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Although the hon. Member for Walthamstow sought to define the difference between polyclinics and GP-led health centres, the latter—at the very least—give the appearance of being embryonic polyclinics. They have many of the hallmarks of a polyclinic and many people struggle to distinguish between the two. The Minister confirmed earlier that the Government are committed
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to introducing one GP-led health centre for every primary care trust, so what assessment have the Government made of whether that initiative will do anything to combat inequality of access? As the hon. Member for Banbury (Tony Baldry) said, if a polyclinic or GP-led health centre is placed in the centre of a city in a particular primary care trust area, it may do nothing to improve access for low-income communities that are some distance away. How well will that policy target resources at the actual problem?

The Minister also referred to the other initiative to introduce 112 new GP practices in some of the poorest communities. The announcement was made a year ago, at the time of the interim Darzi report. What progress has been made? The Minister said that it was happening, but when is it happening? What is the time scale for introducing the new practices, and what is the mechanism for ensuring their arrival? Is it ultimately down to the discretion of the primary care trust? How will the Minister ensure that he delivers that commitment?

I am pleased to hear about the start of the demise of the minimum practice income guarantee. As I have been saying for some time, that reform is welcome. However, the Minister said that it would be phased out, and reports of the agreement with the BMA also mentioned phasing out. What is the time scale for that? Can the Minister give a target date by which we will be rid of that mechanism for funding GPs, which he has agreed has nothing to do with quality or the extent of the challenge faced by GPs, and everything to do with historic payment mechanisms?

Let me move on to QOF—the quality and outcomes framework—which is the basis for incentivising GPs to engage in preventive health care and so on. In a booklet on inequalities of health care, the NHS Confederation specifically considered that subject. It described how the mechanism for rewarding GPs under QOF ends up giving more money to GPs in the wealthy areas—the leafy suburbs—than to those in the poorest areas.

It seems bizarre that a system that is presumably designed to help reduce inequalities and to improve the health of the nation should end up paying doctors more where the problem is least. It does so for two reasons. First, it is easier to hit targets if a patient base is middle class and everybody is informed, educated and understands the importance of preventive health care. They will go along for their screenings and so on. In a community where people are harder to reach, it might be much tougher to hit the targets and to earn the income under the QOF system.

The NHS Confederation also makes the point that the QOF formula remunerates practices with high disease prevalence at a lower rate than practices with a low disease prevalence. It states:

The confederation concludes that the structure of the QOF payment disadvantages practices in deprived communities. I have raised the subject before. What are the Minister and the Government doing to remove that ridiculous distortion, which provides a disincentive to doctors to work in the poorest communities? Surely it should be precisely the other way around.


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When will the Government consider ways of really incentivising GPs to work in the toughest, hardest to reach communities? It seems to me that the money should, as far as possible, be attached to the patient so as to encourage GP practices to take on more patients, and that there should be a premium attached for serving individuals from deprived communities—a sort of patient premium to incentivise GPs to work in those communities.

Next, I want to deal with the exclusion of osteoporosis from QOF. The subject has been mentioned by a couple of speakers. The independent expert panel made the case for osteoporosis to be included, and I disagree with the hon. Member for Walthamstow, who said that that was one more group arguing its particular interest. It is more than that. It is an independent panel that is designed to give dispassionate objective advice to the Government about what conditions should be addressed through the incentive scheme. The Government chose to ignore it.

Mr. Gerrard: I want to make it clear to the hon. Gentleman that I am not in any way disparaging what the panel is saying. It sounded as though he was suggesting that I was doing that. My point was that, inevitably, when decisions are made about what is and what is not included, various interest groups will always believe that their interest has somehow been ignored. The panel is making a perfectly valid point.

Norman Lamb: I am grateful for that clarification; we are clearly in agreement.

Let me quote the National Osteoporosis Society, which states:

the one that has just taken place—

Why is that important? Why should osteoporosis be included in the QOF process? The answer is that the process offers crucial preventive healthcare: there are 300,000 osteoporosis fractures every year, and independent evidence suggests that it should be possible to cut that total by about 50 per cent. through the early identification of a problem and treatment to strengthen bones.

We have an extraordinary opportunity to reduce substantially the prevalence of osteoporosis fractures. The cost to the NHS and social care of treating fractures is some £2 billion a year, and fractures among people over 60 result in 2 million hospital bed days in England alone. Investing in preventive health care upfront could have a massive impact on the cost to the NHS, and it would also be critical in preventing the crisis undergone by patients who have to be admitted to hospital because of a fracture. When old people suffer a fracture, the result can be a permanent deterioration in health, as I am sure the hon. Member for Dartford (Dr. Stoate) can confirm.

Dr. Stoate indicated assent.

Norman Lamb: The hon. Gentleman nods in agreement. I therefore urge the Minister to look at ways of introducing osteoporosis into the QOF system, given the potentially massive benefits that could be achieved.


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I want to ask the Minister about progress on extending hours. I have always believed that there is a benefit to be achieved by extending hours within primary care, and my opposition to the Government’s proposals had to do with the way that they sought to impose them. The announcement earlier this week suggested that virtually no progress has been made in some areas, with just 1 per cent. of practices in Liverpool going for extended hours. I should be grateful if the Minister said why he thinks there is such enormous variation.

The pharmacy White Paper floats the idea that the current rules for GP practices with dispensaries should be changed. Such practices primarily serve rural areas but, taken together, the White Paper and the impact assessment appear to suggest that a GP practice could be forced to close its dispensary if there is a pharmacy within 1 km of it.

I want the Minister to understand just how strongly people in rural areas feel about that. The current service is remarkably attractive, as it means that elderly people with a GP appointment in the early evening can walk out of the building with their medicines and take them straight away. It is an immensely valuable service, and losing it could force an elderly person to make a separate journey, perhaps of some distance. That seems utterly crazy to me, as the impact assessment suggests that the change could result in 700 dispensaries closing, affecting 2 million patients nationwide.

Of great concern also is the possibility, which has been brought to my attention by local dispensing practices, that the change could undermine the viability of the range of medical services that such practices provide. Again, that would be to the detriment of people living in rural areas, and I urge the Minister to reject any change that would result in such closures. It would be a massively retrograde step.

I want to say a word about practice-based commissioning. The Government lauded that as an initiative with enormous potential to develop services in the community. They said that it would provide convenience for patients because often they would not have to travel a long distance to an acute hospital. Lower-cost care closer to home was claimed to be the great potential benefit that could be achieved. Yet when we talk to GPs around the country, we discover that the scheme has largely stalled. It has suffered in part as a result of the reorganisation of primary care trusts. PCTs have been inward looking for the past two years, with people worrying about their own jobs. So many GPs tell me that when they try to engage with their local PCT to get something moving on practice-based commissioning, they get no practical interest or engagement from them. If practice-based commissioning is to achieve the potential that all of us see for it, something has to change to allow it to grow from the bottom up.

The Conservative spokesman, the hon. Member for South Cambridgeshire (Mr. Lansley), referred to NHS dentistry. It is important to touch on that service. I shall confine my remarks to simply asking the Minister a question. When will there be a full and proper assessment of the impact of the new contract on access and on inequality of access? Great claims were made for the new contract and what it could achieve. The claims have not been met in reality. In many parts of the country, people on a low income and people who struggle to travel considerable distances have real difficulty in accessing
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an NHS dentist because there simply are not any available locally. There is an incredibly powerful case for revisiting the issue to make sure that the money available for dentistry within the NHS is deployed to the best possible effect and in particular to ensure access for those who do not have the luxury to be able to afford to go to a dentist privately.

If the Government’s intention for today’s debate was to crow about their record on access to primary care, it has fallen rather flat because the record is not good. The Healthcare Commission today has identified access to primary care as one of the big challenges that we face. Confidence among GPs is at an all-time low. I commended a survey undertaken by Norfolk Liberal Democrats to the Conservative spokesman. I will send him a copy later. When we asked GPs in Norfolk their view of the Government’s stewardship of the NHS, 0 per cent. said that they were positive.

Dr. Stoate rose—

Mr. Lansley: One GP is positive.

Norman Lamb: Well, we will have to move him to Norfolk so that we can change the statistics.

Dr. Stoate: Does the hon. Gentleman realise that if I were to move to Norfolk there would be an infinite percentage increase in the number of GPs satisfied? That would be something of a Government target hit.

Norman Lamb: I accept the point. It is much needed by the Government because at the moment the percentage could not get lower.

Confidence in the Government’s stewardship of the NHS, especially with regard to primary care, is at an all-time low. The record is not good. The Public Accounts Committee reported last week on the cost of the GP contract. The impact on productivity and the change in out-of-hours arrangements have also led to massive problems with access and anxiety among patients about how to access care. That has led, many reports conclude, to a mushrooming in visits to accident and emergency departments at enormous cost to the NHS—again, a counter-productive move.

Access to good-quality primary care, avoiding admissions to expensive acute hospitals, must have high priority. It is time that the rhetoric was matched by measures that will have practical effect and really change things rather than the Government just claiming that they want to achieve change.

4.54 pm

Dr. Howard Stoate (Dartford) (Lab): As the House is well aware, I am still a practising GP, so it gives me great pleasure to have caught your eye, Madam Deputy Speaker, in this important debate. I am sorry that more Members could not find time to be here.

Every Member who has spoken so far has mentioned quality and outcomes and has commented on the variability of services, which is where I want to concentrate my remarks. There is quite wide variability of services, and I want to look at why that is, what we can do about it and what is at the heart of that thorny question.


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I do not want to rehearse all the figures and statistics released by the Healthcare Commission today. Members are aware of them and many of them have been mentioned already. However, one figure from a survey published by the commission in July 2008, based on interviews with 69,000 people in England, showed the variability that I am talking about. One of the things found by the survey was that the overall proportion of respondents who had waited two working days or more for their most recent appointment with a doctor had risen from 74 to 75 per cent. this year, which was a modest change. However, in the highest scoring trust, 89 per cent. of respondents said they were seen by a GP within two working days, yet in the lowest scoring trust only 43 per cent. of people had been seen within two days. That is a far more worrying statistic than any of the others I have heard this afternoon. Furthermore, 23 per cent. of patients who made an appointment felt that they should have been seen sooner.

Those findings have been picked up by the Patients Association, which said:

I am sure that plenty of colleagues in the House this afternoon will have been presented with examples from constituents of people waiting longer than they should to see a GP. The scenario where a patient rings their practice for an appointment and is told that nothing is available for the next three, four or five days, not just with their GP but with any GP, is one that I hear far too often for my liking.

We can argue about the Healthcare Commission figures. Only yesterday, I had a meeting with Anna Walker at which we tried to pick to pieces why there was such a variation in the figures and why it looked as though only 31 per cent. of trusts were able to achieve the GP access target. The answer seems to hinge to a large extent on whether we say to a patient, “Are you able to achieve an appointment in 48 hours?” or “Did you manage to actually get an appointment within 48 hours?” That is when there is a much lower response. The figures need more examination, although that is probably beyond the scope of the debate.

Norman Lamb: I hear the possible explanation of the difference, but does the hon. Gentleman accept none the less that the greatest problem, whatever the measure, is in poorer, inner-city areas?

Dr. Stoate: I entirely accept that point, which is important and worthy of closer examination, and I want to develop it in more detail.

Many patients—often vulnerable ones—tend to accept what they are told. If they are told, “There’s no appointment, come back tomorrow morning and you might be able to get one”, they often do so. They are thus less likely to appear in the figures as missed 48-hour appointments. Other patients who may understand the system better and say, “I know I’m entitled to an appointment within 48 hours” are more likely to be
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given one. That explains to some extent why people in more disadvantaged areas are more likely to accept what they are told and less likely to demand their rights than those in areas with more vociferous and middle class patients.

It is entirely possible for practices, perhaps unwittingly, to deflect patients for 48 hours, and such patients would not be picked up by the surveys. It would thus appear that they were performing better. I find it difficult to accept that situation. Why can many practices—it is probably even the majority—provide a perfectly good service? They have no difficulty whatever in combining 48-hour access with appointments booked two weeks in advance. Why do so many patients and practices have no problems, whereas others seem to run into difficulty time and time again?

We need to go back a long way and look at the origins of primary care in the health service in 1948, when, as Members know, independent contractor status was conferred on GPs. The system has served the UK remarkably well. It has managed to ensure that because GPs are independent contractors—in effect, private businesses working on a profit and loss account—their only payment mechanism is the bottom line of their practice profits. Those profits are the GPs’ income, because there are no shareholders; the GPs share the profits as directors of the company. That has had an enormously beneficial effect on British general practice, and it explains why it is still one of the envies of the world. It is fantastically cost-effective. GPs are focused on what they do very well indeed and the system is extremely cheap, which is one of the things I want to consider. Our system, which is cheap, cost-effective and has served us well, has also allowed quite marked variations of practice and circumstances to build up. Let me suggest one explanation for that.

Remarkably, over that time no Government have seriously challenged independent contractor status, and no Government have seriously looked behind it at exactly what it means. In fact, what it boils down to is that GP practices have been taken for granted. It has just been assumed that GPs are professionals, do a good job, look after their patients, do what they need to do and produce reasonably good outcomes. No one has ever looked beyond that.

On the one hand, depending on which side of the fence one is sitting, one might say that that is a huge vote of confidence in the British general practice system, which has served us well. Others might say that it is mind-bogglingly complacent, because no one has ever looked very closely behind it. It is hardly surprising, therefore, that quite a variable quality has been built into the system.

Under the old red book system, GPs were remunerated in a way that was purely beancounting. They were paid according to the number of patients and of services provided. One added them up on paper and sent the piece of paper off to what was then the family health services authority, and it sent back a cheque each month. That was that.


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