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16 Dec 2009 : Column 271WHcontinued
"They allow practices to develop a sense of pride of caring for their patch."
" In my practice we don't discriminate-anyone living in our area is accepted on our list."
I shall use Dr. Mulka's comments as evidence against the Government's claim that abolishing practice boundaries will increase local accountability. If a patient is not a member of the local community, their needs may well be at odds and even in competition with those who live closest and who may have greater clinical need.
Whatever the number of patient participation groups, welcome though they are, they cannot hope to replace that local link. That reminds us of the consumer-led nature of the Government's proposal, which has been described as a move toward a "medical supermarket" where increasing numbers of patients are routinely seen, not by GPs, doctors or nurses, but by "health care professionals" such as "nurse consultants". We are some way from such dystopian scenarios, but the Government's obsessive delivery of pro-private policies in the NHS inevitably leads in that direction. Many people see the death knell of a publicly resourced and run NHS in proposals such as abolishing GP practice boundaries; creating polyclinics; making PCTs commissioners rather than providers of health care; encouraging NHS hospitals trusts to apply for foundation status; local improvement finance trusts; and-do not get me going on this-private finance initiatives. Moreover, there are other inappropriate and unnecessary market devices.
Such reforms are the logical conclusion to the brave new world of health care partnerships piloted by my right hon. Friend the Member for Darlington when he was Health Secretary. The frequent speeches made during his tenure in Richmond house seemed intent on sending a chill down the spine of GPs and patients and included such baleful gems as the following examples. He said that
"tax funded health care can only be sustainable if it sits side by side with diversity in provision and choice for patients."
What he meant is that it is sustainable only when the local commissioning arrangements allow and indeed favour private sector bids for NHS work. He also talked about
"new private sector providers becoming a permanent feature of the NHS landscape."
"The NHS scores well on fairness but is weak on choice."
Those quotes are all from the same 2002 speech, but seem more akin to a sales pitch than a policy debate. Let us not forget that from 2001 to 2004 our former Prime Minister and right hon. Friend, Tony Blair, was advised on the NHS by Simon Stevens, who promptly joined the US firm UnitedHealth Group, which made $78.85 billion from health care services in 2008, after leaving the Downing street policy unit. By way of a footnote, let me say that at the same time as vehemently opposing President Obama's modest health care reforms in the US, UnitedHealth, with Simon Stevens on board, is bidding for and winning NHS contracts, and will no doubt regard the abolition of GP practice boundaries as welcome "mood music" at the very least.
To return to the local impact of the Government's plan, Dr. Eynon has concluded that, once again, the change is one that suits the well, working person. That brings to mind the inverse care law that I cited at the start of my speech. We must not shape our primary care system around the needs of the middle-class, peripatetic, urban elite who go to their local paper and MP every time they cannot get an appointment to treat their squash injury, as we should not normalise or accommodate the social and environmental impact of fundamentally selfish lifestyles.
By 2018, when the NHS reaches its biblical span of three score years and 10, we shall have seen GPs metamorphose from the avuncular community leaders of "Dr. Finlay's Casebook" to profit-generating assets in a Dr. Foster's cost centre. The NHS was not created to serve a minority who shout loud enough to see a doctor whenever they want, wherever they are. This proposal is designed to satisfy the few, not the many. To abolish practice boundaries is to hasten the demise of the family doctor.
The Minister of State, Department of Health (Mr. Mike O'Brien): I congratulate my hon. Friend the Member for North-West Leicestershire (David Taylor), my constituency neighbour, on securing the debate and on his lively and interesting speech.
Although practice boundaries will be the main focus of my remarks, I also want to address the wider issue of competition and choice within the NHS, because my hon. Friend has made his feelings so plain. It will not surprise him to know that I have some sympathy with a few of his points. I, too, am very conscious of the fact that our party founded the NHS. It was a service to be paid for from taxation, free at the point of need and primarily provided through the public service.
However, in respect of some of the comments about marketisation in primary care, we need to bear it in mind that the NHS has always been a deal between the private and public sectors, because most GPs operate independent private businesses that contract with the NHS, and have done since 1948. Therefore, we must be
a little careful when we discuss the private sector, because some GPs talk about the private sector as if it were something different from them. Actually, they are in the private sector, but they contract with the public sector.
We have an excellent record in primary care, as confirmed by a report earlier this year from the prestigious Commonwealth Fund, but we should never be satisfied. Although many GP practices are excellent, not all are. I agree with my hon. Friend that the most deprived parts of the country sometimes have the poorest provision of primary care with fewer doctors and greater demand-poorer areas tend to have people with a number of medical conditions that need urgent care.
We cannot simply rely on current general practice to address such problems. That approach has been tried for 60 years and it just has not worked. In some places, patients may be restricted to a single practice. They may wish to move, but find it difficult to do so. That is all very well if their practice is good, but what if it is not? We are now pursuing a different approach, investing in 112 new GP practices delivered by any willing provider with a strong track record on reducing health inequalities.
Choice and competition can drive up access and quality, which is important. We are working to improve the quality of primary care in different areas. One thing that GP-led health centres have done is locate in some of the most deprived areas in the country. We have had great difficulty in getting GPs to work in such areas. They find the work hard and the profits small, because the amount of private work that they get is limited. We have invested huge sums over the past decade in new premises, new technology and many more doctors, nurses and other health care professionals.
Yesterday, I went to Barking where a new family centre has been set up. GPs and dentists were encouraged to locate in a deprived area to ensure that it offered the quality of care that local people needed. As a result of many of those people training in that area-I also visited a centre in the Isle of Dogs-some GPs and dentists have chosen to come back and work there because the facilities are good and the buildings new, and they realise that deprived areas can bring a great deal of job satisfaction.
David Taylor: I am listening very carefully to what the Minister has to say. Does he agree that the bigger polyclinics that are envisaged-where a patient may go and, in a sense, be allocated at random a doctor from a very large panel-will make it very difficult indeed to build a relationship of the type that has been the foundation of our health service since 1948, which is that between a patient and a family doctor?
Mr. O'Brien: I think that the NHS and the relationship between patients and GPs have changed since 1948. Some patients want to see the same doctor, particularly if they have a long-term medical condition and they do not want to have to explain their problems all over again to a new doctor. However, some patients are not worried about whether they see the same doctor. If a patient does not have a long-term condition and is, in effect, seeing a GP at random-they might have developed a condition that they just want advice on-they may not be bothered about which GP they see.
There is a tradition of sorts that the relationship between patient and doctor is sanctified. For some people it is, but for others it is not, and we must provide an NHS that enables those people who want to see a particular doctor to see that doctor and those people who are not bothered in the least about which doctor they see not to have to see the same doctor continually. Some people I know do not want to see their allocated doctor at all. They happen to have been allocated to that doctor and end up seeing them. I remember that at some point in the past, although thankfully not at the moment, that was the case for people in my family.
Therefore, we need to ensure that people are able to see the GP who best suits them. My hon. Friend is absolutely right that many people want to see the same GP, but some are not bothered about which GP they see.
We need to provide people with choice, because choice and competition can both make a difference to patients and improve the quality of care. The polyclinics are based in London; we do not have them elsewhere. We have GP-led health centres elsewhere and many are very successful, but the development of polyclinics, which was restricted to the capital, has been enormously successful, particularly in deprived areas. Polyclinics have brought GPs to deprived areas and improved the quality of care in those areas, which we want to continue to work on.
We have pushed power away from Westminster and Whitehall into the hands of primary care trusts, through the world-class commissioning programme, and directly to individual and groups of GPs, through practice-based commissioning. That is all about providing the best possible service for patients-an aspiration that I am sure my hon. Friend shares.
As the Secretary of State has set out, where NHS services are providing excellent quality and performing at the level of the very best, there is no ideological predisposition to look to the market. On the contrary-we want health care provided in the best way that the NHS can possibly provide it. The public service is our preferred provider, but if it is not providing we have to look elsewhere, because the patient comes first.
Where NHS services can deliver, that is good-we want them to deliver-but we are also saying that patients need more power to choose the service that suits them. We in the Labour party created patient choice, precisely because we believe that it should be the interests of patients, rather than those of providers, that determine how health care is provided in this country.
We have already given people far greater choice through the introduction of 90 NHS walk-in centres, which are used by 3 million people every year, and, more recently, through the introduction of GP-led health centres, which enables someone to walk in to see a GP or a nurse while remaining registered at their own GP practice. People can go to the GP-led health centre if they have a random or minor health issue, but if they have a long-term health issue they can still go to see their own GP. They have a choice. Despite fierce opposition to GP-led health centres from some parts of the medical profession and from elsewhere, they have, by and large, proved very popular with patients. Overall, nearly 3 million people have used such a centre already.
Evidence from the UK and from overseas shows that treatments are more effective if patients choose, understand and control their own care. We are putting ever more
information about services in the hands of the public. That information will include the waiting times for a particular hospital and the personal comments of patients at a GP practice, so patients can comment on how good their GP practice is.
This process is slowly transforming the traditional doctor-patient relationship, in a way that gives the patient more power. Some GPs do not like it, but it gives patients more power. A more empowered and informed patient can take a more active role in their own care. They can decide, with their own doctor, which hospital to be treated at, and they can take a rational decision about which GP practice is best for them.
The NHS constitution already gives people the right to choose their own GP practice, but for many people that choice is severely limited. Most patients can choose between only a few practices and some patients have no choice at all. That limited choice reduces the competition between practices to attract patients and weakens the incentive for some GP practices to improve quality. Under the constitution, a GP practice must accept a patient's choice unless there are reasonable grounds for not doing so. At the moment, being outside a practice's boundary counts as reasonable grounds.
As my hon. Friend said, in September the Secretary of State set out our intention that, within 12 months, people should be able to register wherever they choose. For now, the practice that lies closest to someone's home may not be the easiest for them to get to.
I ask my hon. Friend to consider his constituents who commute to work and who may find it far simpler to see a GP near their work rather than taking half a day off to see a GP closer to their home. It is all very well to say, as he did, that employers should be more understanding, but some employers just are not so understanding. In addition, many people get paid by the hour, so they would lose money if they had to take more time off work to see a GP.
I also ask my hon. Friend to consider people with children who go to school beyond the boundary of their GP's practice. Those people may find it easier to register with a GP nearer the school, keeping time off school to a minimum should their child need to see a doctor. Furthermore, some of his constituents may want to change their GP practice because of the better quality of services available at other practices in their area. They may even want to register with the practice closest to their home but cannot do so because it lies just the other side of a line or boundary, or perhaps because of the "closed shop" arrangements that exist in some areas, because a GP practice's list of patients is full or because lines have been agreed about where the boundary between practices will exist.
The qualities and outcomes framework-the new arrangements to ensure that GPs provide greater health care-has attracted a lot of attention, because money is
attached to it. The key thing is that the funding formula is weighted in favour of those people with long-term medical conditions and the elderly. Indeed, there is clear evidence that, since QOF was introduced, health inequalities have narrowed-that is what it is all about. Money follows the patient, so offering people a choice gives practices a strong incentive to improve and attract new patients and retain existing ones.
Similarly, part of the positive impact of the new GP-led health centres has been that they have led other practices to open for longer and to expand their practice boundaries, so that they can compete with new services such as the GP-led health centres. Choice means better access to higher-quality medical care and I cannot see how anyone would want people not to have choice, if that is what choice indeed means.
Of course, given a choice most people will stay exactly where they are; I believe that that is what most people will do. Only a limited number of people want to exercise choice in this regard and, yes, sometimes they are well, middle-class people who just want the choice. Why on earth should they not have it? If they want it, the NHS should be able to provide them with it.
I do not want people to have to go off somewhere and pay privately to get a choice that they really ought to have within the NHS. Frankly, if people are well, young and middle-class, I want them to use the NHS and stay with it. I want them to realise that the NHS will give them a choice, so that later on, when they perhaps really need the NHS for their kids or for themselves when they develop a long-term condition, they will stay with the NHS-those are the people we want too.
However, my hon. Friend is right that we also need to ensure that we care for the people who really need the NHS. They include people from the mining community, such as some of his constituents and some of mine, who have long-term health care conditions. We want to ensure that such people receive the service and the priority that they need.
People with complex long-term medical conditions will want to maintain the continuity of being registered with their local GP, especially when so much of their care will involve other local organisations such as social services, community nursing and diagnostic services.
We want to ensure that where patients want choice, they get it. However, most patients who do not need that choice should not have it forced upon them. In the end, it remains something that patients should choose or not choose for themselves. It is a matter for them.
Mr. Paul Burstow (Sutton and Cheam) (LD): I am grateful for the opportunity to address this important issue on the day on which we rise for the Christmas recess. One curious thing about the lottery process for Adjournment debates is that one can apply assiduously for a topic for many a week, then find that one has the pleasure of securing it on the last day before we adjourn for Christmas. I am sure that we can therefore look forward to a quality debate but not a quantitatively long one.
Many aspects of health care give rise to concerns about how age is used as a proxy to determine-or, in some cases, deny-access to health care, even when the evidence does not support such practices. There is plenty of evidence that age discrimination takes place in cancer and stroke care, cardiology, foot care and continence and palliative care. Rather than going through the evidence for discrimination relating to each of those conditions, I will focus on one area that demands urgent attention-mental health.
After reviewing the literature and evidence, it is hard not to reach the conclusion that the national health service is institutionally ageist. That is certainly the view of doctors specialising in the care of older people, so I welcomed the Secretary of State's admission in October that age discrimination is still commonplace in health care a decade after the national service framework for older people was meant to have banned age bars and age discrimination across the NHS. It is clear that relative to mental health services for people of working age, the mental health services available to older people have got worse. I stress the word "relative" because there have been clear improvements in some aspects of mental health care for working-age people.
I recently hosted a reception in the House on behalf of the Royal College of Psychiatrists to highlight its call to action at a local level and on the part of individual clinicians. I am grateful to the Royal College for providing me with a briefing for this debate. If we took what we know from the published research and applied it to a typical group of 10,000 people over 64, this is what we would find: 2,500 would have a diagnosable mental illness. Of those, 1,350 would have depression, 500 would have dementia and 650 would have other mental illnesses. Most of those people would go undiagnosed and untreated. According to the King's Fund, older people are the only part of the population in which the number of people with mental illness will increase by 2026. If nothing else, we are required to address that demographic demand. A concerted response from Government and the NHS at all levels is necessary.
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