For many years people have been paying lip service to the need for more effort to be put into primary health care services, but very little has been done about the matter. That might be because we have put too much emphasis on hospitals. Health authorities have tended to be more concerned about buildings and influenced by the weight of medical opinion that has, on the whole, tended to concentrate on hospital services.
The Acheson report stated that there was a need for urgent action. The report was published in May 1981, since when there has been not a glimmer of response from the Government. The Government have not commented on their intentions. The main purpose of the debate is to find out the Government's response to the many sensible suggestions in the report about primary health services in inner London.
The report is not radical. All it says is that it is about time that inner London caught up with the rest of the country. It makes a modest proposal and I am surprised that Ministers have not expressed their views on it.
Inner London's problems are difficult. The British Medical Journal of 30 May 1981 states:
Britain's inner cities have some of the worst social and medical problems combined with some of the poorest primary care services … Many of inner London's difficulties are ones about which the National Health Service can do nothing. Compared with the average for England and Wales inner London has more poorer people, more elderly people, more people living alone, more foreigners and immigrants, more single-parent families, more homes lacking basic amenities, generally poorer environmental conditions, and greater population mobility. All of these factors are known to be associated with greater morbidity and mortality, and it is not surprising that, as the Royal College of General Practioners' report has shown, there are more of such problems as tuberculosis, abortion, admission for mental disorder, and suicide.
I agree that the problems are not of the Health Service's making, but it has to cope with some of the problems. Cuts in acute hospital services and local authority cuts have resulted in a diminution of social services for the elderly and have made matters worse. Increases in unemployment are related to an increase in the number of people suffering from depression.
This is not the time to go into the Black report in detail, but it demonstrated a striking
lack of improvement and in some respects deterioration, of the health experience of the unskilled and semi-skilled manual classes (class V and IV), relative to class 1 throughout the 1960s and the early 1970s … a class gradient can be observed for most causes of death being particularly steep in cases of diseases of the respiratory system.
In other words, the unskilled and manual working classes in inner London suffer particularly in health terms.
General practitioners have a key role in primary health care. Most primary health care services are inter-related, but it is worth examining the pattern of primary health care in inner London. GPs in inner London are older than they are in other parts of the country. In inner London about 18 per cent. of general practitioners are aged over 65 years compared with about 6 per cent. in England and Wales. The 1979 figures tell us that there were 52 GPs in London over the age of 70, five over 85 and one over 90. It is difficult to believe that doctors of that age are able to cope with the pressures that are inevitably imposed upon general practitioners in inner London.
The second feature of general practice in inner London is the unsatisfactory premises from which many GPs work. It is interesting that the King's fund, in combination with the medical architectural research union, has developed an experimental programme of adapting existing and unsatisfactory GP premises to show what can be done by using the buildings that are available rather than taking the view that the problem can be solved only by providing new buildings.
It has been suggested that general practitioners in London should play a much greater role in paediatric screening, which would be desirable in seeking to prevent the present mortality rates. However, it is obvious that many GPs, because of their inadequate premises and for other reasons, could not cope with that rather ambitious screening programme.
Another feature of general practitioner services in inner London is the balance between those who work in health centres, those who work in group practices and those who work entirely on their own. The statistics produced in the Acheson report show that in London a larger proportion of GPs do not work in group practices compared with elsewhere. In inner London, 59 per cent. of all GPs do not work in group practices compared with only 28 per cent. in England and Wales. In my constituency, which was covered by the Merton, Sutton and Wandsworth area health authority, which has been replaced by the new district health authorities, the figures show that about 56 per cent. of GPs are not in group practice. That AHA covered both inner London in Wandsworth and the outer London areas of Sutton and Merton.
There is a fairly large proportion of GPs in inner London who have rather small lists. The Acheson report reveals that 17 per cent. of all doctors in inner London had lists of under 1,500 compared with only 7 per cent. in England and Wales. That poses problems when an elderly doctor wants to retire and a younger GP is wanted to take over the practice. A small list cannot sustain an adequate livelihood unless the GP wants to spend a large proportion of his time in private practice, which many of us consider to be utterly undesirable.
It seems that the family practitioner committees should exercise a greater level of responsibility in these matters. There should be a greater degree of manpower planning exercised by the committees to ensure that when GPs retire and cease to practise they are replaced by those who can provide the basis for a satisfactory GP service. The committees should take upon themselves greater responsibility in considering the type of premises from which GPs operate. It would not be a bad thing if the committees were to set up minimum standards and use their influence to ensure adherence to them.
It is an interesting footnote, but I understand that recently the Department of Industry made available £2·5 million to enable GPs to develop computer systems, presumably for their medical records. Many GPs operate from premises and in conditions that are so backward that it is almost laughable to suggest that they might take advantage of the Department's gesture. They need the money spent on much more basic aspects of their operations than the more sophisticated area of computer systems.
It is extraordinary that, at a time of high unemployment, there is a serious shortage of both community nurses and health visitors. The reasons for it are interesting and worth developing. I suggest that too few people are trained in those skills. There are difficulties in operating in inner London. Motor cars are required and many nurses find that, with the wages that they receive, they cannot afford to run one. It would be worth one's while to consider whether they should be provided with motor cars for their work by the health authorities to which they are responsible. There is a disturbingly large turnover of community nurses and health visitors in inner London, presumably because they prefer to go to the less pressurised parts of Britain where working conditions are more congenial. If too few community nurses and health visitors are being trained, it may be worth while to consider financing their training nationally rather than leaving it to the hard-pressed area health authorities.
It is generally agreed that it would be desirable for community nurses and health visitors to have better links with GPs. One model that has been tried in some parts of Britain—indeed, even in some London practices—is that a group practice of GPs should have integrated with it a team of a community nurse, a health visitor and possibly one or two social workers seconded from the local authority. The difficulty with such an approach, although it has much to commend it, is that too many GPs in London operate single practices and they could not cope with such attachments. It would be easier if they were attached to a group practice. It also means that a GP must have an approach to his practice that would make it easy for him to co-operate fully with his support team. Many GPs would not take easily to operating in that way. That has implications for the way in which general practitioners are trained and their attitudes towards working in inner cities.
The report has an interesting table showing the rates of attachment of nurses as recorded by GPs in 1974. In inner London, 25 per cent. of all GPs had nurses attached to the practice, whereas in England and Wales the figure was 68 per cent. There is a clear need for inner London GPs to catch up with the practice in the rest of Britain. However, there are difficulties because of the number of single practices in inner London, the fact that many practices are small, that many GPs are elderly, and that perhaps their attitudes are such that they do not wish to move in that direction.
However, I suggest that the way in which those services—community nurses and health visitors—operate could benefit from a review. Such a review, which should go beyond the Acheson report, might come up with conclusions that would be beneficial to the way in which those primary care services are operated. It is not satisfactory now and the fact that there is a shortage of people may cause one to reflect that one should improve the service.
Inner London, with an increasing proportion of elderly people, is precisely the area where primary services have a major part to play. Improvements in those services would have a large impact on the elderly population in inner London. There are more isolated elderly people in inner London than anywhere else. Because of housing difficulties, their children must move away and the elderly, through their isolation, are much more dependent both on local authority social services and on primary care services so that they can continue to live in their own homes and be kept out of institutions.
Any of us who meet elderly people in our inner London constituencies will know how difficult it is for many of them. Time and again we are approached by elderly people or their children, who beg us to do something about their housing difficulties so that they can live closer together, and the elderly will not be so dependent on these services. All too often this is not possible because of the housing crisis in inner London and we are left with elderly people who are dependent on the services. Any improvement in these services would quickly pay dividends.
If we review these primary services, we find what has been called a planning vacuum in London. The difficulty lies in the structure of the regional health authorities. I have for long believed that there should be a regional health authority covering inner London because this would make it easier to plan services for areas similar to each other. The RMAs have cut London into four cake-like segments, where they are under the pressure of increasing population in the green belt and the outer London suburbs, and have to balance the pressure on their resources between those areas and the deprived inner London areas. This makes it difficult for the RHAs to allocate resources in the most useful manner.
Having a planning body, a RHA covering the whole of inner London could be of benefit only to the health service in London. I have been arguing this for years, but no one has responded to the need. However, I wonder whether there is not some way in which we can have, on a permanent basis, a way of planning services to help the disadvantaged inner London area. I appreciate the difficulties, as there would be an overlap of authorities, and the RHAs could conflict with the planning needs of inner London, but there must be some way in which the RHAs can get together and go in for more planning. Presumably this would involve a district level integration of some of these responsibilities so that some of the primary care services can be better planned. I do not know how far one can take this plan, but there is some possibility that improved services would result.
One of the conclusions that one comes to about this is that, although some of the proposals would cost money, many of them are relatively inexpensive. Therefore, the Government's view that no more money can be spent on the Health Service, and that there should be further cuts in London, does not provide a good enough excuse for not doing something about the proposals in the Acheson report.
I hope that the Minister will take this to heart. We need some will and determination. The people of inner London are disadvantaged and could do with better health care. The real need for development is in the primary health care services. We have the right to ask for a positive response from the Minister and positive action to improve the health care for the many people in inner London who need it greatly.