Clause 20 - Payments relating to past performance
Health and Social Care Bill
9:45 am
Mr Philip Hammond (Runnymede and Weybridge, Conservative)
I beg to move amendment No. 178, in page 14, line 6, leave out from `shall' to end of line 7 and add:
`be substituted with—
(4) The remuneration to be paid under the arrangements mentioned in subsection (1) above to a practitioner who provides general medical services shall, at least in part be dependent upon the quality and outcome of the services provided and shall not ordinarily consist wholly or mainly of a fixed salary.'.
The clause is four lines long instead of one, so it lent itself to amendment. It is designed to repeal the requirement that general medical services remuneration should not consist wholly or mainly of a fixed salary paid to the practitioner.
When the 1977 Act was written, or when this provision was inserted, the assumption was that the basis of such remuneration would be capitation—that practitioners would be paid a sum per person on their list. The Government's policy is clearly to move away from capitation payments, and broadly speaking we would support that policy. It can provide a perverse incentive to practitioners to get the largest list they possibly can in order to maximise remuneration. A high number of patients on a practitioner's list does not necessarily correlate with a high quality of care provided by that practitioner. There might be prima facie reasons for assuming that the larger the practitioner's list, the lower the quality of the care that he is able to provide.
We understand the Government's desire to allow practitioners to be remunerated by reference to quality and outcomes, rather than simply by reference to the number of patients on their list. However, the clause is not necessary to achieve that objective. I refer the Committee to the explanatory notes, which state:
Clause 20 ends the requirement under 29(4) of the 1977 Act that the majority of remuneration of GPs should have reference to the number of patients the GP has undertaken to provide services under General Medical Services.
That is not what section 29(4) of the 1977 Act states. This is not the first time that I have found the explanatory notes to be misleading, so that a member of the Committee who does not have time to read the base legislation may be misled.
Section 29(4) of the 1977 Act states:
The remuneration...shall not...consist wholly or mainly of a fixed salary
that does not relate to capitation. It does not state that the remuneration cannot be calculated with reference to some other criteria such as quality or outcomes. The notes are misleading, and might lead somebody to believe that clause 20 was required in order to allow the Government to introduce remuneration based wholly or mainly on quality of outcomes into the GMS contract. That is not the case. It is already possible to introduce remuneration based on such criteria.
The amendment specifically includes a reference to quality and outcomes. It requires consideration to be given to those factors as a basis of remuneration. To allow remuneration to be based either wholly on capitation, or wholly on a fixed salary, would be a step backwards. Everything that the Government have said suggests that they want to move away from capitation-based payments to ensure that quality of patient experience and outcomes are the principle criteria in determining the remuneration of a practitioner. Clause 20 would allow practitioners to be paid a fixed salary. It removes from the 1977 Act the prohibition on fixed salaries without reference to capitation, which is neither positive nor helpful and flies in the face of the Government's stated objectives.
I am unsure what is in the Government's mind. Members of the Committee will be familiar with the distinction between personal medical services and general medical services. Under personal medical services, practitioners are paid a salary, while under general medical services, they are remunerated in a variety of ways, though with capitation as a significant element of the package.
During the debates on the Health Act 1999, which introduced personal medical services, the Minister assured the Committee that personal medical services would co-exist alongside general medical services. They would not replace them and there would be no pressure to move from GMS to PMS. Despite the assurances, some GPs are—or will be—under pressure to move from GMS to PMS, particularly single-handed practitioners, and that flies in the face of the assurances given in 1999.
The clause—and its ramifications—suggests that the Government, in addition to a full-frontal assault on GMS—to persuade, entice and cajole practitioners into PMS—are working a flanking movement. They are undermining the principals of GMS by giving themselves the power to make a fixed salary the basis of a GMS service contract, which would give it most if not all the characteristics of a PMS contract. Perhaps the Minister can explain what the distinction between GMS and PMS will be? Perhaps he will give an assurance that, even if the clause is passed without the benefit of the amendment, there will still be a distinctive GMS system.
If the Government have a benign reason, such as the one that they gave in ``The NHS Plan'' and other documents, for wanting to re-negotiate the GMS to make it more quality sensitive, they will have no difficulty accepting the amendment. The Minister should either accept the amendment or admit that the Government have a plan to out-flank GMS with a fixed salary system that will make it almost indistinguishable from PMS.