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The Parliamentary Under-Secretary of State for Work and Pensions (Helen Goodman): May I say what a pleasure it is to serve under your chairmanship, Mr. Cook? I congratulate my hon. Friend the Member for Central Ayrshire (Mr. Donohoe) on securing this important debate. Over the years, he has done a lot of work on these matters for his constituents and he is completely committed to seeing a better system introduced. Yesterday, a lot of hon. Members went to an event run by the
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Child Maintenance and Enforcement Commission in the House and they saw the huge amount of work that is going on to improve the situation.

One of the key issues that has been raised this morning is enforcement powers. Judging the rights and wrongs as between the parent with care and the non-resident parent will always be a difficult balancing act. Over the past 10 years, however, we have discovered that the balance was previously in the wrong place. The points that the hon. Member for South-West Bedfordshire (Andrew Selous) has just made about there being a significantly problematic culture are absolutely right. It is a problem if, as is currently the case, only 45 per cent. of non-resident parents pay their maintenance in full.

In the measures that we have recently introduced, we have therefore strengthened enforcement powers. In October 2008, it became an offence for the non-resident parent to withhold information pertaining to a change of address. In August this year, CMEC assumed the power to deduct payments from non-resident parents' bank accounts without recourse to the courts. It also has the power to ask the court to impose a curfew on a non-resident parent. Under the Welfare Reform Act 2009, which secured Royal Assent last month, the commission now also has the power to remove the passports and driving licences of parents who have wilfully or culpably failed to meet their child maintenance obligations. Those powers are controversial, but it is important that we have them, given the context in which we operate.

Hon. Members are clearly still getting a large number of extremely complex cases in their constituency mailbags, and those cases have not been handled properly or as well as any of us would wish. Leaving aside those complex cases, however, the number of complaints against the CSA has fallen by more than half since 2004-05, which is an indication of its improved performance, as are the other performance statistics. The number of children benefiting from the CSA's work has increased by 250,000 over the past five years. The number of cases in receipt of maintenance has gone up from 400,000 to 600,000.

Hon. Members have talked a lot about the quality of the administration, where there have also been significant improvements. In 2004, only 27 per cent. of cases were dealt with within 12 weeks, but that number has gone up to 84 per cent. In 2005, the average time it took to answer the telephone was one minute 40 seconds, but it is now down to eight seconds. I fully understand hon. Members' concerns about their constituents telephoning the CSA and getting different people answering. In essence, the reason is that we have extended the CSA's opening hours so that it can be more available to people. The problem is that of course people cannot work the entire 60 hours a week during which the agency is open.

Mr. Donohoe: Will the Minister address the issue that I raised of the apparent reduction in staffing? I believe that 600 people have been transferred out of the CSA into Jobcentre Plus.

Helen Goodman: My hon. Friend is right about that. However, there are two things I want to say-and I do not want to wipe away the frustration of his constituents when they do not get the service to which they are
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entitled. First, the level of resources going into CMEC and the CSA must take account of the state of the public finances. We must look for efficiencies just as we are doing throughout the public services. Secondly, the reductions have been achieved while increasing the efficiency of the organisation. It is not as if we have been taking resources from the organisation and finding that service provision has collapsed.

One of the main points raised by my hon. Friend was the question of why people cannot move from the old scheme to the current scheme. There is a fundamental reason why we do not do that. We do it only after a significant change of circumstances, by which I do not mean someone's income going up or down, but rather a new child in the family or one or other of the parties making a new partnership. We cannot allow people to choose the scheme they want to enter, because for every parent who would choose to move there would be one in an equal and opposite position of not wanting to move. Giving people that choice would intensify the degree of conflict. I accept that that means people being treated differently, but in running a system we must consider the level of justice being achieved overall.

My hon. Friend and the hon. Member for South-West Bedfordshire asked why it was taking so long to introduce the future scheme. We have the legislation and we must embed the new computer systems. We are doing that on a different basis from previously and are learning from the bad experiences we had. Now we are using off-the-shelf computer systems rather than building our own, which should make them more economical and flexible. We intend new cases to go on to the future scheme from 2011 and everyone to be transferred to it in 2014.

Mr. Donohoe: Will the Minister confirm that under the new system it will be possible to have cross-fertilisation of thinking between the agency, the Treasury and all the driving agencies? If that is the case, many of the complications that I have encountered would be overturned.

Helen Goodman: Among the main benefits of the future scheme will be the fact that it will get data from HMRC and that we shall move from a formula using net income to one using gross income. That system has been used in other countries with significant success.

I am sorry that I shall not be able to comment on every case that hon. Members have raised this morning, because there is not time to do so in detail, and I do not have all the information. However, hon. Members can, if they have not already done so, write to me about cases, which I can look into. I shall comment on a couple of cases of particular concern, starting with the company going into liquidation and the man who was asked to pay twice. The non-resident parent remains liable to pay child maintenance, but he should be able to claim the payments that have been deducted from the liquidator. If he is unsuccessful, the CSA will discuss with him how to handle the arrears.

Mr. Donohoe: Surely it should not be his responsibility. Given that he has done all he should, the agency should pursue the liquidator for the money. He has already paid it.

Helen Goodman: My hon. Friend makes his point with characteristic force and I shall take that thought away with me.

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The hon. Member for Na h-Eileanan an Iar (Mr. MacNeil) raised another case of some concern, about a non-resident parent whose name was on the birth certificate, but who could not possibly have been the father. Once the non-resident parent has provided proof of his infertility or a DNA test has shown that he is not the father, the CSA can revise its original decision, extinguishing all liability for child maintenance, and any payments may be refunded.

Mr. MacNeil: Would that include the fees of £2,400 that the agency is asking my constituent for? That is the point that is causing him quite some concern at the moment.

Helen Goodman: The honest answer, I am afraid, is that I do not know, and I shall have to get back to the hon. Gentleman on that point.

The hon. Member for Northavon (Steve Webb) gave a characteristically well- informed speech and set out a general schema in which we would deal in a fairly automatic way with straightforward cases, but pay greater attention to the hard cases. Generally, that is a good way of administering the scheme, and that is what we are attempting to do. I guess that the difficulty is in discussing which cases are hard.

The hon. Gentleman also made a valid point about people moving off the system altogether and whether people will get everything to which they are entitled from the options service. Gingerbread, for example, is particularly concerned about the re-establishment of what I shall call traditional gender relations, in which for the sake of peace women might not push as hard as they ought. I agree that that is an issue, and I am on top of it. We are considering how we can monitor that effectively.

The hon. Member for South-West Bedfordshire made a good point about the overall culture in which we operate and the difficulties that we face. I hope that hon. Members feel that we are making significant improvements to the child support system overall. We are succeeding at the moment in lifting 100,000 children out of child poverty because of the way in which the system currently runs.

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GP Practice Boundaries

11 am

David Taylor (North-West Leicestershire) (Lab/Co-op): I am pleased to see you in the Chair, Mr. Cook, presiding over a debate on a subject that is highly important to all our constituents. It is good that the Minister responding to the debate is my right hon. and learned Friend the Member for North Warwickshire (Mr. O'Brien), who is my constituency neighbour to the south-west.

If we look at the Government's policy on the NHS since 1997, we can see that a welter of statistics confirm the excellent and vital progress that has been made in many areas. For example, we have over 44,000 more doctors and almost 90,000 more nurses, and 3 million more operations are carried out each year than in 1997, with the number of heart operations more than doubling. Net public spending on the NHS has nearly tripled since 1997. Then it was £35 billion; it is now more than £90 billion. Waiting times are at the lowest level in NHS history.

The risk, however, is that the effectiveness and durability of those fantastic achievements may be undermined by an obsession with organisational and administrative reform of the NHS. In the view of many NHS workers, of patients and indeed of Members of Parliament and community representatives, the commercial mantra of choice is being used as a cloak for the marketisation and privatisation of the NHS.

At the Brighton Labour party conference in September, the Secretary of State for Health said:

That did not exactly come out of the blue, but it caused a great deal of concern among GPs in my constituency and elsewhere. Even those GPs who saw some benefits from that rather rushed reform, such as Dr. Theresa Eynon of the Hugglescote surgery, were quick to express to me their fear that abolishing GP practice boundaries could worsen the plight of those patients most vulnerable to serious long-term health problems.

The Government's plans provide further proof that the inverse care law is alive and well. As the Minister will know, the idea was first proposed by Julian Tudor Hart in 1971. His law states that the availability of good medical care tends to vary inversely to the need for it in the population that it serves. Put simply, those who need health care services the least use them more, and more effectively, than those with the most need.

That is not to say that there is anything inherently wrong with allowing people to register with a GP practice closer to their workplace, thus enabling easier access to the surgery during the working week. Of course there is nothing wrong with wanting to offer more convenient NHS primary care, although I would quietly suggest that employers could be more flexible in allowing their employees to attend GP appointments; the wheels would not come off the local or national economy if such flexibility were more readily available.

If that was what was being proposed, I would not argue with it, and would not be debating the matter today, but that is not the full story. The Minister said in a speech to the Royal College of General Practitioners conference last month:

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That confirms that the Government's intentions are much more fundamental than an improvement to GP accessibility.

The proposal is more to do with the promotion of competition among GP services, supplemented by initiatives such as NHS Choices that utilise the information gleaned from the quality and outcomes framework to give the public somewhat simplistic statistics on GP practice performance. Given all the academic talk of quality and values, the most crucial issue is the future of the truly local services that GPs provide, particularly the invaluable home visits that they make to the homes of the long-term sick, the immobile and the terminally ill.

In the rush, in the words of the Health Secretary, to turn the NHS from "good to great", the Government risk ignoring the needs of that most vulnerable group of patients. I note parenthetically that the next debate in this Chamber is about age discrimination in health care. I shall read the Hansard report of that debate with great interest. The proposed reform does not seek to end home visits, but there is a very real risk that the needs of our fellow citizens with the most complex health problems will be put in direct competition with the health-care requirements of the more affluent workers and families. Each will have a QOF score, but there are no prizes for guessing who attracts the most points and, therefore, funding.

I regret to say that the potential of the change to worsen health inequalities goes even deeper than that. Those with the most complex health needs, particularly psychiatric ones, rely on social services that are geographically tied to the local authority. It does not take much imagination to realise that the consequences of abolishing GP practice boundaries may include an increase in the administrative complexity and cost of providing appropriate care packages for all who need them. Dementia patients living at home will be particularly vulnerable to instability and uncertainty.

All Labour Members hope that the Personal Care at Home Bill, which received its Second Reading this week, and the national care service will together ride to the rescue of all those with social care needs, but a period of uncertainty could result from the abolition of GP practice boundaries. I urge the Government and the Minister to think again, on these grounds alone. I should be most grateful if the Minister made a specific response about the impact of the reform on social care provision.

I turn to the intellectual threads of this reform. The spiritual leader of private health care in the NHS and former Health Secretary, my right hon. Friend the Member for Darlington (Mr. Milburn), has rightly stated on numerous occasions that the health gap between rich and poor has grown inexorably since the creation of the NHS. However, that inescapable conclusion has little to do with structural failings within the NHS, as he would be quick to assert; it has more to do with the wealth of a small number of individuals and the private companies that respond to their every ailment, whether cosmetic or chronic.

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It goes without saying that widening health inequality is a national concern, and I am pleased that the Government have commissioned Professor Sir Michael Marmot of University College London to consider how we could tackle health inequalities more effectively. We should all look closely at his findings and recommendations, and I hope that we will have an opportunity to debate them in the Chamber.

Men and women in our poorest communities are dying on average a decade or more before those of their generation in the most affluent areas. Putting it at its mildest, that is deeply troubling. However, that is due as much to the increased and inherent politicisation of this totemic institution since the 1980s. That culminated in the Labour Government putting up the money-but rarely the arguments-for maintaining the NHS wholly within the public sector.

With the abolition of practice boundaries, we will undoubtedly increase competition within the NHS. That will be especially so in urban areas, as GP practices have to compete for patients with NHS walk-in centres and one-stop primary care centres-the polyclinics championed in the Darzi review. That will merely distract the NHS from tackling health inequalities, as consistent and lengthy patient records will become more difficult to compile.

As someone with three decades in public sector IT, it would be remiss of me not to acknowledge that computer systems have a role to play in solving the problem, but the less said about the benighted NHS agency Connecting for Health the better. There is little doubt in my mind, however, that we would have had greater success in tackling health inequalities since 1997 if we had trusted and promoted the efficiency of the public sector over that of the private sector and its unseen and unaccountable backers and exploiters.

I mentioned the Darzi review a moment ago. We are all familiar with its aim of putting quality at the heart of the NHS. Who could disagree with that? I certainly would not, although I would question the use of other commercially-loaded terms by a senior Government appointee, who is supposed to be a clinical health specialist and not a management guru. Those phrases are more likely to come out of the mouth of the Chief Secretary to the Treasury, my right hon. Friend the Member for Birmingham, Hodge Hill (Mr. Byrne), than one of our most successful and respected surgeons.

However, when my right hon. Friend the Member for Darlington was Health Secretary, he said in a speech to the Commonwealth Fund in Washington 2002 that

Private health insurer Kaiser Permanente of the US is cited as an example of that health care harmony, but I shall resist the temptation to be lured down that profitable but politically promiscuous avenue.

The Darzi review is the foundation for these troubling proposals in primary care, with a specific quote from Lord Darzi's summary letter in "High Quality Care for All" establishing the foundation upon which the Secretary of State decided to proceed.

Lord Darzi said:

That raises the role of primary care trusts in designing and commissioning local primary care services, as they
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also have a vital role to play in the democratisation of health care. By that I mean involving patients in the decisions that most affect their health, which is a welcome development. Leicestershire County and Rutland PCT seems to be going out of its way to illustrate to patients the worst excesses of the catchment area system that currently operates. For example, patients registered at Whitwick surgery who lived four miles or so away in Hugglescote were told by the PCT that they would have to leave that practice and re-register at Hugglescote. That was immensely distressing to the patients concerned, particularly pensioners who had built up a good relationship with the GPs at Whitwick over a number of years.

At this point, it is worth quoting Dr. Orest Mulka of the Measham medical unit. He is a highly respected GP at a well-regarded surgery in my constituency, and he said:

I repeat:

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