I beg to move, That the Bill be now read a Second time.
The Bill is an important part of our programme. It delivers Government commitments to review the contract basis of the delivery of primary care in Britain and to open up options for the more flexible delivery of that essential part of the national health service.
The main purposes of the Bill have been agreed not just with those involved in primary care, but on both sides of the House. I should like to remind the House of the words of the chairman of the British Medical Association on the day on which the White Paper was published:
We, the BMA, are fully behind the Department of Health in exploring the possibilities for making the delivery of general practice and related family services more readily available.
As I said at the time—on the same radio programme—it is not every day that the Secretary of State for Health appears on the "Today" programme with the chairman of the BMA and secures his endorsement for the policy to be announced that day.
What is perhaps even more remarkable is that, during the debate on the Loyal Address, the hon. Member for Islington, South and Finsbury (Mr. Smith) was almost fulsome in his welcome for the direction of the policy. He said:
There is much in the White Paper that the Opposition welcome. We welcome the idea of an enabling Bill"—
which is precisely what the Bill is.
We support the proposal to develop super-surgeries … I welcome the proposal that salaried GPs should be employed by community health trusts … There is much to welcome in the White Paper".
The hon. Member for Southwark and Bermondsey (Mr. Hughes), the Liberal Democrat health spokesman, went even further. He said:
My colleagues and I, subject to finding that the Bill does not say what we expect"—
I think he meant to say, "does say what we expect"—
will vote for the Second Reading of the Bill that has been announced.—[Official Report, 25 October 1996; Vol. 284, c. 247–69.]
I hope that the Bill does not contain provisions that the hon. Gentleman did not expect and that he will feel able to vote for its Second Reading.
The Bill is not being introduced in a confrontational way. It is being introduced in consultation with those responsible for delivering primary care. When the policy was announced—at White Paper stage and when the Bill was published—there was a remarkable degree of consensus in support of it, particularly bearing in mind the fundamental nature of some of the reforms foreshadowed and made possible by the Bill.
Some concerns have arisen since the announcement of the policy and I am happy to say that I hope to be able to deal with most of those concerns during my speech. The objectives of the Government and those involved in primary care are going down the same line, and I am anxious that they should not be derailed by misplaced concerns.
I want to begin by dealing with the background and the status of primary care within the national health service. I have made clear repeatedly the fact that I regard NHS primary care as one of the key successes of the national health service since its foundation. I believe that the success of NHS primary care in its broadest sense—the delivery of general medical services and other services through the primary care network—has probably been the key element in the success of the wider health service, in meeting health needs and delivering needs-led health care to the people of Britain.
The national health service delivers not simply good-value primary care, although it is certainly that, but care that responds to the specific demands of patients—it is close to the needs of patients and is, in the broadest and most important sense of the word, accessible health care for the patient. Primary care is based on the general practitioner, allowing the GP to act as the advocate and friend of the patient finding his way round the specialist services of the national health service. National health service primary care is an important success story.
However, even the biggest success story can be improved on. Some aspects of primary care need attention. We have an opportunity to improve further on the record of success. One example that is often quoted with some force is that, while high-quality primary care is provided in many parts of the country, too often we find that primary care in inner-city areas does not match the standards available in the rest of the country.
That is a serious issue. It is particularly serious, bearing in mind the mission of the NHS to deliver needs-led health care. Some of the greatest need for primary care is in those inner-city areas, where the service has not been as well developed as it should. The uneven distribution of the quality of primary care—in particular the failure to develop the quality of care in the inner cities as fast as in the rest of the country—is one of the concerns that the Bill addresses.
The Bill also addresses a concern at the other end of the spectrum. Some of those involved in the most innovative practices at the leading edge of high-quality NHS primary care find the national contract provided by the red book a constraint on their ideas to develop primary care. It places constraints on the development of ideas across the primary-secondary divide and of new ideas for skill mix and the use of the human resources available to the health service—through the pharmacy service, dental practitioners and other skills available to the dental service—to meet patient need more effectively. The more flexible contract structure envisaged by the Bill would help.
The Secretary of State has spoken about the successes of NHS primary care and about problems in inner-city areas. Will he consider going beyond the provisions apparently contained in the Bill to strengthen the powers of health authorities, particularly regarding dental health? Is he aware that the dental health of children in the north-west is deteriorating rapidly? Does he consider that health authorities should have stronger powers to require fluoridation in areas for which they have recommended it?
The hon. Gentleman is right to say that dealing with fluoridation would substantially widen the scope of the Bill in a way that I would not commend to the House. There will be plenty of opportunities to come back to the issue of fluoridation. I suggest that the House might usefully leave that subject for another day.
One of the explicit purposes of the Bill is to allow a more flexible contract structure for the delivery of NHS dental care, precisely to improve access for patients such as those whom the hon. Gentleman was talking about.
As my hon. Friend the Minister for Health says, it is a novel approach to bring in the Monopolies and Mergers Commission. The Bill approaches the question rightly raised by the hon. Lady by giving greater power to health authorities—in agreement with general dental practitioners in the context of pilots under the Bill—to focus available resources on specific needs, providing precisely the access that she wants. That is a key part of the reason why I am in favour of more flexible contracting power between health authorities and general dental practitioners, and also why money has been provided to the dental access fund, to promote the availability of NHS dentistry in areas where access is a problem.
It is also worth remembering that the number of courses of NHS dental care available has increased over the past 15 years by almost 8 million. The service is not in decline—quite the contrary, it is continuing to grow. Where there are problems—I do not deny their existence—with accessibility, the Bill is designed to address them.
The hon. Gentleman's proposition is illegal under the Dentists Act 1984, and there is no proposal in the Bill to make it legal.
I refer now to the White Paper that the Government introduced last year, which foreshadowed the Bill. I stress again the role that my hon. Friend the Minister for Health played in the extensive consultation exercise that led first to the White Paper and then to the Bill. When I launched the listening exercise at the beginning of last year, it is fair to say that there was a certain amount of scepticism about whether anything would be produced. It is also fair to say that the scepticism was shared by the hon. Member for Peckham (Ms Harman), the predecessor of the hon. Member for Islington, South and Finsbury, who noted her scepticism about the process. The hon. Gentleman stands acquitted of that particular charge, as he did not hold the health brief in time to be able to express scepticism. There was also a certain amount of scepticism in the field.
It is a tribute to my hon. Friend the Minister that he led a consultative process which, in 12 months, produced two White Papers, 70 developments of policy addressing some long-standing concerns in primary care, and the Bill, which introduces some important new opportunities in primary care.
I should like to make a little more progress before giving way to the hon. Gentleman.
I want to stress that it is important that the White Paper that led to the Bill, and the White Paper on primary care, "Delivering the Future", which was introduced in December, are seen together, because they reflect the output of my hon. Friend the Minister's work in the listening exercise. As I said, they bring together more than 70 changes in the primary care regime, which underlines the Government's determination to see the service continue to develop.
As a consequence of my hon. Friend's work, we introduced in December entitlement for primary care practice staff to the NHS pension scheme, the improved general practitioner retainer scheme, the extension of nurse prescribing, updated cost rent schedules, to be negotiated with the profession, a resolution of the long-standing issues surrounding the state of decay of and the perverse incentives on the use of health authority health centres, a new distribution formula—a weighted capitation-led distribution formula—for the general medical services cash-limited budget, and a total of £100 million of new money for the primary care sector, to deliver the service development to which my hon. Friend's work led.
The Bill does not simply introduce new contract models, although that is important. It is introduced as part of a broad-based strategy to improve, strengthen and reinforce NHS primary care as the essential front line of the health service: accessible, high-quality care, being delivered with the strong support of the Government; a patient-focused service, where the Government have seen important improvements over the past 18 years. The two White Papers reflect our determination that such improvements should continue through the five years of the next Conservative Government.
The Secretary of State will be aware that, from 1 April next year, Wakefield health authority, which covers my constituency, will be entirely GP fundholding. It is a pilot scheme, the only one in the country. Does the right hon. Gentleman not feel that we have an opportunity here to have a single budget for primary care and acute care in hospitals? There could be a scheme whereby there was unified provision of services right across the district, and a back-up service to primary care. Does he not feel that there would be some benefit in considering that programme as a single exercise?
The hon. Gentleman makes an interesting proposal. If that is a model that practitioners and local health authorities wish to follow up, I certainly do not want to do anything other than encourage them to do so.
In coming to the House this afternoon, I had not expected bids for pilots to be promoted on the Floor of the House before the Bill had even received its Second Reading, but I am pleased to accept any bids for pilots from hon. Members who may have ideas, such as the hon. Gentleman's interesting and innovative idea on how the powers envisaged in the Bill might usefully be used to strengthen the delivery of primary health care.
It is not another pilot proposal, but in the spirit of agreement across the House on certain aspects of the Bill, I welcome the introduction of a needs-based formula for the cash-limited part of the general medical services budget. Its introduction has, however, highlighted significant disparities in funding, with some health authority areas underfunded, relative to the national average, and others overfunded. Can the Secretary of State say how soon he thinks it will be before funding meets the targets—in other words, before each health authority is funded according to its need, rather than on the old historical basis?
As the hon. Gentleman correctly says, in the distribution that I announced in November, we introduced, for the first time, a needs-led assessment. Hitherto, the distribution pattern was shaped by demand. Introducing needs-led targets creates quite wide disparities between the top and bottom of the scale, between different health authority areas.
As to how quickly we move towards more even funding between different health authority areas, that will need to be judged year by year, in the light of the circumstances in the national health service budget as a whole and the GMS cash-limited element of it. Every time we use the weighted capitation formula system, it is important, where possible, to use it to allocate growth money without creating the feeling in one part of the service that the opportunity for growth or improvement in patient services has been exhausted or stopped for a significant time. The pace of advance is inevitably a function of the amount of money available and the other uses to which it might be put. It would be wrong to seek to reduce that to a time-limited commitment or a formula basis. It is properly a matter of judgment year by year.
Does the Secretary of State agree that, unless far better information is collected, for example on the incidence and prevalence of diabetes at local authority ward level, it will be impossible to know whether those needs are met? When St. Vincent declaration targets are set, we shall never know whether they are met unless we know what the situation is to start with.
The hon. Gentleman is quite right to say that the better management of needs-led health care will increasingly demand higher-quality information on patient experience, the incidence of disease, the prospects of recovery from disease and, indeed, outcome indicators on the effectiveness of treatments that are offered to individual patients. That is an area where the quality of information is improving year by year. I agree with the hon. Gentleman that there is a considerable way to go in improving the quality of the information that is available to the health service.
Against the background of the broad-based commitment to the development of primary care that I have described, I want to go on to talk about the philosophy of the Bill. It makes possible a more flexible approach to the contracts that underwrite the relationship between the health service and the independent contractor professionals who are responsible for delivering NHS primary care.
There are four essential principles underlying the approach set out in the Bill. The first, and perhaps the most important, is that the Bill does not provide for a single, broad-brush change in the contractual relationship between the health service and independent contractors. It provides for the Secretary of State to have power to authorise pilots of new contract models, and part I sets out the provisions that would determine the terms on which those pilots would be allowed to proceed.
Part I is concerned with the terms under which pilots of new contract models are allowed to be authorised by the Secretary of State; part II sets out the terms under which those new contract models can be converted into permanent arrangements. Clause 19(3), at the beginning of part II, makes it explicit that the Secretary of State must have cognisance of the results of pilots before authorising permanent arrangements of the kind envisaged by the Bill, be they for personal medical or dental services or for any of the contract models. Only when the pilot phase is completed do the powers under part II come into effect.
I emphasise that that is an approach to change in the contract models for those practitioners who want to take up that option, based first on pilots; only when pilots have been properly undertaken does the Secretary of State have the power to make the changes general.
I think that the pilot approach will be generally welcome. It appears that at the moment the Secretary of State envisages including general and dental practitioners but excluding nurses, for example, from being able to lead pilots.
As a simple example, there is a project for homeless people near the Imperial War museum that, it strikes me, could well be nurse-led rather than GP-led. Does the Secretary of State accept that it would be perfectly reasonable for a nurse-led or other professional-led pilot scheme to be recognised, if it proved satisfactory after appropriate testing?
The hon. Gentleman raises an important and interesting point. The Bill, as currently drafted, explicitly allows a nurse-led pilot, or indeed a partnership involving both doctors and nurses, to be a lead contractor for the health authority contract. I intend to table some amendments in Committee to deal with some of the concerns about so-called commercialisation, and I can give the hon. Gentleman an assurance, without going into detail at this stage, that those amendments will not prejudice the right of nurses or of partnerships involving nurses to be lead contractors in the delivery of both the pilots and the long-term projects.
I hope that the hon. Gentleman will forgive me if I deal with those subjects in the order in which they arise in my speech. I certainly propose to deal with both of them in the course of my remarks.
I was talking about the importance of the pilot-based approach, which is the basis on which the Bill is constructed. The second principle that I want to underline to the House, because I take it extremely seriously, is that the pilots must be properly assessed before we go on to the use of the general powers under part II.
Clause 5 provides specifically for the evaluation of pilots; it says that the Secretary of State has power to provide for evaluation and that that must be taken into account by the health authorities in the approval and promotion of their projects.
The Labour amendment talks about the absence of clear criteria for evaluation. If I may say so to the hon. Member for Islington, South and Finsbury in an open-minded spirit, I think that that arises from a misunderstanding. Inevitably, under the Bill, the criteria for success will vary according to the nature of the pilot that is being promoted. We expect that the purpose for which a pilot was designed would be set out in the paperwork supporting it. When that was set out, the criteria by which success or failure would be judged would be set out.
It would be difficult to set out criteria for evaluation in the Bill, or even in secondary legislation. The purpose of evaluation must be to find whether the pilot delivers the objects for which it was established. Those objects will obviously vary according to the nature of each pilot. The evaluation must be criteria based. That the criteria should be set out at the beginning of the life of a pilot is not controversial; it is clearly an important part of the discipline underlying the piloting approach.
I thank the Secretary of State for giving way. Is he able to tell me how long a pilot would be allowed to continue before the evaluation takes place? It seems to me that he has learned from other Departments that have conducted pilots and then acted upon them without actually getting any results from the pilots. Could he tell me how long it will be, because that obviously makes quite a difference?
The hon. Gentleman pre-empts my next point. My noble Friend the Under-Secretary of State in another place gave an undertaking there to table an amendment—and table it we shall—to provide for a maximum life of three years for a pilot, to ensure that there is proper assessment of it within that time. I do not propose to table a minimum period, but clearly there must be proper assessment against a set of criteria. The concern in the other place was that a pilot might develop a permanent life by not being assessed at the end of a reasonable period. The amendment will be tabled in Committee.
The first principle is that we have pilots. The second is that they will be properly assessed. The third is that participation in pilots must be voluntary on the part of the professionals concerned. That is why clause 3(2) requires that there should be provision for professional participants to be able to withdraw from a pilot and states:
The Secretary of State may not approve proposals for a pilot scheme unless he is satisfied that they include satisfactory provision for any participant other than the authority to withdraw from the scheme if he wishes to do so.
We cannot make the principle of voluntarism any clearer.
The fourth principle, after we have reassured practitioners that participation in pilots is voluntary, is that if practitioners decide that they are no longer committed to the pilot or if it is agreed that the pilot is not successful, the Government have undertaken that practitioners must have the assurance that they can return to practise on the existing red book or other equivalent basis. The conditions are set out in schedule 1, under which the Secretary of State has powers to provide for preferential transfer of an individual back to the local practitioners list. Schedule 1 is activated by clause 11.
The principles that I have made clear in introducing the policy are: first, that we proceed by piloting; secondly, that pilots must be properly assessed; thirdly, that participation must be voluntary; and fourthly, that participants must have an assurance of their ability to return to practise on the current basis if the pilot is not successful. The Bill provides for all four of those principles. The principles of voluntarism and the return ticket to practise on the current basis are safeguarded in the permanent schemes proposed by clause 20.
I underline that the changes to the contractual framework within which NHS primary care is provided represent fundamental but incremental change in the structure of that part of the health service. The medical magazine Pulse has said that I am an advocate of "big bang" in primary care—the implication being that, if the legislation reaches the statute book, all the ground rules and relationships in primary care will suddenly change. I underline—as I have done on many previous occasions—that that is not the Government's policy. I do not understand how one can pilot a "big bang". The principles of piloting, voluntarism, proper assessment and the return ticket for the practitioner are firmly entrenched in the Bill. They underline the Government's commitment to important—I do not seek to diminish the importance of the change—but incremental change.
The reason why the Government are committed to the process of incremental change relates to the point that I made at the beginning of my remarks. The fact is that NHS primary care is a success story. Its national contracts—in particular, the red book for general practitioners—are the foundation stone on which that success story is built. The continued delivery of services on the existing contractual basis must remain an option. That element of the foundation must be safeguarded, and we are seeking to extend the range of options. We are not seeking to diminish or undermine in any sense the continued delivery of NHS primary care on the proven basis of the red book and other national contracts, when individual practitioners wish to deliver care on that basis.
I wish to deal with some of the concerns that have been expressed about the Bill. First, clause 2(5) clearly requires health authorities to consult in accordance with directions given by the Secretary of State before submitting proposals for a pilot scheme. The clause says:
an authority must (in addition to complying with any requirements about consultation imposed by or under any other enactment) comply with any directions given to them by the Secretary of State about the extent to which, and manner in which, they are to consult on the proposals.
The point about the statement in brackets is that the health authority retains the obligation to consult on any substantial change in the structure of the service under existing NHS practice. The clause imposes an extra obligation to consult on the structure of the pilot in accordance with the requirements laid down by the Secretary of State. The Secretary of State has made it clear that there is to be a commitment on the part of health authorities—and, indeed, on the part of the Secretary of State himself—to consult before pilots are agreed under the legislation.
That is why we have set up national consultative groups, and that is part of my answer to the hon. Member for Belfast, South (Rev. Martin Smyth). We have established specific consultative groups to deal with the concerns of GPs, GDPs and other professional groups, to ensure that there is properly based and properly representative national consultation, as well as the local consultation that health authorities must conduct. The obligation to consult is in the Bill, and is reinforced by the Government's assurances and actions in setting up the consultative process.
I am sure that the Secretary of State will understand why some of us are sceptical about consultation, given our past experience. We consulted widely in Halifax about whether a local hospital should become a trust. Just about everybody said no, but because of the people the Secretary of State had placed there, the hospital became a trust against local people's wishes. Similarly, we do not want to lose 300 beds at the new hospital, and every consultation has agreed with that view. But the people placed by the Secretary of State are saying that we shall lose the beds anyway. Can he give us any guarantees about consultation?
Of course, I give the undertaking that the consultation will be serious, but consultation means what it says; it does not mean delegating the decision-making power to a group of individuals and nor can it mean that. It would a gross derogation of the position of the Secretary of State, who is responsible to this House for decisions, if decisions properly taken by the Secretary of State were delegated informally to groups over which he had no direct control. The proposition that there must be consultation before pilots come forward is provided on the face of the Bill, and, as I said, we have established a series of national consultative groups, to ensure that the specific concerns of the professions about particular types of pilot that might come forward can be articulated within those groups. There will be a proper consultative process on pilots that come forward.
Let me refer to the second concern, which is, in a sense, about a specific form of consultation—the role of the Medical Practices Committee. I understand the concerns that have been expressed about that. Both my hon. Friend the Minister for Health and I have met the chairman of the MPC and we have discussed the subject with the British Medical Association and other interested bodies.
The position of the MPC within the existing red book contract remains completely unchanged by the provisions of the Bill. Regarding the position of the MPC in respect of pilots that come forward under the Bill, we propose to move an amendment in Committee to give the MPC a statutory right to be consulted, if the effect of accepting a particular pilot would be to change the total number of GPs practising in a particular health authority area.
The key interest of the MPC is a statutory right to consultation on the balance between different parts of the country. The balance within a health authority area is something that, in the context of the pilot schemes, we would regard as the primary responsibility of the health authority, although the Secretary of State has a clear responsibility to satisfy himself on all those issues before agreeing to any pilot. That is an approach to responding to the concerns of the MPC and those who have taken up its cause which has commanded reasonably widespread support, and my hon. Friend the Minister for Health will commend an amendment to the Committee to give effect to that.
I now come to the issue of so-called commercialisation. I have always felt that the concern about that is misplaced, because I have never made any secret of the fact that the purpose of introducing the Bill is to provide for a more flexible range of contracts to be available between different elements of the national health service for the provision of primary care. The examples that I have always quoted are those of bringing the community trusts into the provision of primary care; of providing practice-based contracts so that the contract does not have to be directly between the Secretary of State and the individual practitioner, but there can be contracts that bind the practice as an entity; and of contracts that deal with the delivery of health care without needing to observe the precise distinction between general medical services and secondary care, which is inherent in the existing legislation.
The purpose of the Bill—from the days when it was in the process, led by my hon. Friend the Minister for Health, of being born—has been to create a more flexible framework within the national health service. I recognise that some real concern has been expressed, both within the House and outside, which is why I met with representatives of the BMA, to examine whether there was a real difference in terms of objectives. In those discussions, it took us almost no time at all to recognise that we were agreed on precisely the set of objectives that we are seeking to deliver.
We have, therefore, concluded that the best way to address the issue is to ensure that, on the face of the Bill, only members of the NHS family—that is: trusts, NHS dentists, GPs, nurses, which answers the point raised by the hon. Member for Southwark and Bermondsey, and the staff who work for them—should put forward proposals and hold the primary contract with a health authority, or a health board in Scotland, for the provision of personal medical or dental services where a doctor or dentist must be involved, to ensure that the appropriate medical or dental care is given.
We shall therefore move an amendment in Committee to limit the primary contracts to contracts between the health authority and members of the NHS family. It remains true, as it is true within existing law, that those primary contractors have the opportunity to bring in the private sector to provide the support mechanism for the delivery of their clinical service if they wish.
That emphasises the fact that it has always been the Government's intention to deliver improved NHS primary care. Whenever I have been asked whether there will be some supermarket-based surgery, I have emphasised that purely the opportunistic provision of health advice to people shopping in a supermarket is not what the Government are about. The Government are about list-based NHS primary health care, whereby GPs have a population basis to their practice, a commitment to health promotion, a commitment to the development of good health care, and proper prioritisation of health expenditure across the range of their patients. Those commitments will be preserved by the amendment that we intend to move in Committee.
I have been listening carefully to the Secretary of State's words and imagining what an analysis would be when they are printed. Is it not possible for a GP-based service to be extended in co-operation with commercial organisations such as supermarkets, and is it not possible that they would provide facilities, perhaps at a lower cost than would be possible otherwise, to give the greater choice that the Secretary of State is now commending? Although that would not alter the contractual relationships that he properly outlined, would it not be a new move in our national health service, which would be controversial indeed?
No, I do not agree with the hon. Gentleman about the implications. Already, very many general practitioners rely on private sector partners to support and deliver the improved surgery buildings in which many of them now practise. With several GPs I have sat through presentations of proposals by private sector partners to support their service development, and that principle is already in current practice, under the red book contract, of the delivery of NHS general medical services. It would be absurd to remove that option, which is regularly used by today's GPs to improve the service that they deliver to their patients. I hope that the hon. Gentleman would not wish to remove that from GPs in his constituency.
I thank the Secretary of State. His announcement will be welcomed. It deals with the principal concern that has been expressed about the Bill as it was drafted and presented. May I clarify what he appears to be saying—that the contracts that will be placed at the end of the pilot scheme and the pilots approved before that will in every case be between the authorities and, to use his phrase, members of the NHS family? Therefore, will the policing, regulation and so on remain the same as they have been until now, in that they will be professionally managed, and only NHS family members will be able to be the other party to the contract with the NHS?
The hon. Gentleman is right to say that only members of the NHS family will be able to represent the contract with the health authorities. When he says "professionally managed", if he means managed by health care professionals, that is not necessarily true of trusts, but otherwise it would probably be true. I hope that that development will be as widely welcomed in the House as I believe it has been in the health care professions.
The Secretary of State has clarified some matters, but he has left some questions unanswered. Some GPs have told me that they can already be put under pressure by private health insurance schemes to use preferred providers to treat their members. If outside bodies are involved in the provision of health centres, how will the Secretary of State ensure that such pressures will not have an even greater impact on GPs?
With respect, the hon. Gentleman is confusing the pressures that may exist when a patient consults a GP privately—outside the scope of the NHS—with the pressures that might be felt by a GP operating under the existing NHS red book contract or one of the new contracts. A GP operating under one of the new contracts would not experience materially different commercial pressures from the GP who currently delivers NHS care from premises that have been developed in conjunction with a private sector partner.
How has someone who is as close to the Conservative party as Archie Norman got the position wrong? He must have misunderstood the Secretary of State, because he seems to suggest that Asda, which operates extensively in my constituency, would be willing to employ GPs. The Secretary of State has made it clear that that would not be allowed. Archie Norman is so close to the Conservative party that he seeks to become a Conservative Member, so how can he have got it so wrong?
The hon. Gentleman's remarks do not suggest that Archie Norman has got anything wrong or that there has been any misunderstanding. It is interesting that Asda might like to employ GPs, but I am interested in the delivery of list-based general medical care—as I have defined it many times before—with the population bias that is in the current red book contract. The two interests are different.
The question of health authorities' power to employ GPs is also mentioned in the reasoned amendment. I am not in favour of amending the Bill to include that power. If the provision of the purchaser-provider split—I shall not use the emotionally charged phrase "internal market", but shall stick to the phrase that the hon. Member for Islington, South and Finsbury prefers, and I think that the phrases mean the same, anyway—is to mean anything, the health authority already has the power to employ GPs and GDPs. In the case of GPs, the power is provided under section 56 of the National Health Service Act 1977, so there is no need to amend the Bill.
The Bill provides us with new opportunities to address the concerns that I mentioned earlier. I spoke of the importance of ensuring a more even distribution of care and the need to address the weaker areas of NHS and general practice primary care, especially in inner-city areas. We know that it is sometimes difficult to get GPs to commit themselves to partnership arrangements in some inner-city areas. That is what lies behind the enthusiasm of some young GPs and the community trusts to establish an employer-employee relationship to improve primary care in those areas. The Bill will make that possible.
I also talked of the need for a more flexible frontier between the family health services sector and the hospital and community health services sector. The Bill will allow more flexible contracting of the type envisaged by the hon. Member for Normanton (Mr. O'Brien) and will allow the health authorities to address the resource implications of such flexibility when they draw up new contracts.
Thirdly, the Bill allows more flexible use of the human skills available to the health service in pharmacy, optometry, dentistry and medicine, and in nursing and therapy as well. It brings all of them into the more flexible delivery of a health care service designed to meet the specific needs of patients of a particular area. That is the purpose for which the Bill is designed.
I regard NHS primary care as having been a success. The Bill works with the grain of that success story. It addresses some of the weaker areas and reinforces the strengths of NHS primary care. I commend it to the House.
I beg to move, To leave out from "That" to the end of the Question, and to add instead thereof:
this House declines to give a Second Reading to the National Health Service (Primary Care) Bill [Lords] because, while making some welcome provisions for the development of National Health Service primary care, it fails to require health authorities to consult with patients and professional groups on pilot projects before submitting proposals to the Secretary of State; fails to provide for nurses and other primary care professionals to participate fully in pilot projects where appropriate; fails to establish criteria by which the success of pilot projects can be evaluated and fails to provide for health authorities to employ directly general practitioners; and because it includes provisions to allow private companies to employ general practitioners to provide patient care, thereby undermining the doctor-patient relationship and damaging one of the most abiding strengths of British general practice, which provisions will lead to even wider variation in the quality of general practice services available to different patients in different areas of the country and which will pave the way for the further privatisation of the National Health Service and the destruction of the principle of health care being available according to need and free at the point of delivery.
Out of courtesy, I give notice that if the Bill is given a Second Reading, I shall move that it be committed to a Special Standing Committee.
Before dealing with the Bill, I must deal with another matter. Just over an hour ago in the House, the Prime Minister appeared to attribute words to me as shadow Secretary of State for Health that I have never said. I believe that the person whom the Prime Minister indicated as the shadow Health Secretary was my predecessor four times ago—my right hon. Friend the Member for Livingston (Mr. Cook). I know that the Government live in the past, but that was taking matters a little far.
This is the Secretary of State's week for back-tracking. He seemed to spend most of yesterday trying rather unsuccessfully to extricate himself from the hole into which he had injudiciously plunged on the issue of Scottish devolution. Today, taking time out of his busy schedule to turn his attention to the health service, he has climbed down over a central feature of the Bill.
Do you remember, Mr. Deputy Speaker, how the Secretary of State protested when we raised the issue of commercial employment of GPs in the debate on the Queen's Speech? There was no problem at all, he claimed. The British Medical Association thought that his proposals were wonderful, he said. Even when Unichem and others started expressing a public interest in such schemes, the Government were convinced of the way forward. The Health Minister in another place stated explicitly that the Government were happy for commercial employment to take place.
There was a storm of protest. The Secretary of State put it rather delicately: "Some concerns have arisen," he said. There was protest from all the Opposition parties in the House. There was strong protest from the BMA and throughout the health service. Now, at last, the right hon. Gentleman has climbed down. We welcome that, but the mere fact that he thought that he could get away with it is worrying enough. It speaks volumes about the Government's real agenda. Heaven help us if they were elected again.
I shall return in a moment to the commercial involvement of GPs. My fear is that the Secretary of State is leaving a massive loophole in place, which destroys the fine words that we have heard from him this afternoon about the NHS family.
My hon. Friend may wish to consider this point before he returns to the matter. In reply to the intervention that he courteously allowed me, the Secretary of State did not specify a possible route for subsidy or assistance to GPs, possibly associated with pharmaceutical services, as he will be able to direct if the Bill goes through, or with health stores or other equipment connected with the promotion of health. That remains, if not a huge loophole, at least a roadway—probably to the supermarket.
My hon. Friend is right to pinpoint that problem, to which I shall return in a moment. In the meantime, I shall concentrate on the points on which we agree.
We welcome the broad shape and thrust of the Bill. I think that all hon. Members strongly endorse the concept of a primary care-led NHS. It is correct to put the primary care team—doctors, nurses, health visitors, pharmacists and others who are closest to the patient—in the driving seat when making decisions about care and treatment. The Bill proposes a number of ways in which primary care can take a bolder or a better lead.
For example, the proposed new rules for appointing general practitioners to single-handed practices make absolute sense, and we shall support them. They are long overdue. There are many single-handed practices in inner-city areas, and at present the rules state that, if such a practice falls vacant, an applicant who is potentially sufficiently qualified must be appointed to the vacancy—even if he or she may not be the right person for the job. The Bill remedies that by ensuring that appointments to single-handed practice vacancies are appropriate and adequate.
The Bill's provision on the employment of salaried GPs is also welcome. Recruiting GPs is a serious problem—particularly in some urban areas—and this proposal for their salaried employment offers a partial solution. The Bill correctly envisages the employment of GPs by community health trusts. That is fine and we agree with it, as I have said before in the House, but it also envisages acute hospital trusts employing GPs.
Are the Government convinced that that is a sensible proposal? If a GP is employed by an acute hospital trust—particularly if it is the main local provider of surgery and secondary treatment for that GP's potential patients—one must ask: what price the purchaser-provider split? The Secretary of State knows that I do not particularly like the term "purchaser-provider"—I much prefer the "commissioner-provider" division. However, it is an important distinction, and, if a GP is employed by an acute hospital trust to which he sends some or all of his patients, that distinction vanishes.
Why have the Government ruled out the possibility of health authorities employing salaried GPs? I think that the danger of blurring the commissioner-provider distinction is far less in that instance than in the case of acute trusts employing GPs, yet the Government state clearly in the Bill that health authorities will not be entitled to employ salaried GPs. We shall certainly want to return to that matter if the Bill is sent to a Special Standing Committee. The Government must sort out their reasoning on that point.
The Bill's provision for pilot schemes to develop practice-based team care and to develop new models of providing NHS dentistry is very welcome. We particularly like the Government's new-found enthusiasm for pilot projects—it is a pity that they were not so enthusiastic six years ago when they put the internal market in place. At that time, the then Secretary of State—the present Chancellor of the Exchequer—said that he would not entertain the idea of pilot projects as it was simply a way of ensuring that nothing got off the ground. As a result, he implemented the big-bang approach, which led to the internal market and to many of the subsequent problems. It would have been far better if the Government had realised then that pilot schemes, pilot projects and phased introductions were a much more efficient way of examining changes in the health service than implementing the internal market.
I have several questions about pilot schemes. First, what consultation will take place? The Secretary of State pointed out correctly that clause 2(5) says that there will be consultation, but it does not specify who should be consulted. It does not state whether patients will be consulted at any stage in the process. We believe that they should be consulted, and the British Dental Association agrees with us. It has expressed concerns about the nature and extent of consultation before a pilot scheme is established. We need much greater detail and clarification from the Government about that specific point.
Secondly, what provision will be made for nurse-led pilot schemes and schemes that are initiated not just by nurses but by others in the primary care sector? The Liberal Democrats' health spokesman, the hon. Member for Southwark and Bermondsey (Mr. Hughes), has also raised the issue. The Secretary of State has said that the Bill allows such pilot schemes to go ahead. However, that view is not shared universally outside the House, where there is serious concern about whether nurse-led pilots will be possible within the context of the Bill. We believe that that point should be clarified to ensure that such pilots can take place.
Thirdly, what independent evaluation mechanisms will be introduced for monitoring and assessing pilot schemes? Clause 5 says that the Secretary of State has the power to provide for evaluation. However, it is crucial that evaluation criteria are objective and not politically driven. It is no accident that a proper independent evaluation of what has happened with single-practice GP fundholding has not occurred at any stage in the past six years—despite the fact that it has been one of the major planks of the Government's reform of the health service in recent years. Perhaps the reason is that such evaluation must be objective and non-partisan. We shall press that issue in Committee to ensure that the Secretary of State has a duty to initiate independent and objective evaluation commensurate with his powers under the Bill.
On the subject of consultation, I want to ask the Secretary of State a specific question about the White Paper that led to the Bill. Before he issued it last autumn, at what stage did he discuss its contents with the Medical Practices Committee? The committee has a crucial role to play in ensuring proper accessibility to general practice around the country. The MPC must retain its crucial role, which will be even more crucial as the pilot schemes are established under the Bill. It would appear that, before the Government published their White Paper, they did not tell the MPC what was going to be in it. That strikes me as surprising, if not foolish.
I want to refer to two other matters that could have been dealt with in the Bill but were not. The first relates to the training of doctors, particularly the pre-registration house doctor year, part of which should be spent in general practice. The Medical Act 1983 prohibits general practice training in privately owned premises, whereas it can be provided in a health service-owned health centre. That is ridiculous. The General Medical Council has been raising this matter for 15 years. We should encourage students to learn about general practice, but the existing law discourages them from doing so. Why will not the Government take the opportunity of this Bill to put that right? We will co-operate with them in Committee if they want to introduce proposals. I very much hope that this long-standing anomaly, which inhibits the proper training of doctors in general practice, can be and will be put right. We will do everything we can to assist that, if the Government agree.
Secondly, registration protection is required for the titles of "paramedic" and "ambulance". I was astonished to learn recently that anyone can put on a jacket with "paramedic" plastered across the back, can sit in his own private car with "ambulance" plastered along the side, can turn up at the scene of an accident and can offer assistance—sometimes perverse assistance—to the people involved.
As my hon. Friend pertinently observes, it is a little like the Secretary of State speaking on Scottish devolution.
The bogus paramedic may arrive at the scene of an accident in flying tartan colours. He may have no skill and no training, and what he is up to is not monitored. He may cause mayhem. Indeed, the more I think about it, the more apposite the analogy becomes. Surely, statutory protection of such titles as "paramedic" and "ambulance" is needed, and the Bill gives us an opportunity to put that right, too.
I must return to the issue of commercialisation. The Secretary of State said that the primary contract for the employer of a GP must be within the NHS family. So far, so good: we welcome the Government's U-turn. But the Bill continues to allow, and indeed could encourage, the development of an association, including a financial relationship, between a GP and a private commercial organisation.
At present, a GP can subcontract an element of the provision of services—for example, to a deputising service for out-of-hours work. That tends to be the exception rather than the rule, and such action is heavily circumscribed. The health authority must recognise the subcontracted service, must check its quality and must limit the amount of time that it can be used. From what the Secretary of State said today, it seems that he permits and encourages the development of far stronger associations with the private sector.
I am concerned that, even with the Secretary of State's promised amendment, the Bill provides no guarantees about the limits on such commercial involvement in the provision of GP services. We need to know what restrictions, if any, the Secretary of State will impose. This practice is, potentially, wide open to abuse. He may have stopped direct employment, but he is specifically allowing commercialisation by other means.
If, for example, a GP were to develop a link with Unichem—it would be associated with him and would offer complementary services—what guarantee is there that the confidentiality of patients would not be put at risk? What guarantee is there that patients would not be subjected to overwhelming commercial pressures to buy the products of companies involved in a financial partnership? Will the Secretary of State reassure other GPs, who provide a high-quality service and have invested their lives and savings in their practices, that they will not be completely decimated by the activities of a commercial company that has teamed up with a neighbouring GP? Those important questions arise directly from the Secretary of State's comments this afternoon.
From the moment the White Paper was published, we said that the doctor-patient relationship was at risk from the original proposal in the Bill. It is less at risk now that the Secretary of State has climbed down on the issue of direct employment. But there remains the possibility of commercial involvement with GP services, and that also threatens to undermine the doctor-patient relationship. It is still at risk.
As Dr. Ian Bogle, the chair of the GP's committee of the British Medical Association, said recently:
The GP must be free to be the advocate of the patient and to exercise independent clinical judgement. Commercial organisations inevitably have other priorities such as the needs of their shareholders and the requirement for profit. There is no room for a third party in the doctor's consulting room.
That statement expresses effectively and strongly the concern that we still have about the commercialisation of the doctor-patient relationship. That is why I shall urge my right hon. and hon. Friends to vote for our reasoned amendment.
Given our concerns, I shall propose that the Bill be referred to a Special Standing Committee, for the simple reason that the Government have been all over the place with this Bill. The central feature of commercial employment has been withdrawn, but there is continuing doubt about the precise meaning of the replacement provision.
In the other place, the Government tabled 96 new amendments the evening before the debate on Report. They withdrew 89 of them on Report, but reintroduced many of them on Third Reading. Many of them were tidying amendments, which shows that the original text of the Bill was badly drafted and ill thought out. We need a Special Standing Committee to help the Government to sort out their own mind on much of the Bill. Two or three sittings in a Special Standing Committee, where we could take evidence, listen to representation and learn the views of the people involved in primary care would do a world of good and would improve the quality of the Bill.
My hon. Friend has raised an important procedural issue. Would it not be reasonable to assume that, if the Government oppose the motion of which he has given notice, they have something to hide which so far they have not made clear?
An impartial observer might, of course, place such an interpretation on any such action by the Government. It is also possible that the Prime Minister has a secret plan to call an early general election—in which case I think that we would be pleased enough by his decision to forgive the Government for opposing the motion.
Primary care is, of course, crucial. Many provisions in the Bill are welcome, but in some cases we feel that the Government have simply got it wrong. The process that has brought the Bill to the House has been cack-handed from the start, and there are ominous signs that the commercialisation of GP services will remain on the Government's agenda.
Quite simply, this Government cannot be trusted with the health service. They want to turn it from the proud service that it was founded as to the commercial business based on an internal market that it has, in fact, already become, to the detriment—above all—of the patients and others who depend on it. It is time for a Labour Government who believe in the health service to take over.
The Bill is about the provision of primary care to patients by doctors and nurses, and I want to deal briefly with each of those three groups.
First, let me say something about patients. It is clearly desirable for GP services to be convenient and easily accessible. I commend the idea of pilot schemes, and the flexibility foreshadowed in the White Paper and the Bill. The Opposition seem to be raising a hare in regard to commercialisation, but my right hon. Friend the Secretary of State dealt with it very effectively. It is unfortunate that, having said that there are many good things in the Bill, the Opposition still appear determined to oppose it—although the main ground on which they seem to be doing so no longer exists.
I see no objection to the idea of general practices' being available in the most convenient sites for patients. Why not site them at railway stations, for instance? It is interesting to note that a private practice has been successfully established at Victoria station in the past few months. I also think that there should be far more practices in shopping centres: offering such facilities at Boots, for example, would accord very sensibly with the overall concept. I can imagine eyebrows being raised at the idea of siting a general practice at the back of a supermarket, but it would surely be convenient to have one immediately next to the largest supermarket in the district. Let us try out those ideas, by means of the pilot schemes referred to by my right hon. Friend the Secretary of State.
However, I hope that we shall not lose the principle whereby patients are registered with GPs. In some countries, patients can go to any doctor they like, and, if they are not happy with the treatment that they receive from the doctor down the road, they can go to another doctor next time. Indeed, sometimes patients "shop around". Although I think that we should retain the system that allows a patient who is not happy with the doctor with whom he is registered, and who feels that the doctor-patient relationship is breaking down, to change to another doctor, I also think it important to retain the principle of registration. The practice should have all the records of the patient who is registered with it, and, if the patient transfers to another doctor, the records should be transferred as well. We should not discard that procedure lightly.
The Bill is about the provision of services by GPs. It is important for us to have enough GPs, for them to be trained to high standards and for those standards to be maintained. It is worrying to note that the number of trainees entering general practice has been falling steadily: between 1985 and 1995, there was a reduction of 20 per cent.
In fact, the fall has been even greater. A number of trainees come from overseas, and, having completed their training, return to the country from which they came.
My hon. Friend makes a valid point.
I was pleased that the hon. Member for Islington, South and Finsbury (Mr. Smith) raised a specific aspect of medical graduate training. As he explained, new medical graduates must spend 12 months as provisionally registered doctors before obtaining full registration. Their training must include a minimum of four months in medicine and four in surgery, but they are allowed to spend up to four months in general practice. Most pre-registration house officers divide their year between medicine and surgery, spending six months in each. At present, only one university—London—has approved a general practice for pre-registration house officer service, although a number of others are keen to make such experience available to their graduates.
As the hon. Gentleman said, section 12 of the Medical Act 1983 restricts the experience of general practice that may be counted towards the 12 months of general clinical training needed for full registration to that obtained in practices based in publicly owned premises. The fact is that very few general practitioners operate from publicly owned premises. The House may be surprised to learn that, of 3,800 new doctor graduates each year, only three spend part of their pre-registration time in general practice.
Obviously, during their pre-registration year, graduate doctors will be considering how their medical careers are to develop, and deciding on which branch of medicine to concentrate. It is clearly desirable for them to spend part of the time in a general practice, and to see what goes on there. I suggest to my right hon. Friend that that merits consideration. All that is needed is the repeal or the amendment of section 12 of the Medical Act to remove the legal restriction with regard to the premises in which a pre-registration year can be spent.
The House will be aware that I am a lay member of the General Medical Council. As the hon. Member for Islington, South and Finsbury said, the GMC has asked my hon. Friend the Minister for Health to consider taking the steps that I have mentioned. I know that he is not unsympathetic, but he has said that he is not minded to use the Bill as a means of making my amendment. I invite him to reconsider that and I hope that, perhaps in Committee, the opportunity will be taken to amend the Bill, which, after all, is about the provision of primary care services by general practitioners. I hope that he will take the opportunity to discuss the matter further.
There is also the issue of maintaining standards. The House will recall that it passed the Medical (Professional Performance) Act 1995, since when the GMC has been doing a lot of work on the mechanics of implementing those proposals. Tomorrow, it will hold a conference to take the matter further, with a view to implementation later in the year.
Under the performance review proposals, doctors who have not necessarily done something that merits the label of serious professional misconduct, but whose general performance standards have fallen below that which one would reasonably expect, can be assisted by the GMC to come back up to the standard that they should be at. It will be not a punitive procedure, but one to assist and to help bring doctors up to the standard that one would reasonably expect.
Of course, that will apply only to those doctors about whom complaints have been made. Perhaps in passing I could comment that all nurse have to renew their registration with the United Kingdom Central Council for Nursing, Midwifery and Health Visiting every three years and, when they do so, they have to satisfy the council that they have kept abreast of medical knowledge and development. There is nothing comparable in relation to doctors. Having completed his training and been registered as a doctor with the GMC, a doctor can remain on the register and, although he may go for years without practising, he can come back and practise without having had anything by way of refreshers.
I am not suggesting that that happens; nor am I trying to raise a scare about this. I know that much work is being done by the royal colleges with regard to accreditation. It seems that there is scope for steps to be taken to ensure not only that doctors are trained, as they are, to high standards—people would not come from all over the world to train here as doctors if we did not have such fine training facilities—but that they should maintain them and keep abreast of developments in the medical sector throughout their working life.
In 1986, a report was published by the then Mrs. Cumberlege, which recommended that the Department of Health should agree a limited list of items and simple agents that may be prescribed by nurses. In 1989, the Crown report put more detail on the proposal and made the point that enabling nurses to prescribe would benefit doctors, nurses and patients. The Government subsequently made sympathetic noises about the idea, but seemed reluctant to act, so, in 1991, when I was successful in the ballot for private Members' Bills, I introduced a Bill to enable nurses to prescribe.
After an initial lack of enthusiasm, the Department of Health embraced the proposal and assisted me in getting the legislation safely through the House, after which it was assisted in its passage through another place by the same author of the original 1986 report, who was by then Baroness Cumberlege, sitting on the Back Benches. It was just before the 1992 general election that I went to the other place and saw the Queen's Assent being given to several Bills, including my own, immediately followed by the order for the dissolution of Parliament to precipitate the general election, so I only just made it, but the Bill did get on to the statute book.
Progress since has been disappointingly slow. We have had eight pilot sites on nurse prescribing, but we still await the results of those. I am pleased, however, that, on what appears to be the eve of another general election, the Government plan to extend prescribing to a further seven trusts and their White Paper refers to full implementation by 1998. I hope that that will be adhered to.
Originally, the proposal was that only a limited range of drugs and dressings could be prescribed by nurses, and that nurse prescription should be restricted to district nurses and health visitors. I believe that the pilots have shown that the range could be extended and certainly that the ability to prescribe could be given to more nurses. Practice nurses are an obvious example. Nurses in cottage hospitals and hospices where there are no doctors in constant attendance are another group that could be considered for prescribing powers.
When I introduced my private Member's Bill, there was some suspicion about it among doctors, who saw their role in prescribing being eroded. I think that attitudes now are different. Doctors recognise the value of a role for nurses in prescribing, which of course relieves doctors of work, saves them time and enables them to apply their skills in other ways. As the Crown report says, nurse prescribing benefits doctors, nurses and patients.
The Bill recognises that changes are needed in the provision of primary care. It proposes changes with an approach that, if any criticism could be made, is cautious. I hope that the House will give it a Second Reading.
I am obliged to you, Mr. Deputy Speaker, for calling me early in the debate to enable me later to attend a dinner with Madam Speaker. I am sure that the Government Front-Bench team will understand that I do not mean any discourtesy if I am unable to be here during the winding-up speech.
It is a great pleasure to follow the hon. Member for Chislehurst (Sir R. Sims) and my hon. Friend the Member for Islington, South and Finsbury (Mr. Smith). It is nice to be in a forum where there is so much that we agree with, and, in particular, that the Minister for Health was so uncomfortable when he was being goaded almost and invited to respond to the points on section 12 of the Medical Act 1983. Being a lay member of the General Medical Council, like the hon. Member for Chislehurst, I want to develop in a little more detail both the points that he and my hon. Friend the Member for Islington, South and Finsbury have made on the matter.
It may be that, with a little persuading, the Minister will make an announcement in his reply to the debate. I am sure that, in his mind, he has almost reached the conclusion that, because of all-party support, he can very easily yield to requests for action. It is a discrete problem, and it stands as an issue on its own, quite apart from anything else that the General Medical Council is doing on its fitness to practice procedures.
As the hon. Member for Chislehurst rightly said, it is astonishing that only one university has managed to maintain a long-running scheme for pre-registration house officer posts in general practice. That one scheme is supervised by St. Mary's hospital medical school, at Lisson Grove health centre, in west London. The benefits of the scheme are well documented, and I am sure that the Minister—as he so regularly reads the British Medical Journal—will no doubt recall Joe Wilton's article of 11 February 1995, which documents that experience so well. If he cannot immediately recall the article, I am sure that he will be able to do so in the next few hours. Other arrangements to provide a spell in general practice have occasionally been made by universities—usually to deal with pre-registration house officers experiencing problems in their hospital training—with demonstrable educational benefits.
As the Minister well knows, the GMC is responsible for overseeing the pre-registration year. It wishes, as we all do, that year to be a high-quality experience for the new graduate, setting the seal on basic medical education and providing an excellent foundation for a career in medicine. The council has long encouraged the use of general practice in the pre-training year, but the legal obstacle created in the 1983 Act and in previous legislation still remains, and it is a major blockage. Last November, the GMC consulted on new recommendations for the pre-training year, and many educational institutions commented on that technical provision of the law and asked the GMC to press for its abolition.
I shall give only one example of the obstacle in operation, from the many examples that the GMC received. It is from Dr. Jamie Bahrami, who is the director of postgraduate general practice education at the university of Leeds. He responded to the chairman of the GMC education committee by stating:
I would, however, like to bring to the attention of the Committee that the restriction placed in the Medical Act on the use of Health Centre as the only suitable location for training in General Practice is outdated and requires urgent revision.
There is therefore a problem, although change has taken place and is taking place. General practitioners are increasingly practising in buildings that are not publicly owned, and the fact that those buildings are not publicly owned prevents medical schools from incorporating a four-month training period in the pre-registration year. Obviously, that situation cannot be continued indefinitely. It is an extraordinarily unsatisfactorily situation in which, out of 3,800 new doctors who graduate each year, only three have the option to do some of their pre-registration house officer training in general practice. That restriction to publicly owned premises no longer has any purpose or even any meaning.
Figures recently issued by the joint committee on postgraduate training in general practice show a fall in the number of certificates of completion of GP training from 2,562, in 1981, to 1,866 in 1995. The joint committee has also drawn to the attention of the Department of Health evidence of problems of recruitment to general practice.
Today's debate and the Bill present the Government with a crucial opportunity in their drive towards primary care led by the NHS. They provide the Minister with a wonderful opportunity to tell the House that he is now no longer prepared to tolerate that outdated, anachronistic and antediluvian obstacle. Instead of finding an excuse—I am sure that he would be able to trump one up; it would not take him long to do so, if he wanted to—he can take positive action and give a commitment that will encourage universities and their medical departments to move ahead in offering a four-month training period to trainee general practitioners in their pre-registration year, should they wish to take advantage of it.
If the Minister will do that, I am certain that it will encourage more GPs to enter that part of medical practice. Perhaps it will also begin to stem the loss of such GPs, because of the enormous pressures of general practice. If the Minister gives that commitment, I am certain that he will go down in history as the Minister who did at least a little bit of good, with all-party support, during the Bill's passage.
I will return to the matter of consultations by Conservatives a little later in my speech, for the benefit of the hon. Member for Southwark and Bermondsey (Mr. Hughes), as he recently placed a letter on that subject in my local newspaper, and his comments were entirely untrue. I will remind him about that later.
If my general practitioners are happy with the Bill, so are my constituents. Many hon. Members will recall occasions on which doctors have not been happy with changes proposed by the Government and have not hesitated to use their surgery power as a source of patient protest. I hope that such confrontation between a Conservative Government and the medical profession is in the past—except for the occasional broadside from the current British Medical Association Council chairman in office, which is probably essential to his re-election.
Such avoidance of confrontation has much to do with the Government's approach, and particularly with their ever greater preparedness to listen to the professions. Nowhere has that been better demonstrated than in the Government's approach to the future of primary care. I pay tribute to my right hon. Friend the Secretary of State, and I support the tribute that he paid today to my hon. Friend the Minister for Health for his listening exercise. I believe that he has conducted that exercise on such a wide scale that use of a Special Standing Committee, as requested by the hon. Member for Islington, South and Finsbury (Mr. Smith), is unnecessary.
I would normally have a great deal of sympathy for such a request, as I believe in the Special Standing Committee approach for very detailed and complex legislation—such as the Mental Health (Amendment) Act 1994, which used that approach and was much the better for it. On this occasion, however, because of the wide consultation exercise conducted, such an approach is not justified.
I believe that the Bill will consolidate the great success of the Government's reforms in primary care and build upon them substantially to provide the even wider range of services for patients which is its aim. It must be clear from what has been proposed in the two White Papers, much of which is provided for in the legislation, that primary care in this country will change considerably from next year: it will get even better, and will show that, through its national health service and general practitioners, this country continues to provide one of the finest health services in the world—a fact that is continually borne out by my constituents.
I accept that the dynamic changes to come follow almost constantly imposed changes over the past seven years—changes for the better—which general practitioners have not enjoyed. The new changes will succeed because they will be GP-led. The initiatives that the Bill heralds through pilot schemes will lie entirely with GPs and will not be imposed from above. I hope that such an approach will raise morale among GPs and encourage recruitment as well as leading to increasing rewards for them, as is their due.
Last month, anticipating the Second Reading of the Bill, I wrote to all the general practices in my constituency outlining what is proposed in the Bill and referring to what is in the White Paper entitled "Primary Care: Delivering the Future", which will also be implemented through the legislation. Bearing in mind that GPs are probably under even greater pressure than Members of Parliament—if that were possible—I enclosed a quick questionnaire for them to complete.
No, it did not come from central office—it was my own composition and I should be happy to send a copy to the hon. Gentleman, who might be educated by it.
I suppose that I should not have been surprised that less than half of those quick questionnaires have been returned so far, such is the work load of GPs. However, the replies that I have received have been interesting, helpful and supportive of the Bill. They all welcomed the opportunity to develop new services for patients. The only caution came from those who already felt overstretched in meeting existing demand from patients. As my right hon. Friend the Secretary of State said again today, however, the opportunities provided for by the legislation are entirely voluntary.
There was no shortage of ideas for new services that my GPs would opt to introduce. Education on drug and alcohol misuse as well as detoxification and support were mentioned frequently, followed by dietetics, chiropody and physiotherapy. Such new services will follow those which GPs have introduced in recent years such as epidurals, vasectomies, sclerotherapy, psychology, counselling, acupuncture, adolescent clinics, participation in schemes for doctors on call out of hours and nurse practitioners.
That all represents an ever wider range of services which are for the greater convenience of patients because they are available at the surgery, closer to the patient, and it is all thanks to the Government's reforms in primary care. Only one failure was reported—by a GP who had introduced a dermatology service which proved too expensive for the health authority and is now back in the hospital.
I received less enthusiastic responses to my question about whether GPs welcomed the new opportunities for budgetary control of wider services. Most of them did not welcome that, because they did not see themselves as financial managers. That is perhaps not surprising, since most of those who responded to my survey are non-fundholding GPs and as such are in a minority among the GPs in the Dorset health authority area. Obviously, I am disappointed about that, as I am sure is my hon. Friend the Minister.
However, I should point out that GPs in the Bournemouth area have not seen budget holding to be as advantageous as GPs elsewhere in the country because of the already high level of service and management provided by Dorset health authority and the equally excellent Dorset Healthcare NHS trust and the Royal Bournemouth and Christchurch hospitals NHS trust—I pay tribute to the chief executives, Ian Carruthers, Roger Browning and Stuart Marples. I regret that the Lib-Lab Bournemouth council has passed a resolution opposing the trusts and their self-managing status, and I intend to pursue that issue in the forthcoming general election.
It was not surprising to find little enthusiasm from my GPs for the opportunity to consider the establishment of new super-surgeries. The supermarket approach was regarded as totally inappropriate. The provision of a surgery service where people shop, and perhaps even a primary care centre where a range of services is available—such as a dentist, an optician and a pharmacy in a one-stop shop—is a bold idea and is more likely to appeal to the new providers such as the NHS trusts, private health care providers and other commercial companies envisaged in the White Paper, "Choice and Opportunity".
The future of the NHS is or should be about bringing the health service closer to the patient, not the other way round. As my right hon. Friend the Prime Minister told the House earlier today, it should be about better ways of delivering national health services to patients.
My questionnaire also asked about the White Paper entitled "Primary Care: Delivering the Future", which includes proposals made possible by the Bill. The GPs all welcomed access to the NHS pension scheme for practice staff from September, but they expect it to be properly funded and not an expense to be faced by the practice. A reservation was raised by a constituent of mine who is a practice nurse. She said that staff employed by trusts and health authorities will have the automatic right to opt into the NHS pension scheme, but practice staff will not. She feels that that would divide staff rather than remove barriers. Perhaps my hon. Friend the Minister will respond to that concern in his reply, as he did in the letter that I received from him last week.
There was a broad welcome for the full implementation of nurse prescribing next year, with the warning that they must also accept the medico-legal risk of any complications rather than its being borne by the GP, who currently accepts the risk.
No doubt my hon. Friend the Minister will take account of yesterday's news about fraud in the payment system of prescriptions to pharmacists. Perhaps he will use this opportunity to comment on that.
There was little welcome for the easing of restrictions on overseas doctors entering general practice here. That will not surprise my hon. Friend the Minister, because he will be aware of the latest report of the medical work force standing advisory committee of the General Medical Services Committee, which said that it was wrong that Britain should continue to be a net importer of doctors.
As my hon. Friend the Member for Chislehurst (Sir R. Sims) said, the number of doctors training for general practice has been falling steadily over the past six years. Rather than lowering the standards by attracting overseas doctors, we should do more to train our own, perhaps by establishing a new medical school. I put it to my hon. Friend the Minister that a new millennium medical school to train more British doctors might be an appropriate initiative for our medical profession to commemorate the millennium.
I have found my consultation with GPs very helpful. As I have said, the results of that consultation contradict what the hon. Member for Southwark and Bermondsey said in my local newspaper, the Bournemouth Evening Echo, when he said:
the Liberal Democrats—
pride ourselves on always doing our best to find out what is really happening on the ground, unlike the Conservatives.
Having heard what I have said, I hope that he will accept that my consultation exercise is probably far better than anything that he has ever done in my area. I have been following the excellent example of my hon. Friend the Minister, who has listened to and learnt from the professions. I am sure that that has resulted in a better Bill and a better service to patients.
The hon. Member for Bournemouth, East (Mr. Atkinson) has a bit of a cheek. I am delighted that he has followed our example and has surveyed his general practitioners. I will happily swap my survey with his, so that he can see the best practice and realise the inspiration for such exercises. General practitioners in Bournemouth and everywhere else have probably never had so many surveys. If the Tory party is now encouraging its people to send them out, it is following the good example of my colleagues and hon. Friends. As the Minister has often said, we have been carrying out surveys for months and they have been very helpful.
I am not sure that the hon. Member for Bournemouth, East understood all the questions that he asked, or the answers. I am not pretending that I do either. Some of the services about which he was reciting responses seemed slightly beyond his present understanding, but we are all here to be educated. I was caught out on a similar subject yesterday.
On Second Reading of the National Health Service Bill, soon after the war, Mr. Clement Davies, then leader of the Liberal party, said:
Surely, the one consideration should be: What is likely to give the best and fullest service to the people, wherever they may be?"—[Official Report, 1 May 1946; Vol. 422, c. 251.]
That was the right test then, and it is the right test now. It is always the right test for health service legislation. Our primary consideration should not be what is best for doctors, nurses, physiotherapists, radiographers or any other professionals, but what is best for patients. Of course, if the professionals are not on board and their proper concerns have not been addressed, there is a risk of the legislation not being good. That is the spirit in which my party approaches the Bill.
The Secretary of State said—subject to misunderstanding of the syntax—that so long as the Bill, when published, contained nothing fundamentally different from what was trailed and provided that it dealt with some of the concerns that had been and were being expressed, my hon. Friends and I would be minded to support it. I will therefore explain our position in the light of the Bill and the Secretary of State's speech.
The national health service is probably the most brilliant creation of the British welfare and social services this century. We have to go on building on this great creation. I am in favour of best practice and innovation developing in the health service. I do not want a drab, uniform national health service. To use a phrase from somewhere else, I am in favour of a health service where a thousand flowers bloom—but we are concerned that the blooms in the health service should be in a national health service garden and under the supervision of a national health service gardener. The danger, before the Secretary of State's speech, was that the Bill would breach that principle.
I acknowledge the way in which the Government have gone through the procedure. They published a White Paper and there has been consultation. The Minister should not be full of self-congratulation about the consultation—to be fair, he has not done so thus far, but others said how wonderful he was. No doubt the consultation was carried out assiduously. I have heard some say that it was a good exercise, while others have been less complimentary. I suppose that that is the lot of any Minister. It was right to carry out that consultation.
I feel that one aspect, however, is missing from the procedures of the House. When a White Paper is published, consideration of it should be charged first to the relevant Select Committee before the measures are incorporated in a Bill. My hon. Friends and I have also often proposed the publication of draft Bills, so that the drafting errors that often occur can be ironed out.
I am not against the idea of the Bill being committed to a Special Standing Committee. This is not the most obvious Bill for that procedure, because of all the work that has been done already and the general happiness of the professions with the measures. I am slightly concerned that the proposal to refer the Bill to a Special Standing Committee may be an excuse to delay it. We have to have an election by 22 May and it is likely to be by 1 May, if not earlier. This would probably not be the first Bill to be considered in the next Parliament, so I would rather we put a Bill on the statute book before then, given that it has broad support.
Unless the wind-up speech from the Labour Front Bench persuades my colleagues and me that the Special Standing Committee has a specific purpose that can add to the benefit of the Bill without delaying it, I shall not be persuaded that it would be appropriate to support the idea. I am not opposed in principle, but I believe that we may be able to achieve the necessary changes in Committee.
I pay tribute to the work done in the other place. Unusually for such a Bill, it started in the House of Lords, where it was well worked over. I pay particular tribute to my colleagues, Lady Robson of Kiddington and Lord Alderdice, who did the bulk of the work for us. They picked up particularly on two issues. One has been addressed fully, but the other has not. The first was that there should be NHS pension rights for nurses. The Government have now conceded that practice nurses, in particular, should be in the NHS pension scheme. That is a welcome advance, which could be written into the Bill. I know that there is always debate about what is written into Bills, but I ask for that to be reconsidered.
The second particular issue raised by my colleagues in the other place was the length of pilot schemes. I am grateful to the Government for having moved on that. The Secretary of State dealt with part of the problem—saying that they should not run for more than three years—but the Government have not yet conceded that they should have a minimum period. My colleagues in the House of Lords argued for an 18-month minimum. I take a more flexible approach and think that they could be shorter, but pilot schemes—I welcome the fact that the Bill is pilot scheme-led—should have a minimum period sufficient to show that the water has been tested. The Minister could usefully accept a 12-month minimum.
I welcome the Secretary of State's confirmation that any of the professions in the health service can lead the pilot projects. Nurses and other professions will welcome that. They will be glad to have heard it and had it read into the record.
Most of all, I welcome the fact that the Secretary of State appears to have listened to the British Medical Association and all the representations made in the House of Lords and in this House by all Opposition parties, as the hon. Member for Islington, South and Finsbury (Mr. Smith) said, that we should restrict the opportunity for commercialisation. That is a considerable change of Government policy, and a welcome one. I regard it as a sensible move to get maximum consensus for the Bill.
I want to raise the matters flagged up in the Labour party's reasoned amendment which have some merit, especially the one dealing with commercialisation. Had there not been an announcement by the Secretary of State, my colleagues and I would have voted for the reasoned amendment. The announcement dealt with the reasoned amendment's main core, although I shall come to some subsidiary matters in a second.
I am prepared to accept that clause 2(5) guarantees—I take what the Secretary of State said to confirm this—that there will be consultation with professional groups and patients on all pilot schemes. I should say, however—the point has been made from the Opposition Benches before—that the health service's record on consultation is not one of brilliant success. We have all been through consultation processes during which the public have expressed an overwhelming view, but the blessed people in charge have ignored it. Will the Minister confirm that, as a result of the Bill, there will be a duty in law not only to take into account consultation responses but to give them reasonable and proper weight? If not, is he prepared to table amendments to ensure that?
Putting aside for a minute the fact that, at local and regional level, we have a very undemocratic health service, about which I have strong views, we cannot ask people for their views—whether on primary health provision, hospital closures or mergers—and then say, "Thank you very much. We have consulted but we are going to ignore you." When we have sought the views of doctors and professionals, just as the hon. Member for Bournemouth, East, myself and others have, we need to take them into account.
The Bill does not address the question that has been raised on both sides of the House about how we will ensure that we have enough GPs for the next generation. I cannot express strongly enough that, unless we make general practice far more attractive, many parts of the country will be short of GPs just as they are short of NHS dentists now. It is a very serious issue indeed. Given that medicine generally for doctors will move away from being as acute based towards being more community-based and primary-care led, which I support, we must ensure that we recruit enough GPs.
I agree with advice that my hon. and learned Friend the Member for Montgomery (Mr. Carlile), the hon. Member for Islington, South and Finsbury, the other two hon. Members who serve on the General Medical Council—the hon. Members for Chislehurst (Mr. Sims) and for Gower (Mr. Wardell)—and I have received. We should amend the Bill—I hope that the Government will—to allow pre-registration training to take place in private practice premises.
There is very good practice around. My local medical and dental school, the United medical and dental school just over Lambeth bridge, has a department of general practice, and is developing ways in which to provide training for GPs in general practice. We need to go down that road. We must ensure that the Government give high priority to GP training and the effort to bring GPs into the profession. We are short of nurses and specialists in some places and short of community nurses, but we are really short of GPs. We may have to do something about ensuring that we pay them adequate student grants to ensure that they enter general practice rather than hospital medicine.
The Bill does not deal with several important funding issues. The first, about which there is huge concern, has remained the subject of no comment at all so far. My colleagues and I believe that the greatest inequity in the organisation of funding for individuals in the health service is the fact that general practice is funded differently—depending on whether one is a fundholding GP or not. Until doctors are funded on a similar per capita basis for each patient, the funding system for general practice will be unfair.
I am following closely the hon. Gentleman's argument. Can he, however, tell me how it is possible to base a population-needs funding assessment on a single GP practice? That is surely not possible. It is possible at locality level, however, where several GP practices are grouped together.
I understand the question. I think that funding on such a basis is possible. I would be happy to talk to the hon. Gentleman after the debate about that. Fair funding would mean that, no matter how one organised one's practice, one would be paid pro rata according to the number of patients one treated. Such a basis does not differ according to whether one is talking about a single-handed practice, a six-partner practice or a collection of practices. The criterion for me is the same.
Secondly, we must have a fair funding system for hospital and local community health services. We have a capitation system and weighted capitation, which adds in criteria for deprivation, morbidity, mortality, ethnicity and so on, but we do not weight everything. The reality is that the system is still unfair. The Government are moving towards a fairer system, but until we weight the funding to take account of the needs of the community, more deprived areas will be at a disadvantage. Parts of my constituency, as well as those many others such as the hon. Members for Islington, South and Finsbury, for Halifax (Mrs. Mahon) and for Dulwich (Ms Jowell) are deprived. All health service funding should be needs-based. That we have not yet established.
Thirdly, the Bill does not address the fact that, as is my party's view, GPs should be paid for their core services and additionally paid if they do other things. We need to ensure that that happens not only in theory but in practice.
Fourthly, as I said, I hope that we can write into the Bill that everybody in the NHS can be part of the NHS pension scheme, and therefore avoid the anomaly that people who worked for a GP who worked for the health service could not have pensions funded. That needs to be corrected.
The Bill does not address a set of issues about charges. It is inequitable and conducive to bad health to go on raising money from charging certain people for certain NHS services. I know that there is dispute about this. The Government have not accepted my view. I remind them that not only is my party committed to abolishing charges
for eye and dental checks: the Royal National Institute for the Blind in its briefing for today's debate makes the point clearly when it says:
An eye test is an essential part of any prevention strategy being not simply a sight test but also an eye health check".
It says that eye tests help to prevent blindness, and I entirely support its call on the Government
as a matter of urgency to extend the exemption categories for free eye tests to include those aged 60 and over".
It says that it would seek ways in which to use the Bill to achieve that.
I ask the Government in Committee or on Report to accept that there should be free eye and dental checks, as well as accepting the principle that, in future, we must review all other charging again—not just for tests but, for example, for glasses. A woman came up to me this morning in my constituency and said "Simon, I am having to pay a huge amount for glasses"—not for lenses, but for glasses—"which goes beyond what I can afford." The whole system of prescription charges and charges for services needs comprehensively reviewing. It needs to be simplified, and we need to avoid pensioners having to fill in a 17-page form for exemption from such services.
I am slightly confused about the role, as enunciated by the Secretary of State, that is envisaged in the Bill for the Medical Practices Committee. My understanding is that the MPC is meant to ensure generally that we have enough manpower. Although it will be consulted, there is a danger of the provision of services becoming divorced from adequate strategic planning.
The health service suffers badly from the lack of strategic planning. I know that the Minister will say that there are regional outposts of regional chairman—chairing nobody—but my party's view is that at almost no additional public cost we could have democratically elected regional health authorities in England and the same sort of bodies in Wales, Scotland and Northern Ireland. Such bodies could be responsible for strategic planning and take advice from and be governed by a body such as the MPC.
Regulation needs to be strengthened. I argued yesterday for an inspectorate to ensure that hospital doctors, nurses, practices and super-surgeries are doing their jobs properly. It could be the umbrella organisation under which bodies such as the Mental Health Commission operate. We also need to ensure that we regulate the professions well.
The hon. Member for Islington, South and Finsbury made a point that I was going to make about people who are currently completely outside the regulatory system. On a recent Radio 5 programme compiled by somebody I know called Ed Hall, the hon. Member for Islington, South and Finsbury and I were asked for our comments about bogus paramedics, bogus ambulance personnel, and so on. This is a scandal, and we should deal with it. There are still many unregulated people around the peripheries of the health service, and there is no excuse for that. They could risk lives and, indeed, cause lives to be lost. We should ensure that the people who carry out primary health care are authorised, professionally competent and certified as able to do the work.
Finally, if we are to ensure that doctors are true to their Hippocratic oath and to themselves, and that they are free agents for the health service, we must ensure that they are not able to be bought, as it were, by other interests. The Secretary of State was helpful in saying that in future all the people who contract, for the purpose of the pilot schemes, will have to be in the NHS family. I accept that. I strongly share the view—and I have received representations on this—that it would therefore be quite wrong for acute hospital trusts to employ GPs. These trusts should not be empire building—they have plenty to do in running their present services. I hope that the Bill will be amended to make it clear that, at most, only community trusts or those with community purposes might be able to employ GPs. I hope that we can reach agreement on that.
If we are to be absolutely sure that a coach and horses cannot be driven through the theoretical provision that contractors with the NHS will be members of the NHS family, there has to be the same openness—or better—for people in the health service that we in this place are now required to have. All contracts with GPs need to be in the public domain so that I, the hon. Member for Bournemouth, East and all our colleagues, but above all the public, know exactly with whom the GPs in each constituency have contracts and for what services.
I am absolutely in favour of having GPs in my local shopping centre at Surrey Quays. That is fine. I have no problem with that. I have no problem about having GPs in the Elephant and Castle shopping centre or at Victoria station. I am very keen that they should be where the people are. I have never been to Lakeside, that great shopping centre in Essex where everybody goes, which is the largest in the country, although my brother and his wife go there quite often. If thousands of people do all their shopping there, it should have GP surgeries. That is fine, but we have to know that they are independent, free-standing surgeries of GPs who are not dancing to the tune of a supermarket, a drugs company or a load of international arms dealers. How can we know? There has to be a register that every member of the public, every patient, every Member of the House of Commons can look at. That independence must be established at the core of the Bill.
We are moving towards a health service that will have much less conventional practice. We need to take it out into the public, just as the best public health in the early part of the century was taken out to the public in the streets, on the beaches, in the fairgrounds, and so on. At the same time, we need to ensure that people understand that the person with whom they are dealing is an NHS contractor.
Above the optician, the dentist, the doctor, the physiotherapist and the clinic should be a sign in bold letters to say that this is somebody who works for the NHS. The great guarantee in our health service has to be that the practitioner is under independent scrutiny, acting professionally for the public health service, and regulated by the public health service in the interests of the public. If we do that, primary health care has a great future, but, if we allow it to be subsumed and captured by private interest, principally for private gain and profit, the public service will be put second and the patient will certainly be put second as a result.
The hon. Member for Southwark and Bermondsey (Mr. Hughes) made a comment that I thought particularly interesting. Having talked about the history of the health service, he said that we must continue to build on that great record. It is a shame that he did not go on to say that two thirds of the history of the health service has been under Conservative Governments. It is sad that we are so often told that we have run down the health service, when the great institution that we are talking about today, which we seek to improve further for the millennium and into the next century, has been created under Conservative policies and backed by Conservative spending plans. We are, however, at one in our desire to see that its great record is built on for the future.
The main reason why we are here today is to look at how to build on the success of the health service and at how we can take it forward to meet the health needs of the country into the next century. Since the Conservative Government came to power, spending on the health service has gone up by 74 per cent.—by almost three quarters. Whereas we are now spending £724 each year on the health service for every man, woman and child, 18 years ago the sum was just £444 in real terms.
There has been an incredible increase in the money that has been put into the health service, and I think that we all agree that that is right. That is why Conservatives so much welcome the Prime Minister's pledge that throughout the term of the next Parliament, for each of those five years, a Conservative Government will increase investment in the health service in real terms. It is unfortunate that the Opposition parties, which make great play of their commitment to the health service, are not willing to repeat that commitment—
Certainly the minority Opposition party is, but it is willing to commit to spend money on absolutely everything. It is a shame that the Labour party has not been willing to repeat that commitment and show its commitment to the future funding of the health service.
Our policies have enabled us to improve the service as it is delivered in doctors' surgeries and hospitals throughout the country. There are 55,000 more nurses than there were 18 years ago, and there are 22,500 more doctors and dentists—including 3,500 more NHS dentists, which is often overlooked—than when the Government came to power in 1979. There has also been a significant onslaught to reduce the weight of administration, accepting that there has to be good administration but recognising that it should not be at the cost of patient care.
On average, there is now one senior manager to 77 other members of staff working in medical provision in the health service. That ratio is very low and it should be recognised as such. It is unfortunate that the Opposition seek to make cheap points out of that and undermine the good and important work that is done by a very able team of administrators in our health service.
It is also a fact that, over the past 10 years, some 750 schemes costing more than £1 million each have been completed. That is more than one a week, and it is testimony to our determination to continue to create an improvement in the physical presence of the health service in our communities by improving buildings and building new hospitals to meet future needs.
We have seen a dramatic drop in waiting lists. In 1987, 200,000 people were waiting more than a year for treatment on the health service. That has now dropped to just 15,000. That is a fantastic testimony to those who work in our health service. They deserve our credit and thanks for what they have done. It is also true that half of those who need hospital treatment are seen at once. Half of the remainder are seen in five weeks. Only a minute fraction wait for 12 months or more. The reality is that we are now treating some 4 million patients a year more than in 1979, and we are treating 2,250,000 more than in 1991 when the health service reforms started.
We should remind ourselves of the words of the right hon. Member for Livingston (Mr. Cook). It was he who said that the acid test of health service reforms would be whether they treated more patients. I notice that the shadow spokesman on health tried earlier to dismiss the words of the right hon. Member for Livingston, because if they were made by his predecessor by four they were of no relevance. We should go back to those words. If the acid test is whether the reforms will treat more people, we are now treating 2,250,000 more patients than when the reforms were started.
The reality is that under the last Labour Government we had no idea whatever of the level of activity, because the figures were not collated. We did not know how much operations or drugs cost, because Labour did not believe in measuring such costs. It is only because of the measures put in place by the Government that we can make such comparisons and realise that we are making improvements in the number of patients being treated.
I accept what the hon. Member for Dulwich (Ms Jowell) is trying to get at, but the reality is that we are treating more patients, treating them faster, and bringing down waiting lists; and we have almost completely done away with waiting lists of 12 months or more.
The issue of fundholding is at the core of the debate. By April this year, 60 per cent. of the country will be covered by fundholders. That is disappointing in a way; it represents significant strides, but in my constituency more than 90 per cent. of patients are covered by fundholders. Because that percentage is so high, the benefits that fundholders have achieved for their patients have been enjoyed by all members of the community, regardless of whether they are personally covered by a fundholder.
I want to take the House on a tour of some of the new facilities in my constituency, to bring home how the changes have benefited us. In Glossop, in the very north of my constituency, the Manor House surgery run by Dr. Oldham and his colleagues has been transformed. It has developed into one of the most outstanding doctors' practices anywhere, and was recently voted the fundholding practice of the year.
All the doctors' practices in High Peak are breaking new ground and providing better services. In New Mills, a town of almost 10,000 people, Dr. Williams and his colleagues have developed a stunning new surgery, one of the most modern and elegant that I have seen. Patients feel that they are being treated like human beings, with respect and dignity; they feel that they are getting the best possible treatment, because they are not in shabby and rundown surroundings.
The same doctors' practice has opened a new surgery in Hayfield, which did not previously have a surgery, providing better facilities for people in small villages. In Chapel-en-le-Frith two new surgeries have been constructed: one by Dr. Bartholomew and his colleagues, and one by Dr. Oliver and hers. Dr. Bartholomew has also built a new surgery in Whaley Bridge. Those doctors are extending and improving the facilities that they offer and delivering better health care.
In Hope, Dr. Moseley and his colleagues have built a new practice; and there are new premises in Buxton. As my hon. Friend the Member for West Derbyshire (Mr. McLoughlin) is on the Front Bench today, I should mention the facility at Eyam, which is in his constituency but serves some of my constituents. Right across the area there has been new investment in better surgeries, run by a team of young, dynamic, go-ahead general practitioners who are determined to make fundholding work and who want to build on the success of our health service with the best-equipped surgeries that the country has ever known.
Last September, I brought the Prime Minister to my constituency and took him to one of those doctors' surgeries. The day did not start off terribly well: I asked some of the people standing outside the surgery, who had clearly seen that something was going on, why they had turned up. They said that they had been looking out of their window and, seeing all the police cars converging on the surgery, had come down because they thought that a drugs raid must be—
I accept your guidance, Mr. Deputy Speaker.
The Bill, which is so important, seeks to build on what has been achieved. We have a tremendous amount to be proud of. Like other hon. Members, I have consulted general practitioners in my area about the way in which they want matters to proceed. They recognise the progress that has been made and that it would not have been possible without the changes introduced by the Government; but they also recognise the need to take matters further in the future.
Practitioners talk about how they have developed new services, such as a drugs cabinet in the hospital at Tameside; the unused drugs of patients being discharged are placed in the cabinet to be re-used, rather than being wasted as they were before.
There is a tremendous list of new facilities; my hon. Friend the Member for Bournemouth, East (Mr. Atkinson) referred to some in his constituency, and it is the same in mine: today, we have audiology in Glossop; direct listing of gynaecology services; new dermatology teach-ins; an additional district nurse; physiotherapy and occupational health services; direct links with the pathology laboratory; complementary therapy, such as Alexander treatment and acupuncture; new chiropody services; and something called sigmoidoscopy, about which you, Mr. Deputy Speaker, probably know more than I do—it does not sound awfully nice.
Through fundholding, general practitioners have been able to bring down the waiting lists for everybody in the community—not only for fundholders' patients, but for all who use the services. Previously, the wait for dermatology was two years; now it is only four weeks. For gynaecology it was up to 20 weeks; now it is only four. For ear, nose and throat treatment, it has been reduced again, from 20 weeks to four. The average waiting time for in-patient treatment has been brought down from 18 months to 3.7 months.
That does not apply only in the large practices; progress has been made in small practices, too. Dr. Cox, who runs a surgery in Tideswell, says:
In our case we now have numerous outreach clinics involving consultants from Sheffield and Chesterfield. Thus our patients are saved long journeys and waiting lists are greatly reduced.
In addition, we have introduced physiotherapy, dietetics and recently Citizens advice into our surgery. We may have introduced these services in time but there is no doubt that the internal market has empowered fundholders and providers now listen with an open ear.
I hope that the Bill will build upon such changes. We must address the concerns that exist and recognise that some improvements need to be made. I have concerns about the way in which doctors' practices sometimes work in relation to the district health authority, when it appears that their budgets are easy pickings. I am concerned that North Derbyshire health authority, having top-sliced 5 per cent. off its budgets last year, is planning to do the same again this year.
For a relatively small surgery, that could mean a reduction of £40,000 in one year. I hope that the Minister will bear such practices in mind and reassure the House that he will try to ensure that they have security in their budgeting plans for the future.
We need to reconsider the efficiency index, whereby GPs are expected to improve their levels of activity by 2.75 per cent. each year. They are well able to meet that: one GP's practice in my constituency was able to increase its efficiency by more than 34 per cent. in one year alone. I hope that my hon. Friend the Minister will examine the ratio set by the Department of Health, whereby one episode in secondary care equates to 54 in primary care. I think that he would accept that that represents a big disincentive to health authorities to reconfigure their services, and that it should be reassessed.
I am concerned also about the point raised by my hon. Friend the Member for Chislehurst (Sir R. Sims), who spoke about the recruitment of new GPs. There appears to be evidence that we are finding it difficult in many parts of the country, and especially in inner cities, to recruit new people to general practice.
I hope that my hon. Friend the Minister will consider how the problem can be tackled head on. I thank him for his help, on a visit to my constituency a year or 18 months or so ago, in the matter of out-of-hours support. He directly addressed the concerns of GPs and enabled a formula to be found whereby their needs, in a generally rural area, could be met. It is clear, however, from other GPs' practices, that they have not all been able to find solutions, and I hope that we will continue to examine the matter to ensure that we can deal with it effectively and for all.
The key point regarding all such concerns is that the Government are addressing them; they know that they exist and they are seeking to build on what has been done, to make the health service better for the future.
The core of the Bill—this is why I support it so strongly—is that it reflects patients' wishes and recognises that GPs know what is best for their patients. They know that patients would like to be treated closer to home if that is possible. They know that patients would be happy for their GPs to carry out minor surgery, if that is possible. The principle is that, where appropriate, care should be carried out at primary, not secondary, level. That is important in a constituency such as mine. Many of my constituents are referred to general hospitals some miles away in the big cities. They may have to go to Tameside, Stockport, Manchester, Macclesfield, Sheffield or Chesterfield because they come from a spread-out rural area. The more that we can enable things to be done in people's localities, the better it is for us all.
We should give GPs the opportunity to advance the pilot projects that they believe are possible because they know better than we ever could—and better than health authorities or any elected body, whatever the Liberal Democrats may suppose—what is possible. They have the vision to make it happen. It is vital that we impose as few restrictions as possible on what can be done. We need to encourage GPs to think widely. That is why I read the Opposition's reasoned amendment with sadness. It states that the Bill
fails to require health authorities to consult with patients and professional groups on pilot projects before submitting proposals to the Secretary of State".
I do not believe that that should be a requirement, because it is GPs who are most trusted.
If people were told by their GPs that they were going develop our health service in a certain way, people would trust them; there is no one people trust more. As my hon. Friend the Member for Bournemouth, East said, if GPs are happy, so are my constituents. That is because the trust is so great. To build in an unnecessary level of consultation with people who do not know as much about the issues, who might be worried about change and will not be readily reassured by GPs would be a mistake. GPs should have the ability to work up their pilot schemes and have them taken to the Secretary of State.
The hon. Gentleman referred to the reasoned amendment. The Minister will no doubt deal with this later, but unless I misunderstand, under clause 2(5), there must be consultation about pilot schemes before they are submitted. I think that that is important. The hon. Gentleman will have to persuade his colleagues as well as the Opposition if he wants to remove consultation. I urge him to think again. Involving patients and the public in decisions is a hugely important way of developing primary care.
One can push consultation too far and stifle enthusiasm so that GPs do not go ahead with some of their more exciting and dramatic ideas because they lack general support. It would be a tragedy if such enthusiasm were stifled because of the consultation process.
It is also unfortunate that the reasoned amendment states that the Bill
fails to establish criteria by which the success of pilot projects can be evaluated".
I do not understand how that can be done in advance. If we say that GPs should be encouraged to produce ideas for pilots and think widely, we cannot now establish the criteria for all circumstances because we do not know what the pilots will be. It is in the light of the proposals that are made that we will best be able to judge how the pilots should be evaluated.
Four key principles that underlie the Bill should be put on record. Patients must continue to have the right to be registered with a GP. A disadvantage of some overseas systems is the lack of registration with a particular GP. Such systems involve additional bureaucracy and mean that records cannot be so readily brought to hand.
Concern has been expressed about the involvement of GPs within shopping centres. I do not believe that people trundling a shopping trolley round Tesco would want to visit a GP by going through a little door between the frozen peas and the band-aids. If I were shopping in Tesco and there was something wrong with me, the last thing that I would want is for my constituents to see me popping in to see the GP there. Many people would feel like that. That is why some of the more extravagant schemes dreamed up by the Opposition would not be put forward. GPs may wish to open centres where people are at work, in stations and in shopping centres but they would be wary of being brought under the direct control of a supermarket or similar organisation.
I want to reinforce an important point which was implicit in what the hon. Gentleman said. There are many services that it is hugely important to keep confidential, such as family planning and sex advice to young people. In such cases, people would not want to be seen popping in to see GPs in a supermarket. A range of things will be needed. For well women or well men services, or blood pressure checks, the nearer the service is to where hundreds of people shop, the better. No one would be embarrassed by such check-ups.
The hon. Gentleman makes a valid point. We must remember that the people who will be pushing the schemes and developing the ideas are those who are most sensitive to patients' needs: the GPs. The more extravagant schemes would not be put forward.
I said that there were four principles. The second is that legislation should ensure that there are national safeguards for both practitioners and patients. Thirdly, there must be public accountability for the use of funds. Fourthly—this is vital—if pilots are unsuccessful, it must be possible to revert to the previous arrangement. If a pilot scheme did not work and GPs could not go back to their earlier arrangements, many GPs would be reluctant to try the scheme.
I hope that the Minister will be able to reassure us, here or in Committee, that pilot schemes can be worked up free from the stifling intervention of health authorities that do not like the proposals. Clause 2(2) states:
Subject to any directions given to them by the Secretary of State, an authority must—
Clause 2(3) states:
if asked to do so by a qualified person who wishes to provide piloted services.
A request to an authority under subsection (2) must—
I hear a little alarm bell in respect of what may be prescribed under the final section about what requirements may be set down.
I am concerned that it should not be possible for a health authority to stifle go-ahead, dynamic GPs who have ideas that are not entirely in keeping with those of the health authority. Even if health authorities do not believe that such ideas are the best way forward, I hope that the Secretary of State will continue to bear in mind the fact that there should be a wide cross-section of projects so that the best proposals can be developed.
Inevitably, there are good and bad general practitioners and practices. That is recognised by the provision in the Bill that a GP does not automatically have to be appointed if he is deemed to be unsuitable. If a health authority is not to sort out the good pilot projects put up by GPs from the bad, who will?
There are different grounds whereby a health authority may raise concerns. If an authority says that a GP is an alcoholic or has something fundamentally wrong with him, that would be relevant and should be taken into account. But the fact that a pilot scheme proposes something that is not immediately in tune with what the health authority thinks is the way forward should not rule it out. If the health authority is to be directly involved, there needs to be a right of appeal directly to the Secretary of State, so that good, exciting and innovative projects are not knocked on the head early in the consultation process.
I hope that the Bill receives cross-party support. It is encouraging that Labour is, lately, agreeing that fundholding has been beneficial, but its proposals for locality-based commissioning are not what fundholding or non-fundholding doctors want. In my constituency, GP fundholders can cover between 3,000 and 10,000 people. To suggest that GPs should cover areas of between 50,000 to 150,000 people is to be out of touch.
It is strange to hear Labour talking as if pilots were its idea and that there should have been pilots when fundholding was introduced. I was working at the Department of Health as a special adviser at that time, and we knew why Labour wanted pilot schemes—it wanted to kill off the idea of fundholding at birth. Labour did not want the system to have time to grow, and it wanted to make sure that the system moved at a snail's pace so it would not be a success.
This important Bill shows the way forward, and will lead to a better NHS that will serve patients better. The Bill will prepare the health service for the challenges of the next century. Above all, it shows that the Government are listening to GPs, because they know what is best for their communities and for their patients, and they will work to find an exciting future. I commend the Bill to the House.
I should like to start by responding to one of the arguments made by the hon. Member for High Peak (Mr. Hendry). He sought to convince the House that the Opposition parties argued for pilot studies rather than for a leap in the dark at the time of the "Working for Patients" reforms, because we wanted to frustrate their implementation. He said that that was perfectly clear to him when he worked at the Department of Health. I suggest that that shows how out of touch those involved in developing the project in government were with the mood within the health service.
At the time, I was working in a university as a health economist on contract to health authorities, and people in the health service and academic commentators said time and again that it was necessary to set clear standards, to evaluate whether the health reforms were both effective in terms of improving patient care and cost-effective. Those in government who were driving the "Working for Patients" project stood in the way of evaluation because they felt that it might reveal that the proposed reforms were not in the best interests of patients. The same lobby of NHS staff and commentators had argued for years that there should be a thorough and independent analysis of the benefits, as well as the disadvantages, of GP fundholding. The Government resisted that.
Finally, the Audit Commission carried out such an assessment in a report—I understand that the Department of Health used every trick in the book to try to persuade it not to undertake it. Yet last year the report was published, and what did it find? It found that some benefits had come from fundholding, and some costs. It quantified the benefits and costs, and found that benefits for patients worth £202 million had been achieved at a cost to the NHS of £236 million. In other words, the benefits were less than the costs.
That is a good point. The report looked at the cumulative costs and benefits of the fundholding scheme. One could certainly re-examine the system were it to continue for another five years, but that is unlikely—even if there is no change in Government. The Bill demonstrates to the House and to the country that fundholding has not been the panacea that it was originally supposed to be, and that it is not enough to ensure that high-quality primary health care is provided for everybody. But if fundholding were to continue, we could review it.
It is important to draw on the independent analysis, to pick out the benefits that have come from fundholding and to retain them, while chucking into the dustbin of NHS history the disadvantages—the inequity, the creation of a two-tier system and the high administrative costs of running purchasing on a practice-by-practice basis.
Primary care is the jewel in the crown of the NHS. It is what enables us to achieve a relatively high health status for the population at a lower cost than any other advanced industrial country. That was brought home to me vividly after the previous election, when I visited Washington DC. I visited a number of private and public—in US terms, state-funded—hospitals, one of which was the notorious DC general hospital, a public hospital dealing with patients who did not have the money or the insurance cover to go for private care. In some ways, I was surprised by what I saw, because it looked very much like a workaday NHS district general hospital. The level and quality of care seemed similar. It was not as plush as the private hospitals, but it provided a high quality of clinical care.
The difference between the United States system and the United Kingdom system was brought home to me starkly when I was shown the maternity ward. I was staggered that the majority of patients in the ward—who had given birth a day or two before—had received no antenatal care whatever. They had simply gone into labour and gone to the public hospital. Inevitably, that results in the United States having higher perinatal and infant mortality rates, despite spending more than twice as much of its national wealth on health care as we do. We have achieved more with the primary-care-supported NHS than the US has been able to achieve.
It was equally shocking and surprising that the only patients discharged from that maternity ward with any post-natal health care provided by the public system were mothers who were deemed to be "at risk". "At risk mothers" in Washington DC fell largely into two categories—homeless parents and drug addict parents. Almost by definition, those two groups, although entitled to post-natal health services, would not get them because nobody could trace where they had gone following their discharge.
When the Secretary of State and my hon. Friend the Member for Islington, South and Finsbury (Mr. Smith) opened the debate, it was clear that—although there are some sharp differences between the two main parties—there is substantial agreement on much in the Bill. My hon. Friends and I support the measures that seek to improve the distribution and quality of primary health care services.
I ask the House to consider this: we all talk and have done for a number of years about the importance of a primary-care-led national health service, but we need to be clear what we mean by that. We need to be clear about who does the leading—is it GPs or is it nurses? Who, in primary care, are the leaders? By what means do they lead? Do they lead solely by placing contracts and by controlling the money for primary and secondary care, or by using the research base of effective innovation and clinical practice? Above all, where are they leading the NHS?
The Government have a national health strategy—"The Health of the Nation" strategy—which specifies goals towards which they want the NHS and public policy in general to lead the nation. In this debate and in subsequent debates in Committee, we need to establish whether the Bill will give the Secretary of State—whoever occupies that position in future—the power to ensure that the leaders of the NHS in primary care are leading towards goals that he or she, as Secretary of State, and the House, as guardian of public resources, want achieved. There must be a line of accountability for primary care.
It has been said for many years that there is a striking inequality in the distribution of resources for primary care. Some months ago, I asked the Library to check in respect of each health authority how many GPs were provided in relation to the population served. The figures range from one GP for every 1,661 patients in the Cornwall and Isles of Scilly health authority area and one for every 1,702 patients in the Isle of Wight to, at the other extreme, one GP for 2,218 in Wigan and one for 2,253 in Rotherham. In other words, Cornwall and the Isle of Wight get substantially more GPs per patient than Wigan or Rotherham, so GPs in Cornwall have substantially more time per patient and more time per consultation.
I can see the hon. Gentleman shaking his head—he or any other hon. Member is welcome to intervene, but those are the figures prepared by the Library, whose staff will dig out the same information for him if he wants it. [Interruption.] I cannot hear what he is saying, but he should either get up and contribute to the debate or keep quiet.
In my intervention on the Secretary of State's speech, I made it clear that I welcome the fact that the cash limits exposition booklet, which sets out for next year the basis on which the Government intend to fund the NHS for both secondary and primary care, will start to redistribute resources for primary care more equitably around the country. The effect, over time, may be that the Cornwall and Isles of Scilly health authority, as a result of Government policy, gets relatively fewer GPs per head of population and that Wigan and Rotherham get relatively more. I was, however, pleased to hear the Secretary of State's commitment that there would be no cut in absolute terms to GP provision in any part of the country and that growth money should be used to iron out the inequalities.
In October 1995, the Centre for Health Economics at the university of York produced a report on the issue of equity in primary care. It concluded that the allocation of funding and the distribution of the work force in primary care is extremely unequal in England and suggested that the Government should introduce an allocation based on the population served and its health needs. The centre estimated at that time—some two years ago—that, if resources were allocated according to population and need, the North West region would receive 447 additional GPs and the Northern and Yorkshire region would receive 311, while the South and West region had, according to the centre's calculations, 356 more GPs than its fair allocation.
In May 1996, a private sector company, North-West Surveys and Research, produced a similar piece of work, which estimated that an equitable distribution of resources for primary care would shift 700 GPs from the area south of a line drawn between the Wash and the Severn to the area north of that line. However, I stress that it is a question not only of shifting resources from north to south, but of shifting resources within health authorities and regions in the south and north, so that the provision of primary health care in every locality and community meets the needs of the population.
The introduction of a needs-based allocation for primary care is, as I said, a welcome development. The principle is right, although I believe that the methodology that the Government have adopted is wrong. The initial targets set for allocations in years to come in the cash limits exposition booklet produced for next year's allocations show that the historical allocation, which was based on demand for and utilisation of services in the past, reveals a sharp mismatch with need. For example, the two health regions with the poorest financial allocation in years past—indeed, next year as well, because they still lag behind and will not catch up in one year—are the two health regions with the highest score for "underprivileged area status" in the public health common data set; and the two best funded regions are the two with the lowest score for underprivilege.
The figures also show that the two regions that are the most poorly funded for primary care have stillbirth rates that are higher than the national average; and the two regions that are best funded per head of population for primary care have a lower stillbirth rate than the national average. It is a case of those who have will receive more and those who have not will receive less.
That has been the historical situation, but the Government have addressed the problem and have taken a small, but welcome, step in next year's allocation, to move towards an equitable distribution of resources. As I said, the principle is right, but the methodology is wrong—perhaps not entirely wrong, but wrong in significant respects. For example, the actual cash allocation next year for non-cash-limited general medical services per patient—or, to be strictly accurate, per resident—in the Kensington, Chelsea and Westminster health authority area is £21.49, which is the highest cash amount for any health authority; whereas the lowest cash amount for any health authority is in South Staffordshire, where residents receive £13.69 per head.
One would think therefore that, when a needs-based allocation was introduced, Kensington, Chelsea and Westminster health authority, over time, would receive less per patient for primary care and that South Staffordshire health authority would get more. That assumption, however, could not be more wrong. Under the Government's needs-based allocation formula, Kensington, Chelsea and Westminster, despite the fact that it already gets more per resident than any other health authority in the country, is deemed to be the most underfunded health authority in the country. When it finally reaches its target, it will receive, at current prices, £5.36 per patient on top of the £21 or so that it already receives-20 per cent. more in real terms—whereas South Staffordshire health authority, currently receiving the lowest funding per resident of any health authority, will receive only 92p per patient more.
The principal reason for that anomaly—and it is an anomaly, which needs to be corrected—is the way in which the Government have applied what they call their market forces factor. The principle of reflecting wage costs in inner London and the south-east and the cost of premises in inner London and the south-east in the funding formula is right, but I do not accept that the gearing—the amount of extra weighting—that Kensington, Chelsea and Westminster gets, which is 36 per cent. extra money under the market forces factor part of the formula, is appropriate to its needs. Its funding for primary care, already the highest of any health authority, will increase by a larger percentage than will the funding of any other health authority. The needs-based capitation formula for cash-limited general medical services should be revised to reflect need more sharply.
I want to discuss not only the quantity of resources available for primary care, but the quality of primary care. The hon. Member for High Peak spoke about the importance of the NHS efficiency index, but the efficiency index measures the quantity of care provided, whereas we need instead a quality index—perhaps we should call it an effectiveness index. Little or nothing in the Bill will address the issue of clinical outcomes: the extent to which primary care treatments work—the extent to which they make patients better, or better able to live with a disease or the disability that they have.
It is essential for us to develop measures to address issues that are being debated in the health service, such as skill mix—arguments about which clinical activities should appropriately be done by GPs and which by practice nurses. Should nurses prescribe? Should they do an initial screening and consult patients before patients see a doctor in general practice?
There are arguments for and against, but we should take decisions on the basis of the clinical effectiveness of a nurse intervention or a GP intervention in similar situations. One will find that in some cases a nurse can provide as good a clinical outcome as a GP and, if that is the case, one should redraw the boundary and allow a nurse to undertake that primary care activity. However, we need evidence of the effect on the patient—of the clinical outcome.
Most of the work on outcomes has been done in secondary care. In some ways, it is easier to do it there because, as doctors and other clinical workers in secondary care are direct employees of the NHS, one can to a limited extent require them to do clinical audit. That is much harder in primary care, where primary care practitioners are currently independent contractors, and it may become harder still if the job of providing primary care services and GP services as envisaged in the Bill is contracted out to private, commercial operations.
Nine out of 10 consultations between doctor and patient take place within primary care, so we need a great deal more work on the effectiveness of those consultations, and we need to establish lines of accountability that will allow the NHS, which is buying the care, to ensure that high-quality care is provided by primary care clinicians.
I am interested to hear what the hon. Gentleman says. People in secondary care have not been compelled to audit their care outcomes—far from it. The royal colleges have of their own volition gone into the field very heavily. The hon. Gentleman probably knows that my father is involved in the biggest project: the confidential inquiry into perioperative death. That was a voluntary activity; it has been enormously successful.
The hon. Gentleman is now talking about how one measures outcomes in primary care. That will be much easier to do in future because, first, many more fundholding general practices are introducing information collection technology in the form of new computers, and secondly, the Government are funding several projects throughout the country, such as the one on Teesside, which are specifically aimed at measuring outcomes in primary care. I think that the hon. Gentleman will find—
Order. The hon. Gentleman should have finished a while ago. He is fully aware, with his experience in the House, that interventions should be brief and to the point.
Although it is true that clinical audit has been driven by the royal colleges, the thing that made it take off was the fact that the NHS agreed to provide a certain proportion of paid clinical time—I believe a session a month—to enable it to happen. It was possible for the NHS to do that in relation to secondary care. It is much harder to do it in relation to primary care.
Admittedly, as information technology becomes increasingly available in primary care, the capture of the data needed for a clinical audit will be easier, but I do not agree with the hon. Member for Stockton, South (Mr. Devlin) that that has come about as a result of GP fundholding. It has come about as a result of Government investment in information technology in primary care. We need to ensure that that provision is made equally and fairly in all general practices, irrespective of status.
I have received complaints from non-fundholding practices in my constituency not only that they are unable to obtain as much grant as is given to fundholders, but that they are unable to obtain support for the information technology that they need to improve and develop their clinical practice. That is wrong. The technology is needed in all practices.
Technology used in different practices should be compatible, because data collected using incompatible systems are impossible to audit across the locality. To me at least, that emphasises the need to ensure that the NHS, albeit without heavy central direction, is driving forward the audit process in primary care. If it does not, dozens of different computer systems will be used among the various practices, and it will be impossible to assess the effect of clinical interventions across localities and from one health authority or region to another. We need to be able to do so if we are to drive up standards of clinical care.
The amount of good, solid information about effective clinical practice in primary care is pretty small compared with secondary care. Through their NHS research and development programme, the Government are supporting the centre for reviews and dissemination at the university of York. It has produced a number of clinical practice guidelines, only three of which relate to practice in primary care—the guidelines on cholesterol screening and on the prescription of anti-depressants, and the controversial guidelines on prostate cancer screening, which were published last week. Most of the guidance on good clinical practice relates to secondary care, and we need to develop a greater emphasis on evidence-based medicine in primary care.
The Select Committee on Health, in its report on purchasing, recommended that GP fundholders should be required to submit a clinical practice plan to their health authority each year before receiving their budget. I am sad to say that that recommendation was rejected out of hand by the Government. The Labour party addressed the Select Committee's proposal in its policy on commissioning.
I presume that the Bill, if enacted, will require quality thresholds and outcomes to be built into contracts for bought-in primary care services, otherwise the purchaser would be buying a pig in a poke. When a health authority is purchasing care from a secondary care provider, it establishes standards and quality thresholds in the contract. If that is to apply to contracted-in primary care services, the Government will have to develop mechanisms to ensure quality control. Such mechanisms should be applied throughout primary care, whether provided by traditional, non-fundholding practices, fundholding practices or the new contracted-in practices.
I hope that the Minister will address that issue in winding up or later in Committee, and I hope that the Government will be able to give us some answers.
I especially like the Bill's flexibility and its imaginative approach to pilot schemes, which those at the sharp end of health care may wish to adopt. I am, as the House is possibly tired of hearing, fortunate in my constituency in having forward-looking GPs. In fact, I cannot think offhand of any aspect of health care in which Lancaster does not excel. I may be biased, but our new premises mean that it is getting better all the time. Many of my local GPs, who were among the first fundholders, have extended the services they offer their patients almost beyond belief. I am sure that they will be happy to introduce pilot schemes to extend their services still further, because that is especially important in a country area.
Not all new ideas, which seem fine on paper or in the first flush of enthusiasm, will work in practice. One of the strengths of the Bill is that if a pilot scheme is not as good as first hoped, it can be terminated and the practice involved can return to the status quo without penalty or humiliation. That means that practices will be more willing to start pilot schemes than if they thought they could not get out of them.
The elderly often look back longingly at the old cottage hospitals. Time lends enchantment, but they were delightful places. I vividly remember that we used to hold sewing bees for the hospitals and mend all the sheets. We put our hearts and souls into those hospitals, but nobody could pretend that they were high-tech. They were supported by the whole community, but they could not supply the sophisticated care that is now required.
The rapidly expanding health centres that are springing up all around the country are able to provide a range of services. They are, in effect, modern versions of the cottage hospital. The pilot schemes will enable health centres to extend the range of services that they provide, which is very important in an isolated rural area. The speed of the changes in the primary care sector is astonishing. Only a few years ago, it was unheard of for consultants to stray from their hospitals and leave the barrier of their entourages and consulting rooms. Now, many consultants attend doctors' surgeries, to the great benefit of patients. Again, that innovation is especially important in scattered areas where not everybody has a car. It is marvellous that people can go to their local health centres and be seen by a consultant; it also cuts waiting times.
Another strength of the Bill is that the pilot schemes will not be able to drag on. They will be carefully assessed within a time limit of three years. Nothing is worse than a pilot scheme that drags on and on, with nobody knowing whether it is a success or when it will end.
Not every area is as fortunate as mine. Inner cities still face severe problems. Sometimes I have to remind my constituents that the Government run services not only for Lancaster but for the whole country, and the Bill will provide for less fortunate areas. It will enable medical practices and community trusts to employ doctors in salaried posts. Many young single doctors may be willing—as a social service, to repay the training they have had and to do their duty by those less fortunate than themselves—to serve in a difficult inner-city area, but the need to invest in premises and to enter a long-term commitment to a partnership can be a frightening deterrent. Doctors who have worked for only four or five years may be able to fill a serious gap in areas that are now almost barren of doctors.
The pilot projects may also push forward the boundaries of the care and advice that can be given by nurses and trained pharmacists. The way in which we use our pharmacists is a scandalous waste of talent and training. On the continent, pharmacists provide advice: they are almost as good as doctors and, in many ways, are better. That does not happen in this country and it must be very frustrating for highly trained pharmacists to spend so much of their lives just dishing out pills. They are capable of giving a wide range of advice and the pilot projects should take advantage of their expertise.
The same applies to nurses. In the past two or three years the range of services that nurses can offer has gradually widened, sometimes unofficially. Again, pilot projects could extend that range still further. It is a waste of talent and enthusiasm if we train someone highly and then do not use them to the utmost. The Bill will help us to do that.
I have spent the past 35 years in medical practice in inner-city west Belfast, so I have listened carefully to the debate this afternoon, especially to the hon. Member for Lancaster (Dame E. Kellett—Bowman). More and more people in the higher income brackets are turning to private medicine, whether we like it or not.
If the Bill becomes law and eventually, by Order in Council, applies to Northern Ireland, the important question for me and for those I represent will be how it applies to people in inner-city areas and to people who are deprived. We all remember the Black report a few years ago on inequalities in health care. It was an important report, but it was shelved. People refer to it from time to time, but it was not taken seriously by the Government at the time.
I pay tribute to all those involved in primary health care. As every hon. Member accepts, it is a magnificent service provided by well trained people. The standard among general practitioners today is probably the highest in the history of medicine. I pay tribute to all members of the primary care team. Much has been said about community nurses. The Bill refers to nurse-led pilot schemes, and I would certainly support them.
For years, nurses in the United States have played an important role. I accept what the hon. Member for Lancaster said about wasted talent, referring to nurses and pharmacists. They are highly trained people. In the United States, nurses have the authority to give out certain drugs. There is no reason why that should not apply in the United Kingdom.
That is equally true of pharmacists. People in deprived and inner-city areas ask the pharmacist for advice, but that should be put on a proper footing. I know that the Bill deals with that.
Social workers and health visitors are all worth their weight in gold. I want to say a special word about the psychiatric nurse. In the communities, the community psychiatrist plays an important role, but the pivotal role is played by the psychiatric nurse. That is the person to whom a GP would first refer a patient with a mental health problem, and later perhaps to the psychiatrist.
No hon. Member has referred to the role of occupational therapists. If the Bill becomes law, its application in inner-city areas could give rise to a major problem in regard to occupational therapists and housing. The GP or the primary care team may be concerned about a patient with disabilities, but there may be a waiting list of six months or a year for recommended modifications to be made to the patient's home, such as the installation of a stair lift. I also find that what the patient wants, and what the occupational therapist and housing executive agree, sometimes differ widely.
I listened carefully to the Secretary of State's speech. He spoke about the flexible approach to contracts. No one would disagree with that. I accept the general principle of pilot schemes. We are tied down by day-to-day work in general practice, but the biggest handicap for general medical practitioners is the increased administrative work that they have to do. They are trained to treat patients. I shall not go into the question of fundholders versus non-fundholders, but administration and administrative staff seem to be increasing, not decreasing.
The Secretary of State spoke about the evaluation of pilot schemes, which is essential. There are many aspects to pilot schemes. Although I have studied the Bill carefully, there are many aspects that I do not fully comprehend. I appreciate that regulations will be issued after the Bill becomes law.
The Secretary of State said that the Medical Practices Committee would be given a statutory right to be consulted. I hope that that will be meaningful consultation.
Many Opposition Members are concerned about commercialisation, and I share their concern. When we talk about flexibility, do we also mean privatisation? I would be worried about that.
The question of health authorities employing a GP has been discussed. Earlier we heard reference to a hospital trust employing a GP. If that GP is a fundholder, a distinct conflict of interests could arise.
When the time comes, I will judge the Bill in relation to inner-city and deprived areas. I hope that it will be amended to build in certain safeguards to protect the quality of primary care. Mention has been made of the quality of primary care, as opposed to the extent or the cost of the care. The quality of the care is important.
The family doctor service must remain fully within the national health service, and not be open to direct or indirect privatisation. GPs will oppose provisions in the Bill that would allow private companies to be involved in running the family doctor service. GPs must be free to be advocates on behalf of their patients and to exercise independent clinical judgment. The Secretary of State, I think, quoted Dr. Bogle of the British Medical Association, who said that there must be no third party in the consulting room. No one would argue with that.
I have read the Labour amendment with care and would accept its main points—that the Bill
fails to require health authorities to consult with patients and professional groups on pilot projects
and that it
fails to provide for nurses and other primary care professionals to participate fully in pilot projects".
Reference was made earlier to pilot schemes and the single-handed doctor, and the quality of such a doctor. I would support that approach. We heard that, if an advertisement had been placed three times and no suitable candidate found, the post would be frozen. If a practice became available, perhaps because a single-handed doctor had died, the local authority would advertise for a doctor, but the committee might not think that the quality of an applicant was good enough, so that person would not be appointed. I point out that the practice size would dwindle day by day, as people went to other doctors. I have seen many examples of that. It is important that a proper doctor is appointed and that there are incentives for such a person to go into that area.
I have some criticism of certain bodies—GPs are no more perfect than anyone else. In some cases, doctors from other practices sit on the committee and decide who should or should not be appointed to the single-handed practice. It might be in the interest of those doctors that no one was appointed, so that the patients would go on to other doctors' lists. The question of viability arises; the practice might simply disappear. I do not know the position in Great Britain, but that has happened many times in Northern Ireland. Many things happen in Northern Ireland, however.
Independent monitoring schemes are important, as is the training of young doctors. I see the GPs of today as the best ever. I was a trainer myself in medical practice, and I had nothing but admiration for the young doctors who came into our health centre—extremely able young men and women. Standards are rising all the time. The problem is that as the administrative arrangements increase, doctors must spend more and more time on administration, and therefore less time with patients.
We can all pay tribute to paramedics, especially anyone who has been at the scene of a road traffic accident and seen the efficiency of paramedics in action. However, it must be said that some are not trained in such matters. It seems that, if anyone puts on a big coat with something written on the back to the effect that he is a paramedic, everyone steps aside to let him in. There must be protection for the public in that regard.
The Government must consult every member of the primary care team—not just general practitioners, but nurses, social workers and health visitors or their representatives. I am not sure how the Government will do that, but it is obviously extremely important. I have read the British Medical Association briefing document for today's debate and, like that organisation, I would be concerned about the involvement of private companies in the running of the NHS family doctor service.
The criteria for assessing the value of pilot schemes must be clearly defined. GPs working on pilot schemes should be represented through their recognised local medical committees. Such committees are statutory bodies, and therefore proper, full and meaningful consultation should take place with them. We have already referred to the fact that pilot schemes would be voluntary, so I shall not re-examine the issues involved.
The question of salaried GPs has arisen many times over the years. Doctors have different views on the subject, but the Bill puts the case for salaried general practitioners. I mentioned the problem of replacing doctors in inner-city areas while patient numbers remain viable. In such circumstances, salaried positions might appeal to some doctors who would like to be freed from the administrative detail associated with running a business. Doctors are not trained in business, and many would like to concentrate solely on patient care. There is a role for a salaried service, but it should not be introduced across the board.
I accept that funding is limited. The noble Baroness Thatcher said, "You can't solve every problem by throwing money at it." We accept that general point, but funding is very different for fundholders and non-fundholders. I am not sure that fundholding always benefits patients. I accept that many doctors opted for fundholding initially because they believed that it would serve their patients' best interests. However, I am unhappy about certain aspects of fundholding.
I appreciate that the Bill deals with England, Scotland and Wales and does not apply to Northern Ireland. However, if it becomes law, it will be extended to Northern Ireland by an Order in Council. Some doctors in Northern Ireland who applied to become fundholders were not accepted on financial grounds, although their practices were organised and fully computerised.
I have listened to the hon. Gentleman's comments with interest. Having regard to his own experience as a GP in west Belfast, does he not think that improvements could be made? It is all very well to claim that fundholding has led to discrimination, but does he not think that we should make progress? Does he agree that fundholding has proved generally beneficial to practices that have selected that option, and that we should proceed down that road rather than saying, "Fundholding is discriminatory and some practices are not doing so well"? We should encourage all practices to do better.
Fundholding will work only if all doctors become fundholders and if we have an equitable system for doctors and patients. I do not have the figures for fundholding and non-fundholding GPs in Northern Ireland. I did not agree with the principle of fundholding when it was introduced, but it is here to stay so there is no point arguing about the fundamentals. The system will work properly only if all doctors are fundholders—no one can deny that fact. In Belfast, the patients of fundholding GPs are often treated first while those of non-fundholders remain on the waiting list. That is wrong.
I pay tribute to the Royal College of General Practitioners, which has played a major role in elevating general practice within the national health service in the past 20 years. Some 20 or 25 years ago, doctors used to make jokes about general practitioners. That does not occur any more, and the standard of general practice is very high. We have some difficulties encouraging doctors to train in that area, but that is an extremely complex problem that I cannot explore now.
I am honoured to be a member of the Royal College of General Practitioners. It believes that standards of care must be maintained, that it is important to retain central elements of the existing system and that people must have universal free access to general practitioners. Continuity of care is a key point. In order to maintain quality of care, we should establish a proper process that will enable trusts and local health authorities to appoint GPs. Almost all general practitioners have completed vocational training satisfactorily—90 per cent. of practising doctors have passed the Royal College of General Practitioners examination. I support the Bill's general concepts, although I have expressed some serious reservations.
I apologise to the House for not being present for the beginning of the debate. My absence was due partly to my busy schedule and partly to the fact that I went to look at a school for my son, who is now nine weeks old. Like most people in their early or mid-forties, I have not had great experience of the national health service. However, I recently experienced its primary care services at first-hand with the birth of my son. I was extremely impressed, as was my wife—which is perhaps more important—with the service provided.
My wife received excellent pre-natal care from her GP and from the hospital. During the delivery at St. Thomas's hospital—I shall briefly digress from primary care provision—two midwives, a doctor, a senior registrar, a paediatrician and an anaesthetist were present in the delivery room. I was proud to be known as a Conservative MP, just in case some of the staff were not particularly happy about it. However, I discovered later that one midwife had trained in Leicester at the time of the last election and had voted for me—which is a feather in my cap. My wife and son received excellent treatment, which was very reassuring.
No, it is not. Since the delivery, my wife has received post-natal care, and the standard of NHS at-home care is also excellent. Initially, a midwife called every day, and now my son is seen by a GP or a health visitor every other week. A tremendous range of services are available—I think that my son is due to have his injections on Thursday—and the treatment is first-class.
I cite that personal experience because it has given my wife and I great confidence in the NHS and in its primary care provision. Our experience counter-balances the stories that one reads from time to time—which usually appear in the cheaper press—claiming that NHS treatment is not good. Primary care—which I hope will benefit from the pilot schemes mentioned in the Bill—should aim to prevent disease and maintain health standards. I hope that my hon. Friend the Minister for Health will refer to that point in his winding-up speech.
Primary care is about general health and fitness. That is not to say that we want a nanny state to determine the fitness or health of every individual. The Evening Standard refers to an advertisement for eggs with runny egg yolks, and says that some people are already complaining about it because those are bad for us. With all due respect to my hon. Friend the Member for South Derbyshire (Mrs. Currie), those of us who like our egg yolks runny do not need the state to tell us, in the cause of prevention, that they are bad for us.
I do not want a nanny state, but I would like a greater concentration on health and fitness promotion. Leicestershire health authority is to be congratulated on the information that it provides, even if it sometimes strays a little towards the nanny state.
Being a 45-year-old male, and having had very little medical treatment during my life, I am a classic example of a person who does not often use primary care or the NHS until the age of 50. Apparently, from the age of 55 I will become a bit of a liability to my GP and to the health service as a whole. That is the usual pattern: if one is fortunate enough to be healthy, one does not use health care services until one is about 55.
I am grateful to my hon. Friend, but I rather hope that I will stay out of hospital altogether, as I sometimes feel shaky at the knees just walking into a hospital.
We have seen the Government's White Paper, "The Health of the Nation", and we have seen the way in which local health authorities pursue preventive measures: it could be called health encouragement. My hon. Friend mentioned cycling. If children walked or cycled to school, they would remain healthier. I am sure that the hon. Member for Belfast, West (Dr. Hendron), who was a general practitioner, would agree with me that we must encourage our children to be fit and healthy. The discouragement of competitive sport in school has made children less willing to take to the playing fields, but I am glad to see that the Department for Education and Employment is now putting that right.
Gyms are a flourishing commodity around London and elsewhere: there is one in the House of Commons, and one nearby, which I use. The use of gyms shows that people are concerned about their health. By staying healthy and fit, they reduce the burden on the NHS. I have seen reports that GPs may now be able to prescribe courses at gymnasiums for their unfit patients.
Being healthy and fit starts at school. Health promotion in schools can be particularly useful, especially in primary schools. I went to a primary school in my constituency on Friday. I saw the lunches that the children were bringing from home instead of having the lunches provided by the school. They must have been just as expensive as the £1.15 that the school charges for lunch, but they contained food that was not the most healthy.
Yes. It was delivered to our school, but it was always tepid and no one drank it. Many of those third-pints of milk were taken away undrunk, because no one liked the stuff. The hon. Lady is right in that we should encourage a greater nutritional content in school meals. I think that we agree entirely on that.
If health professionals and teachers develop an awareness in schoolchildren of the importance of eating the right food, and not just crisps and chocolate, less of a burden will be placed on primary health care.
People in Leicestershire are concerned about air quality. Air quality in London, Leicester or wherever affects the number of asthmatics who go to their doctors or have to attend hospitals. We should examine this problem, and take a holistic approach to health care and prevention. If we could reduce the pollution in our cities, fewer children and others would go to their doctors. I am keen for some of the pilot schemes proposed in the Bill to work hand in hand with other agencies towards that end, and I hope that something along those lines will be discussed in Committee.
Fundholding is growing in popularity. Doctors in Blaby have said to me that they do not like fundholding, but the next year they have decided to become fundholders because of the benefits, and the following year they have said that there are also benefits for their patients. As I said to the hon. Member for Belfast, West, that is how to make progress. We must ensure that the service is getting better, and that improvements are always being made.
I recently went with my wife, who was then pregnant, to a fundholding surgery in Blaby. It was a bit of an emergency: my wife was concerned. We went there at short notice—we are not registered with that practice, because we are registered in London. We received excellent treatment. I say to those who knock fundholding practices, "What were things like 30 years ago? Indeed, what were they like 18 years ago?" The treatment that one receives in a national health surgery is better than it was before, and one should think back before criticising and harping on about what may not always be perfect now.
Two fundholding surgeries in my constituency—a health centre in Blaby and one in Countesthorpe—have recently installed ECG machines. The Blaby Lions organised sponsored walks to raise the money for those machines. I see no reason why local people should not help raise money for local health centres. I should pat myself on the back, because I took part in both sponsored walks, although I did not complete one of them.
If we were to abolish GP fundholding, as some Opposition Members want—I am not sure about members of the Opposition Front Bench, who seem to vary slightly—what would we lose? What facilities would we lose? What freedom to employ additional staff and to use alternative treatments would we lose? From my limited personal experience, I think that we would lose a great deal.
We should also consider the rising expectations of patients. Patients are no longer happy to put up with the grotty GP surgeries that they have perhaps had to put up with in the past. One may say that patient expectations are too high, but I do not agree. We should expect decent, well-run, clean surgeries, with the latest equipment if possible. We should be working towards achieving that where it does not exist.
Patients must also take responsibility for their own primary health care. If a heavy smoker—this also relates to health promotion—is not given all the treatment that he wants, we should say to him, "Surely you too are responsible for your health, not just the doctor or the hospital. You are responsible for looking after yourself." Otherwise, we become a nanny state that says to people, "Whatever you do, we will look after you," and I do not think that that is right.
I went to the casualty department at St. Thomas's hospital with my young son just before Christmas—treatment in casualty is primary health care. I was appalled by what the excellent staff of the hospital had to put up with on a Thursday evening before Christmas. It was quite shocking. I shall not be too rude about the people, except to say that they were drunks, layabouts and louts, and were being extremely rude to one another and to the staff. We should tell them that they are responsible for what happens to them, especially those who were dripping with blood, having fallen over in drunken stupors. As many doctors have pointed out to me, those are the same people who call doctors out in the middle of the night to say that they have a bit of a sore throat. We must make individuals more responsible for their own primary health care.
Linked to that is the question of compensation. I hope that, in Committee, we shall consider giving more protection against vexatious litigation. Once, when someone fell ill, the standard cry would go up, "Is there a doctor in the house?" I fear that we are now approaching the situation that exists in America, where doctors pass by on the other side because they are frightened of being sued. That is dangerous: doctors who have taken the Hippocratic oath, and are interested in the well-being of their fellow man, should not be subject to that fear.
Leicester is fortunate in having three general hospitals—Leicester royal infirmary, Glenfield hospital and Leicester general hospital. All have good reputations, and a great deal of money has been spent on them recently; but a project is now under way to establish whether it would be better to concentrate the care that they provide on two sites. I shall not comment on whether that would be desirable, because I am not a health professional. I shall say, however, that I think it right to allow the professionals who are most closely involved—surgeons, consultants, nurses and managers: those who must provide the care—a decent say. I regret to say that at least one Labour Member representing Leicester has said that that is wrong. We should view the position in its entirety, and consider what is best for the people of Leicester.
While it has been increasingly difficult to obtain dental care on the NHS in the recent past, I am delighted to note that it now seems to be becoming easier. Not long ago I registered with an NHS dentist in Leicestershire, and, although it is true that one has to wait for a while for treatment, I commend the dentist who has treated me on several occasions. I suspect that the cost of crowning two teeth was relatively inexpensive. People say that NHS dentists are useless, but I was able to sign up with that dentist in an emergency, and he has given me excellent treatment.
One provision in the Bill aims to reduce bureaucracy—I am sure that we would all welcome that—by unifying health budgets and making contracts easier. As my hon. Friend the Minister will know, people have complained that the growth of GP fundholding and other reforms have led to an increase in paperwork. Part of that may have been necessary, but I think that we should consider carefully how we can reduce it to the minimum.
I welcome the Bill. I believe that it is another step towards improving primary health care—and we all want the best primary health care for our constituents.
Although I support the amendment, I am not denying that there are good things in the Bill, such as the new rules for appointing GPs in single-handed practices, and the provision of salaried GPs. I am glad that community trusts will be able to employ GPs, although, like others who have spoken, I am very worried about the acute trusts. I fear that there could be a blurring of the purchaser-provider split, and even—as the hon. Member for Belfast, West (Dr. Hendron) suggested—a conflict of interests in regard to GPs who might be employed as fundholders.
The Secretary of State outlined some of the good aspects of pilot schemes—for instance, the fact that permanent arrangements will not be introduced unless they have been agreed by the Secretary of State. There must be proper assessment, but there is some doubt about who will carry it out. Participation is to be voluntary, but I wonder whether sweeteners will be offered in some instances. Participants must be given an assurance that they can return to current practice if the alternative does not prove satisfactory, and I welcome most of the proposed arrangements. I feel, however, that we need clarification in regard to who will be consulted.
As I said to the Secretary of State in an intervention, past consultation has left some of us less than enamoured of the practice. I mentioned a recent consultation exercise relating to a 300-bed reduction. I do not know whether we shall ever get our new hospital in Halifax—which is being built under the now infamous private finance initiative—but there has been plenty of consultation about it, and not a blind bit of notice has been taken of any of those who have been consulted. As the winter has gone on, it has become clear that we can hardly manage with the beds that we have now. I hope that the nurse-led pilot schemes will be allowed to continue; I should like to see much more detail in that regard.
The Secretary of State said that primary care should be a friend to patients, but I think that the Bill fails on a number of counts. There are one or two missed opportunities. The question of commercialisation is, I believe, still there. The last link has not been fractured; it is still in the original proposals. It seems to me that the Secretary of State is pandering to the Tory right in his bid for the leadership, which may have clouded his judgment a little and led him into what is essentially another attempt—in at least one part of the Bill—to take more privatisation to the heart of the national health service.
Let me say a little about GPs and the primary care system. Although that system is envied by most of the developed world, we should not overlook the fact that we are facing a crisis. That crisis is best summed up by the British Medical Association, which recently stated:
GP morale is at its lowest ebb for many years, caused by excessive workload, the continuing out of hours burden, too much bureaucracy and falling remuneration relative to comparable professions".
Those are the BMA's words, not mine.
I know—as do all other hon. Members, if they are honest with themselves—that that statement is true. Only last week, along with other Labour members of the parliamentary Yorkshire group—a fairly large group—I met doctors from the Yorkshire region. Dr. David Smith, a GP, told us that the GP service was in crisis. It was failing to recruit. Patients' expectations had been greatly raised by developments in treatments, but there had been a doubling in night work, and a massive transfer of work from secondary to primary care that had not been properly funded. Many people have overlooked that.
Will the hon. Lady draw a distinction between the morale, as she puts it, of GPs who are in fundholding practices and that of GPs who are not? Following correspondence and conversations with GPs who have entered into fundholding arrangements, I have the clear impression that morale is very high. Those doctors are able to offer a range of services that their patients appreciate, and can raise quality by being able to send patients to the right hospitals for the right treatment. Labour's policies, if implemented, would remove that benefit.
The opposite is true. Commissioning would allow all GPs to offer services without added bureaucracy and paperchases.
Dr. Smith and his colleagues also confirmed what we already knew: that equity in care is not a reality. He told us that many GPs had overspent in the past two years keeping fundholding practices, that a two-tier system was developing and that the internal market in health had led to a paperchase. I have many local examples, but I want to refer to one involving Glenfield hospital. This example might interest the hon. Member for Blaby (Mr. Robathan). I have raised this matter before in the House with the Secretary of State.
A constituent of mine who has been waiting 15 months for a heart bypass operation and who should have gone to Leeds general infirmary but cannot because it has stopped doing elective surgery, has been offered an operation at the Glenfield cardiac care unit in Leicester, but the letter states clearly that it has stopped doing elective surgery except for the patients of GP fundholders in Leicester, so here is a classic example of a two-tier system in his constituency. However, my constituent, who should be going to Leeds general infirmary, can go to Glenfield and jump in front of non-fundholders' patients, regardless of clinical urgency. It is not worst first; it is who can pay.
There is, of course, a question of funding. As I think the hon. Lady will understand, the whole NHS requires funding and is enormously expensive. I think that she will find that she is incorrect. I have not of course read the letter. There are three general hospitals in Leicester, all of which offer excellent care. I should say that Glenfield offers particularly good care in cardiac surgery because it has some of the latest, most expensive state-of-the-art technology that she will ever have seen.
I checked this matter with the administrators, and it is absolutely true. I was looking after the interests of my constituent, and he can have the operation in weeks at Glenfield rather than waiting months for the operation to take place in Leeds.
If the Bill is passed without amendment, the present two-tier system will continue. Patients will carry on being treated on the basis not of need, but of other factors: age, where they live, who their GP is and what status he has. Patients will come well down the list of priorities.
The increase in the number of patients who are being struck off doctors' lists will continue, and that worries me. The Bill does not deal with that because the internal market has encouraged that increase. The trust between the doctor and the patient is threatened by the cash price factor in the internal market.
In November 1995 I introduced a ten-minute Bill to deal with that very problem. I suggested what I consider were modest proposals. At some stage during the passage of this Bill, I intend to table an amendment to try to get the proposals in my Bill written into it. Patients should know at the very least why they have been struck off a doctor's list. Practices are becoming increasingly large. Before such a drastic step is taken, there should be discussion between doctors on whether another doctor can take the patient on board because being struck off has a devastating effect on people.
I make it absolutely clear that the amendment that I hope to introduce is not a "doctor-bashing" amendment, but just a few weeks ago in Halifax I was contacted by an elderly lady, Mrs. Mary Walker, and her husband, who had used the same practice for 47 years. I spoke to her on the telephone and arranged to see her at a later date. She was incredibly distressed that she had been struck off her doctor's list. No reason was given, and of course a doctor does not have to say why. Obviously, the family health services authority got her another doctor, but she died before I could see her. Such cases happen over and over again, so the Government need to deal with the matter. People should at least be told why they have been taken off or offered another doctor within the same practice, because having to travel outside their region can present major problems for elderly people and for women with young children.
If I table that amendment, it will not be because I am anti-doctor. I have the highest regard for our GPs and the system. I also recognise that they have a legitimate right to say, "The relationship has broken down and I cannot treat this patient." Of course the General Medical Services Committee, in some advice a couple of years ago—which could be tightened up a little—pointed out that a patient may be struck off if there is violent or threatening behaviour towards a doctor or his family. As I have said, there could be a complete breakdown between doctor and patient. Scurrilous and unfounded allegations might be made against a doctor. There could be prescription fraud or the persistent breaking of appointments.
All those things could happen, but the Bill misses the boat. If we are really talking about patients, the Bill could have included measures on that, but it does nothing to deal with the problem. Instead it deals with what I believe is the hidden agenda of the Conservatives: if, God forbid, they ever got in again, privatisation of the NHS would be top of their list. That trend is in the Bill. The Secretary of State has just slightly pulled back from what he was going to do, but a strong link remains and it still threatens one of the abiding strengths of British primary care, that the GP's role as "patient's champion" and "gatekeeper" to the NHS. That could be undermined with this commercialisation.
That undermining of the doctor-patient relationship is destabilising and adds to the destabilisation that we have already seen with GP fundholding. The hon. Member for Bury St. Edmunds (Mr. Spring), who intervened to talk about GP fundholding, has now left the Chamber, but I should like to have drawn his attention to The Mail on Sunday, which showed the downside of GP fundholding. Its article stated:
Dr. Ian Dunn and his seven colleagues, who look after 16,000 patients in the area"—
I think it is Long Eaton, Derbyshire—
became fundholding GPs—joining the scheme which has become the flagship of the Tory Party's NHS reforms. Theirs was one of the largest practices in the country to take over management of its own patient budget, in this case around £2.5 million a year.
Now they have been thrown out
because the GPs have overspent their budget by £300,000. They did so because they did not want to stop patients from being treated. Therefore, there is an unravelling of that flagship.
No. I am sorry. I must get on. Other hon. Members want to speak and the hon. Gentleman has not been in the Chamber most of the night.
As my hon. Friend the Member for Islington, South and Finsbury (Mr. Smith) has said, even though the Government have pulled back now and there has been a little bit of a withdrawal from the commercialisation that was envisaged in the first place in the White Paper and in the Bill, many companies have shown an interest in being able to employ GPs. They include Asda, which has well-known links to the Tory party—I do not need to go over them again; they have been well expanded in the Chamber—UniChem, the United Kingdom's largest drug supplier, which has plans to build health centres and to employ GPs; and PPP Healthcare, which proposed a pilot scheme involving the provision of GP services at the company's private hospitals, with referrals to the hospitals.
The hon. Member for Southwark and Bermondsey (Mr. Hughes), who I hope votes with us tonight, said that he did not think that the location was important. It is important if it is in the same place as a private hospital and patients are referred straight there. Such hospitals do not train NHS staff. They are leeches on the back of the NHS, and the sooner we realise that, the better.
The public should be warned. The Government have back-tracked slightly on the commercialisation. Should they ever be elected again, within days, the Secretary of State for Health would introduce a Bill to bring that commercialisation and privatisation right into the heart of the NHS again.
As I have said, Labour Members welcome pilot schemes, with all the provisos and everything else. I do not think that I have been too negative. I have tried to be honest about the Bill. There are things in it that I welcome, but, if hon. Members really want to safeguard the NHS and to keep it as a national health service, they should support the reasonable reasoned amendment tonight.
The nice thing about speaking in this part of the evening—the "black hole" part of it—is that the Front Benchers, with one or two very odd exceptions, have gone to dinner, and it is possible to indulge in as many heresies as one likes without their knowing what has been said. I shall briefly try out one or two heresies on the House in this speech. Generally, however, we have come to praise a measure that we think has potential to do some good, although we have reservations on some matters—such as on evaluation procedures and on planning mechanisms that will remain after the Bill is passed—and questions about links with the private sector. Those reservations and questions will undoubtedly be expressed in amendments to the Bill.
As I said, we generally welcome the Bill and the Government's conversion to an approach of progress through pilot measures. However, we wonder how different the health service would have been if, some years ago, the Government had approached their reforms to the health service in the same spirit. We even forgive the Government for their use of the word "flexibility" in the Bill. Over the years, we have come to worry about their use of that word to describe health service reform, although I think that it may have some positive benefits in this context.
We particularly welcome this opportunity squarely to address the issue of quality in the health service—in a manner in which it has so far not been addressed by the Government. If Ministers had set quality as their objective in their health and education measures of the past 18 years, how different their programme would have been. If they had simply set the objective of organisational improvement instead of directing all their energies towards organisational change, how different their health and education agendas would have been.
I was delighted last week to hear a speech by my hon. Friend the Member for Islington, South and Finsbury (Mr. Smith) on health care quality. He said:
In Government, we will shift the balance of attention from quantity to quality.
That shift of emphasis is long overdue, and it has great, positive implications for the way in which we approach health matters.
With some reservations, therefore, I come to praise. We come to praise GPs. When people in the United Kingdom tell us that they have been to see the doctor, that they are going to see the doctor or of what the doctor has told them, they are of course talking about their general practitioner. For most people, the GP is the person who represents the health service, at close quarters and most intimately. GPs are also the gatekeepers to the secondary care system, in a system that works splendidly for most people. When the system works well, it works extremely well.
One of the heresies that I should like to suggest to hon. Members, however, is that occasionally the system does not work so well, and that one of our responsibilities is to ensure that we do something about it when and where it does not work well. If we believe that everyone in the United Kingdom—wherever they live, and to whichever part of the community they belong—has the right of access to a quality general practitioner working in quality premises with quality support, we have to say that some aspects of the current system do not work well at all. The system is not delivering that objective to many people in the most stressed and disadvantaged parts of this country.
Listening to Conservative Members, I often think that they speak for "comfortable England". It has to be spoken for, and many people are prepared to speak for it. However, some of us have a duty to speak for "uncomfortable England" and for "uncomfortable Britain". I have been speaking only about England because Conservative Members speak solely for England. In uncomfortable Britain, however, parts of the health service and of the primary health service do not work as well as they should. There is a gap between the type of service that Conservative Members speak about and the type of service experienced by the constituents of some Opposition Members. We have a duty to close that gap, and we should try to close that gap in debating and passing this legislation.
When we say "primary care", we instinctively think of general practitioners, although 90 per cent. of primary care is not delivered by GPs but by other health service professionals. That is the -first uncoupling that we must perform.
We now have a primary care system that is driven by individual professionals rather than by interdisciplinary health care teams, although I think that most hon. Members think that the system should be driven by interdisciplinary care teams. The Bill presents the opportunity to move in that direction.
The question, however, is why do we not have such a system now. Why do we not have as the norm primary health care teams, particularly in those parts of the country that are most disadvantaged in health terms? Why do we not have teams of doctors, community nurses, health visitors, community midwives, pharmacists and other professionals working together on a team basis in those areas where need is greatest and where health provision is often most scant?
We know that about 30 per cent. of GP activity could be delegated to nurses without detriment to quality. Why have we not converted that insight into the way in which we deliver health care through primary health care teams? The question I am really asking—it is a type of heresy—is why do we have one system when we would benefit from having another? Why have we grown accustomed to one system—a system of individual professionals working separately—when we need interdisciplinary health care teams, particularly in those areas of greatest need?
One of the Bill's provisions gives a clue about why we have one system whereas we need another. It is the provision dealing with changing the way in which appointments to general practice are made when no satisfactory candidate presents himself or herself after three re-advertisements. People will be amazed to discover that, heretofore, we have had a system in which unsuitable candidates have been appointed simply because there have been three advertisements. Why has that been done when it was not in the public interest to do so? It was done because that is how we have organised primary care and because those who control the system—the professional bodies—have had such power inside the system.
Prompted by this Bill, I should like to ask whether the individual contractor system has worked well. Has the Medical Practice Committee—the MPC—succeeded in matching need to supply across the land? How can it have been done when some health authority areas now have a third more GPs per head of population than others? In some places, spending is almost two thirds higher than in others. If the individual contractor system—which is linked to the power of the professional bodies—had worked well, such disparities would not exist.
I can express another heresy by asking whether the system has delivered guaranteed high quality clinical care. Fortunately, in most places it has, because of the quality of most GPs, but it has not been delivered uniformly. More importantly, we do not know whether the system delivers high quality care because there are no effective procedures to monitor clinical care in general practice. That is one of the consequences of the individual contractor system. The autonomy that is part of the individual contractor system is an autonomy from effective clinical audit. Such autonomy is allowed increasingly less frequently in the secondary care sector, and it should not be allowed in the primary sector—but it has been.
One of my hopes is that, because of the advent of salaried GPs, we can begin to ensure the performance of clinical audits and to prescribe practices and to take all the other action that we knew was necessary but which we were unable to take because of the way in which the individual contractor system has worked.
I want to refer to my area, which, as my hon. Friend the Member for York (Mr. Bayley) has reminded the House, has the lowest spend on non-cash limited primary care per head of population for any area in the country. In his annual report last year—it was an excellent report—the local director of public health pointed out that the Cannock Chase area has the highest number of practitioners who operate singlehandedly, as well as practitioners with the largest list sizes and the highest level of secondary referrals anywhere in the health authority.
I went to the health authority—it was then the family health service authority—and pointed out that evidence, which was also linked to further findings revealing that the area has the greatest health need of anywhere in the district. So we have the worst health and the worst primary care. I asked the FHSA what it could do about it but the answer was that it could do nothing because it did not have the power or the instruments to intervene. It could do nothing about the distribution or the quality of primary care.
There is a town in the constituency that I hope to represent after the election which does not have a woman GP. The health authority has said that, apart from prevailing upon doctors, it can do nothing about it. It is a scandal that we cannot ensure that women have access to a female GP in a substantial town. We have not been able to do those things because we do not have the levers inside the system to direct primary care in the way that we know it should be directed.
There is a huge primary care agenda and the Bill begins to offer an opportunity to do something about it. The Secretary of State, rather coyly, tries to reassure everybody in sight by saying that this is not a pilot with a big bang. I hope that it is a pilot with a big bang, because it has huge potential to do the strategic things to primary care that we have never been able to do before.
I support my hon. Friend the Member for Halifax (Mrs. Mahon) in her comments about the way in which it is possible for general practitioners to strike people off their list without any explanation or appeal. I have been concerned about that for some time. It is an affront to natural justice, but it is a direct consequence of proceeding on an individual contractor basis as opposed to a salaried basis. Presumably, when we move to a salaried basis, it will not happen, because it will be inconsistent with a publicly provided service.
I had a constituent recently who was severely mentally ill. He had spent time in mental hospitals and in prison. We searched everywhere for suitable provision for him and I had reached the end of my tether. I wrote a letter to every possible contributor to care for this person and said that, unless something happened soon, this person would kill himself or someone else. In October 1995, as a health care team, including a consultant psychiatrist, was on its way to see him, he committed suicide.
I asked for a review to be carried out to find out how that could have happened. I wanted to know why the system had let that person down. The trust carried out a review under the proper procedures. Perhaps the most striking thing to come out of the review was the fact that the person had been on a three-month rota between different GPs who did not know his medical history, sometimes did not have his records and were prescribing inappropriately for someone with his condition. They made it too easy for him to kill himself. The report said:
The role of the General Practitioner was acknowledged as important in his care and indeed of other people with mental health needs. However, this is often, and was in this case, sabotaged"—
that is a strong word—
by the ability of GPs to remove patients from their register at will.
The report goes on:
The idea that those people who have the greatest potential mental health needs can be removed from a general practitioner's list every three months appears incongruous with the philosophy of community care.
In its recommendations, the report said:
General Practitioners who want to remove those people from their register who have severe mental illness should only do so after discussions and consultation at a formal Care Programme Approach Review.
That would be bad enough if it was an isolated case, but it is not. I went to the old FHSA and asked about the strike-off rate of patients by GPs in my area. I discovered that we had the highest in the county—385 removals between 1992 and 1994.
Just this month, an elderly couple, one aged 82 and one aged 87, were deregistered for no apparent reason. They were informed by second-class post in a letter received on 21 January that they were being deregistered on 28 January. There was also the family whose mother had cancer and who were all removed from a list three weeks before her death, seemingly for no apparent reason. The stories go on.
I accept that there are difficult patients but we must do something with them. Some of the most difficult have the most severe conditions or come from the most distressed areas. No doubt some of them are very costly, but we cannot have a system where removal can take place without any explanation or right of appeal. I support what was said by my hon. Friend the Member for Halifax, and I hope that, together with its provisions to secure the right of people to choose doctors, the Bill will help to secure their right not to be removed arbitrarily from a doctor's list.
I want to issue another heresy. The Bill says that it will cost very little—it talked about £6 million as a set-up cost in the next year. I think that, potentially, it will cost us a great deal. The infusion of resources into a revamped team-based primary care sector that the Bill promises is likely to be enormous. If it is not to come from an already stretched secondary care sector, we should be honest about the funding. We must be honest about how we fund the health service. The Government talk rhetorically about extra funding year on year, but we know that that does not stand up over the next two or three years. We must be serious about whether we want to fund the health service so that it can develop in the way promised in the Bill. We have a duty to give the people of this country a choice about whether they want to do that.
My final heresy is to say that I am prepared to ask people to pay a health premium payment, an HPP—we must not use the word tax. We must ask them whether they want to make such a payment to secure the future of the health service for ever. I say that as someone who was born in the year in which the national health service was founded. We have a choice coming up: we have to decide whether we want to guarantee the future of the health service for the next half century. If we do, I am afraid that we must pay for it.
I listened with considerable interest to everything that the hon. Member for Cannock and Burntwood (Dr. Wright) said—I hope that I have got his constituency right. He was fortunate to follow the hon. Member for Halifax (Mrs. Mahon), who, I think, used to be a nurse in the national health service. Shortly before her came the hon. Member for Belfast, West (Dr. Hendron). I am not sure whether he still has time to practise, but he has considerable experience in the national health service. I shall not follow my hon. Friend the Member for Blaby (Mr. Robathan) with a run-down of my various ailments over the past few years because it would take too long. I congratulate him on the birth of his son—I am sure that that is a happy occasion for all concerned.
Before coming to my main points, I question the way in which the hon. Member for Cannock and Burntwood attempted to elevate his arguments with the word "heresy". I did not find anything that he said in the least heretical and I do not imagine that those on the Labour Front Bench, or anybody else, will send him to the stake for what he has just said. He made a thoughtful, interesting and at times wrong-headed speech, but he should not try to persuade us that his arguments are any the better by describing his interesting remarks as heretical. We all listened with interest, but his arguments are not advanced one jot by over-egging their description.
I agree that not all primary care comes from general practitioners. It is right to stress that. I shall elaborate on it in a moment. I shall also talk about the interdisciplinary practices that he referred to. There is an interesting agreement across the House on those points.
I should like to be controversial to start with by picking a few holes in Labour's reasoned amendment. Why on earth did they draft it in that way? The third line says that the Bill
fails to require health authorities to consult with patients and professional groups on pilot projects".
A failure to require that does not mean that they cannot or need not do such things. I suggest that that is a wholly otiose collection of words in that particular part of the proposed amendment.
The reasoned amendment goes on to say that the Bill
fails to provide for nurses and other primary care professionals to participate fully in pilot projects where appropriate".
No doubt they will participate when appropriate. Primary legislation is not required for that.
I ask my hon. Friend to be a little patient, because I am making a fascinating point.
The reasoned amendment goes on to say that the Bill
fails to establish criteria by which the success of pilot projects can be evaluated and fails to provide for health authorities to employ directly general practitioners".
The Bill may not include such provisions, but that does not detract from its value. The reasoned amendment goes on:
it includes provisions to allow private companies to employ general practitioners to provide patient care, thereby undermining the doctor-patient relationship".
That is one of the more interesting—or perhaps less interesting—non-sequiturs that new Labour has come up with in recent weeks. The fact that one doctor has a
different contractual arrangement with the person who pays his salary than does another has no bearing on the way in which he should provide patient care. To suggest that the doctor-patient relationship is undermined and damaged by that is simple poppycock. I suspect that the Labour party knows that, and merely wanted to add words to the amendment for the sake of it.
The amendment winds up with these wonderful words:
the destruction of the principle of health care being available according to need and free at the point of delivery.
Nothing that is printed above those final two lines of the amendment has any bearing on that conclusion.
Does my hon. and learned Friend agree that flexibility is at the heart of the Bill—flexibility to adapt to local conditions that vary from one part of the country to another? Concomitant with that is the fact that pilot schemes for that purpose are inherent in the Bill.
I was not in chambers. The hon. Gentleman has been known to make inaccurate remarks of that sort before. I shall not rise to it.
I want to take issue with the hon. Member for Cannock and Burntwood and some of his hon. Friends who have been here for a little longer than the hon. and voluble Member for Thurrock (Mr. Mackinlay) who sits for the provisional Labour party. The hon. Member for Cannock and Burntwood made some valuable points about the primary care aspects of the Bill. Primary care is not always provided by the general practitioner; it is provided by a range of health professionals who play a complementary role to that of the GP. Visiting our general practitioner is the main point of contact with the NHS for most of us. However, a constituency Member of Parliament has to take a wider view and no doubt Ministers at the Department of Health have a better view of the bigger picture.
My constituency is fortunate in its primary care teams. I trust that they will be strengthened and their flexibility—to use the word chosen by my hon. Friend the Member for Bury St. Edmunds—will be enhanced by some of the provisions in the Bill.
A range of medical professionals operate from Market Harborough, Kibworth, which is half way between Market Harborough and the city of Leicester, and the borough of Oadby and Wigston, which is the part of my constituency closest to the city of Leicester: health visitors; district nurses; occupational therapists; radiographers; and those engaged in the provision of continuing care, particularly for patients who have been in one of the three major hospitals in the city of Leicester and are not ready to go home, but need to convalesce or spend some time in a halfway house first.
All those people perform valuable and valued services in south-east Leicestershire. It is right, as the hon. Member for Cannock and Burntwood said, to think not only of general practitioners. Despite the fact that there is not, I think, a single fundholder, my constituency is fortunate in having excellent general practitioners who are dedicated to the national health service as an institution and to the care of their patients.
I admit that I have not been present for much of the debate because of other duties in the House, but I was particularly interested in many of the remarks by the hon. Member for Cannock and Burntwood (Dr. Wright). I know his area well—Cannock Chase and Burntwood. There used to be a major mental health hospital—St. Matthew's—in his area.
Does my hon. and learned Friend believe that the patients—the people of this country—would receive better health care, better treatment and better attention if the doctors, male or female, were salaried or, as at present, private professionals contracting to the national health service? Does he believe that the morale of doctors would be improved and that people would get better treatment if, as the hon. Member for Cannock and Burntwood suggests, they were salaried rather than contractors?
When criticising the reasoned amendment, I pointed out that the allegation that a link with a private company that employs a general practitioner damages the quality of health care is fallacious. I hope that I have therefore already answered my hon. Friend in addressing the terms of the amendment. There may well be some excellent doctors who will want to continue as self-employed practitioners, and some excellent doctors who will want to become employed doctors. To me, what is important is the service and the care that they deliver, not the manner in which they are remunerated.
I should like to expand a little further on the provision of community primary care services, especially in so far as it affects my constituents. We were fortunate to be visited in the past fortnight by my hon. Friend the Minister, who was able to see for himself at first hand the provision of primary care not only in my constituency but in the city of Leicester. I trust that he came back to London with the message that, "If you want to be ill, Leicestershire is the place to do it." The county has some of the best equipment, personnel and hospitals at all levels, and is a credit to the NHS.
My hon. Friend the Member for Blaby has already discussed for some little while the three major acute hospitals in the city of Leicester, so I shall not repeat what he said. However, I remind my hon. Friend the Minister of what he will have been told when he came to Market Harborough not so long ago about the benefits of the local provision of primary care, particularly that given through the Market Harborough and District hospital on Coventry road in the town and in the local health centres.
I should like to draw the attention of my right hon. and hon. Friends on the Front Bench to clause 27, which deals with pharmaceutical services. There has been considerable debate in my constituency about the provision of such services by rural GP practices. There is a competition, not to say an outright squabble, between pure pharmacists, who have shops and want to provide prescriptions, and rural GP practices, which earn quite a lot of their income by prescribing NHS drugs, thus enabling them to invest in the services that they want to provide for their patients. I trust that we can find our way to a sensible resolution of the dispute between rural GP practices and pharmaceutical service providers during debates on the Bill.
I should like to comment on the huge number of regulations suggested in the Bill. There is hardly a clause that does not provide for the creation of regulations. I am all for the proper use of regulations in order to deliver a particular service well, but I ask my right hon. and hon. Friends on the Front Bench to bear very much in mind the problems of over-regulation. I gently chide them so that we do not end up with so much red tape and the binding of people to regulations that they cannot deliver what they are required to deliver.
The Opposition amendment complains—mention of it has been made by me, if not others—about the link between private employers and the provision of national health service GP services. I want the Government to encourage partnership between the private sector and the public sector.
One extremely good example of such partnership is the Macmillan green ribbon appeal at the Leicester Royal infirmary. As a consequence of that appeal, £1.5 million has been raised in the past year. The appeal committee was chaired by Mr. James Wilson of Gaulby in my constituency. As a result of the huge amount of money that he and his colleagues on the appeal committee have been able to raise, a whole new oncology building has been built next door to the royal infirmary.
That is a classic example of the proper exercise of partnership between the private sector and the public sector. The NHS will benefit from the building, while the private sector has played a useful role in building it and ensuring that its use will soon be under way.
The Bill ought to be welcomed. The Official Opposition's amendment is confused, confusing, and detracts from some of the better points that have been made by some Opposition Members, which is to be regretted. I trust that my hon. Friend the Minister will beat a speedy path back to Market Harborough so that he can see some of the other wonderful things that are going on in hospitals there.
I should say in response to the hon. and learned Member for Harborough (Mr. Gamier) that I have no difficulty at all in defending, and, indeed, supporting the reasoned amendment tabled by my right hon. and hon. Friends. It is constructive. All Labour Members have made it very clear that the principle of a discussion of primary care is to be welcomed. Indeed, we have been calling for it for some considerable time.
Parts of the Bill are to be welcomed, too, but since other hon. Members want to speak I shall not dwell on those aspects, save to say that the principle of piloting is a very good idea and is being welcomed around the country. I know that in Birmingham, which has been at the forefront of developing ideas for local commissioning of the kind that Labour Members have been suggesting, people are coming up with some fairly imaginative ideas for pilots that the Government could take up if the Bill is enacted.
There are nevertheless significant weaknesses in the Bill, which so far the Government have not addressed. The first is one of principle. I still fail to see—I mentioned this the last time that I contributed to a debate on the health service—how the Government can think that an effective primary care strategy can work, with the co-operation that it involves between different parts of the health service, if it is grafted on to a market mechanism whose ethos is splitting up the health service into different units and making them compete with each other.
That is very different from saying that there is anything wrong with separating the commissioning from the providing of health care, which makes a good deal of sense. For the health service to function effectively as a national service—whether that be nationally or in the locality—co-operation and team work of the kind mentioned by my hon. Friend the Member for Cannock and Burntwood (Dr. Wright) is required, not competition.
With respect, a number of hon. Members want to speak, so I will make progress. I will not be able to take any interventions. If the hon. Gentleman wants to know how the system to which I referred can work and focus more on quality, I could do worse than refer him to the speech on quality in health care and the building of a co-operative ethos in the health service made by my hon. Friend the Member for Islington, South and Finsbury (Mr. Smith), the shadow Secretary of State for Health, only last week.
I should like to address the problems in the Bill and I hope that, in winding up, the Minister will clear up some points on which I at least am still a little hazy. The Government have said that they have listened to the criticism about what has been described as the supermarket surgery—the commercialisation aspects of the Bill—and that they will table an amendment to address them. I am still rather confused about what the Government intend to do.
It has been said—I think that the Secretary of State indicated it when he opened the debate—that the question of direct employment of general practitioners by commercial enterprises will not be acceptable under the proposed amendment. Will the Minister clarify exactly what is meant by direct employment? Perhaps more to the point, does he envisage indirect employment, and what might the consequences be for commercialisation of the health service?
I put to the Secretary of State earlier a problem that already exists when there is a commercial relationship between a patient and an outside body, and the impact that it can have on GP referral patterns. Such a problem is equally relevant when the relationship is between the GP and commercial areas. GPs are telling me that, if a patient comes to see them under the health service but is a member of a private health insurance scheme and a referral is needed, there can be pressure on the GP—if the referral is to be through the private insurance scheme—to refer to the preferred provider. So the GP's role as a purchaser of health care can be compromised.
If it can happen that way round, it can also happen if the GP is tied into a commercial firm outside. I ask the Minister to define exactly what the Government mean when they talk about employment, and where the boundaries are. There is also a question relating to acute trusts. The Minister said in the last debate on this matter, and the Secretary of State mentioned it again today, that while it is unlikely that acute trusts would employ salaried GPs, the Government were not prepared to rule it out. They said that it would be ruled out only where there is a conflict of interest. When the Minister winds up, I want him to talk about where he thinks that there would be a conflict of interest, and equally important where he thinks that there would not.
My hon. Friend the Member for Islington, South and Finsbury mentioned earlier that if a local acute trust employed a salaried GP, that might create a problem in that it would be cornering the market for referrals, which would put pressure on the GP. I also see a problem if the acute trust was not in a local area and was trying to attract business—to use the market term—for its own hospital by employing a GP in another area. I ask the Minister to clarify how he will guard against those problems.
If commercial enterprises can have a role in this, and if acute trusts can employ GPs, why cannot health authorities? The Secretary of State said earlier today that it would compromise the purchaser-provider split, but the GP's role is one of both purchaser and provider. The Government are saying that a health authority cannot employ a GP because the GP is a provider of health care, but what about the fact that a GP is also a purchaser of health care? If the GP is employed by an acute trust, that compromises the purchaser-provider split. If a health authority is to fulfil the role of identifying health needs in an area and enable the development of primary health care, what reason is there for preventing it from employing GPs?
There are flaws in the Bill, but that does not remove the value of discussing primary care and having new legislation on that. There is a shortage of GPs. There are recruitment problems, and they must be addressed. The boundaries that used to exist between secondary and primary care are becoming fuzzy and in many places are breaking down. It is no longer easy to determine exactly what should take place in a hospital and what should take place in a local health centre, but the structure of NHS finance still maintains that division, which is not there in reality.
I give just one example. If a patient on a low income needs to get to a hospital that is not nearby, it is likely that he or she will get financial assistance for transport, but if the same patient needs the same treatment and instead gets it at the local health centre, he or she cannot get financial assistance to get there because it is not funded in the same way. Those anomalies need to be addressed. I welcome the Bill in so far that it has started the discussion, but without the reasoned amendment tabled by the Labour party it is flawed.
If a primary health care strategy is to be developed and is to mean what it says in developing a national health service that prevents ill health as well as treating the consequences of ill health, it needs to look beyond the boundaries of the health service. It is a fact that the life expectancy of somebody in the lowest income tenth of the population is eight years less than that of somebody in the highest income tenth of the population. Unless we as a society address the problems of poor housing, of the benefit system and the poverty trap, of the availability of work and of low pay, a primary health care strategy will not work. A multi-disciplinary approach is needed to tackle the problem, not just within the health service but between the health service and our economic policies.
Sadly, from "The Health of the Nation" White Paper onwards, the Government have not shown themselves willing to acknowledge the huge link between poverty and ill health. Until the Government address that issue, we shall not have an effective primary health care strategy in this country.
I give a very warm welcome to the Bill. It is fundamental and is a natural development of the way in which health care is going. This afternoon, however, I appeared on a television programme with the hon. Member for Dulwich (Ms Jowell). I think that she will recall that our conversations appeared at complete odds. She talked about "crisis in the health service", constantly running the health service down, somehow suggesting that GPs are to be in the pay of unscrupulous commercial organisations.
It is all very well for the hon. Lady to say, "Rubbish," but that is the truth.
What worries me is that such a performance is deeply damaging. It does not enhance her own cause and it worries the patients outside. The hon. Lady carries a grave responsibility when people then ring up believing the erroneous and totally inaccurate information fed to them by the Labour party. On the one hand, the Labour party says that it is all for the national health service, but on the other it bashes it down, runs it down and denigrates all the work that we have done.
It is a curious fact that when I talk to people in their own homes and we discuss the health service, they say, "I'm very worried." When I ask them why they are worried, they tell me that they are worried because of what the Labour party says—that the health service is in crisis. It is in no crisis at all. Indeed, when we discuss the situation a bit more, people tell me that they understand that the Conservatives have put more money than ever before into health care.
It is important that we try to brush away the cobwebs and confusion put about by the Labour party and look more positively at what the Government are trying to do. We are trying to move ahead with the times. We have recognised that we have reached a stage where GPs are able to provide a service that is second to none. Give them their freedom, allow them to become fundholders—as more than half the country's GPs are—and it is excellence that they provide. I have seen the differences for myself in a fundholding practice, which now carries out minor surgery. It has consulting rooms where people are given counselling about various problems. People come in to give physiotherapy. It has employed nurses. It links up with osteopaths. There is no end to the services that an effective GP fundholding practice can provide.
There is another side to the coin, however. While such practices are going full blast in perhaps the more prosperous areas—in my constituency they are a wonderful showcase of modern medicine—I am aware that there are GPs working on their own, particularly in the inner cities, which are less attractive to GPs, who badly need to expand the services that they would like to provide.
Would it not make marvellous sense for such a GP to branch out and set up a relationship, say, with the local supermarket or shopping centre to bring in private finance, like the private finance initiative, which the Labour party is not a bit against, as I understand it, to bring in fresh money and fresh enterprise and thus be able to provide the services that they are not able to provide on their own? That is known as flexibility and moving with the times; it will certainly respond to patients' needs, and I believe that it will be greatly appreciated.
I am worried about the Labour party's allegation that there will be unscrupulous behaviour and that doctors will be in hock to companies which will insist on selling only those drugs and treatments that generate a profit to themselves. That allegation totally ignores all the safeguards which are built into the Bill to ensure that the health service continues to provide the excellence, honesty and integrity that it has always provided.
It is reassuring that in another place a number of their Lordships conceded that the Bill would provide services that will be much appreciated. The fact that the pilot schemes have to be referred to the health authority and then to the Secretary of State, and that he can veto unsuitable schemes, shows that we are not allowing unscrupulous people to get through. I would be more worried about too much red tape and bureaucracy slowing up a jolly good idea, which would spoil what we are trying to do. We could be almost too careful. I hope that my hon. Friend the Minister will address that point.
We have moved into an age in which we should be expanding and taking advantage of all the outside interests which could benefit patient care. That is the name of the game, and I give the Bill a warm welcome and wish it a safe passage.
I had a nightmare last night that I believe was brought on by the Secretary of State's words following the Queen's Speech, as quoted by my hon. Friend the Member for Islington, South and Finsbury (Mr. Smith). Perhaps it happened because Asda is prominent in my constituency or because I have met Archie Norman once or twice on business connected with Asda and my constituents. He is obviously an able entrepreneur, and I know that he now has other roles in the Tory party.
In my nightmare, I imagined Asda setting up surgeries in my constituency. A patient would go to an Asda surgery and tell the doctor that he was suffering from stress; shortly afterwards, he would receive an advertisement for Asda products—low-fat, easy-to-cook, microwaveable nouvelle cuisine, perhaps—that would be good for his condition. I imagined in my nightmare that such a tie-up might happen.
The Secretary of State told me today that I was completely wrong and that there would be no commercial pressures. My hon. Friend the Member for Islington, South and Finsbury was kind, and the hon. Member for
Southwark and Bermondsey (Mr. Hughes) was disingenuous, in responding to that. The latter regarded it as a pledge that was there for all time, but I believe what Colin Brown wrote in today's The Independent. He said:
Mr Dorrell agreed to revise the clause after the British Medical Association warned that it would ask GPs to make the proposal for `supermarket surgeries' an election issue.
I rather think that that is why the proposal has been dropped. It is potentially dangerous, because it shows that privatisation, perhaps by stealth, could happen in primary care if the Conservatives won a further term. I am sure, however, that the public will have understood that message.
I understand that the Minister played a critical role in securing that pledge from the Secretary of State; that is because he has been at the front line of the consultations and knows that GPs do not want commercialisation or commercial pressures, as the BMA made very clear. Will he make it absolutely clear that clause 14 will be dropped from the Bill? It was said that only health service bodies would make provision, but under the clause a non-health service body could do so.
If the clause is dropped, my nightmare will not come true—at least not for the moment: I should like to be completely sure that it was dropped for all time and not merely to woo the electorate. The public have made it absolutely clear that they do not want doctors provided by commercial organisations.
In Morley in my constituency, there is an extremely active community pharmacy, the Janet Ward pharmacy, that has an excellent system of working with a local GP and providing a genuine community service, taking care of all the pensioners and people in serious and urgent need. To do that, it has to maintain large stocks, and it is running an excellent business. It is helpful if such community activities can be part of an NHS contract, as is suggested in the Bill. I am in favour of that.
The pharmacy, however, is just down the road from the Asda store, which undercuts its prices for drugs. As a result, it is becoming more difficult for it to stock the necessary range and quantity of drugs. Two aspects of the Bill are therefore working in conflict with one another. I do not want to deal with the specifics of the sale of drugs and price maintenance, but that is not unrelated to continuing community pharmacies.
We broadly welcome the Bill, as long as the commercial clause 14 is dropped. We consider that the Bill gives a welcome flexibility in GP contracts and view it as a boost for local co-operation in the provision of primary medical services. It is a departure from the narrow competition of fundholding. The patient is currently disadvantaged by the rigidity of a system that prevents GPs from taking a greater role in the development of services.
I am glad that the Government have come to see the value in Labour's policy of local commissioning. Apart from our concern about the role of acute hospitals trusts, which my hon. Friend the Member for Birmingham, Northfield (Mr. Burden) mentioned, the Bill, once it has been pruned of its more dangerous elements, is to be welcomed.
I have some specific questions for the Minister. Nurses and midwives have been mentioned several times. In Committee in the Lords, Baroness McFarlane tabled an amendment to make the right of nurses to set up a primary practice an explicit part of the Bill. Baroness Cumberlege rejected that as unnecessary, because she believed that the Secretary of State would look favourably on some nurses' pilot schemes; but how will we get such schemes unless that is made clear in the Bill?
I welcome the possibility of pilot schemes in NHS dentistry. It is worrying that NHS dentists have almost disappeared in some places, especially where there is a sufficient potential base of private patients.
On commissioning, I asked the Secretary of State about the time limit for schemes. I was glad that he said that he would table an amendment to set a maximum time of three years but I am surprised that he does not think that we need an amendment to set a minimum time. The British Medical Association suggests 18 months, which is a sensible time for a pilot to run. It is important that pilots run for a complete financial year because the way in which schemes are financed is important.
I am not convinced that the Bill and its explanatory and financial memorandum allow enough money. For the financial year 1997–98, a provisional £6 million has been allowed. Clause 16 allows for public funding of the costs of preparing the pilot schemes. It sets limits on such funding and allows for repayment if conditions are not complied with, but is there a potential additional cost to health authorities that the Secretary of State will not fund? It is unrealistic to think that £6 million will cover the cost of preparing, managing, monitoring and evaluating schemes.
I am worried about the single budget for health care. It is right to have one, but once schemes are up and running, clause 32 provides that health authorities will fund costs from cash-limited expenditure that currently funds hospital and community care. We are told that the single health budget is intended to boost cottage hospitals, but the Government have closed 245 of them since 1990. There is no estimate in the memorandum of how much will have to be transferred from the non-cash-limited budget that is currently used for general practice. Will any shortfall come out of health authority purchasing power? There will also be an effect on secondary care funding. I doubt whether all the changes can be funded from £6 million and efficiency savings in primary care.
We welcome much of the Bill but we need to be convinced that the Secretary of State has really chopped off his previous commitment to the commercialisation of services. I would like to be sure that that is not, as The Independent says, an electoral response. We are concerned about the effect of commercialisation on the doctor-patient relationship.
We are concerned about the distribution of GPs around the country. I agree with the hon. Member for Chislehurst (Sir R. Sims) and my hon. Friend the hon. Member for Gower (Mr. Wardell) about the importance of the present restriction on general practices coming into pre-registration training. It is anachronistic to talk about health centres as the Bill does. It suggests that all progressive general practices are in health centres. I should not have thought the Secretary of State would want to cut out fundholders from undertaking such work, but that is what he is doing by using only practices within publicly funded health centres. I hope that he will consider that carefully. It is time that I sat down, but I hope that the Minister will comment on some of those important points.
I very much welcome the Bill, which deals with primary care. Primary care is regarded by many as the jewel in the crown of the NHS, and it is also the envy of other health services throughout the world.
It is often said that many professions enjoy low public esteem and certainly—according to the polls—we as Members of Parliament share with journalists and estate agents that low esteem. Even the clergy sometimes have difficulties. But one profession that enjoys considerable public esteem is the medical profession—our GPs. That is because they are a central part of life in our cities, towns and villages. The local accessibility and the trust that they have developed among their patients and in their communities are so valuable. Part of the primary care provision is the role of community nurses, to whom I pay special tribute. Many of my constituents have talked about the role that they play.
In the evolution of GPs—and latterly of fundholdersthere has been an expansion in the services they offer. We can all remember the old-fashioned premises in which doctors used to operate, which were not at all user-friendly. Today—particularly in GP fundholding practices—one enters an environment that is wholly different from that of the past. Services such as minor surgery, chiropody, improved diagnostic procedures, ultrasound, X-ray facilities and pharmaceutical services are provided, and these are greatly valued by local communities.
I saw that for myself in the village of Lakenheath in my constituency, which has 5,500 residents. Doctors in the village wanted to increase the scope of the pharmaceutical services that they provided to the community. Another pharmacist came along and wanted to set up a rival operation but, interestingly, local people passionately wanted only the doctors to provide the service. Whatever the pros and cons of that issue were, it underlined the value of primary care services and how much they are trusted and appreciated in our communities.
I have mentioned the enhanced range of services that are available, but following GP fundholding there has been an additional drive to quality. This has been led by the fact that realistic choices are given to GPs to pursue better services for the treatment of their patients. In the past few weeks, I have written to all the GP fundholders in my constituency, and I am slowly beginning to receive replies. Many are concerned about the setting up of the so-called locality GP commissioning groups. They have asked me what these will mean in practice, and whether GPs will lose the right to direct patients to hospitals of their choice. They are concerned about the potential additional bureaucracy of the so-called consultation process involved in the setting up and operation of the commissioning groups.
The truth is that there have been many changes at the primary end of the NHS, but it is now basically working very well indeed. If it ain't broke, don't fix it—that is the principle. However, there is a feeling that the current national arrangements are inadequate as they are insufficiently flexible. It is true that the needs of communities differ from one part of the country to the next. But at the heart of the Bill—this is what makes it so welcome—is additional local flexibility to allow GPs to match their skills to the needs of their communities and patients. The Bill will also provide a legal framework for medical and dental services. I particularly welcome the fact that pilot schemes are seen as part and parcel of the way in which it is envisaged the Bill will operate.
My hon. Friend the Member for Blaby (Mr. Robathan) referred to preventive medicine. In the expansion of primary care facilities in this country, we have seen an ever greater emphasis on preventive medicine. Health care needs are being brought to the attention of the people. We would all like to live to a ripe old age in a healthy way, and I am sure that hon. Members will agree that Dame Barbara Cartland is a shining example of that.
The fact is that local flexibility needs to adjust to different circumstances. When I served on the Select Committee on Health, I went to the east end of London, where there are considerable problems with respiratory and bronchial ailments that need to be addressed at a primary level. Those problems are being addressed and the services will be enhanced by the Bill.
I also welcome the fact that, as primary care has evolved, there has been greater use of complementary medicine, especially by GP fundholders. Homeopathy is now seen to work at a complementary level and many doctors believe that there is some value in that. Hon. Members will recall that my hon. Friend the Member for Aylesbury (Mr. Lidington) introduced a Bill to bring chiropractic into the mainstream of accepted medical practice and the same change of attitude is happening in respect of osteopathy—an holistic approach, which has been pioneered at the primary level and is so welcome in expanding services in this country.
I am delighted to say that, on Friday, my right hon. Friend the Secretary of State will come to my constituency to visit Newmarket hospital—indeed, some years ago when he was a junior Minister, he was involved in the decisions about the future of the hospital. He will see that out of that £8 million project has come an important bridge from primary care to the sort of services that are offered at the hospital, leading up to acute care facilities. The level of satisfaction among out-patients is high and the services that are offered, working closely with GPs, including radiography and physiotherapy, are greatly valued.
That flexibility is so important. Only this afternoon, I received a letter from a GP in Newmarket telling me how successful the new hospital was and how well he was able to slot in his activities at primary level with those of the hospital. We now have a spectrum of NHS services that is clearly enhancing patient care.
I want to make one point in respect of acute care. Many spurious points have been made about the health of the NHS as a whole. As I go around the main acute care hospital in my constituency, the West Suffolk hospital in Bury St. Edmunds, and look at the staggering range of new facilities that has been introduced over the past few years—from the day surgery centre to the state-of-the-art intensive care wards to a brand-new £500,000 operating theatre—I know that more patients are being treated and better services are being offered. I pay tribute, on behalf of my constituents, to the range of facilities that are now offered.
I ask my hon. Friend the Minister to comment on one issue that has been brought to my attention by GPs in my constituency, which is the fact that many of them feel that the route into working in hospitals—the possibility of moving up and perhaps becoming consultants—has become increasingly attractive relative to the alternative of staying on as GPs. Many feel that for a variety of reasons the attraction of being a GP, as opposed to working in a hospital environment, has lessened somewhat in the past few years. I should be grateful if my hon. Friend would comment on that.
The level of actual NHS satisfaction is extremely high. The expansion of primary care has been greatly welcomed, not only in my constituency but throughout the whole country. At the heart of the Bill is a principle with which I wholeheartedly agree: the principle of pilot schemes to ensure that the flexibility inherent in the Bill is introduced appropriately. The Bill also ensures legislative changes to make the carrying out of primary care more appropriate.
The Bill moves primary care into a further stage of sophistication and attractiveness. I very much welcome it.
I welcome some of the measures in the Bill, such as appointments to single-handed practices, the move towards practice-based contracts and the provision for salaried GPs. Yet I reflect that, when Aneurin Bevan founded the national health service, the guiding principle was that the health service should be available according to need and free at the point of delivery. Sadly, 18 years of Tory rule have seen the erosion of that principle, and I fear that, if the Bill is passed as it stands, it will lead to the destruction of that principle.
We have already had the introduction of individual GP fundholding, which, with the internal market, has without question brought about a two-tier health service. Many patients are no longer treated on the basis of need. Instead, other factors such as age, where they live or whether their GP is a fundholder are considered important.
Last year, I was at the European Surgical Institute in Hamburg with several British consultants. One of them told me that he had been telephoned by a GP who asked him what he charged to do a hernia operation privately. He replied: "Seven hundred pounds." The GP replied: "I will give you £10,000; do it for £300." That is not the language of health care but the language of the market trader.
Senior staff to whom I have spoken in the health service confirm that treatment is no longer available on the basis of need. I fear that, if the Bill is passed in its present form, it will accentuate the variation in the quality of services that patients receive and encourage cherry picking.
I listened to what the Secretary of State said about amendments that would be tabled in Committee, and I welcome what he said. However, the Bill as drafted offers no safeguards against the growth of a two-tier health service—a two-tier health service in which hospital services are effectively being denied patients who are not registered with a GP fundholder.
Recently, in another place, Baroness Jay said that there is surely something wrong when Lincoln county hospital writes to all non-fundholding GPs in its area, cancelling out-patient appointments for the rest of the financial year, although it is telling fundholding GPs that they can continue to send their patients there.
The Bill will have a significant effect on the way in which the health service operates. Pilot schemes are a key feature of the Bill, which I welcome. I also welcome the Government's change of mind on pilot schemes. It is quite a surprise to many people in the medical profession and elsewhere. My hon. Friend the Member for Islington, South and Finsbury (Mr. Smith) expressed his surprise earlier.
I recall the remarks of Dr John Marks, chairman of the BMA, at the time when the right hon. and learned Member for Rushcliffe (Mr. Clarke) was Secretary of State for Health, suggesting that we should have pilot schemes, to which the Secretary of State replied that he would not agree to them because the BMA would sabotage them.
The provision in the Bill that allows "other bodies" to become involved in the formulation of pilot schemes by sponsoring someone who has an existing NHS contract or by allowing them to apply to become health service bodies is obviously deeply worrying. We must wait until the Committee stage to discover what more the Secretary of State has to say on that point.
Supermarkets, large pharmaceutical companies and private health care companies have all been considering the feasibility of becoming involved in pilot schemes. Asda has been considering plans to provide rental space for GPs in supermarkets. Unichem has plans to build up to 20 new health centres and has suggested that it should employ GPs as part of a consortium with BUPA. PPP Healthcare proposed a pilot scheme involving provision of GP services at the company's private hospitals with referrals for hospital care to the hospital. We shall need to discover in Committee what the Secretary of State plans.
Those are significant concerns—concerns about the integrity and quality of primary health care and about the very existence of the national health service. I know that they are shared by the BMA and general practitioners. Only yesterday, I spoke to a general practitioner in my constituency, Dr. Sahni. He tells me that, to his knowledge, about 80 to 90 per cent. of GPs consider most of the proposals in the Bill to be extremely damaging. As Dr. Sahni pointed out, when a large pharmaceutical company becomes involved the emphasis is no longer on patient care. Commercial organisations would be under pressure to maximise income and it is probable that they would seek to sell a range of services and products that are not necessarily in the interests of patient care.
Some aspects of the Bill risk destabilising the general practitioner service. At the moment, patients know that the NHS family doctor has a contract with the state. The BMA has stated that the family doctor service remains, and must remain, fully within the NHS and not be open to direct or indirect privatisation. Under the Tory Government, we have seen creeping privatisation. It is no longer possible for the majority to get free eye tests, which are an essential health check, and the number of dentists offering treatment under the NHS continues to fall. That is the legacy of the Tories, and I fear that the Bill provides for more privatisation.
Doctors to whom I talk tell me that they are disillusioned and demoralised, and we must take account of what they say. They are dedicated professionals, but they have enormous difficulty securing the best care for their patients because of the internal market and creeping privatisation.
We cannot run primary or secondary health care like a supermarket. Doctors know that, the Opposition know that and the people of our country know that, but Conservative Members do not know it. Like Opposition Members, doctors and the public believe that general medical services must remain fully within the NHS; that GPs must be free to exercise independent clinical judgment; and that the Bill, as it stands, will fundamentally destroy the basic principle of the NHS. The public ask why the Tories never learn.
The Secretary of State's announcement on commercialisation was a huge climbdown, but it was born of coercion rather than conviction. At the launch of the White Paper "Choice and Opportunity" that preceded the Bill, the Secretary of State was glorying in headlines that heralded the "big bang" style deregulation of general practice. It was claimed that the way would be opened for supermarkets and other private companies to employ GPs. The GPs would then be accountable to their employers—a different prospect from supermarkets or any other potential landlord being able to offer premises for rent to GPs.
Before the Secretary of State's climbdown, Asda and Unichem were trailed as having an interest in employing GPs, PPP Healthcare had already submitted a bid and one central London GP claimed to have had three approaches from private companies. The future appeared to be one of American-style health maintenance organisations that could pick and choose between patients.
What has happened? We know that the Secretary of State now deals with health as his day job, while moonlighting—much to the irritation and embarrassment of his colleagues—on devolution, Europe and constitutional matters. For the benefit of the House, perhaps the Secretary of State can clear up the confusion on whether he speaks on constitutional matters—
We are concerned to ensure that the Secretary of State is fighting for patients and not fighting to become the Leader of the Opposition after the election. The difficulty is another example of the chaos that is besetting the Government. During the Secretary of State's distractions, GPs have been standing up for the values of the national health service—hence today's climbdown.
The proposals for the privatisation of primary care have been dropped not out of conviction, but to avoid a row with the British Medical Association in the run-up to the election. If the Government thought that they could get away with it, they would go ahead.
The Secretary of State said in his opening remarks that he thought that the concern raised by Labour and the BMA about the commercialisation of general practice was misplaced. The implication was that the misunderstanding was on our part. Let me remind the right hon. Gentleman of his comment to Pulse:
If a service cannot be provided using other routes, commercial enterprise may offer a solution.
Even though the Government have backed off, there is still enormous scope, as my hon. Friend the Member for Islington, South and Finsbury (Mr. Smith) rightly pointed out, for a new relationship between the private sector and general practice—a relationship that we believe would be to the detriment of patient care. Despite the Secretary of State's climbdown, we shall use the Committee stage, if the Bill secures a Second Reading, to ensure that further avenues to privatisation and fragmentation of the national health service are closed.
The Secretary of State spoke today about
the importance of the pilot-based approach.
We welcome that change of heart, but it will surprise many in the NHS who still have the bruises to show from the previous round of Tory NHS reforms. The then Secretary of State, the right hon. and learned Member for Rushcliffe (Mr. Clarke), still speaks proudly of imposing the Government's dogmatic internal market on a reluctant health service. He said at the time:
I was quite sure that if you isolated a few places as pilots, all the best efforts of the BMA element in the medical profession would be bent to ensure that it failed.
Had he shared the more consensual approach preferred by the current Secretary of State, we would not be saddled with a bureaucratic competitive market that is universally detested in the NHS.
Then there is the Secretary of State's discovery of the value of GP commissioning. Welcome to Labour's cause, which appeared in the White Paper, "Choice and Opportunity". Labour's proposals will ensure equity between patients, less bureaucracy and co-operation between GPs in the procurement of patient care.
GP fundholding, however, has reinforced inequity between patients. Whether or not people have fundholding GPs has become a major and unfair determinant of whether they get hospital treatment. As the Audit Commission remarked, fundholders tend to come from suburbs and shires, rather than inner cities, and, as a natural corollary, tend to look after more affluent and less socially deprived patients.
We also welcome the Government's climbdown today on the critical role played by the Medical Practices Committee in central work force planning, and ensuring within the terms of its remit that there is an even spread of family doctors across the country. As my hon. Friends have made clear during the debate, there are parts of the country that suffer from chronic shortages of GPs. In my health authority and that of the hon. Member for Southwark and Bermondsey (Mr. Hughes), 20 GP vacancies are currently unfilled.
I pay tribute to the Medical Practices Committee for its rigour in checking the eligibility of GPs to practise. It is worth noting, and I am sure it is not accidental, that, since the NHS was created, only one bogus GP has ever entered practice. That demonstrates the rigour with which the committee applies itself to its task.
We welcome the fact that the Secretary of State was so adamant that the Bill as at present drafted does not preclude nurse-led pilots. That must be made clear to the BMA and the Royal College of Nursing, which have slightly different concerns, but are both clear that the Bill as drafted excludes that possibility. We shall return to that in Committee if the Bill secures a Second Reading, so that the position can be made absolutely clear.
As my hon. Friends have said, there are parts of the Bill that we welcome and support. We hope that the proposal to allow community trusts to employ GPs will help to address the chronic problems of GP recruitment in some areas. The move towards practice-based contracts is welcome, as are the new rules for the appointment of GPs to single-handed practices. The only question is why it did not occur many years ago. Hon. Members raised many other issues during the debate that we shall wish to pursue in Committee, if the Bill gets that far.
My hon. Friend the Member for Gower (Mr. Wardell) drew attention to the worrying decline in the number of medical trainees entering general practice. He suggested that medical students should conduct part of their training in general practice. He makes common cause with the hon. Member for Chislehurst (Sir R. Sims), and I hope that it will be possible to proceed with the proposal on the basis of cross-party support.
My hon. Friend the Member for York (Mr. Bayley) made a valuable contribution to the debate, setting out in detail the inequity in the distribution of primary care resources. He also underlined the enormous discrepancy between the number of GPs per patient in different parts of the country. The inequitable distribution of national health service resources is one of the Government's worst legacies, and will be addressed as a matter of priority by a Labour Government.
The hon. Member for Belfast, West (Dr. Hendron) raised concerns about the conflict of interest in acute trusts that employ GPs. We share his concern, but the situation was not illuminated by the Secretary of State's explanation as to why the purchaser-provider split is blurred by health authorities employing GPs, but not by acute trusts doing the same thing. My hon. Friend the Member for Halifax (Mrs. Mahon) drew attention to the threat to the doctor-patient relationship posed by the involvement of the private sector in the delivery of primary care. She gave the example of PPP Healthcare, which wants to establish a base for GP services at its private hospitals in London.
My hon. Friend the Member for Cannock and Burntwood (Dr. Wright) raised an important issue regarding the lack of women GPs. He cited the example of the town just outside the boundaries of his constituency where there are no female GPs. Women should have the opportunity to register with female GPs if they prefer to do so, and it is quite wrong for the health service to deny them that choice.
However, we must understand some of the issues that lie behind the recruitment difficulties. More women are entering medical school, but the family-unfriendly nature of employment in the health service often makes it difficult for women, in particular, to combine the responsibilities of rearing a family with the responsibilities of general practice. There are other outstanding issues which the Secretary of State failed to address today, that we shall pursue if the Bill is sent to Committee.
I share many of the hon. Lady's concerns about the improvements that the Bill must deliver. However, given the Secretary of State's announcement—which I think we all welcome—do the hon. Lady and her colleagues intend to press the reasoned amendment? Do they want the Bill to fail tonight, or do they want to get it on to the statute book?
We want to ensure that the points that we have made in our reasoned amendment are put to a vote in the House. We believe that, unless they are addressed, the Bill will be seriously weakened. I look forward to hearing the Minister respond to those issues in winding up.
In his concluding remarks, the Secretary of State mentioned that GPs who leave pilot schemes will be able to return to independent contractor status. We welcome that assurance, which will undoubtedly reassure GPs who wish to participate in pilot schemes. However, we were concerned by the Secretary of State's failure to mention any protection for patients who registered for pilot schemes that were discontinued. Listening to the Secretary of State—who is now chatting to his hon. Friend the Minister for Health—one was left with the impression that patients' interests are peripheral to the Bill. That impression was strengthened by the Secretary of State's remarks about the need for consultation with patients, to which we refer in our amendment.
My hon. Friend the Member for Islington, South and Finsbury pointed out the lack of detail on the precise course that any consultation should follow. No reference was made by the Secretary of State to the need for the view of patients to be fully considered before pilot projects are established.
In Committee—if we reach that stage—we shall pursue that issue, and shall seek an assurance from Ministers that pilot schemes will not proceed without first having been open to comment and consultation with patients. We shall also press the Government on the need for patients to be properly protected in the event of a pilot scheme being discontinued, and on the need for proper consultation with patients.
The Secretary of State did not provide any detail on what the proposals in the Bill will do to address the crisis in NHS dentistry and to ensure that people have access to NHS dentists. Many people in the world outside would like to know what the Government intend to do. The British Dental Association found that one in three people have trouble finding an NHS dentist. There are enormous regional variations.
When the White Paper was published, the Secretary of State remarked:
The last 17 years have seen … steady growth of NHS dentistry".—[Official Report, 15 October 1996; Vol. 282, c. 589.]
That glib claim shows no understanding of the real problems that many people face when trying to find an NHS dentist. He should speak to his hon. Friend the Member for Blaby (Mr. Robathan), who admitted that it has become harder in recent years to find an NHS dentist.
The hon. Gentleman has not been present for the whole of the debate, so I shall not give way.
We want the Government to explain how the proposals are intended to solve that problem.
The White Paper, "Choice and Opportunity", was welcomed for its recognition that the two-tier service engendered by the Government's reforms is unacceptable. It stated:
It will be important not to create inequity of resources for patients of different practices.
Sadly, the Bill offers no safeguards to prevent that. We shall return to that matter if the Bill reaches Committee.
The White Paper also admitted that the Tories have neglected primary care in many parts of the country. That is not a startling revelation to Opposition Members. It says:
The quality of service for some patient groups in some areas is not always high.
That was another welcome admission, but again the Bill contains no proposals to end the unacceptable variations in the standard of primary care across the country.
Other issues should be given detailed consideration. Whistle blowing was brought back into the spotlight this week by the dreadful revelations at Ashworth hospital. As independent contractors, GPs currently have the freedom to raise issues of concern on behalf of their patients. Should the Bill be passed in its current form, and should the employment of GPs become the responsibility of NHS trusts, that freedom would be curtailed. We do not believe that that would be in the interests of patients. We believe that that freedom should be preserved.
Should the Bill reach Committee, we shall want to discuss the lack of detail on the process by which pilot projects will move to permanent schemes, and the impact of a single budget for health care with its attendant risks, to which a number of hon. Members referred.
This may be the final debate on health in this Parliament: it certainly will be if the Government have their way. The Bill provides a building block, and in part we welcome that. The manner of its management in the other place, and the Secretary of State's announcement today, constitute an extraordinary climbdown. The Government wanted to privatise general practice, but they realised that they could not get away with it.
My hon. Friend the Member for Islington, South and Finsbury made it clear that amendments were withdrawn on Report in the other place and did not reappear on Third Reading, without any adequate explanation. We have now had a major climbdown by the Secretary of State. Given the chaotic management of the Bill, we believe that, before it goes to Standing Committee, consultation should be held with professional interests and groups that will be directly affected. That is an important part of ensuring that the legislation will work in practice.
In essence, the Bill is a long-overdue response to problems of the Government's own making. The British Medical Association has said:
GP morale is at its lowest ebb for many years, is caused by excessive workload, the continuing out of hours burden, too much bureaucracy and falling remuneration relative to comparable professions".
It is because those problems have been ignored for so long that there is now an acute shortage of GPs in so many areas.
As my hon. Friends have made clear, there is much in the White Paper and the Bill that we welcome, but—as careful reading of, in particular, the White Paper reveals—it is a very quiet and muted apology for the damage that the Government have done to the national health service. It comes at the tail end of a Parliament, before a general election that we hope will produce a Labour Government—a Labour Government who will use the acceptable parts of the legislation to rebuild primary care, and to rebuild a national health service in the interests of patients and of all the people of this country.
I listened to the speech of the hon. Member for Dulwich (Ms Jowell) with some interest. I am glad that the Bill is broadly supported by the House; indeed, the hon. Lady claimed that it was long overdue. It is somewhat unusual in such circumstances for the Labour party to table a reasoned amendment that would deny the Bill a Second Reading, and I cannot quite square that with what has been said.
Having heard both the hon. Lady's speech and that of the hon. Member for Islington, South and Finsbury (Mr. Smith), as well as supporting speeches from other Opposition Members, I think it was clear that they were straining to highlight issues that divide the House, when there was a general consensus on the principles of the Bill—although, of course, we shall have to address certain issues in Committee.
I do not think that the hon. Lady made a terribly good job of distancing her party from what the Government are trying to do. She does herself no credit by trying to raise scares, and trying to elevate issues that were, perhaps, always at the periphery of what was happening as we introduced the legislation to a central position that they never held. I am delighted to be able to say that there is a great deal of consensus between the Government and the medical profession, whose members consider the Bill necessary. [Interruption.] We are hearing the normal sedentary interventions from the hon. Member for Cardiff, West (Mr. Morgan). If he had been here to listen to the debate, he would have found that many of his hon. Friends broadly welcomed the Bill.
Let me return for a moment to the genesis of the proposal. Primary care has served the country well since the national health service was brought into being in the late 1940s. It has had an honourable career for some 50 years, but during those 50 years, it has largely remained unchanged: it is still delivered in the same form as when it was first introduced. Those who read the original document advising patients what to do to register with a general practitioner back in 1948 will note that the sonorities are the same—and that, moreover, the details are the same.
A truth has been acknowledged by all the professionals who provide the primary health care team: a truth that is certainly recognised by the Government and, perhaps somewhat grudgingly, by the Labour party. Although Labour Members may now have been converted to some of the principles in the Government's proposals, I do not recall their initiating a debate such as this when they had the opportunity to do so in government. The truth is that this is a service that needs to change. Things have moved on; the ability to deliver primary care has developed, and the various roles of the primary health care teams have changed. Those teams want to perform in a different way, and the Bill, together with the White Paper, takes the debate forward by light years.
As my right hon. Friend the Secretary of State said, I have had the benefit of going around the country listening to the ideas of all the primary health care professionals about how to take the service forward. I enjoyed that exercise. The Bill has been largely formed not by what Ministers thought should happen to primary care, but on the principles that were set out by primary health care professionals. I pay tribute to all those who were involved in the listening exercise and the exercise that followed it. Much hard work was put into it. I pay tribute both to every professional who attended and to officials in the Department and all the regions, who have been working vigorously to make the Bill a proposal that is fit to come before the House and be put into legislation over such a length of time.
The hon. Member for Dulwich made a point about NHS dentistry, which was not referred to in great detail in the debate, but which was also mentioned by the hon. Member for Morley and Leeds, South (Mr. Gunnell). The answer to her question is that the Bill will provide, should dentists choose to use it, an entirely new and more flexible option of contracting with health authorities to provide dental health care. It was extremely unfair of her to quote selectively from what my right hon. Friend the Secretary of State for Health has said about NHS dentistry. It is true that, in recent years, the overall volume of dentistry provided through the NHS has increased. It is also true that the number of dentists providing that treatment has increased, but the Government have never shied away from the proposition that, in certain regions, there are difficulties in the provision of NHS dentistry, which will be tackled through the Bill and through new arrangements.
Very quickly, may I support what my hon. Friend says? When there was a problem in my constituency in the village of Poynton and we made out an excellent case for the appointment of a salaried dentist by the family health service authority, as it was then, there was no problem in getting a salaried dentist appointed to ensure that dentistry was available under the NHS in my constituency.
I am grateful to my hon. Friend for recognising that. That has happened in other ways, not least the access fund that was put in place by the Government last year and which we hope to develop.
The hon. Member for Islington, South and Finsbury asked about GPs being employed in acute hospitals. Associated with that is the question of why we have suggested that they should not be employed by health authorities. Of course it is a recognised principle, which will hold if any arrangements are to be approved, that, if a scheme comes forward for approval, especially at the pilot stage, by my right hon. Friend the Secretary of State and an apparent conflict of interest is set within the scheme, it would not be approved. However, it would be foolish to rule that out in principle.
If Labour Members chose, as I suppose that many of them do, to consider local hospitals, particularly accident and emergency departments and some of the admissions wards, where GP provision is increasing, they would find that GPs' occasional involvement in the acute sector is extremely important. There should be mechanisms in the Bill to allow that to happen, if it is appropriate. The hon. Member for Southwark and Bermondsey (Mr. Hughes) asked for a specific example of why that freedom needed to be kept in the Bill. That is a good reason why. Health authorities employing GPs would undermine the authorities' role as holders of the stage between all providers of health care. That is an important principle. Health authorities' role as arbiter would be weakened if they were to become a regular provider as well as a purchaser.
I do not intend to give way just now. I may give way later if I reach the point that the hon. Gentleman raised.
As my right hon. Friend the Secretary of State rightly pointed out, if there is a defined and specific need, there is existing power in the legislation to deal with that.
On consultation and pilot proposals, I can assure the hon. Member for Islington, South and Finsbury that we expect the existing requirement for health authorities to consult community health councils and therefore patient representatives to remain in place. Of course we expect consultation to be carried out as widely as possible.
One thing I never quite understand about the Opposition is that they keep saying that the health service is too bureaucratic and castigating us for that, yet they always seek to build every last detail and possibility into primary legislation. Primary legislation should be about overall responsibilities and principles. In the health service, we are well accustomed to developing guidance that flows from primary legislation.
The hon. Member for Islington, South and Finsbury and other Labour Members asked about nurses' ability to make proposals as doctors and dentists do. Conservative Members have always said that nurses are key members of the primary health care team. Nurses have a role to play in future developments in primary care, and we recently gave expression to that belief in the proposals in our White Paper "Delivering the Future". We will ensure that the changes that we intend to make to the Bill allow nurses to play a full part in the new arrangements.
Although it was perhaps slightly off the subject of the Bill, the hon. Member for Islington, South and Finsbury made a point on paramedics. I should like to respond to that point—as the matter has recently been in the news—and make the position clear. There are a number of ways in which an unqualified person who turns up in an ambulance—on which he has attached a blue light and stripes, after having bought himself a yellow jacket—would find himself at some risk if he tried to provide patient care. If he were unqualified and did not hold a statutory certificate from the Secretary of State, he could be guilty of assault and subject to criminal charges. If he pretends to be medically qualified, he would fall foul of the Medical Act 1983. If he gives drugs to a patient, he would fall foul the Medicines Act 1968. So I hope that we can put to rest any possible doubts on that matter.
My hon. Friend the Member for Bournemouth, East (Mr. Atkinson) rightly referred to the widening scope of services that are now being performed in primary care. That is of course one of the principles upon which we will be building with this legislation, and it will open up many frontiers for the future.
My hon. Friend the Member for Chislehurst (Sir R. Sims), and particularly the hon. Member for Gower (Mr. Wardell), mentioned a point about pre-registration house officers and section 12 of the Medical Act 1983, and I listened extremely carefully to them. Although I do not want to give a specific undertaking during this debate, I understand that it is very important that training of future general practitioners takes place in the very best context.
That is a matter that we have been discussing—in the context of wider reforms and perhaps of other legislation—with the General Medical Council. If it is possible to meet the concerns of my hon. Friend and the hon. Gentleman while being satisfied about the type of training provided, I will try to do so. If at all possible, I will attempt to table an amendment in Committee to deal with that important point.
I was grateful to the hon. Member for Southwark and Bermondsey for his broad support for the Bill. He asked a question about pilots having a minimum time. Although I think that it is right that there should be a maximum time—which we have agreed to set in the legislation—it is difficult to determine the purpose of a minimum time. We will be developing evaluation criteria in wide consultation with the professions, and of course it will be necessary that a reasonable period is set. However, it is not right to set a specific minimum, whether it is 18 months or 12 months, because it should be based on principles.
My hon. Friend the Member for High Peak (Mr. Hendry) made a very good constituency speech in which he mentioned all the excellent developments—which can now perhaps be introduced more widely—that fundholding has brought to his constituency. The entire purpose of this legislation is to latch on to innovations that have occurred in fundholding—whereby GPs have been purchasing acute care with great innovation, harnessing that technique and applying it to primary care. He also asked for an assurance that health authorities would not be able to stifle schemes. That is why the legislation specifically provides that any scheme proposed by a general practitioner or NHS interest comes to my right hon. Friend Secretary of State and is not blocked.
The hon. Member for York (Mr. Bayley) spoke of his concern about equity, although he conceded that fairness is being introduced since we started examining health allocations across the country. He complained about the pace of the reallocations, but everyone does. Those who lose on reallocations think that change is probably happening too quickly, whereas those who are potential gainers think that it is too slow. However, we must be careful when considering cash allocations to GP practices. The valid point was made by a Labour Member—I cannot remember who—that it is difficult to make an allocation on the small population of a GP practice base. We have to proceed, but we must do so with care. I am happy to take on board the principle of equitable distribution.
My hon. Friend the Member for Lancaster (Dame E. Kellett—Bowman) was right to point to the strength of the pilot approach. She also talked about the role that can be played by pharmacists and nurses. That will be reinforced in the Bill.
The hon. Member for Belfast, West (Dr. Hendron) is experienced in these matters. I was pleased to have his general support for the legislation and for the Bill's concept. Perhaps we will be able to examine some of his concerns should he be fortunate enough to serve on the Committee.
Some of my other hon. Friends supported the legislation and I welcome that. The hon. Member for Cannock and Burntwood (Dr. Wright) said that he came to praise the Bill. That seemed to be the general approach of the Opposition and I wish that they would translate that approach into specific action in the Lobby tonight.
I do not intend to give way, as I have only a short time left.
I always enjoy the speeches of the hon. Member for Morley and Leeds, South. He never lets a change of circumstances ruin a well-prepared speech. He spoke about a nightmare—his nightmare was Asda. The hon. Member for Southwark and Bermondsey was going a little too far when he said that arms dealers would be taking over primary care. Mr. Colin Brown of The Independent has a lot to answer for. He raised that hare at the outset of the debate on the Bill and it just shows that there has been concentration on the periphery of what the Bill is about. It is best that we now get down to the substance.
I apologise to the hon. Gentleman but I do not intend to give way. He can take me to task later.
My hon. Friend the Member for Bury St. Edmunds (Mr. Spring) spoke about the role of community nurses and local flexibility, which is exactly what the Bill is about. He made an important point about the attractions of primary care and what the Bill would do for that.
Underpinning the entire debate are a number of firm principles. Primary care must be for patients. It must provide the best service, as close to patients as possible and in the best possible circumstances. It is also about the provision of a satisfying career for those who provide primary care—whether they are doctors, nurses, midwives or practice staff. We have paved the way towards recognising their role with the provision of practice staff pensions. They must be able to fulfil their aspirations by providing care in a way that was not possible previously.
The Bill is about the detail set out in the White Paper. It is about recruitment and improving prospects for education. As I went, around the country, I heard the message that, with primary care developing as quickly as it was, it was essential that there should be more training and research in primary care. That point was mentioned by several hon. Members on both sides of the House and we have responded to it. We want to make the primary care environment a place in which people will be proud to practice and in which they can deliver standards of care to which they could only aspire some time ago.
What is most important is the simple message that these are voluntary principles. For anybody who is hoping to take up part I arrangements when the Bill reaches the statute book, I want to place firmly on the record the fact that this is voluntary. Anybody who chooses not to participate in the new arrangements will be able to move back to the arrangements with which they are familiar. That is the principle on which we have approached the Bill.
We have listened to what the professions have had to say and have iterated that in the legislation which we will now take forward. Primary care has served the country well for 50 years. It is time for a new generation of primary care to take that jewel in the crown of the national health service through to the next century. That will be done by the medical professions—doctors, nurses and all those who support them. It will be done by the Bill, which I am delighted to commend to the House.
I am sorry that the Opposition cannot reflect what was said by the hon. Member for Cannock and Burntwood who came to praise the Bill. Opposition Members tried to do that, but they are determined to oppose it tonight. I commend the Bill to the House.
|Division No. 73]||[9.59 pm|
|Abbott, Ms Diane||Cousins, Jim|
|Adams, Mrs Irene||Cox, Tom|
|Ainger, Nick||Cunliffe, Lawrence|
|Ainsworth, Robert (Cov'try NE)||Cunningham, Jim (Cov'try SE)|
|Anderson, Donald (Swansea E)||Cunningham, Rt Hon Dr John|
|Anderson, Ms Janet (Ros'dale)||Cunningham, Ms Roseanna (Perth Kinross)|
|Armstrong, Ms Hilary|
|Ashton, Joseph||Dafis, Cynog|
|Austin-Walker, John||Dalyell, Tam|
|Banks, Tony (Newham NW)||Darling, Alistair|
|Barnes, Harry||Davidson, Ian|
|Barron, Kevin||Davies, Bryan (Oldham C)|
|Battle, John||Davies, Rt Hon Denzil (Llanelli)|
|Bayley, Hugh||Davies, Ron (Caerphilly)|
|Beckett, Rt Hon Mrs Margaret||Davis, Terry (B'ham Hodge H)|
|Bell, Stuart||Denham, John|
|Benn, Rt Hon Tony||Dewar, Rt Hon Donald|
|Benton, Joe||Dixon, Rt Hon Don|
|Bermingham, Gerald||Dobson, Frank|
|Berry, Roger||Donohoe, Brian H|
|Betts, Clive||Dowd, Jim|
|Blunkett, David||Dunwoody, Mrs Gwyneth|
|Boateng, Paul||Eastham, Ken|
|Bradley, Keith||Ennis, Jeff|
|Bray, Dr Jeremy||Etherington, Bill|
|Brown, Rt Hon Gordon (Dunfermline E)||Evans, John (St Helens N)|
|Ewing, Mrs Margaret|
|Brown, Nicholas (Newcastle E)||Fatchett, Derek|
|Burden, Richard||Faulds, Andrew|
|Byers, Stephen||Field, Frank (Birkenhead)|
|Caborn, Richard||Fisher, Mark|
|Callaghan, Jim||Flynn, Paul|
|Campbell, Mrs Anne (C'bridge)||Foster, Rt Hon Derek|
|Campbell, Ronnie (Blyth V)||Foulkes, George|
|Campbell-Savours, D N||Fraser, John|
|Canavan, Dennis||Galbraith, Sam|
|Cann, Jamie||Galloway, George|
|Chisholm, Malcolm||Gapes, Mike|
|Clapham, Michael||Garrett, John|
|Clarke, Tom (Monklands W)||George, Bruce|
|Clelland, David||Gerrard, Neil|
|Clwyd, Mrs Ann||Godman, Dr Norman A|
|Coffey, Ms Ann||Godsiff, Roger|
|Cohen, Harry||Golding, Mrs Llin|
|Connarty, Michael||Gordon, Ms Mildred|
|Cook, Frank (Stockton N)||Graham, Thomas|
|Cook, Rt Hon Robin (Livingston)||Grant, Bemie (Tottenham)|
|Corbett, Robin||Griffiths, Nigel (Edinburgh S)|
|Corbyn, Jeremy||Griffiths, Win (Bridgend)|
|Corston, Ms Jean||Grocott, Bruce|
|Gunnell, John||Morns, Rt Hon Alfred (Wy'nshawe)|
|Hall, Mike||Morris, Ms Estelle (B'ham Yardley)|
|Hardy, Peter||Morris, Rt Hon John (Aberavon)|
|Harman, Ms Harriet||Mudie, George|
|Hattersley, Rt Hon Roy||Mullin, Chris|
|Henderson, Doug||Murphy, Paul|
|Hendron, Dr Joe||Oakes, Rt Hon Gordon|
|Heppell, John||O'Brien, Mike (N Warks)|
|Hill, Keith (Streatham)||O'Brien, William (Normanton)|
|Hodge, Ms Margaret||O'Hara, Edward|
|Hoey, Kate||Olner, Bill|
|Hogg, Norman (Cumbemauld)||O'Neill, Martin|
|Home Robertson, John||Pearson, Ian|
|Hood, Jimmy||Pendry, Tom|
|Hoon, Geoffrey||Pickthall, Colin|
|Howarth, Alan (Stratf'd-on-A)||Pike, Peter L|
|Howells, Dr Kim||Pope, Greg|
|Hoyle, Doug||Powell, Sir Raymond (Ogmore)|
|Hughes, Kevin (Doncaster N)||Prentice, Mrs Bridget (Lewisham E)|
|Hughes, Robert (Ab'd'n N)|
|Hutton, John||Prentice, Gordon (Pendle)|
|Illsley, Eric||Primarolo, Ms Dawn|
|Ingram, Adam||Purchase, Ken|
|Jackson, Ms Glenda (Hampst'd)||Quin, Ms Joyce|
|Jackson, Mrs Helen (Hillsborough)||Radice, Giles|
|Jamieson, David||Randall, Stuart|
|Janner, Greville||Raynsford, Nick|
|Jenkins, Brian D (SE Staffs)||Reid, Dr John|
|Jones, Barry (Alyn & D'side)||Robertson, George (Hamilton)|
|Jones, Ieuan Wyn (Ynys Môn)||Robinson, Geoffrey (Cov'try NW)|
|Jones, Jon Owen (Cardiff C)||Roche, Mrs Barbara|
|Jones, Dr Lynne (B'ham Selly Oak)||Rogers, Allan|
|Jones, Martyn (Clwyd SW)||Rooney, Terry|
|Jowell, Ms Tessa||Ross, Ernie (Dundee W)|
|Kaufman, Rt Hon Gerald||Rowlands, Ted|
|Keen, Alan||Ruddock, Ms Joan|
|Kennedy, Mrs Jane (Broadgreen)||Salmond, Alex|
|Khabra, Piara S||Sedgemore, Brian|
|Kilfoyle, Peter||Sheerman, Barry|
|Lestor, Miss Joan (Eccles)||Sheldon, Rt Hon Robert|
|Lewis, Terry||Shore, Rt Hon Peter|
|Liddell, Mrs Helen||Short, Clare|
|Litherland, Robert||Simpson, Alan|
|Livingstone, Ken||Skinner, Dennis|
|Lloyd, Tony (Stretf'd)||Smith, Andrew (Oxford E)|
|Llwyd, Elfyn||Smith, Chris (Islington S)|
|Loyden, Eddie||Smith, Llew (Blaenau Gwent)|
|McAllion, John||Snape, Peter|
|McAvoy, Thomas||Soley, Clive|
|Macdonald, Calum||Spearing, Nigel|
|McFall, John||Spellar, John|
|McKelvey, William||Squire, Ms Rachel (Dunfermline W)|
|McLeish, Henry||Steinberg, Gerry|
|McNamara, Kevin||Stevenson, George|
|MacShane, Denis||Strang, Dr Gavin|
|McWilliam, John||Straw, Jack|
|Madden, Max||Sutcliffe, Gerry|
|Mahon, Mrs Alice||Taylor, Mrs Ann (Dewsbury)|
|Marek, Dr John||Thompson, Jack (Wansbeck)|
|Marshall, David (Shettleston)||Timms, Stephen|
|Marshall, Jim (Leicester S)||Tipping, Paddy|
|Martin, Michael J (Springburn)||Touhig, Don|
|Martlew, Eric||Trickett, Jon|
|Maxton, John||Turner, Dennis|
|Meacher, Michael||Vaz, Keith|
|Meale, Alan||Walker, Rt Hon Sir Harold|
|Michael, Alun||Walley, Ms Joan|
|Michie, Bill (Shef'ld Heeley)||Wardell, Gareth (Gower)|
|Milburn, Alan||Wareing, Robert N|
|Miller, Andrew||Watson, Mike|
|Mitchell, Austin (Gt Grimsby)||Wicks, Malcolm|
|Moonie, Dr Lewis||Wigley, Dafydd|
|Morgan, Rhodri||Williams, Rt Hon Alan (Swansea W)|
|Williams, Alan W (Carmarthen)||Wright, Dr Tony|
|Wise, Mrs Audrey||Tellers for the Ayes:|
|Worthington, Tony||Mr. Eric Clarke and|
|Wray, Jimmy||Ms Angela Eagle.|
|Ainsworth, Peter (E Surrey)||Cran, James|
|Aitken, Rt Hon Jonathan||Currie, Mrs Edwina|
|Alison, Rt Hon Michael (Selby)||Curry, Rt Hon David|
|Allason, Rupert (Torbay)||Davies, Quentin (Stamf'd)|
|Amess, David||Davis, David (Boothferry)|
|Ancram, Rt Hon Michael||Day, Stephen|
|Arbuthnot, James||Deva, Nirj Joseph|
|Arnold, Jacques (Gravesham)||Devlin, Tim|
|Arnold, Sir Thomas (Hazel G)||Dicks, Terry|
|Ashby, David||Dorrell, Rt Hon Stephen|
|Aspinwall, Jack||Douglas-Hamilton, Rt Hon Lord James|
|Atkins, Rt Hon Robert|
|Atkinson, David (Bour'mth E)||Dover, Den|
|Atkinson, Peter (Hexham)||Duncan, Alan|
|Baker, Rt Hon Kenneth (Mole V)||Duncan Smith, Iain|
|Baker, Sir Nicholas (N Dorset)||Dunn, Bob|
|Baldry, Tony||Durant, Sir Anthony|
|Banks, Matthew (Southport)||Dykes, Hugh|
|Banks, Robert (Harrogate)||Eggar, Rt Hon Tim|
|Bates, Michael||Elletson, Harold|
|Batiste, Spencer||Emery, Rt Hon Sir Peter|
|Beggs, Roy||Evans, David (Welwyn Hatf'ld)|
|Bellingham, Henry||Evans, Jonathan (Brecon)|
|Bendall, Vivian||Evans, Nigel (Ribble V)|
|Beresford, Sir Paul||Evans, Roger (Monmouth)|
|Biffen, Rt Hon John||Evennett, David|
|Body, Sir Richard||Faber, David|
|Bonsor, Sir Nicholas||Fabricant, Michael|
|Booth, Hartley||Fenner, Dame Peggy|
|Boswell, Tim||Field, Barry (Isle of Wight)|
|Bottomley, Peter (Eltham)||Fishburn, Dudley|
|Bottomley, Rt Hon Mrs Virginia||Forman, Nigel|
|Bowden, Sir Andrew||Forsyth, Rt Hon Michael (Stirling)|
|Bowis, John||Forth, Eric|
|Boyson, Rt Hon Sir Rhodes||Fowler, Rt Hon Sir Norman|
|Brandreth, Gyles||Fox, Rt Hon Sir Marcus (Shipley)|
|Brazier, Julian||Freeman, Rt Hon Roger|
|Bright, Sir Graham||French, Douglas|
|Brooke, Rt Hon Peter||Fry, Sir Peter|
|Brown, Michael (Brigg Cl'thorpes)||Gale, Roger|
|Browning, Mrs Angela||Gallie, Phil|
|Bruce, Ian (S Dorset)||Gardiner, Sir George|
|Budgen, Nicholas||Garel-Jones, Rt Hon Tristan|
|Burns, Simon||Garnier, Edward|
|Burt, Alistair||Gill, Christopher|
|Butcher, John||Gillan, Mrs Cheryl|
|Butler, Peter||Goodlad, Rt Hon Alastair|
|Butterfill, John||Goodson-Wickes, Dr Charles|
|Carlisle, John (Luton N)||Gorman, Mrs Teresa|
|Carlisle, Sir Kenneth (Linc'n)||Gorst, Sir John|
|Carrington, Matthew||Grant, Sir Anthony (SW Cambs)|
|Carttiss, Michael||Greenway, Harry (Ealing N)|
|Cash, William||Greenway, John (Ryedale)|
|Channon, Rt Hon Paul||Griffiths, Peter (Portsmouth N)|
|Chapman, Sir Sydney||Grylls, Sir Michael|
|Clappison, James||Gummer, Rt Hon John|
|Clark, Dr Michael (Rochf'd)||Hague, Rt Hon William|
|Clarke, Rt Hon Kenneth (Rushcliffe)||Hamilton, Rt Hon Sir Archibald|
|Hamilton, Neil (Tatton)|
|Clifton-Brown, Geoffrey||Hampson, Dr Keith|
|Colvin, Michael||Hanley, Rt Hon Jeremy|
|Congdon, David||Hannam, Sir John|
|Conway, Derek||Hargreaves, Andrew|
|Coombs, Anthony (Wyre F)||Harris, David|
|Coombs, Simon (Swindon)||Haselhurst, Sir Alan|
|Cope, Rt Hon Sir John||Hawkins, Nick|
|Cormack, Sir Patrick||Hawksley, Warren|
|Couchman, James||Hayes, Jerry|
|Heald, Oliver||Needham, Rt Hon Richard|
|Heath, Rt Hon Sir Edward||Nelson, Anthony|
|Heathcoat-Amory, Rt Hon David||Neubert, Sir Michael|
|Hendry, Charles||Newton, Rt Hon Tony|
|Heseltine, Rt Hon Michael||Nicholls, Patrick|
|Hicks, Sir Robert||Nicholson, David (Taunton)|
|Higgins, Rt Hon Sir Terence||Norris, Steve|
|Hill, Sir James (Southampton Test)||Onslow, Rt Hon Sir Cranley|
|Hogg, Rt Hon Douglas (Grantham)||Oppenheim, Phillip|
|Horam, John||Ottaway, Richard|
|Hordem, Rt Hon Sir Peter||Page, Richard|
|Howard, Rt Hon Michael||Paice, James|
|Howell, Rt Hon David (Guildf'd)||Patnick, Sir Irvine|
|Howell, Sir Ralph (N Norfolk)||Patten, Rt Hon John|
|Hughes, Robert G (Harrow W)||Pattie, Rt Hon Sir Geoffrey|
|Hunt, Rt Hon David (Wirral W)||Pawsey, James|
|Hunt, Sir John (Ravensb'ne)||Peacock, Mrs Elizabeth|
|Hunter, Andrew||Pickles, Eric|
|Hurd, Rt Hon Douglas||Porter, David|
|Jack, Michael||Portillo, Rt Hon Michael|
|Jackson, Robert (Wantage)||Powell, William (Corby)|
|Jenkin, Bemard (Colchester N)||Rathbone, Tim|
|Jessel, Toby||Redwood, Rt Hon John|
|Johnson Smith, Rt Hon Sir Geoffrey||Renton, Rt Hon Tim|
|Jones, Gwilym (Cardiff N)||Riddick, Graham|
|Jones, Robert B (W Herts)||Robathan, Andrew|
|Jopling, Rt Hon Michael||Roberts, Rt Hon Sir Wyn|
|Kellett-Bowman, Dame Elaine||Robertson, Raymond S (Ab'd'n S)|
|Key, Robert||Robinson, Mark (Somerton)|
|King, Rt Hon Tom||Roe, Mrs Marion|
|Kirkhope, Timothy||Rumbold, Rt Hon Dame Angela|
|Knapman, Roger||Ryder, Rt Hon Richard|
|Knight, Mrs Angela (Erewash)||Sackville, Tom|
|Knight, Rt Hon Greg (Derby N)||Sainsbury, Rt Hon Sir Timothy|
|Knox, Sir David||Scott, Rt Hon Sir Nicholas|
|Kynoch, George||Shaw, David (Dover)|
|Lait, Mrs Jacqui||Shaw, Sir Giles (Pudsey)|
|Lamont, Rt Hon Norman||Shephard, Rt Hon Mrs Gillian|
|Lang, Rt Hon Ian||Shepherd, Sir Colin (Heref'd)|
|Lawrence, Sir Ivan||Shepherd, Richard (Aldridge)|
|Legg, Barry||Shersby, Sir Michael|
|Leigh, Edward||Sims, Sir Roger|
|Lennox-Boyd, Sir Mark||Skeet, Sir Trevor|
|Lester, Sir Jim (Broxtowe)||Smith, Sir Dudley (Warwick)|
|Lidington, David||Smith, Tim (Beaconsf'ld)|
|Lilley, Rt Hon Peter||Smyth, Rev Martin (Belfast S)|
|Lloyd, Rt Hon Sir Peter (Fareham)||Soames, Nicholas|
|Lord, Michael||Speed, Sir Keith|
|Luff, Peter||Spencer, Sir Derek|
|Lyell, Rt Hon Sir Nicholas||Spicer, Sir Jim (W Dorset)|
|MacGregor, Rt Hon John||Spicer, Sir Michael (S Worcs)|
|MacKay, Andrew||Spink, Dr Robert|
|Maclean, Rt Hon David||Spring, Richard|
|McLoughlin, Patrick||Sproat, Iain|
|McNair-Wilson, Sir Patrick||Squire, Robin (Hornchurch)|
|Madel, Sir David||Stanley, Rt Hon Sir John|
|Maitland, Lady Olga||Steen, Anthony|
|Major, Rt Hon John||Stephen, Michael|
|Malone, Gerald||Stern, Michael|
|Mans, Keith||Stewart, Allan|
|Marland, Paul||Streeter, Gary|
|Mariow, Tony||Sumberg, David|
|Marshall, John (Hendon S)||Sweeney, Walter|
|Marshall, Sir Michael (Arundel)||Sykes, John|
|Martin, David (Portsmouth S)||Tapsell, Sir Peter|
|Mates, Michael||Taylor, Ian (Esher)|
|Mawhinney, Rt Hon Dr Brian||Taylor, John M (Solihull)|
|Mayhew, Rt Hon Sir Patrick||Taylor, Sir Teddy|
|Mellor, Rt Hon David||Temple-Morris, Peter|
|Merchant, Piers||Thomason, Roy|
|Mitchell, Andrew (Gedling)||Thompson, Sir Donald (Calder V)|
|Mitchell, Sir David (NW Hants)||Thompson, Patrick (Norwich N)|
|Moate, Sir Roger||Thornton, Sir Malcolm|
|Monro, Rt Hon Sir Hector||Townend, John (Bridlington)|
|Montgomery, Sir Fergus||Townsend, Sir Cyril (Bexl'yh'th)|
|Tracey, Richard||Wheeler, Rt Hon Sir John|
|Tredinnick, David||Whitney, Sir Raymond|
|Trend, Michael||Whittingdale, John|
|Trotter, Neville||Widdecombe, Miss Ann|
|Twinn, Dr Ian||Wiggin, Sir Jerry|
|Vaughan, Sir Gerard||Wilkinson, John|
|Viggers, Peter||Willetts, David|
|Waldegrave, Rt Hon William||Wilshire, David|
|Walden, George||Winterton, Mrs Ann (Congleton)|
|Walker, Bill (N Tayside)||Winterton, Nicholas (Macclesf'ld)|
|Waller, Gary||Wolfson, Mark|
|Ward, John||Yeo, Tim|
|Wardle, Charles (Bexhill)||Young, Rt Hon Sir George|
|Waterson, Nigel||Tellers for the Noes:|
|Watts, John||Mr. Sebastian Coe and|
|Wells, Bowen||Mr. Timothy Wood.|
|Division No. 74]||[10.15 pm|
|Abbott, Ms Diane||Cann, Jamie|
|Adams, Mrs Irene||Chidgey, David|
|Ainger, Nick||Chisholm, Malcolm|
|Ainsworth, Robert (Cov'try NE)||Clapham, Michael|
|Alton, David||Clarke, Eric (Midlothian)|
|Anderson, Donald (Swansea E)||Clarke, Tom (Monklands W)|
|Anderson, Ms Janet (Ros'dale)||Clwyd, Mrs Ann|
|Armstrong, Ms Hilary||Coffey, Ms Ann|
|Ashdown, Rt Hon Paddy||Cohen, Harry|
|Ashton, Joseph||Connarty, Michael|
|Austin-Walker, John||Cook, Frank (Stockton N)|
|Banks, Tony (Newham NW)||Cook, Rt Hon Robin (Livingston)|
|Barnes, Harry||Corbett, Robin|
|Barren, Kevin||Corbyn, Jeremy|
|Battle, John||Corston, Ms Jean|
|Bayley, Hugh||Cousins, Jim|
|Beckett, Rt Hon Mrs Margaret||Cox, Tom|
|Beggs, Roy||Cunliffe, Lawrence|
|Bell, Stuart||Cunningham, Jim (Cov'try SE)|
|Benn, Rt Hon Tony||Cunningham, Rt Hon Dr John|
|Benton, Joe||Cunningham, Ms Roseanna (Perth Kinross)|
|Berry, Roger||Dafis, Cynog|
|Betts, Clive||Dalyell, Tam|
|Blunkett, David||Darling, Alistair|
|Boateng, Paul||Davidson, Ian|
|Bradley, Keith||Davies, Bryan (Oldham C)|
|Bray, Dr Jeremy||Davies, Chris (Littleborough)|
|Brown, Rt Hon Gordon (Dunfermline E)||Davies, Rt Hon Denzil (Llanelli)|
|Davies, Ron (Caerphilly)|
|Brown, Nicholas (Newcastle E)||Davis, Terry (B'ham Hodge H)|
|Bruce, Malcolm (Gordon)||Denham, John|
|Burden, Richard||Dewar, Rt Hon Donald|
|Byers, Stephen||Dixon, Rt Hon Don|
|Caborn, Richard||Dobson, Frank|
|Callaghan, Jim||Donohoe, Brian H|
|Campbell, Mrs Anne (C'bridge)||Dowd, Jim|
|Campbell, Menzies (Fife NE)||Dunwoody, Mrs Gwyneth|
|Campbell, Ronnie (Blyth V)||Eagle, Ms Angela|
|Campbell-Savours, D N||Eastham, Ken|
|Canavan, Dennis||Ennis, Jeff|
|Etherington, Bill||Loyden, Eddie|
|Evans, John (St Helens N)||Lynne, Ms Liz|
|Ewing, Mrs Margaret||McAllion, John|
|Fatchett, Derek||McAvoy, Thomas|
|Faulds, Andrew||Macdonald, Calum|
|Fisher, Mark||McFall, John|
|Flynn, Paul||McKelvey, William|
|Foster, Rt Hon Derek||Mackinlay, Andrew|
|Foster, Don (Bath)||McLeish, Henry|
|Foulkes, George||McNamara, Kevin|
|Fraser, John||MacShane, Denis|
|Galbraith, Sam||McWilliam, John|
|Galloway, George||Madden, Max|
|Gapes, Mike||Maddock, Mrs Diana|
|Garrett, John||Mahon, Mrs Alice|
|George, Bruce||Marek, Dr John|
|Gerrard, Neil||Marshall, David (Shettleston)|
|Godman, Dr Norman A||Martin, Michael J (Springburn)|
|Godsiff, Roger||Martlew, Eric|
|Golding, Mrs Llin||Maxton, John|
|Gordon, Ms Mildred||Meacher, Michael|
|Graham, Thomas||Meale, Alan|
|Grant, Bernie (Tottenham)||Michael, Alun|
|Griffiths, Nigel (Edinburgh S)||Michie, Bill (Shef'ld Heeley)|
|Griffiths, Win (Bndgend)||Michie, Mrs Ray (Argyll Bute)|
|Grocott, Bruce||Milburn, Alan|
|Gunnell, John||Miller, Andrew|
|Hall, Mike||Mitchell, Austin (Gt Grimsby)|
|Hardy, Peter||Moonie, Dr Lewis|
|Harman, Ms Harriet||Morgan, Rhodri|
|Harvey, Nick||Morley, Elliot|
|Hattersley, Rt Hon Roy||Morns, Rt Hon Alfred (Wy'nshawe)|
|Henderson, Doug||Morris, Ms Estelle (B'ham Yardley)|
|Hendron, Dr Joe||Moms, Rt Hon John (Aberavon)|
|Heppell, John||Mudie, George|
|Hill, Keith (Streatham)||Mullin, Chris|
|Hodge, Ms Margaret||Murphy, Paul|
|Hoey, Kate||Nicholson, Miss Emma (W Devon)|
|Hogg, Norman (Cumbemauld)||Oakes, Rt Hon Gordon|
|Home Robertson, John||O'Brien, Mike (N Warks)|
|Hood, Jimmy||O'Brien, William (Normanton)|
|Hoon, Geoffrey||O'Hara, Edward|
|Howarth, Alan (Stratf'd-on-A)||Olner, Bill|
|Howells, Dr Kim||O'Neill, Martin|
|Hoyle, Doug||Pearson, Ian|
|Hughes, Kevin (Doncaster N)||Pendry, Tom|
|Hughes, Robert (Ab'd'n N)||Pickthall, Colin|
|Hughes, Simon (Southwark)||Pike, Peter L|
|Hutton, John||Pope, Greg|
|Illsley, Eric||Powell, Sir Raymond (Ogmore)|
|Ingram, Adam||Prentice, Mrs Bridget (Lewisham E)|
|Jackson, Ms Glenda (Hampst'd)|
|Jackson, Mrs Helen (Hillsborough)||Prentice, Gordon (Pendle)|
|Jamieson, David||Primarolo, Ms Dawn|
|Jenkins, Brian D (SE Staffs)||Purchase, Ken|
|Johnston, Sir Russell||Quin, Ms Joyce|
|Jones, Barry (Alyn & D'side)||Radice, Giles|
|Jones, Ieuan Wyn (Ynys Môn)||Randall, Stuart|
|Jones, Jon Owen (Cardiff C)||Raynsford, Nick|
|Jones, Dr Lynne (B'ham Selly Oak)||Reid, Dr John|
|Jones, Martyn (Clwyd SW)||Robertson, George (Hamilton)|
|Jones, Nigel (Cheltenham)||Robinson, Geoffrey (Cov'try NW)|
|Jowell, Ms Tessa||Roche, Mrs Barbara|
|Kaufman, Rt Hon Gerald||Rogers, Allan|
|Keen, Alan||Rooker, Jeff|
|Kennedy, Mrs Jane (Broadgreen)||Rooney, Terry|
|Khabra, Piara S||Ross, Ernie (Dundee W)|
|Kilfoyle, Peter||Rowlands, Ted|
|Lestor, Miss Joan (Eccles)||Ruddock, Ms Joan|
|Lewis, Terry||Salmond, Alex|
|Liddell, Mrs Helen||Sedgemore, Brian|
|Litherland, Robert||Sheerman, Barry|
|Livingstone, Ken||Sheldon, Rt Hon Robert|
|Lloyd, Tony (Stretf'd)||Shore, Rt Hon Peter|
|Llwyd, Elfyn||Short, Clare|
|Simpson, Alan||Touhig, Don|
|Skinner, Dennis||Trickett, Jon|
|Smith, Andrew (Oxford E)||Tyler, Paul|
|Smith, Chris (Islington S)||Vaz, Keith|
|Smith, Llew (Blaenau Gwent)||Walker, Rt Hon Sir Harold|
|Smyth, Rev Martin (Belfast S)||Wallace, James|
|Snape, Peter||Walley, Ms Joan|
|Soley, Clive||Wardell, Gareth (Gower)|
|Spearing, Nigel||Wareing, Robert N|
|Spellar, John||Watson, Mike|
|Squire, Ms Rachel (Dunfermline W)||Wicks, Malcolm|
|Steel, Rt Hon Sir David||Williams, Rt Hon Alan (Swansea W)|
|Steinberg, Gerry||Williams, Alan W (Carmarthen)|
|Stevenson, George||Winnick, David|
|Strang, Dr Gavin||Wise, Mrs Audrey|
|Straw, Jack||Worthington, Tony|
|Sutcliffe, Gerry||Wray, Jimmy|
|Taylor, Mrs Ann (Dewsbury)||Wright, Dr Tony|
|Taylor, Matthew (Truro)|
|Thompson, Jack (Wansbeck)||Tellers for the Ayes:|
|Timms, Stephen||Mr. David Clelland and|
|Tipping, Paddy||Mr. Dennis Turner.|
|Ainsworth, Peter (E Surrey)||Carttiss, Michael|
|Aitken, Rt Hon Jonathan||Cash, William|
|Alison, Rt Hon Michael (Selby)||Channon, Rt Hon Paul|
|Allason, Rupert (Torbay)||Chapman, Sir Sydney|
|Amess, David||Clappison, James|
|Ancram, Rt Hon Michael||Clark, Dr Michael (Rochf'd)|
|Arbuthnot, James||Clarke, Rt Hon Kenneth (Rushcliffe)|
|Arnold, Jacques (Gravesham)|
|Arnold, Sir Thomas (Hazel G)||Clifton-Brown, Geoffrey|
|Ashby, David||Colvin, Michael|
|Aspinwall, Jack||Congdon, David|
|Atkins, Rt Hon Robert||Conway, Derek|
|Atkinson, David (Bour'mth E)||Coombs, Anthony (Wyre F)|
|Atkinson, Peter (Hexham)||Coombs, Simon (Swindon)|
|Baker, Rt Hon Kenneth (Mole V)||Cope, Rt Hon Sir John|
|Baker, Sir Nicholas (N Dorset)||Cormack, Sir Patrick|
|Baldry, Tony||Couchman, James|
|Banks, Matthew (Southport)||Cran, James|
|Banks, Robert (Harrogate)||Currie, Mrs Edwina|
|Bates, Michael||Curry, Rt Hon David|
|Batiste, Spencer||Davies, Quentin (Stamf'd)|
|Bellingham, Henry||Davis, David (Boothferry)|
|Bendall, Vivian||Day, Stephen|
|Beresford, Sir Paul||Deva, Nirj Joseph|
|Biffen, Rt Hon John||Devlin, Tim|
|Body, Sir Richard||Dicks, Terry|
|Bonsor, Sir Nicholas||Dorrell, Rt Hon Stephen|
|Booth, Hartley||Douglas-Hamilton, Rt Hon Lord James|
|Bottomley, Peter (Eltham)||Dover, Den|
|Bottomley, Rt Hon Mrs Virginia||Duncan, Alan|
|Bowden, Sir Andrew||Duncan Smith, Iain|
|Bowis, John||Dunn, Bob|
|Boyson, Rt Hon Sir Rhodes||Durant, Sir Anthony|
|Brandreth, Gyles||Dykes, Hugh|
|Brazier, Julian||Eggar, Rt Hon Tim|
|Bright, Sir Graham||Elletson, Harold|
|Brooke, Rt Hon Peter||Emery, Rt Hon Sir Peter|
|Brown, Michael (Brigg Cl'thorpes)||Evans, David (Welwyn Hatf'ld)|
|Browning, Mrs Angela||Evans, Jonathan (Brecon)|
|Bruce, Ian (S Dorset)||Evans, Nigel (Ribble V)|
|Budgen, Nicholas||Evans, Roger (Monmouth)|
|Burns, Simon||Evennett, David|
|Burt, Alistair||Faber, David|
|Butcher, John||Fabricant, Michael|
|Butler, Peter||Fenner, Dame Peggy|
|Butterfill, John||Field, Barry (Isle of Wight)|
|Carlisle, John (Luton N)||Fishburn, Dudley|
|Carlisle, Sir Kenneth (Linc'n)||Forman, Nigel|
|Carrington, Matthew||Forsyth, Rt Hon Michael (Stirling)|
|Forth, Eric||Legg, Barry|
|Fowler, Rt Hon Sir Norman||Leigh, Edward|
|Fox, Rt Hon Sir Marcus (Shipley)||Lennox-Boyd, Sir Mark|
|Freeman, Rt Hon Roger||Lester, Sir Jim (Broxtowe)|
|French, Douglas||Lidington, David|
|Fry, Sir Peter||Lilley, Rt Hon Peter|
|Gale, Roger||Lloyd, Rt Hon Sir Peter (Fareham)|
|Gallie, Phil||Lord, Michael|
|Gardiner, Sir George||Luff, Peter|
|Garel-Jones, Rt Hon Tristan||Lyell, Rt Hon Sir Nicholas|
|Garnier, Edward||MacGregor, Rt Hon John|
|Gill, Christopher||MacKay, Andrew|
|Gillan, Mrs Cheryl||Maclean, Rt Hon David|
|Goodlad, Rt Hon Alastair||McLoughlin, Patrick|
|Goodson-Wickes, Dr Charles||McNair-Wilson, Sir Patrick|
|Gorman, Mrs Teresa||Madel, Sir David|
|Gorst, Sir John||Maitland, Lady Olga|
|Grant, Sir Anthony (SW Cambs)||Major, Rt Hon John|
|Greenway, Harry (Ealing N)||Malone, Gerald|
|Greenway, John (Ryedale)||Mans, Keith|
|Griffiths, Peter (Portsmouth N)||Marland, Paul|
|Grylls, Sir Michael||Marlow, Tony|
|Gummer, Rt Hon John||Marshall, John (Hendon S)|
|Hague, Rt Hon William||Marshall, Sir Michael (Arundel)|
|Hamilton, Rt Hon Sir Archibald||Martin, David (Portsmouth S)|
|Hamilton, Neil (Tatton)||Mates, Michael|
|Hampson, Dr Keith||Mawhinney, Rt Hon Dr Brian|
|Hanley, Rt Hon Jeremy||Mayhew, Rt Hon Sir Patrick|
|Hannam, Sir John||Mellor, Rt Hon David|
|Hargreaves, Andrew||Merchant, Piers|
|Harris, David||Mitchell, Andrew (Gedling)|
|Haselhurst, Sir Alan||Mitchell, Sir David (NW Hants)|
|Hawkins, Nick||Moate, Sir Roger|
|Hawksley, Warren||Monro, Rt Hon Sir Hector|
|Hayes, Jerry||Montgomery, Sir Fergus|
|Heald, Oliver||Needham, Rt Hon Richard|
|Heath, Rt Hon Sir Edward||Nelson, Anthony|
|Heathcoat-Amory, Rt Hon David||Neubert, Sir Michael|
|Hendry, Charles||Newton, Rt Hon Tony|
|Heseltine, Rt Hon Michael||Nicholls, Patrick|
|Hicks, Sir Robert||Nicholson, David (Taunton)|
|Higgins, Rt Hon Sir Terence||Norris, Steve|
|Hill, Sir James (Southampton Test)||Onslow, Rt Hon Sir Cranley|
|Hogg, Rt Hon Douglas (Grantham)||Oppenheim, Phillip|
|Horam, John||Ottaway, Richard|
|Hordem, Rt Hon Sir Peter||Page, Richard|
|Howard, Rt Hon Michael||Paice, James|
|Howell, Rt Hon David (Guildf'd)||Patnick, Sir Irvine|
|Howell, Sir Ralph (N Norfolk)||Patten, Rt Hon John|
|Hughes, Robert G (Harrow W)||Pattie, Rt Hon Sir Geoffrey|
|Hunt, Rt Hon David (Wirral W)||Pawsey, James|
|Hunt, Sir John (Ravensb'ne)||Peacock, Mrs Elizabeth|
|Hunter, Andrew||Pickles, Eric|
|Hurt, Rt Hon Douglas||Porter, David|
|Jack, Michael||Portillo, Rt Hon Michael|
|Jackson, Robert (Wantage)||Powell, William (Corby)|
|Jenkin, Bemard (Colchester N)||Rathbone, Tim|
|Jessel, Toby||Redwood, Rt Hon John|
|Johnson Smith, Rt Hon Sir Geoffrey||Renton, Rt Hon Tim|
|Jones, Gwilym (Cardiff N)||Riddick, Graham|
|Jones, Robert B (W Herts)||Robathan, Andrew|
|Jopling, Rt Hon Michael||Roberts, Rt Hon Sir Wyn|
|Kellett-Bowman, Dame Elaine||Robertson, Raymond S (Ab'd'n S)|
|Key, Robert||Robinson, Mark (Somerton)|
|King, Rt Hon Tom||Roe, Mrs Marion|
|Kirkhope, Timothy||Rumbold, Rt Hon Dame Angela|
|Knapman, Roger||Ryder, Rt Hon Richard|
|Knight, Mrs Angela (Erewash)||Sackville, Tom|
|Knight, Rt Hon Greg (Derby N)||Sainsbury, Rt Hon Sir Timothy|
|Knox, Sir David||Scott, Rt Hon Sir Nicholas|
|Kynoch, George||Shaw, David (Dover)|
|Lait, Mrs Jacqui||Shaw, Sir Giles (Pudsey)|
|Lamont, Rt Hon Norman||Shephard, Rt Hon Mrs Gillian|
|Lang, Rt Hon Ian||Shepherd, Sir Colin (Heref'd)|
|Lawrence, Sir Ivan||Shepherd, Richard (Aldridge)|
|Shersby, Sir Michael||Townsend, Sir Cyril (Bexl'yh'th)|
|Sims, Sir Roger||Tracey, Richard|
|Skeet, Sir Trevor||Tredinnick, David|
|Smith, Sir Dudley (Warwick)||Trend, Michael|
|Smith, Tim (Beaconsf'ld)||Trotter, Neville|
|Soames, Nicholas||Twinn, Dr Ian|
|Speed, Sir Keith||Vaughan, Sir Gerard|
|Spencer, Sir Derek||Viggers, Peter|
|Spicer, Sir Jim (W Dorset)||Waldegrave, Rt Hon William|
|Spicer, Sir Michael (S Worcs)||Walden, George|
|Spink, Dr Robert||Walker, Bill (N Tayside)|
|Spring, Richard||Waller, Gary|
|Sproat, Iain||Ward, John|
|Squire, Robin (Hornchurch)||Wardle, Charles (Bexhill)|
|Stanley, Rt Hon Sir John||Waterson, Nigel|
|Steen, Anthony||Watts, John|
|Stephen, Michael||Wells, Bowen|
|Stem, Michael||Wheeler, Rt Hon Sir John|
|Stewart, Allan||Whitney, Sir Raymond|
|Streeter, Gary||Whittingdale, John|
|Sumberg, David||Widdecombe, Miss Ann|
|Sweeney, Walter||Wiggin, Sir Jerry|
|Sykes, John||Wilkinson, John|
|Tapsell, Sir Peter||Willetts, David|
|Taylor, Ian (Esher)||Wilshire, David|
|Taylor, John M (Solihull)||Winterton, Mrs Ann (Congleton)|
|Taylor, Sir Teddy||Winterton, Nicholas (Macclesf'ld)|
|Temple-Morris, Peter||Wolfson, Mark|
|Thomason, Roy||Yeo, Tim|
|Thompson, Sir Donald (Calder V)||Young, Rt Hon Sir George|
|Thompson, Patrick (Norwich N)||Tellers for the Noes:|
|Thornton, Sir Malcolm||Mr. Timothy Wood and|
|Townend, John (Bridlington)||Mr. Sebastian Coe.|