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The 1990 contract, introduced by the Conservative Government, extended that arrangement a bit by producing 27 outcome measures. GPs fulfilled those measures: they sent their pieces of paper off; they got paid. They were process measures, not output measures. They looked at how many patients had their blood pressure checked,
how many had a new patient examination and how many had been given advice for obesity. Not once were GPs to produce any evidence that they had done any good by that method.
All Members in the Chamber this afternoon have spoken about quality and outcome, yet the words “quality” and “outcome” effectively did not exist until 2004, with the new GP contract that this Government introduced. For the first time, GPs were measured on the quality and the outcome of what they were doing. The indicators in the QOF are all evidence-based. They are all carefully thought through by a panel of independent experts; agreed between the profession and the NHS Confederation as being the right indicators; and carefully monitored. The question is not how many patients’ blood pressure has been measured, but what percentage of those patients have blood pressure within a certain range—what percentage of diabetics, for example, have cholesterol levels below 4, not how many people’s cholesterol levels have been checked. The intention is to measure the number of patients whose measures have been improved, thereby leading to improved patient outcome on an evidence-based system. Ironically, although all hon. Members on both sides of the Chamber bang on about the need to improve the QOF, before 2004 it had never even been properly considered. This Government deserve a huge vote of confidence for doing that.
I should like to take issue with my GP colleagues, but not only with them. There is variable quality, and some of it is down to GP practice; sometimes GP practices could, should and must do better. I intervened on the Minister to draw attention to the problem of 0844 numbers, which is an example of where GPs have not been very friendly to their patients. He needs to look at that. It is obvious to me that some GPs could and should do more, and I believe that with a bit of incentive they probably will be able to sort that out. The fact is, however, that we have allowed the variability to continue for too long.
Mike Penning (Hemel Hempstead) (Con): The hon. Gentleman is very generous in giving way. The undertaking that he is asking for from the Government, and particularly from the Minister, to abolish the use of 0844 numbers was given by the Under-Secretary of State for International Development, the hon. Member for Bury, South (Mr. Lewis), some time ago, when he was a Health Minister, and nothing has happened.
Dr. Stoate: I accept that. I also accept the Minister’s assurance that the matter is being looked into by the Government. I await, as does the hon. Gentleman, the outcome of the Government’s deliberations, and I hope that this will be sorted out quickly. I think I have explained why there is so much variability, why practices have such different approaches, and why some provide services that are not up to the standard that we would like to see, whereas others motor ahead and produce everything that the Government want.
The Minister mentioned the MPIG or minimum practice income guarantee. He is right to say that it was an historical device to ensure that when the new GP contract was brought in, no practice would suffer huge financial loss as a consequence—at least for the first three years, until its practice income had taken off and it had managed to produce income from elsewhere. However, I would counsel caution. We must not simply
dump on GPs more and more of the work that they are currently unable to do, because it simply will not work if the Government expect GPs to work even harder to recoup income that will be removed from them when the MPIG goes.
Let us consider the average working day for the average doctor. It is a sobering thought, and I want to share it because I think it is important. The average GP sees 35 to 40 patients a day. At 12 minutes or so per appointment, that is six or seven hours of consulting time. On top of that, they make home visits, of which there may be an unlimited number. They also have to undertake medical examinations for people requiring HGV or taxi-cab licences; write referrals to hospital consultants if a patient needs to be referred; and read and action all the letters that come in during the day to the practice from consultants who are treating their patients in hospital. They have to action pathology reports and electrocardiogram reports that come into the practice on a frequent basis, and they have a sea of repeat prescriptions to write for people who remain on medication. On top of that, the majority of GPs run clinics for child health surveillance, minor surgery, maternity care, diabetes, dermatology and joint injections. The majority of GPs are involved in teaching or training the next generation of GPs, and on top of that, they are expected to keep abreast of recent developments and ensure that they are up to date with the best possible medical practice and the latest Government missives. That is a pretty daunting work load. If we embrace the idea that a GP can simply do more because the incentives and QOFs have changed, the MPIG is going and there is a lot more work from extending their hours into the evenings and weekends, we have to be careful lest we kill the golden goose simply by putting more and more on to already hard-pressed practitioners.
I should like to say a word or two about the Government’s relationship with GPs. I have been critical, with good reason, of some aspects of GP performance, but the opprobrium that has been heaped on GPs in recent months by the media and other groups is undeserved and counter-productive. GPs are well rewarded under the terms of the new contract, and there are justifiable questions about how the profession has been allowed to dispense with out-of-hours services so lightly and with so little penalty. However, it was the Government who signed off on the deal, and much of the responsibility for the shortcomings in the contract must lie in their hands.
Blaming the profession for having the temerity to make a good deal and then looking for ways to recoup the money that was spent on the contract is not a tenable long-term position for the Government to take. In a letter sent to me after a recent meeting, a group of GPs in my local area commented:
“You expressed the view that the Department of Health had a high regard for general practice, and saw GPs as a key component in the redesign and modernisation of the health service. The general feeling from my colleagues was that the Department of Health had a very strange way of demonstrating their regard for general practice, as demonstrated by their public pronouncements and attitude.”
That group of GPs is not a recalcitrant minority that is anti-reform and dismissive of the need to change—quite the reverse, in fact. They are progressive practitioners who are doing their level best to work with the Government to improve access and delivery of services.
Norman Lamb: I completely agree with the analysis that the hon. Gentleman has offered. Does he think that that sort of thing has led to this extraordinary loss of confidence among general practitioners in the Government’s stewardship of the NHS, which I am sure he accepts has taken place?
Dr. Stoate: Well, that has been hyped as well, because personally, I do not see the complete loss of confidence that the hon. Gentleman mentioned with regard to his area of Norfolk. I obviously cannot comment on his local GPs, but my local GPs have not completely lost confidence, and neither have the GPs with whom I work closely up and down the country, those who write or phone me, or those with whom I work on many groups on medical matters. However, I accept that GPs’ thoughts about the way in which things are going has taken a knock. I should like the Minister to clarify the Government’s position and make the case that they are not anti-GP; they are not trying to bash the system, but simply trying to get better care for patients.
I have given the House examples of cases in which GPs have felt undervalued and taken for granted. I do not think that the Government are going to win any friends among GPs unless we try to redress that important issue. During these difficult financial times, Ministers may believe that GPs will not win any friends by complaining about their pay and conditions. That is a fair point, but a damaged relationship between Government and GPs will have long-term consequences. We have seen examples of imported, privately contracted “para-GPs” who work 9-to-5 shifts with a half-hour break, providing GP services for patients in areas where there is a shortage of GPs. Their turnover rate is impressive and at one level they provide good value for money. They get a good throughput of patients, but whether patients are satisfied with that type of medicine and consultation is another matter. I do not believe that that is the way to proceed. Asking GPs to do more all the time without appropriate resources will not only alienate GPs; ultimately it will damage patient care and prevent GPs from being able to rely on the prevention and early detection of disease, which it is important that they do.
I am in favour of the GP-led health centre model, as I have said on a number of occasions. A group of GPs in my local area has just been awarded a contract from a company to provide an out-of-hours centre and a GP-led health centre in Ebbsfleet, which is a fast growing area of my constituency. Those are the very GPs who are keen to progress, work with the Government and see the Government’s model pursued.
Mr. Bone: I am interested in the point that the hon. Gentleman makes. The centre that he describes seems similar to something in my area. Was that group of doctors engaged in that activity before the Government imposed their target for one such health centre in each PCT? Does it pre-date that target?
Dr. Stoate:
No. It was a response to the Government wanting to put a GP-led health centre into my area. The GPs have taken up the idea with a vengeance. They have seen that there is a gap in provision in the area. There is a new development around Ebbsfleet International station in my constituency, which will see many thousands of new houses and businesses moving into the area, and they recognise that there will be a need for new health
facilities in the area. My local hospital has also looked forward to the expansion of its services as the population rises. That is entirely natural.
What is important is that the GPs feel themselves to be supported, properly resourced and adequately advised by the primary care trust to make sure that the scheme is a success, because they want it to be a success. My point to the Minister is that if we are to make sure that GPs are willing to pick up the baton and run with it and produce extra services, we must send out a message that we are supporting them in the same way as we expect them to support their patients. I have heard from Members in all parts of the House that currently there is a real gap between the thinking of GPs who want to get on with the scheme and their perception of how the Government see them. That leaves something to be desired. I hope that my hon. Friend will look into that.
The hon. Member for North Norfolk (Norman Lamb) mentioned the Dispensing Doctors Association and the view that we should be careful about how we handle dispensing practices. I am pleased that the consultation leaves four options open, and that the Government do not yet have a preferred view on how dispensing practice is dealt with. It is possible that when the consultation is finished, things will stay as they are. I emphasise that dispensing practices are a useful resource in some rural areas and provide a very good service to patients. I would like to make sure that that is not damaged.
The other side of the coin is to ensure that pharmacy also has good access to patients. As has been mentioned in the debate, pharmacists can and already do provide a range of services that is expanding all the time and can be an important part of primary care delivery in the front line. I am pleased to see them expand those services. I am pleased, too, that the Government took seriously the report on the future of pharmacy from the all-party pharmacy group, which I chair. The report has received favourable comments from Ministers and I am pleased that they have examined closely some of our suggestions on how pharmacy might be progressed. That is a positive development.
GP patient access is fundamental to how people see the health service. General practice is the front line of the health service. Ninety per cent. of all care takes place in a primary care setting. The majority of people see their GP or their GP practice three, four or five times every year. If we can ensure that we build on general practice, not only can we improve patient outcomes and patient well-being, but we can keep hospitals free of cases that are less serious and ensure that they can get on with the heavy duty and high-tech cases that only they are equipped to deal with. If we get that right, we will have a health service that we can be proud of and continue to be proud of into the future. I am sure that that is what everyone in the House wants and what Ministers want.
5.14 pm
Dr. Richard Taylor (Wyre Forest) (Ind): It is a delight to follow the hon. Member for Walthamstow (Mr. Gerrard). Having trained in London rather a long time ago, I know what the standard of general practice was then, and I am very pleased to hear that it is so much better.
I am delighted to follow the hon. Member for Dartford (Dr. Stoate), because he has removed the need for some of what I had intended to say. I had intended to stand
up for GPs, because their morale is incredibly low. Indeed, after I talked to my GP he sent me a few thoughts:
“Why are we under attack when we are efficient, good value for money and valued by our patients?”
His practice spends precisely 2 per cent. on management, because the doctors do most of the management. This is his perception:
“Government has no idea of what we do and what we achieve. The fiasco of out of hours shows this. As did our over performance in QOF. Which should be a thing of celebration not criticism.
Consultations are now highly complex. Minor illness is dealt with by nurse practitioners. We are dealing with complex cases inadequately supported by the acute trust”.
My GP’s description supports what the hon. Gentleman said about timings in the day almost to the minute. GPs start work at about 7:30 am and finish at 6:30 pm. Six hours and 40 minutes are taken up in consultations, with 34 patients seen, but GPs are also engaged in making telephone calls, writing referrals, looking at reports, making home visits and so on. They therefore fully justify their pay. I hope that the Minister will acknowledge that to make GPs feel a little less disregarded and insufficiently appreciated.
I know that our time is limited, so I will focus the rest of my speech on out-of-hours care, which is crucial. Access to out-of-hours care, which is not the function of A and E departments, is what has really brought the Healthcare Commission ratings on emergency care down. Years ago, GPs provided out-of-hours care, which meant that they were working night and day, which was not very good. As a patient, one felt guilty about ringing up a GP in the middle of the night, knowing that they had been working all day. Then we had the local co-operatives, which were excellent. They were a conglomeration of the local GPs working together in a rota to cover the nights, so that they did not have to work in the day as well.
Unfortunately, we lost the co-operatives when the contract was introduced. It was amazing that GPs were no longer expected to work at weekends, which meant that PCTs had to provide out-of-hours care. However, in my area and many others that has not been a success. I am pleased to say that the PCT in my area realised that it had to reform the service, which was put out to competitive tender. Rather to my surprise, a conglomerate of GPs from Suffolk has taken over the provision of out-of-hours care in the whole of Worcestershire.
I am so far very pleased with the intentions of that firm, although I am going to follow its progress closely. There is a bit of a flaw in the contract, which was short sighted but understandable, in that the firm covers only the patients of GPs registered in Worcestershire. Unfortunately, the rest of my hospital covers the area right on the Shropshire border, so when patients from Shropshire, from as little as three or four miles away, turn up in the middle of the night with something rather nasty, the firm says that it cannot take them, because the contract is not with the Shropshire GPs. I am looking into the matter, because it is in the firm’s interests to take more people, because it will get the money for doing so. That was a difficulty with the contract when it was first written, but I am optimistic that it will be improved.
The one thing that would most helpfully improve out-of-hours care has been mentioned, which is a single telephone number. If people are really desperate, 999 is
fine, but we want another number. As I have said before in similar debates, people do not know whether to contact out-of-hours care or go the minor injuries unit, the A and E department or the walk-in centre. They do not know who to ring, so we want one number. In previous debates with the Minister, he has said that he is looking into the supply of a single number.
An organisation called NHS Pathways operates a brilliant triage system that has been trialled in various parts of the country, and those trials have been successful. I have here the minutes of the AGM of the North East Ambulance Service NHS Trust, where NHS Pathways was trialled:
“The year also saw confirmation that the clinically-based assessment system—NHS Pathways—was a safe and efficient method of call handling...The clinical evidence-base underpinning it means NEAS is in a position to assess calls from a much wider range of patients, not only those who have chosen to access the ‘999’ number, and to use alternative pathways of care that can be referred to from the system that is most appropriate for the patient’s needs.”
The trust has already noted areas of “significant improvement”, including a “considerable reduction” in the number of patients going to A and E departments unnecessarily.
NHS Pathways is a marvellous triage system, and if it—or something similar—could be accessed from a single phone number, it would be a huge help, particularly for out-of-hours care. I should very much like to find out from the Minister whether he will push NHS Pathways as a useful form of access, and whether we can aim to have a single number.
5.22 pm
Mr. Peter Bone (Wellingborough) (Con): It is a pleasure to follow the hon. Member for Wyre Forest (Dr. Taylor), who, as usual, has made some powerful and important points about the health service. I start by thanking GPs across the country for what they do. I know that we are discussing access to primary care, and that we have totally ignored dentists, whom I would like to mention briefly. GPs are valued by my constituents, and not least by me and my wife, as one of them effectively saved my wife’s life. It was an advantage in that situation that the GP knew her, because she had been a patient for a number of years. Many of the GPs in my area are concerned that, if we were to introduce GP-led health centres, that continuity might not continue.
Age Concern is also worried about that. That matter has not really been touched on in the debate so far. Age Concern states:
“Many older people value the continuing relationship they have with their GP—that must be retained in any reform of the system. We would therefore want a commitment that the personal GP patient relationship would be protected.”
That is extremely important. Another point that Age Concern makes is rather the reverse of the Minister’s wish to make more time available to patients in the evenings and at weekends, so that people who go out to work can have access. Age Concern makes the very fair point that it wants to ensure the same amount of weekday availability for the people whom it represents, because that is when older people want to go to see their doctor.
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