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Mr. Neil Gerrard (Walthamstow) (Lab): I have been in the House for 16 years, and if I had to identify a service that I believed to have been transformed during that time, it would be the health service. In fact, that transformation has happened over the last 11 years.
I remember what primary care in east London was like in the mid-1990s. It was characterised by single-handed GPs working in totally inadequate premises, often houses that had been converted into surgeries. It was characterised by the frequency with which people found it impossible to register with a GP, because virtually none of the GPs had open lists. It was characterised by the fact that both GPs and patients were in absolute despair at what happened when GPs tried to refer patients to secondary care. The patients had to wait months and months for treatments or diagnoses.
I saw the difference myself earlier this year. I have visited my GP five or six times in the past year, which is more often than I had visited a GP in the previous 20 years. I saw how quickly my GP was able to secure for me the diagnostic test that I needed. The position of 10, 11 or 12 years ago had been completely transformed.
As for patient choice, in those days there was no choice. People waited. If there was a choice, it was this: they waited or they paid. That is the choice that faced people 10 or 12 years ago. I remember seeing people who were desperate to get treatment. They would say to me, I do not agree with private medicine. I do not like private medicine. What should I do? The alternative was to wait and wait and wait. Now, as a result of the local improvement finance trust programme, I am seeing new health centres with groups of GPs operating in them, and GPs being encouraged to invest.
A few weeks ago I visited a practice very near my home, where GPs demonstrated the investment that they had been encouraged to make in their premises to deliver better access and better services. They talked to me about the extended hours as well. I am very pleased that 39 of the 47 practices in my local PCT area are now offering those extended hours. I cannot understand for the life of me why anyone should think there was something wrong with that. Certainly none of the GPs to whom I have spoken think that there is anything wrong with it.
Mr. Lansley: As the hon. Gentleman is extolling larger practices and the benefits of extended opening hours and increased access for patients, can he explain why the GP patient survey shows that on all five measuressatisfaction with telephone access, 48-hour access to GPs, advance booking, appointment with a specific GP and satisfaction with opening timesthe performance of small practices with fewer than 2,000 patients was better than the performance of large practices with more than 15,000 patients?
Mr. Gerrard: All I can say is that I observe what has happened on the ground. What I observe is that people are able to see their GPs more quickly, that they are seeing them in better premises, and that where GPs are grouped together, they frequently offer better access to patients than single-handed practices. That is not to say that single-handed practices cannot workI can think of examples that work wellbut I remember what it was like when we were almost entirely dependent on such practices.
For people who have jobs where they are paid hourly, taking time off during the week is not a trivial thing to do. It costs them money. Many people in permanent full-time jobs may be able to have a half-day holiday, but if an hourly paid worker takes half a day off, it costs them half a day's pay.
There are some issues about extended opening. GPs still have some issues with that. They need to sort them out and they need help with that. Obviously, if they are going to have extended opening hours, they will have to have receptionists and support staff there for longer. That is not always easy, particularly in smaller practices. Extended opening hours benefits patients. It certainly benefits local hospitals as it keeps people from attending accident and emergency when that is not appropriate.
We still have too many people who are not registered with GPs. In an area such as mine, that is partly because of the nature of the population. There are significant numbers of people there who come from cultures where primary care does not exist, or does not exist in a form that would be recognisable to them.
Non-registration used to happen because of closed lists and because people found it impossible to find a GP they could register with. Now, with the new GP contracts, the vast majority of my local GPs are opening their lists up and trying to attract patients. It is possible now for everyone to find a GP and to get to see them.
Mr. Bone: I am listening carefully to the hon. Gentleman. Does he agree that it could be different in different parts of the country? In my area, which is fast expanding, it is difficult to get on to a GPs list? One has to refer them to the primary care trust to force them on to a particular doctor's list, so I do not think that what he says is necessarily repeated across the country.
Mr. Gerrard: That may well be the case. However, what the hon. Gentleman has just described is what I was seeing until relatively recently. Until relatively recently, I would have had to ask the PCT to step in and to ensure that someone got on to a list. However, over the past year or two, I have seen a significant shift on that and many more practices are offering open lists.
I understand the points that have been raised about people wanting to see their own GP and forming a relationship with them. Of course that is true, but what is also important to many people is that they are able to be seen when they need to be seen. They value that as well as having a relationship.
There are still issues about appointment systems. I see great variation between one GP practice and another. Some run systems where they meet 48-hour targets and are able to deal with advance bookings. Others do not have systems in place that allow them to do that. A lot of that is about simple administration, getting better administration and getting the practices that are not delivering a proper appointment system to learn from the ones that are.
Mr. Stewart Jackson:
I am listening to the hon. Gentleman's comments with great care. Obviously, he comes from the perspective of an inner-London constituency. Why is it, if things are so great, that it is only in the 12th year of a Labour Government that the Minister is promising to look at the quality and outcomes framework? If polyclinics or GP-led health centres are
such a good idea, why has not the Department of Health decided to have consensus by piloting them in some areas and seeing whether they work first?
Mr. Gerrard: There are a number of issues there that I was not talking about, but I will come to the question of polyclinics in a moment. I want to finish my points about the appointments issue. One of the problems is that, when a practice does not have decent systems, is not delivering on appointments and could do so if it improved its administrative systems, PCTs are relatively powerless to do anything about it. They cannot impose systems on GPs. Therefore, when things go wrong, it can sometimes be difficult for the PCT to deal with that. However, we measure the targets on appointments across the whole PCT, even though it does not have direct responsibility for that.
I agree with some of what the hon. Member for South Cambridgeshire (Mr. Lansley) said about patient involvement, and I think it was a mistake to get rid of the community health councils, but we must be careful about the ways in which patients are involved and the ways in which we listen to patient opinions. In the past few years, I have come across examples where the PCTand in one case the General Medical Councilwas taking action against a GP and patients were protesting and signing petitions and coming to me and saying that that person was being extremely badly treated. In my opinion, the truth was that they were familiar with the standard of treatment they had been getting so they did not realise how appalling it actually was; they thought the GP was a nice person, and he might well have been, but he was not actually delivering much for them. However, just because of that familiarity, they assumed things were okay.
In terms of polyclinics, I would be absolutely against developments that led to existing GP practices being closed, as we want that relationship between GPs and patients to remain, but I also firmly believe that many tasks that have traditionally been done in hospitals can be moved out and be done efficiently elsewhere, and that one of the models through which that can be achieved is the polyclinic. My PCT will be among the first in London to have a polyclinic. That will be implemented on a hub-and-spoke model and discussions are already taking place as to how that might operate. GPs want to be involved, and it is perfectly possible that there will be a bid to operate that polyclinic from a consortium of local GPs. I would welcome that; I hope it happens, and if it does, I hope that it succeeds. It does primacy care services no good to set up an artificial argument between polyclinic and GP.
I want to raise a couple of specific points on access to primary care, the first of which relates to the quality and outcomes framework. A number of Members were approached on this by the National Osteoporosis Society, which was disappointed that osteoporosis was not included within that framework. I can understand that; whatever we include, there will always be other people who are disappointed that their particular interest is not there. One issue the society raised, however, was that there should be a new system for reform of the quality and outcomes framework involving the National Institute for Health and Clinical Excellence and patient groups,
and that a consultation had been promised in autumn of this year. It was keen to know when that might take place, because it and other interest groups might want to have some input into it. Therefore, I would be grateful if the Minister could give us some information on that.
In May 2004, the Department of Health launched the consultation, Proposals to Exclude Overseas Visitors from Eligibility to free NHS Primary Medical Services. That consultation exercise had a number of aims, including getting the rules on eligibility for access to primary and secondary care matched and ensuring that failed asylum seekers and unauthorised migrants did not have routine access to NHS primary care. I recognise that this is a complicated and sensitive issue, and that we cannot simply say that anybody can come here as a visitor and have whatever costly treatment they wantalthough I suspect that the most costly treatment would result from visitors accessing secondary rather than primary care, and I also suspect that some of the really costly stuff would result not from failed asylum seekers or unauthorised migrants, but from relatives of people who are already settled here. My concern, and I think that of a lot of health professionals, is the potential effects of denying access to primary care to vulnerable people. It could be argued that a failed asylum seeker should not get medical treatment, but if they have not been removed, it is an immigration problem and should be dealt with by the Home Office, not through the denial of access to medical care.
No decision on the consultation has been announced, even though it has been promised a number of times. Neither has there yet been even a report on the consultation results. The Department was asked by the Global Health Advocacy Project, under freedom of information legislation, for the results of the submissions that were made to the consultation and a list of those who made them. It released the list but refused to release the actual submissions. Some arguments about that are currently being made to the Information Commissioner, but I shall not pursue them now. On the basis of the list, a lot of the respondents were contacted, so we know what many of them said. It was clear from the responses that health professionals were concerned about the possible consequences of the denial of care.
Médecins du Monde UK, which runs a UK clinic, has produced a report pointing out that although GPs themselves might understand the current regulations, administrative staff do not necessarily. That has led to people who should have been treated, such as citizens of other European economic area countries or asylum seekers whose claims had not been determined, being denied treatment. Médecins du Mondes evidence suggested that service users coming to its clinic had been in the UK for an average of three years, which does not suggest health tourism. It also stated that the vast majority of the visits to the clinic were to do with primary care such as antenatal services rather than expensive, specialist care.
The real issue is the public health effects of denying access to treatment. People might have infectious diseases or conditions that are cheap to treat if they are caught early and treated by the GP, but if they are left will end up requiring emergency hospital admissions costing far more. If people are barred from access to GPs, they will end up in hard-pressed accident and emergency services.
As I said, we have not seen the results of the consultation. I hope that the report in The Observer last Sunday suggesting that the Government would not go ahead with barring access to primary care was right. I fully understand that we cannot have an NHS that provides expensive care free to the rest of the world, but if there is an immigration problem, we should deal with it as such through the Home Office, not by pressurising people to remove themselves by denying them access to medical care, particularly if the consequences are health risks to other people.
There have been huge improvements in primary care in east London in the past 10 to 12 years. There have been improvement in facilities, in peoples ability to access them and in the secondary care that follows on. Referrals to secondary care happen very quickly now so that people can be treated. I do not want that to be marred by a wrong decision about vulnerable people. While they are here in the UK, we should allow them to receive primary care.
Norman Lamb (North Norfolk) (LD): It is good to follow the hon. Member for Walthamstow (Mr. Gerrard). I agreed with much, but not all, of what he said. He made some important points about key public health concerns and on the basics of decency and humanity towards people who are in this country. I shall be interested to hear the Ministers response.
I also agreed with the hon. Member for Walthamstow that we must not allow ourselves to drift back to the access to diagnostics and treatment of the 1990s. The Conservatives will not be pleased to hear me say that their judgment that we should remove all targets and have no other mechanism to guarantee access to diagnosis and treatment is dangerous, and could easily lead to waiting times drifting back towards the lengths that we experienced in the 1990s.
Mr. Lansley: I thought it was Liberal Democrat policy to oppose top-down process targets, but the hon. Gentleman seems suddenly to have shifted. My view on patient choice and contracts is that where something is wanted, the primary care trust or the relevant commissioners contract for it to be provided; they do not have a Government target to make it happen.
Norman Lamb: I am grateful to the hon. Gentleman for giving me the opportunity to expand on Liberal Democrat policy. Our policy, which is based on how the system works in Denmark, is to give a personal entitlement to treatment within a defined period of time, which depends on the condition, and where someone does not receive their treatment within that defined period, it is paid for privately. That guarantees access for every citizen, irrespective of their income or wealth. Health economists tell us that in Denmark the approach has resulted in a radical improvement in the efficiency of state hospitals, and not in a great leakage to the private sector. I commend that approach to himperhaps he should re-examine it. [Interruption.] It is not the patient passport at all, because the treatment is paid for in its entirety. Without any mechanismeither a target or an entitlement to access treatmentthe great danger is that we will drift back towards having much longer waiting times.
This debate is timely, coming, as it does, on the day when the Healthcare Commissions annual health check report is published. It is worth repeating that we in this country have an immensely valuable network of primary care that we should cherish and build on, and, although each of us has concerns about various aspects of primary care and access to it, many other countries envy enormously our network of primary care.
The debate is timely, because the Healthcare Commissions chairman, Sir Ian Kennedy, pointed out that one of the key areas highlighted in the report was the need for improvement on GP access. He said:
Primary care trusts must redouble their efforts in areas such as access to GPs and the provision of choice.
poor performance clustered around major cities.
The report shows that the worst areas in London, where there has been a complete failure to meet the target, are the inner-city ones, where the need for access is perhaps at its greatest. The performance map for the whole country again shows that the areas of weakness and of failure are almost entirely clustered around the inner cities, where the need is at its greatest. Of particular concern is the situation in north-west and north-east England.
Six of the eight PCTs in the South East Coast SHA area achieve the access to a GP indicator, compared to only one of the 31 PCTs in the London SHA area.
Sadly it turns out that our current GP system has actually led to a larger inequality in the distribution of GPs across the country over the past two decades even as the overall number of GPs has increased.
The situation is still deteriorating. A Department of Health report earlier this year confirmed that two thirds of the most deprived fifth of PCTs are more than 10 per cent. below the English average for the number of GPs per 100,000 of the population, which is worse than the figures for 2002. In a period that has seen massive increases in investment in the health service, inequality of access to GPsin relation to the number of GPs operating in an areahas worsened. For example, Barking and Dagenham, which is one of the poorest boroughs in the country, has 48.3 GPs per 100,000 of the population, but Devon has 81or nearly double. In areas where need is greatest, access is worst.
What are the Government doing to redress that imbalance, which is bound to have an effect on health inequalities? Everyone signs up to the need to reduce the inequalities, but some of the things that have happened in the past 10 years are bound to have worsened the problem. That is why I described the Governments record as complacent: they have allowed this situation to continue for so long.
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