded, but then try to dictate in detail—sometimes in absurd detail—how GPs should go about their processes, rather than measuring their performance and rewarding them on the quality and outcomes of what they do.

Mr. Bradshaw: How would the hon. Gentleman give this new power to patients, when both he and the right hon. Member for Witney (Mr. Cameron) have said that they would give the BMA a veto over opening hours?

Mr. Lansley: Those words have never passed my lips or those of my right hon. Friend. The focus is on patient choice. There is something absurd about the entire argument. The negotiation of the GP contract in 2004 was the moment when GPs said, “If we offered Saturday morning surgeries up to now, we will stop doing so. If the primary care trust wants us to do Saturday morning surgeries, the contract states that the PCT will commission that as a local enhanced service.” Most PCTs did not do so.

We discussed the matter in February this year. The Secretary of State and the Minister were in a stand-up row with the BMA about it, quite unnecessarily. The Secretary of State admitted that he did not know how many primary care trusts commission, through their local enhanced service, extended GP opening hours. The Minister will not say whether that is happening or not, but we will probably end up going back to a local enhanced service in order to do it on a locally determined basis, which is precisely where PCTs should have been in the first place. The present situation is outrageous. The relationship between Government and general practitioners has been damaged to a remarkable and deeply unwelcome degree.

There is much in the GP patient survey that the Government seem to have ignored by focusing on extended opening hours and nothing else. Look, for example, at
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patients wanting to book ahead. The fact that almost 10 per cent. of patients in the survey wanted extended opening hours was the basis upon which the Government created a raft of policy. We know that almost exactly the same number, just under 10 per cent. of those in the survey, wanted to be able to book ahead for their appointments but were unable to do so. Why? That is a consequence of the Government having introduced their 48-hour target, rather than GPs being able to manage their appointments system in the way in which they want.

So we have ended up with the Government creating unhappy patients, in large measure, by introducing a target. Another part of the survey revealed unhappy patients as a consequence of the Government’s own contract. They ignore one and blame GPs for the other, when clearly it was the Government’s fault. It is an outrageous abuse of the Government’s position to blame GPs, as they have done. I do not have to be a friend of the BMA to defend GPs against the way in which the Government have behaved towards them.

The Minister said that changes are needed to the quality and outcomes framework. There are benefits in shifting GP remuneration towards the global sum and the quality and outcomes framework instead of the correction factor. It is important that the QOF responds to evidence about what is likely to deliver quality. When the Minister responds, perhaps he can explain this. The Darzi review in June stated:

The expert panel for 2008-09 recommended that there should be a new indicator for osteoporosis and for peripheral arterial disease. The Government did not do that in 2008-09, because they wanted to focus all the points on their extended opening hours—directed enhanced services. For 2009-10, the opportunity existed to introduce a new indicator and the expert panel had told them to do it, but it is not among the clinical indicators that have been added. Effort and money were spent on delivering expert advice on the QOF, and the Government have ignored it. Perhaps the Minister will explain that.

GP commissioning is central to our policy, although I will not explain at length why it is central. When the Minister spoke about devolving decisions, he talked about devolving decisions to primary care trusts. Devolving decisions to GPs has disappeared from the lexicon of Ministers, as it has from most of the next stage reviews that were published over the summer. We know from the Audit Commission’s work that was published in June that practice-based commissioning has stalled. Most GPs feel that their primary care trust does not support it, that they do not receive any management support for it and that they do not have the opportunity to do anything. As a consequence, very few GPs have been able to commission any new services.

I know where we stand—we want to create proper, powerful GP commissioning as a basis. The integral strength of primary care, in being able to manage the care of patients by someone with whom they have a relationship, points directly to that conclusion. Ministers used to talk about practice-based commissioning—when Tony Blair talked about reform of the national health service, practice-based commissioning was one of his key reforms—but it has disappeared. If the Minister is going to talk about primary care when he replies, perhaps
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he will tell us whether practice-based commissioning is still the Government’s policy, because I think that it is disappearing.

Norman Lamb: May I commend to the hon. Gentleman a Liberal Democrat survey of GPs in Norfolk that asked about practice-based commissioning? In answer to the question whether GPs thought practice-based commissioning had improved patient care, just 11 per cent. felt that it had, with only 6 per cent. saying that it had had a considerable impact on their practice. In Norfolk, therefore, practice-based commissioning is simply not happening in most practices, and that is very depressing.

Mr. Lansley: Yes, it is depressing. Indeed, what the hon. Gentleman describes is consistent with what the Audit Commission said in its document earlier this year. It said, understandably, that the few practices where GPs had grabbed hold of practice-based commissioning and were using it creatively tended to be the same ones that had substantial experience of fundholding, so they are responding only now, 11 years later.

I do not want to go back to fundholding. I want to develop GP commissioning that is relevant and applicable to every GP practice, so that they can all use the kind of freedoms that came with fundholding. More to the point, however, I want to do that within a better accountability framework, in which the PCT’s role is that of strategic commissioner, if necessary policing the boundary between commissioning and provision, and in which patients exercise greater choice than under fundholding.

We are talking about access to primary care, but the Minister did not mention dentistry, as though dentistry in primary care did not exist. If my hon. Friend the Member for Hemel Hempstead (Mike Penning) catches your eye, Mr. Deputy Speaker, I hope that he will have time to say something about dentistry. The Minister did not talk at all about the process of accessing urgent care. However, for many patients, one of the central issues is how they can get hold of somebody. That obviously includes the out-of-hours service, which is, at least in theory, an extension of general practice, out of hours. However, that has not been true of the out-of-hours service since the introduction of the new contract, because the service has been taken away from GPs.

We know that in many places GPs continue to manage out-of-hours services through co-operatives. My personal experience is that where that happens, GPs and patients locally find that the service still meets more of their objectives. Indeed, I am surprised that the Minister did not speak positively about the benefits of that, since Devon Docs, which operates out of his constituency and which I had the privilege of visiting earlier in the year in Marsh Barton.

Mr. Bradshaw: Did you tell me?

Mr. Lansley: Yes, I did. Devon Docs provides a service not only in Devon, but under contract in parts of the north-west, such as St. Helens and Warrington, if my memory serves me correctly.

Anne Moffat: What would the hon. Gentleman do, given the fact that his party destroyed dentistry by privatising it?

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Mr. Lansley: I am sorry; I should not have given way. My hon. Friend the Member for Hemel Hempstead will say something about primary care access to dentistry later. I will leave that to him, because I know that he feels strongly about it.

I do not want to go on about the out-of-hours service in detail, but it is just not good enough for Ministers to treat access between 8 am and 8 pm, five days a week—or even including the weekend—as a sufficient answer to the issues that the public have raised. The GP patient survey does not touch on out-of-hours services to find out what patients’ experiences are. We need to ensure that GPs feel that the out-of-hours service properly integrates with the service that they provide during the week, and we need to ensure that it is more accessible from the patients’ point of view.

This is all part of an urgent care approach. Interestingly, the Next Stages review documents all over the country are saying that we need to reform access to urgent care, but no one is doing anything about it. My hon. Friend the Member for Hemel Hempstead might add to this later. It is clear that we need to think hard about how people first approach the NHS. If they want to go to a walk-in centre, that is fine. But if they want to pick up the telephone, they often find themselves not really knowing whether to ring NHS Direct, their local GP, a different number for the out-of-hours service, another number for a dental service or 999. They are not sure about any of these things, even in an emergency. In fact, the figures demonstrate that large numbers of people end up ringing 999 when there is not an emergency.

We need to arrive at a position in which there are just two numbers. If there is an emergency, people should ring 999. If there is not, they should ring another number. Clearly there is work to be done regarding that other number, because I understand, having spoken to Ofcom, that the numbers that we could use are being progressively taken by others across Europe. We have to do this on a Europe-wide basis, and others across Europe are taking the relevant 116 numbers. If we do not get our skates on, the proverbial beach towels will have been laid across all the numbers—and we can guess who is doing that.

Access to primary care is not confined to GP practices. It also includes health visitors. I suppose we all choose to cite numbers selectively to serve our purpose, but it is astonishing that, although the Minister can get up and tell us how many additional practice nurses there are, he will not tell us how many health visitors there are. Health visitors are also instrumental in the process of delivering better health care. Their numbers have been declining: we have seen a 10 per cent. decline in the past three years. We saw 800 health visitors leave the profession in 2006, while only 330 were being trained, even though there were nearly 800 applicants for such posts.

We need to restore a more universal health visiting service. We, at least, have made it clear that we will make a start by making the resources that were to be used for outreach workers at Sure Start centres available for health visitors who would see mothers when they came home shortly after their babies had been born and see them through those first few weeks. That would be instrumental in delivering an improvement.

The Minister said that he wanted to improve access to pharmacy. I will not go on at length about pharmacy, but pharmacists are constantly being led up the hill.
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They were led up the hill over the pharmacy contract. They were told that, instead of the old scheme, they would have a new scheme in which their payment would increasingly be geared to the commissioning of additional services, particularly in the area of public health, such as screening. They are now being told the same thing again, three years after the previous pharmacy contract. That did not happen before, and all their expectations were frustrated. They believe that it will happen again now. At the moment, however, I see no evidence that primary care trusts are launching into this process—indeed, quite the opposite.

If we look at the way in which the Government are approaching the cardiovascular risk assessment programme—this was part of the quality and outcomes framework announcement in relation to the GP contract—we see that it is being geared to be delivered through GP practices. There is good evidence, however, that we do not have the risk-assessment tool available to see what the Government are planning to do, still less the cost-benefit evaluation that supports it. At least, there ought to be an opportunity for pharmacists and pharmacy chains to offer the same service on the same basis. As far as I can see, the information that triggers the risk assessment can be gained in a pharmacy as readily as in a GP practice. If we are talking, as we often are, about men in their 40s and 50s who probably have no reason to be visiting their GP, but find themselves in pharmacies from time to time, this may well be a more convenient and acceptable way for them to access pharmaceutical services.

Let me move on to polyclinics. The Minister behaves as if these are somehow an accomplished fact. In many places across the country, we are just beginning to realise what the evidence shows—my hon. Friend the Member for Banbury made clear what was happening in his area and it is occurring elsewhere—which is that the choices made by the primary care trusts, entirely at the behest of the Government who told them to have a polyclinic in every area, are entirely inappropriate in the view not only of local GPs, but of local populations.

Norman Lamb: Is not part of the problem the fact that this is being imposed on the basis of such a tight time scale? I am told that, in Norfolk, the estate review for the whole county had not been completed before the instruction came to just get on with producing a polyclinic or a GP-led health centre. That took away the capacity properly to commission and to determine priorities within the county.

Mr. Lansley: I entirely agree. Some GP practices had plans to get together to create more accessible physical accommodation, but because those plans could not be accommodated within the Government’s mandatory timetable, they were not able to adapt the polyclinic plan to their particular local circumstances. Yet that is what they should be doing. This is not rocket science; it is very straightforward. If we want more access to outpatient clinics in the community, more access to diagnostic services and to therapists in the community—all of which we do—and if the Government want to make £1 million available to a primary care trust to achieve that, the PCT should have that money and be able to decide on the best way of implementing those objectives.

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It is interesting to note what is happening in London. Having had the benefit of Boris’s election campaign, which put wind in our sails, we have been campaigning, but it is quite clear that NHS London does not want to do what the Government have told it to do. The Prime Minister said from the Dispatch Box last year that London would have 150 polyclinics and the subsequently published document said that each polyclinic would be a large building with 25 GPs in it and all the rest of that stuff. Now, however, NHS London has arrived at the point where most of what it wants across London is the so-called hub-and-spoke model, which means that most GP practices stay where they are and do what they were doing before. Put into the so-called hub are outpatient clinics, diagnostics and therapists—all perfectly okay from my point of view, but that is not what the Government told London to do. It just shows the poverty of the ideas in the Government’s original proposals.

Mr. Neil Gerrard (Walthamstow) (Lab): The hon. Gentleman is confusing two different things, as a GP-led health centre is not the same as a polyclinic— [Interruption.] Well, let me tell the hon. Gentleman about London, which is a subject that he raised. My PCT is going to be in the first wave of polyclinics. It told me and other MPs in the area very clearly and simply that a polyclinic is not the same thing as a GP-led health centre. Indeed, the GP-led health centre is a completely separate proposition from the hub-and-spoke polyclinic that is being introduced. I do wish that the hon. Gentleman had talked to some people in London before telling us what he thinks is actually happening there.

Mr. Lansley: Well, I do talk to people in London. Indeed, I talked to the chair of the joint health overview and scrutiny committee in London—and Mary told me exactly what was happening. I do not have them with me now, but I have received written answers from the Minister on the definition of a polyclinic and a GP-led health centre—and they are virtually the same, in the Minister’s own words.

My point is that the Darzi report said that there would be 150 polyclinics in London. I hope that we will end up with a small number of polyclinics in places where it makes sense locally, and with a large number of investments—again where it makes sense locally—in GP or primary access to diagnostics, therapists and other services that might otherwise be provided in a hospital context. If that happens, it means, frankly, that we have won the argument to the benefit of London. Everywhere else in the country, however, it seems that people are still being told to do something on the basis that it is the same as what is recommended in the Darzi report which was published in London, and even London now appears to be abandoning that. The collapse of the Government’s policy seems to be nearly complete.

I hope that people working in general practice and primary care understand that we value what they do, and that we want to re-empower them by doing away with some of the top-down targets that the Minister spent all his time talking about. We want to give them the support that they need in order to deliver the best possible care for patients. We will make the accountability less to the bureaucracy and less to what the Minister wants them to do, and much more to patients, and we will build that accountability throughout the country.

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