I beg to move,
That this House
notes the forthcoming implementation of the European Working Time Directive (EWTD) in relation to junior hospital doctors;
further notes the changes to General Practitioner out-of-hours services following the implementation of the new GP contract;
is concerned by the British Medical Association's estimate that, from August 2004, the EWTD requirements could lose the NHS the equivalent of 3,700 junior doctors;
is alarmed by the failure of Ministers to quantify adequately the likely demands of the EWTD in medical manpower and money costs;
is further alarmed by the Government's complacency over the 'SIMAP/Jaeger' judgements made by the European Court of Justice and the disproportionate impact they will have on smaller hospitals;
notes that cost estimates for GP out-of-hours cover are rising yet the extent of cover is likely to decline;
deplores the failure by Ministers to anticipate the impact that the new GP contract will have on community hospitals and notes with alarm that several are already under threat;
and wishes to see the implementation of out-of-hours cover in a form that maintains a GP-led service in which the high standards of care and accessibility traditionally associated with primary care in England are maintained.
We would have had an opportunity to discuss the subject before the recess, on the eighth allotted day, but the competition among Departments to register incompetence meant that, on that occasion, the Home Office outdid the Department of Health. However, we have moved on to the Department of Health. While the Government are obsessed with Europe, the Opposition are putting the national health service at the forefront of our concerns.
Today's motion addresses two issues: the impact of the further implementation of the European working time directive, specifically in relation to junior doctors; and the implementation of the out-of-hours services component of the new GP contract. Those two distinct issues are obviously related, and they disclose common concerns. Although there have been positive intentions throughout, the measures are having perverse practical effects, and even when such effects have been identified, Ministers have failed to act to clarify or, if necessary, amend the proposals. Where it has not been possible or appropriate to amend them, Ministers have failed to give the necessary support for the service to implement the changes, in the face of mounting evidence of the problems and associated costs. Not only are the Government showing a lack of support; they are showing a degree of complacency about the impact of the changes.
So, the charge is one of a lack of competence. It is not one of a lack of positive intentions, but, in practice, the Government are not delivering on what they have said they will deliver on. That is the problem with this Government. In the light of what my right hon. and learned Friend Mr. Howard was saying at Prime Minister's Question Time earlier, it is clear that the Government did not assess the risks involved and respond to them before they introduced and sought to implement these policies.
Does my hon. Friend agree that, while the Government have tried in regard to this issue, they have had one hand tied behind their back, because when Ministers have gone to the European Parliament to seek the support of socialist MEPs on this issue, they have received absolutely none—from their own MEPs in Brussels?
My hon. Friend is right, and I pay tribute to the work that he has done in drawing attention to the impact of the working time directive.
However, when my hon. Friend, the shadow Secretary of State for Trade and Industry challenged his opposite number on this matter, she simply would not say that she was going to deal with those Labour MEPs, or that we could feel confident that they would support the UK interest in any future changes to be made to the working time directive. Those MEPs do not support the UK interest, and voters will need to know that on
Before I address the issue of the working time directive, I want to make it clear that we are not questioning the principle—far from it; we support it—of reducing junior doctors' hours to a level that is consistent with patient safety and the best interests of the doctors themselves. I shall not reiterate the history of this issue; it is well known to some hon. Members, especially to those Conservative Members who have experience of introducing the new deal on doctors' hours. I suspect that the introduction of reduced hours for junior doctors would be achieved in the best interest of the health service without the intervention of the European working time directive. However, we have to deal with the directive, and it is causing inflexibilities.
The agreement was reached on junior doctors in May 2000. In October 2000, there was the so-called SIMAP judgment relating to primary care doctors in Spain, the effect of which was to define the nature of working time when one is resident and on call, and, in effect, to treat all the time that one is on the premises and available for work as working time, regardless of whether one is working or asleep. I know that it was not the Government's intention to treat the time that one is asleep as working time, but that is the practical effect of that judgment. It was April 2002 before the Department invited pilot studies from around the country to see how the implementation of the working time directive could be achieved, and July 2003 before Governments collectively, or a number of member state Governments, approached the Commission to try to secure changes in consequence of the SIMAP judgment and its adverse effects on health care in particular.
In October 2003, the so-called Jaeger case made it even more clear that all the time during which one was resident and on call would be treated as working time. In particular, it added the further inflexibility and adverse effect that compensatory rest for the time worked on call, including while non-resident and on call, would need to be compensated for immediately—in effect, before the following period of work. To give my hon. Friends a sense of what that means in practice, an NHS doctor—a senior registrar or consultant—who is non-resident and on call, and who is called up several times during the night, either to go to the hospital or to take consultations over the telephone about patients, must be compensated with additional rest before commencing their next period of work. Of course, the chances are that before they commence their clinic or operating list the following morning, they will have to have compensatory rest. Evidently, as Ministers understand, problems will ensue for hospitals from having arbitrary and, in effect, overnight changes in their operating lists and clinic rotas.
The hon. Gentleman is making some interesting and important points. I apologise for missing the first few moments of his speech, and I wonder whether he has already put his remarks in the context of the Government's unprecedented 33 per cent. improvement in investment in primary care. Will he move on to that and establish the proper context for this debate eventually?
I am grateful for the hon. Gentleman's contribution. I have not talked about primary care yet, and I will do so later.
On investment in hospital services, the hon. Gentleman raises an important point, because all the issues that I am discussing have implications—not only the working time directive but "Agenda for Change" and the implementation of the consultants contract, which I shall mention briefly later. The combination of those changes not only imposes significant financial and managerial challenges for the NHS, but those financial challenges may obviate—this will worry Labour Back Benchers—the resources that the Government so trumpet in terms of growth in activity in the NHS. I have spoken to a number of chief executives of a range of hospital trusts, whom I have asked how much more it will cost them in this financial year, 2004–05, to deliver the same activity as in the preceding financial year. The answers vary, but the average is between 8 and 9 per cent. extra. In the context of what the hon. Gentleman asserts are unprecedented increases in the amount of money available—we agree absolutely that more money must be available for the NHS—that shows the importance of managing and introducing changes in a way that delivers growth in activity and investment with reform. That is what the Prime Minister says—I heard him say it again at Prime Minister's questions—but he spends the money and does not deliver the reform.
Is it not also about delivering improvements in the quality of services and ensuring that primary care trusts manage their services much more effectively in the future?
I have no disagreement with the hon. Gentleman, but I think that as we proceed it will become clear that managing the system depends more on enabling hospitals to make changes effectively than on relying on the Government, who have done abjectly little to help hospitals implement the working time directive in a timely fashion.
Will my hon. Friend confirm that when he spoke of an 8 or 9 per cent. increase, he was referring only to the implications of the directive and not to the implications for community hospitals of the GPs' contract, which is likely to involve a further huge expenditure?
I was talking about the increase in costs for acute trusts. As my hon. Friend will know from his constituency experience—and from his constituent Dr. Holden, who speaks for the British Medical Association on these matters—if GPs were compensated fully for their work in community hospitals and for the quality of that work, there would be a substantial additional cost. The Government do not propose to meet that cost, but it raises serious issues for community hospitals.
Does the hon. Gentleman think that consultants who are called out during the night and whose sleep is therefore very disturbed should have a break afterwards? Would he expect an airline pilot who has been asked to do an extra shift and fly to America to work his normal shift in the morning? Would he expect a pilot who has just flown for eight hours to fly for a further eight hours, or would he prefer that pilot to have a rest after flying across the Atlantic in the middle of the night before flying back the next morning?
I think we should work with consultants on a flexible, agreed and negotiated basis, as has been happening increasingly. Yes, compensatory rest is desirable, but it is certainly not desirable for it to be granted as a legal requirement before the next period of work, as that would result directly in adverse consequences for operating lists and for clinics. There may be a case for it in some circumstances, but it will depend on the extent of the interruption during the night.
The whole structure in the NHS is being driven not by flexible local negotiations, as it should be, but on the basis of European Court of Justice judgments about the circumstances of an individual German doctor, which do not strike me as relevant to the way in which we manage the health service.
So the hon. Gentleman is saying that if a consultant surgeon has to operate in the middle of the night it is okay for him to proceed with his morning operating session, although it would certainly not be okay for an airline pilot who has flown for an extra session to fly a plane the following morning. I would not want to be the patient of a doctor who had been out in the middle of the night and was expected to carry on as normal without a proper rest period.
I respect the hon. Gentleman's professional expertise, but he has moved the goalposts. I was talking about non-resident on-call doctors. It is very unlikely that night surgery would not have been allowed for in rotas relating to clinics or operating lists for the following day, as the hon. Gentleman probably knows from his experience.
We may all agree that the working time directive should not be imposed on us. The Government at least seem to agree with that, but what have they done about it? In a recent response to the House of Lords European Union Committee, the BMA commented that the implementation of the directive could involve the equivalent of 3,700 junior doctors from August 2004, and that the implementation of the 48-hour limit in 2009 could involve the equivalent of between 4,300 and 9,900. In its evidence to the Committee, the Royal College of Physicians said:
"in its present shape and form, compliance will have serious long-term effects for continuity of care, patient safety, and the education and training of doctors."
The BMA said:
"The BMA considers that the requirement made in the Jaeger judgement that compensatory rest should be taken before returning to work has huge service and workforce planning implications and is likely to be unworkable and in most cases unnecessary."
In January this year—nearly four years after the agreement on junior doctors, more than three years after the SIMAP judgment and months after the Jaeger judgment—the Minister of State, Mr. Hutton, told the Royal College of Surgeons:
"Complying with the Working Time Directive need be neither costly nor a burden."
That is odd, given that the Minister told the European Standing Committee on
"We indicated at the end of last year a worst-case scenario of between 6,000 and 12,000 additional doctors" and
"The cost in relation to doctors would be between £380 million and £780 million."—[Official Report, European Standing Committee C,
We must see that alongside the Government's allocation of £46 million over three years for specific action to help implement the directive.
I recall the Minister sending the NHS this message in January: "Do not worry, it is not a problem, you can do it, it will not cost much—just get on and do it." At the same time, Ministers knew that according to the worst-case scenario thousands more doctors and hundreds of millions of pounds would be required. In evidence to the Commission, they said that the implementation of the Jaeger judgment would cost tens of millions. They knew there was a problem, but they did not tell the NHS what they proposed to do about it.
In its evidence to the House of Lords European Union Committee, the BMA said of the pilot studies:
"proposals for these pilots were not initiated until April 2002, about four years after the implementation of the EWTD and less than 2 years before the extension of the Directive to junior doctors. The final results . . . are unlikely to be in time to aid the implementation of the EWTD for junior doctors."
In fact, I suspect that the final evaluations will come in around November.
That is fine, is it not? If hospital consultant posts are to be changed in time for implementation in August 2004, design for that change should really have started in August 2003. If junior doctor rotas are to be changed and additional junior doctors recruited, the process should already have started: no less than a six-month lead time is required. We are already in the period during which hospitals should have taken action to achieve compliance with the directive.
The medical profession has done more than Ministers and the Department in initiating the "hospital at night" programme, which the Minister will no doubt describe to us. The BMA, to its credit, has been pushing for years to secure action and awareness. On
"it seems that the government has only just grasped the potential impact of these changes. Too little has been done too late."
That, I am afraid, is the sorry story of the working time directive.
My hon. Friend referred to the debate on
Perhaps the Minister will take up that question. The estimates have indeed related to doctors. My personal view is that the scope of "Agenda for Change" should enable the nursing profession to be compliant with the working time directive without substantial additional costs. My argument rests on the implications for doctors' hours and the costs to the NHS.
I am interested in what the hon. Gentleman said about "Agenda for Change", which he prayed in aid in relation to supporting the NHS in meeting our obligations under the working time directive—but is not his party opposed to "Agenda for Change"? Did not Mr. Spring make it clear when he was appointed as shadow spokesman that he was against national pay bargaining for the NHS?
No, he did not say that. He is in favour of NHS trusts and foundation trusts having the freedom to respond locally—through pay, if necessary, as well as other conditions of service—to their particular needs. Is it the Minister's view that hospitals should not have that freedom? If so, let him say so. I said to him in the Standing Committee that considered the Health and Social Care Bill last year that we support "Agenda for Change" and the ability of nurses, in particular, to be supported in extending their role and to have their work reflected in their rewards, and it is entirely appropriate for that to be negotiated. Review bodies provide a national pay framework, and it is in the interest of NHS trusts that they should do so, but that is a framework, not a straitjacket. Is the Minister saying that the Government want to put the NHS in a national pay straitjacket?
The hon. Gentleman knows, because he does his homework, that "Agenda for Change" incorporates an element of flexibility in meeting local pay terms. That has always been the case. The Government have always supported "Agenda for Change". The issue is whether the Opposition do. The hon. Member for West Suffolk made it clear in his first interview as shadow public services spokesman that the Conservative Opposition are against "Agenda for Change" precisely because it is a national pay agreement and he would prefer to revert to local trust contracts. If the hon. Gentleman is saying that this is one further aspect of his health policy reforms that he has abandoned, we would welcome that news.
I am not having any of that. We have made it clear throughout that we favour hospitals having the freedom to manage themselves and respond to their particular needs. If the Minister is against that, let us put that on the record. I am not having the suggestion that by allowing that freedom we necessarily abandon either pay review bodies or "Agenda for Change". There is nothing that my hon. Friend or I have said that would suggest that an incoming Conservative Government—before too long, we hope—will abandon or reverse "Agenda for Change", but it must be regarded as a framework rather than a straitjacket.
There are practical implications. Managers at a district general hospital told my hon. Friend Dr. Murrison—he may refer to this in more detail later—that, being in deficit, they cannot afford to pay staff to be treated as working while they are sleeping, so they have to move to full shift working, and to some extent from doctors to nurse practitioners. That may be entirely acceptable, but if staff on full shifts are not then fully employed, the activity needs to be increased to ensure that they are.
The hospital managers said:
"this may require the closure of some units and the transfer of work to units with spare capacity. This will affect many of the medical low volume specialties where there is a requirement to have residential specialist staff".
Hospital at night can achieve many things, but there cannot necessarily be cross-cover, for example between non-paediatric and paediatric staff. Cross-cover is not possible on obstetrics, if people are not obstetric-trained and experienced, or on anaesthetics. Some rotas simply have to be staffed with those specialists. If the hospital cannot scale up from the five doctors that it has now to the arguably nine or 10 that will be required for a full shift a few years hence, those units will close.
There are some hospitals that cannot attract greater volume because the distances or the means of travel are too difficult, but for the very same reason cannot be closed. How are they supposed to survive within the same budget and yet meet "Agenda for Change"?
That is an important point. The directive will bear harshly on some specialties and in some remote areas. The Isle of Wight has special problems that will have to be managed.
Our prospective parliamentary candidate in Southport, Mark Bigley, reports:
"The Hospital Trust says they cannot run A&E services at Southport due to the impact of the EWTD on junior doctors' hours."
There may be a complementarity between what local people want there and what my hon. Friend wants on the Isle of Wight. They know that centres of excellence and major specialties may have to be concentrated—perhaps in Southampton, in my hon. Friend's case—but they want access to stabilisation and treatment more locally and accessibly, so that large numbers of people do not have to be referred a great distance away for routine treatment.
My colleague in Enfield, North referred me to the health hospitals review document of Barnet and Chase Farm hospitals, which says:
"Neither the doctors nor the funding is available for the hospitals simply to 'grow' their teams out of this problem."
That may bear on maternity, for example, or obstetrics.
I do not know the precise circumstances, because it is in Scotland, but even today The Herald reports:
"New rules cutting the number of hours worked by junior doctors and consultants, which make staffing multiple maternity hospitals more difficult are threatening units across Scotland."
Before the hon. Gentleman goes through the complete list of prospective Conservative parliamentary candidates—at least some of them know where the constituency is, which is not the case in Hall Green, as I noticed from a recent visit—can he tell us how he will square these demands for additional funding with the fact that his party voted against the 1 per cent. national insurance increase? How can he reconcile that? It is a fundamental question.
With respect, it is not fundamental to the implementation of the working time directive. We have committed ourselves to the resources for the NHS, to support not only reform but the additional transitional costs, which the Government are clearly not doing, when one compares the costs that they anticipate for the working time directive with the £46 million that the Minister has promised.
When we had a modest one-and-a-half hour debate on GP contracts—one of the major changes in the NHS—on the back of the Health and Social Care Bill last July, the Minister made a statement in response to my hon. Friend Sir Patrick Cormack, who told me that he wished to be here today but had to attend an important meeting with a constituent and so sends his apologies. The Minister said to my hon. Friend:
"I know from my work as a constituency MP that our constituents place a high premium on around-the-clock access to a GP, 24 hours a day, seven days a week. It is a defining characteristic of our primary care services."—[Hansard, 8 July 2003; Vol. 408, c. 1050.]
That is the promise from this Government, but what is the reality? A shift to emergency nurse practitioners and paramedics. Perhaps that is acceptable, because it is appropriate care. A shift to NHS Direct's handling the calls. Perhaps that is fine too, although it turns out that the Minister of State, Ms Winterton said in a reply to me that she had no estimate of how many primary care trusts were going to ask NHS Direct to handle their calls for out-of-hours services, so quite how NHS Direct will be able to staff up to provide that service, I do not know. However, as a consequence of a shift to NHS Direct's handling the calls, do we shift from risk management by GPs to risk management by the NHS Direct clinical assessment software? That is not the same GP service that people thought that they had before.
Everywhere that I have gone around the country, people have told me that they expect that their GP out-of-hours service will be run with fewer GPs. In one place that I visited recently, I was told that roughly speaking, the point would come where a GP sat in a centre and never really went out on call because there would not be enough GPs available in the service to enable them to travel around the country; they would have to sit in one place. Will this be a GP-led service? That is the issue.
What do GPs themselves say? In January, the health journal Pulse surveyed 1,168—
Yes, they voted for it. We have no dispute with the GP contract in principle: it is a good framework. Quality and outcomes in replacement of item of service is a good framework, but we are talking today about the implications for and the management of the out-of-hours service, and it would be helpful if the Minister would focus on that, rather than trying to divert attention from the issue, which is all that the Government have done throughout the debate.
What did Pulse say? Of 1,168 GPs, 83 per cent. intended to opt out, and the actual figure will probably be higher. Although 51 per cent. said that they would work out-of-hours shifts, only 12 per cent. anticipated working significantly more than the amount necessary to recover the money that they would lose by opting out. That implies a substantial reduction in GP availability for out-of-hours services. What did the GPs—not the Conservative Opposition—think would be the consequence? Some 92 per cent. said that more patients would be seen in accident and emergency. Accident and emergency departments in many places are already seeing up to double-digit percentage increases in admittances. Some 90 per cent. of GPs expected their Monday morning work load to climb. Some 72 per cent. said that patients would get more inappropriate advice and poorer quality care, and 62 per cent. thought that patients would be less safe. That is being said not by me, but by GPs themselves.
The hon. Gentleman is raising an important subject, but is he not being a little simplistic? At the moment, many GPs choose to contract out of the system, and out-of-hours care is frequently provided by providers such as Primecare. That has already caused huge problems in various parts of the country. Is it not a little simplistic just to blame the changes on the GP contract, when many GPs are not taking those responsibilities on themselves at the moment?
I plead guilty to the charge of simplicity, and it is kind of the hon. Lady to levy it at me. I am normally accused of talking too much about the detail—the Minister would accuse me of that. However, I do not share the hon. Lady's sentiment. GP co-ops and GP-led services are delivering a good service in many places across the country—I think in the balance of them. In my view, it would be better for us and for the Government if they made it clear that, although the individual obligation on GPs to provide out-of-hours cover to their own list was removed, there was none the less the expectation, in the context of the GP contract as a whole, that co-operative systems led by GPs would be developed. Letting GPs design the local out-of-hours services—
I have given way to the hon. Gentleman twice, so I shall now try to conclude because there are other hon. Members who are clearly itching to contribute to our discussions.
We have a contract, much of which is good, but the Government have not focused on the problems. We are moving away from precisely what the Government promised. The Minister promised 24-hour access to a GP service, but what we will have will not necessarily be a GP service, and will perhaps not even be GP led or GP managed in effect. The perverse results go on, including the cancellation of Saturday surgeries. I do not know what proportion of surgeries that involves, but one PCT told me that even before the start of the contract, 60 per cent. of Saturday morning services had gone. I suspect that the figure across the country is at least that.
The Government have not commissioned GPs in community hospitals. My hon. Friends will know that many GPs look after beds in community hospitals and provide services to minor injuries units there. They are integral to the continuation of those local, accessible services. The Government publish documents telling us how important community hospitals are, which we know from personal experience. They provide step-up care for patients and step-down care from hospitals, and deal with the problems of delayed transfer of care from hospitals. However, the Government have not put in place a framework to enable PCTs to carry out that commissioning. I spoke to one chief executive of a PCT, who had better be nameless—for the sake of clarity, this was not the PCT in my constituency—who said that community hospitals were something that the Government had put in a box marked "too difficult".
That is the story of the working time directive and the GP out-of-hours service. The Government have failed to act on the working time directive, and if they do not act now, they might fail to deal with the implementation problems of the consultants' contract. Will the Minister ensure that things that could be done, such as commencing negotiations immediately on the staff grade and associate specialists, will be done?
The Government failed to prepare for the out-of-hours changes. The Audit Commission has demonstrated how many complex changes are occurring at once and how important good financial management is, but that also requires leadership from the Department and Ministers. The costs escalate. It seems that the GP out-of-hours service will cost nearly double what it has cost until now, but most PCTs will receive only 60 or 70 per cent. of the additional cost, and many cannot afford the rest. They are therefore having to make cost-driven changes to the GP out-of-hours service.
Complacency is written through the Government amendment like sugar writing through a stick of rock. No reference is made to the new deal, or to the fact that we are reducing junior doctors' hours. There is no reference to the impossibility of compliance by August 2004 or the need for urgent interim action, as recommended by the House of Lords. We need urgent action not only by the European Commission, but by the Government to decide what will happen in August 2004 if the Commission has not delivered a satisfactory solution to the SIMAP and Jaeger problems.
There is no reference in the Government amendment to the implications for smaller hospitals or for sub-specialties. It contains no reference to GPs' concerns about out-of-hours services, no reference to the loss of Saturday morning surgeries, no reference to the threat to community hospitals and no reference to the issues that the Government have found too difficult. They do not want to deal with the issues that are too difficult; they have handed them out to the service without the resources or support to make things happen. If the Government find this matter all too difficult, we have an answer: step aside and let us deal with it.
I beg to move, To leave out from "House" to the end of the Question, and to add instead thereof:
"welcomes the overall aims of the European Working Time Directive (EWTD) to ensure humane working hours for doctors in training;
further welcomes the Government's lobbying of the European Commission and other EU Member States which has resulted in the Commission's giving assurances that they will bring forward legislative proposals on the EWTD before the summer;
notes the dramatic reduction in the hours of doctors in training which means that 95 per cent. of them now work for 56 hours or fewer;
congratulates the Government on the increases in workforce numbers and medical school places, which mean there are now almost 7,000 more consultants and 55,000 more nurses than there were in 1997, and that 6,030 students entered medical school in England in autumn 2003; welcomes the work being done in the National Health Service in implementing new ways of working that contribute to modernising and improving services and meeting the obligations of the Directive;
and joins the Chairman of the BMA's General Practitioners Committee in welcoming the new GP contract as being 'better for patients and better for everyone working in general practice' and notes that it will allow primary care trusts to offer patients a safe, high quality service, with care delivered by the most appropriate professional, through better use of more joined-up services."
Mr. Lansley has brought to the House's attention his hon. Friends' concerns about the new contract for GPs, the provision of out-of-hours services and the implementation of the European working time directive. He is perfectly entitled to do that, and I give him credit for the way in which he presented his case. However, he has not set out the one thing that we are entitled to expect from him: his alternative. For example, are the Conservatives in favour of the new contractual arrangements covering the provision of out-of-hours services, yes or no? Those have been supported by 80 per cent. of GPs. Would they have agreed to the changes themselves? Sadly, no one is any the wiser. Do they believe that junior doctors should be covered by the provisions of the European working time directive? Will they commit themselves to match the expansion in the number of doctors, nurses and allied health professionals that the NHS is seeking to recruit over the next four years? It seems not.
On all those questions, the hon. Member for South Cambridgeshire had nothing to contribute, except for his usual diet of doom and gloom, mixed with a new element and exciting addition to the menu—sanctimonious hot air. The House should have heard from him this afternoon answers to all the basic questions I mentioned, but predictably, all we had was his familiar recycled rhetoric—and pretty indigestible stuff it was, too.
First, let me deal with his concerns about the European working time directive, which is where he started his detailed remarks. The Government strongly support the need for employees to enjoy fair standards of employment protection, whether in the NHS or anywhere else. In respect of the NHS, an obvious importance should be attached to ensuring that front-line staff work reasonable hours and have proper rest periods. The working time directive is a crucial part of that framework. It establishes minimum entitlements for employees as well as providing for the right of individuals to choose to work longer hours if they want to. I therefore believe that it helps to support the important objective of British competitiveness, as well as the employment rights of British workers.
Every Member in the House would agree that doctors working in the NHS must be employed on terms that ensure high-quality care to patients, and that their hours of work are part of that equation. That is uncontroversial. The question for the Minister is whether his task, as the representative of the doctors' employer, has been made easier or more difficult by the introduction of the European working time directive as interpreted through the two judgments. As an employer seeking to deliver agreed objectives, is his task easier or more difficult?
It has been made immeasurably more difficult. I have acknowledged that on previous occasions, as the right hon. Gentleman, who reads all my press releases on the Department's website, would confirm. There is nothing new about that. I shall develop my concerns about the SIMAP/Jaeger judgments in a few moments, but it is obvious for anyone who observes these issues that the European Court's interpretations of the definition of working time—and, crucially, in the Jaeger case, of when compensatory rest should be taken—have made matters immeasurably worse. In fact, on the Jaeger case, the UK Government made representations to the European Court, arguing for precisely the opposite interpretation of the directive. Sadly, we lost that argument in the Court, but I do not believe that we have lost it in the wider court of opinion among the Council of Ministers and the Commission—a point to which I shall return.
It is clear not only from today's debate but from all previous debates on these matters that there is a disagreement between Government and Opposition about the terms of the directive and whether we should provide for these rights in law at all. The hon. Member for South Cambridgeshire has made it clear that he believes that we should not. For the sake of making progress on the substantive issues, I shall not develop arguments about that particular issue today, although it is worth pointing out that all the negotiations surrounding the wording of the directive took place under the leadership—if that is the right word—of the previous Conservative Administration.
On at least one point, however, there is likely to be general agreement across the House and outside it—that implementing the European working time directive in the light of recent decisions of the European Court of Justice presents a very considerable challenge to the NHS and particularly to specialties such as paediatrics and obstetrics. The NHS is taking action at a number of different levels to respond to that challenge. In the course of my remarks, I want to set out how we are attempting to achieve that in more detail, but it might be helpful if I first set out the general principles that we have been following.
First, our priority must be to implement the directive in a way that maintains both the quality and accessibility of NHS services. Our response will not be based on the assumption that we will have to restrict access to vital health care services, which would be contrary to the wider public interest, and disproportionate. That is why we have ruled out that approach.
We are committed instead to maintaining and improving local access to services and have published guidance aimed at ensuring that that principle is fully reflected in local NHS decision making. The focus of the guidance is on redesigning services—not relocating them—around the needs of local populations. The NHS, in implementing the directive, needs fully to develop the contributions of different hospitals and primary, intermediate and social care providers as part of a sensible and integrated approach.
Secondly, in implementing the directive, we must not substitute tired consultants for tired junior doctors because that would benefit neither doctors nor patients. Instead, we need to look carefully, as we have, at the contribution that the whole NHS work force can make in helping to reduce the hours that junior doctors currently work. The EWTD is not therefore just about the hours that doctors work, but goes much wider and deeper.
Thirdly, as we make progress in implementing the directive—and we are—we need to maintain and, where possible, improve the quality of junior doctor training, helping to ensure that the doctors of the future are as well equipped as possible to meet the challenges of a lifetime of professional practice. So in meeting the requirements of the directive—clearly the obligation of the NHS—we must be careful not to compromise on the standards of medical education and training. That, too, would not be in the long-term interests of doctors or patients.
In all those areas, work is already well advanced and I will spell out the progress that has been made. I reject the Opposition's suggestion that little or nothing has been done. They would say that, but the opposite is true. The Department has worked closely with the Academy of the Medical Royal Colleges, individual royal colleges, the BMA—whom I met again this morning to discuss the issue—the NHS Confederation and other organisations to put in place the necessary reforms to help the NHS to implement the directive sensibly. We will continue to do so, working closely with the professions to effect sensible and effective solutions to the very real challenges posed by the directive. Those measures have been backed up by additional investment to help accelerate the necessary changes.
It is true that we do not accept the interpretation that the European Court has recently placed on the meaning of the directive, either in relation to the definition of working time or when periods of compensatory rest should be taken. As I said earlier when Mr. Dorrell asked me to confirm it—I do so freely again—the decisions of the Court in both cases have made implementing the directive considerably more onerous and difficult for the NHS. That is true not just of the NHS in Britain, but for every health care provider across the EU. The SIMAP decision will have a particularly serious impact on the NHS, as it directly affects the pattern of resident on-call rotas worked by junior doctors. It does so, as the hon. Member for South Cambridgeshire rightly said, by requiring periods of time spent asleep but on call to count as working time.
We are working precisely to achieve that. If the hon. Gentleman can hold on to his hat for a moment, I will set out precisely the level of progress made at the European Commission and Council of Ministers level.
As I was saying, the judgment has a particularly serious impact on resident on-call time. Given the existing pattern of resident on-call working in the NHS, it will be difficult to comply with that interpretation unless we employ thousands of additional doctors and radically change working practices and on-call rota arrangements. On the Jaeger case, I agree completely with the BMA that, in relation to when compensatory rest should be taken, the ruling is unworkable and unnecessary. Again, we argued in the European Court for a different outcome.
As I have said, these cases have raised concerns right across the European Union. It is not just Britain and the NHS that will face difficulties in implementing the decisions. With the exception of Greece and Lithuania, all member states and all the accession countries have expressed their support for a review of those aspects of the directive. Together with the Health Ministers of Sweden, Denmark and the Netherlands, I raised our concerns over the impact of the rulings with the Commission last July.
In January, the Commission began a consultation on amending the directive to deal with, among other things, the impact of the SIMAP/Jaeger rulings. On
"the key message from our discussions today is that an urgent European Union solution is needed to address the impact of the recent European Court of Justice rulings."
"I am aware of the practical difficulties experienced by the health sector in particular. As the commission indicated at the March Employment Council, I intend to bring forward legislative proposals on the working time directive before the summer."
We very much welcome that acceptance on the part of the Commission that the directive needs to be amended.
We have responded to the Commission giving details of the changes that we are seeking to the directive, and many other member states have done the same. Copies of these documents are available in the Library, and I assume that Mr. McLoughlin has familiarised himself with them. We will clearly need the support of other member states who have expressed their concerns over the two recent rulings. The proposals for change need to be taken forward as quickly as possible, because
In the meantime, good progress has been made in reducing junior doctors' hours. Our strategy has been twofold. We have sought first to develop an employment contract for doctors in training that reflects the requirements of the Directive and, secondly, to increase the size of the workforce substantially. We have achieved both.
The new contract for doctors in training was successfully negotiated with the medical profession and put into effect in December 2000. The arrangements limit the maximum weekly working hours of doctors in training to 56, which is less than the 58 hours specified in the directive—
Yes, the new deal. The arrangements also specify necessary daily and weekly rest requirements. To support the introduction of the contract, we invested in excess of £150 million over the first three years to implement the contract.
What would the Minister's attitude be if junior doctors wished to opt out of the working time directive, perhaps because of shortages or particular problems in a hospital?
Under the terms of the directive, junior doctors are able to express such a preference. It is not the job of Ministers to say to individual doctors who wish to exercise that right whether they should or should not do so. That would be contrary to the spirit, letter and intent of the directive, because it is an individual choice for members of staff in the NHS and elsewhere. I fully support the retention of an opt-out in the directive, for the reasons that I gave earlier. It preserves flexibility, which all employment protection measures need if they are to work sensibly and not place unnecessary or unforeseen burdens on business or public services. It also allows us to keep our competitive edge, which is crucial in the context of the European Union. The Government's position on the opt-out has been made clear and I hope that I have dealt with the hon. Gentleman's concern.
As a result of the new contract for junior doctors, there has been a substantial fall in the number of hours that junior doctors are working. It is also pertinent to remember that the hours that junior doctors work are self-certified, so it is not my figures—which is just as well—that show that but those of junior doctors themselves.
People who work longer hours have been required to be more open and honest, but is it possible that some junior doctors have not returned full details of the hours that they have worked out of a concern to keep the medical profession going and provide proper care for patients?
That is always a possibility and I would not rule that out in every individual case, but it is worth bearing it in mind that the statistics that we collect on the hours that junior doctors work are certified by them and they are paid a premium for working more than the minimum hours specified in the new deal. I strongly suspect that the figures are as accurate as we could hope them to be.
In March 2001, immediately after implementation of the contract began, only 55 per cent. of doctors in training were compliant with the new deal requirements. However, latest figures show that 83.6 per cent. of all junior doctor posts are now fully compliant with the new contract, with 95 per cent. of all doctors in training compliant with the weekly limit on working hours. Substantial progress has been made on the part of the directive concerning maximum working hours. Regrettably, I did not hear any acknowledgement of that in the remarks of the hon. Member for South Cambridgeshire.
We have also rapidly expanded the number of doctors working in the NHS. There are more than 7,000 more doctors in training working in the NHS today than was the case in 1997, when Mr. Dorrell was in charge. The number of associate and staff grade doctors has also increased by more than 3,300.
The expansion in the NHS work force is not confined to junior doctors. The number of consultant posts has increased by more than 7,000 since 1997, which represents an increase of 34 per cent., and we are making progress on increasing the number of doctors by a further 15,000 by 2008, over the 2001 baseline figure. That means that not only are we moving rapidly towards a consultant-delivered service, but we have substantially more specialist registrars to provide high-quality services and reduce further the work load of existing doctors in training. We have also met the target for an additional 1,000 specialist registrar posts 18 months ahead of schedule, and expect more to be established over the coming months.
To maintain those increases we are also training a record number of medical students. Medical school intake in England has increased by 2,281 since 1997, representing a 60 per cent. increase. More than 6,000 students entered medical school in England in autumn 2003—the highest number ever recorded. The Government achieved their target of increasing the number of medical students by more than 2,000 places two years earlier than anticipated.
We have similarly increased the number of non-medical staff working in the NHS. Between September 1997 and 2003, the number of qualified allied health professionals rose by nearly 11,000, exceeding NHS plan targets. By the end of September 2003, more than 16,300 former nurses, midwives and health visitors had returned to work in the NHS since February 1999. In total, there are an additional 67,500 more nurses working in the NHS today than in 1997. All those increases will help the NHS in meeting its obligations under the working time directive.
I am sorry to have to say that, in relation to consultants and nurses, my amendment understates the actual numbers of additional staff that have been recruited. [Interruption.] I shall not withdraw the amendment, but at least on this occasion no one can accuse us of spin.
My right hon. Friend has put his finger on the crux of the problem. The negotiations on the working time directive were concluded in early 1993 by the then Conservative Government, who messed things up. They did not foresee the problems that would be caused by the legal judgments or that would result for the training of medical staff. This Government are now sorting out those problems, given the length of time that it takes to train doctors and consultants.
I am grateful to my hon. Friend for those remarks. I am glad that he feels that I have got to the crux of the matter, although I believe that I am about to come to that—
The hon. Member for South Cambridgeshire took 40 minutes to reach no particular point, so if hon. Members will be patient, I may be able to score at least one home run. That is all that I hope to do.
Recruiting more doctors, although essential, will not, by itself, be enough. The rapid and extensive growth in doctor numbers represents a massive achievement for the NHS, which comes back to the point made by the hon. Member for Rochford—
I apologise. That is where my sister lives. I do not think that she voted for the hon. Gentleman, although I had better check that. I doubt whether we could recruit the many thousands of additional doctors needed to meet the effect of the SIMAP and Jaeger rulings if our only response to the directive was to replicate existing patterns of working by junior doctors. That relates to the discussion about costings that we had in the European Standing Committee.
The costings that we provided for the European Standing Committee were based on the assumption that the response was based solely on recruiting additional junior doctors and staff-grade doctors—those who are not consultants, but are not in recognised training posts. Although one cannot be 100 per cent. accurate, the cost of employing doctors is generally higher than the costs of recruiting additional nursing staff, and that was the point made by the Under-Secretary of State for Trade and Industry, my hon. Friend Mr. Sutcliffe, when he summarised the debate in the European Standing Committee.
I am sorry if Mr. Francois felt that we had not provided him with the costings, but my hon. Friend was making the point that, if we need fewer doctors but more nurses, the overall cost of compliance is likely to be less than those figures, not more. By the look on the hon. Gentleman's face, I am still struggling to get that point across to him.
"The cost of recruiting several thousands of extra . . . doctors . . . would run to hundreds of millions of pounds per annum"?
"The alternatives to employing additional doctors, as set out above, are likely to cost approximately the same as recruiting more doctors."
That is completely contrary to the point that the Minister is making.
No, with great respect to the hon. Gentleman, I do not believe that to be the case. The point that I am trying to make today—
If the hon. Gentleman wants to reconfirm the point, I will certainly give the Floor to him again.
I was quoting one of the papers supplied to European Standing Committee C—the UK response of
"Please specify, as precisely as possible, the additional costs directly attributable to the SiMAP and Jaeger case law."
The Government said:
"The cost of recruiting the several thousand extra middle grade doctors required for the UK would run to hundreds of millions of pounds per annum. This includes on-costs, overheads and training costs. The alternatives to employing additional doctors, as set out above, are likely to cost approximately the same as recruiting more doctors."
That is not the point that the Minister is making.
It is. The costs are approximately the same; we are not saying that they would be in addition to the all-doctors option. [Interruption.] The hon. Gentleman obviously cannot digest the point that I am making—by the sound of it, nor can other Conservative Members.
The options are the all-doctors solution, which we cost, and other options that involve the substitution of additional health care staff. Of course there will be costs, but, clearly, as we are not pursuing the all-doctors solution, they will not be those of the all-doctors solution. I do not want to labour my point any further, but, in general, the costs of employing nurses tend to be less than those of employing doctors—so, for obvious reasons, I do not want to go on any further about that issue.
No, I will not; I have dealt with that point. [Interruption.] I am sure that the hon. Gentleman will make a speech and we all look forward with bated breath to his comments.
No, I am not giving way to the hon. Gentleman.
It does not make sense to pursue the option of recruiting additional doctors as the only response—
On a point of order, Mr. Deputy Speaker. This is a serious point. When we debated this matter in the European Standing Committee, the Minister had to leave the sitting before the end. There were reasons for that and we did not quibble, but the Under-Secretary of State for Trade and Industry, Mr. Sutcliffe, who remained to the end, made an offer, as reported at column 34 of Hansard, that the Minister would write to me specifically on that matter to lay out the Government's case. I have that copy of Hansard here. I have not received that letter. That is the point on which I am seeking to persuade the Minister to give way.
I understand the point that the hon. Gentleman is making, but ministerial answers to hon. Members' questions are not matters for the Chair.
I would certainly want to apologise if there has been any discourtesy to the hon. Gentleman in not receiving a reply from me. I will arrange for him to receive a proper response. I apologise to him if he has not yet had one.
We need to expand the NHS work force, but our response to the directive must be focused on a wider array of fronts if we are to succeed in meeting the challenge that it presents. The crux of my difference with the hon. Member for South Cambridgeshire—I think that my hon. Friend Rob Marris will agree—is that we need to re-examine the traditional ways of working, which have often placed too much of a burden on doctors in training, leading to long hours and sometimes unacceptable working patterns.
New models of care and new ways of working are already being developed in many hospitals that utilise the potential of all staff, such as greater use of multidisciplinary team working. That will involve more staff working differently—staff working more flexibly to enhance patient care and improve NHS productivity. Those are precisely the sort of changes that the NHS should be making irrespective of the requirements of the working time directive, because they will allow hospitals to lessen the individual burden on some staff, while making the delivery of services more efficient.
That work is being taken forward by 32 NHS trusts, which have been developing new roles in delivering NHS services since 2002, to meet the requirements of the directive. In fact, one of the trusts is in the constituency of the hon. Member for South Cambridgeshire, at Papworth hospital, which has been making significant progress. I am sure that that trust has kept him briefed. Some trusts, including that at Papworth, have tested new roles for non-medical staff, such as extending traditional roles for nurses and therapists and creating some entirely new roles. Some NHS trusts are developing new working patterns for doctors in training and others have changed the way that consultants work. Some have combined those approaches with changing the way that a service is delivered, taking the opportunity to streamline the service and improve the standard of care.
For smaller district general hospitals—about which many right hon. and hon. Members will be concerned—the work of those 32 NHS trusts has shown that compliance with the directive can be achieved by a combination of such changes to working patterns, including full shift working for senior house officers and expanding roles for additional staff.
Four NHS trusts—Homerton, which is now a foundation trust, Liverpool, Wirral and Morecambe Bay—are leading the work on the hospital-at-night project, which is considering different ways to provide acute care during unsocial hours. I think that the hon. Gentleman said that the British Medical Association devised the hospital-at-night project.
I am grateful to the hon. Gentleman for that clarification, but that is not strictly the case, as I am sure, with hindsight, he will be aware. The hospital-at-night concept was jointly devised by the postgraduate deans, the Department of Health and the BMA. It has been co-ordinated by the Department of Health, and we are very happy to have the BMA's support.
The hospital-at-night model proposes one or more multidisciplinary teams working in the hospital over night that, between them, have the full range of skills and competencies to meet patients' immediate needs. That is why the agreement on cross-cover that we have reached, to which I referred earlier, with the Academy of Medical Royal Colleges is so important. It will help to establish the right focus on patient safety and good clinical governance needed to underpin any such change.
The work of the 32 NHS trusts involved in helping us to implement the working time directive shows—in a sense, this is the hub of the difficulty—that there is certainly no one-size-fits-all solution. The hon. Member for South Cambridgeshire assumed, for most of his remarks, that there was a solution and that the only reason why the NHS was having difficulties was that the Government had not told them the solution to the working time directive problem.
The changes that are taking place in those 32 NHS trusts are replicable, but because every trust will have different circumstances, a different population to serve and a different work force to deploy, it will have to reach a view itself, based on its own experiences, about the kind of measure that it needs to adopt. Those 32 trusts have shown what can be done, and it is now clearly the job of the trusts that are not yet fully compliant to take the appropriate action to secure the maximum possible compliance. That is why I was particularly pleased that the House of Lords European Union Committee chose to highlight the positive progress—those were its words—of all the pilot sites in its recent report into the Commission's review of the working time directive, published on
The different solutions that are being developed in those pilot sites—both on what works and, clearly, what does not work—are being systematically shared with the rest of the NHS. We are providing targeted support to strategic health authorities to help them to identify the solutions that will help the trusts in their own areas and to get those solutions into every organisation that needs them.
We have been reviewing the way that we train junior doctors to find out whether we can make the arrangements more efficient and effective. In parallel with implementing the working time directive for doctors in training, we are gearing up for a major reform of training itself. The modernising medical careers initiative will introduce better managed and better structured training programmes for junior doctors.
It is clear that we in this country take much longer to train our doctors than is taken elsewhere, not because they get more training here, but because their training is not always well supported and, frankly, not always very well organised. That is why the modernising medical careers strategy is being introduced It will see us take a specialty-by-specialty approach to streamlining training, but it is clearly not a quick fix that will have an impact by
The role of the Department, which was the focus of the remarks of the hon. Member for South Cambridgeshire, is simply to support the NHS in meeting the legal requirements of the directive. That is precisely what we have been doing and we are doing this in the widest possible collaboration with the professional and regulatory bodies, NHS employers and those responsible for professional education and training. Measures that will help the NHS meet the requirements of the directive are being put in place and they are being implemented as we speak. I express my thanks and appreciation for the hard work of NHS staff up and down the country who are committed to this endeavour.
Meeting the new requirements that recent case law in the European Court of Justice has imposed on us will be a considerable challenge for the NHS. I cannot assert that every shift worked by every NHS employee after
The new contract for GPs was the second focus of the hon. Gentleman's remarks. As I understand it, the essence of his argument and the motion is that the extent of GP out-of-hours services will decline as a result of the new contract. That claim is entirely without foundation. It ignores both the statutory duties of primary care trusts to ensure the provision of out-of-hours services and the reality on the ground. In making his argument, he completely disregarded the new national quality standards that all out-of-hours service providers will be required to meet. They were introduced by this Government and are designed to deliver precisely the service that he now says that he wants to see in place.
I am pleased that the House has got back to debating the quality of care for patients, which is the focus of the Government's amendment. I was concerned that all we seemed to be worried about was the way in which the contract is to be implemented. Will my right hon. Friend comment on the views expressed by a local GP? Dr. Amit Bhargava took the trouble to write to our local newspaper to explain to people in Crawley how important the GP contracts are and what changes they will involve. It is important that we move forward and provide a range of services for people and Dr. Bhargava congratulated the Government on taking the steps to do that. We need to return to that issue.
I am grateful to my hon. Friend for that contribution because it introduces a different perspective from that provided by the hon. Member for South Cambridgeshire. I shall return to his assessment shortly.
The other problem with the hon. Gentleman's remarks is that they reflected a profound misunderstanding of the new contract. They gave rise to the obvious questions about what changes he would introduce to the new contract if he is as concerned about the situation as he claims to be. As in all the main arguments that he deployed, we heard absolutely nothing of substance from him.
As the hon. Gentleman well knows, the new contracts are designed, in part at least, to deal with the long-standing concerns of GPs about the onerous nature of their statutory obligation to organise the delivery of out-of-hours services themselves. Under legislation agreed by the House last year, that obligation has been transferred to primary care trusts. It has not been dispensed with or evaporated; it is still there and is now the responsibility of PCTs where it properly belongs.
"The current 24-hour responsibility has deterred many young doctors from pursuing a career in general practice and has contributed to the current shortage of GPs"
The Whitworth hospital in Darley Dale in my constituency provides a first-class service. It is a community hospital staffed by GPs and has a minor casualty unit that serves more than 8,000 patients each year. Does the Minister believe that the new GP contract reflects the work that the local GPs do and is there any danger that the services that I have described could be under threat?
I do not want to see any threat to such services. The new GP contract has absolutely nothing whatever to do with the work of GPs in community hospitals. That is secondary care, which has never been covered under the terms of their employment in primary medical services. The activity in secondary care that the hon. Gentleman describes has nothing to do with the primary medical services contracts of GPs, but I shall deal with that point in a minute because it is another one about which the hon. Member for South Cambridgeshire was not particularly well informed.
The changes do not mean the end of out-of-hours cover. We know already that GPs will continue to be involved in delivering these services. We have made extra investment available to provide for that—something that the hon. Gentleman and the motion now seem to be concerned about. As he knows, GP practices are required to give proper notice of their wish to opt out so that appropriate alternative contractual arrangements can be made.
The hon. Gentleman said that he drew some of his information from Pulse. I do not whether he has seen it, but I have a story that appears under the headline "Smooth start for first out-of-hours services after GP opt-outs". Perhaps he has simply not had the chance to see it or perhaps he decided not to use the story for reasons that others will speculate upon.
My right hon. Friend is being too modest about the achievements of the new GP contract. John Chisholm, in particular, is so enthusiastic about it because, for the first time, it allows GPs to broaden the range of services that they offer, to ensure that patients can be seen within 24 hours of request when that is considered necessary and to offer a new range of services that are currently carried out in the secondary sector. It has been shown many times that patients would far rather be treated by their own GP locally. Clearly, if GPs are to provide so much extra during the daytime to enhance patients' services, they will have to be able to rely on other professionals such as pharmacists, paramedics, nurses and other health personnel to take some of the burden off them for the services that might best be provided by other people anyway. The whole point is the enhancement of services and the integration of different skills within the health service to ensure that patients get a better deal throughout the entire patient experience and not just when they attend a GP's surgery.
I am grateful to my hon. Friend, because I can now dispense with what is left of my speech. I am sure that that is probably what everyone wants me to do. He is right. With respect to the hon. Member for South Cambridgeshire, he did not address those aspects of the reforms in any substance. In hindsight, I am sure that he would want to reflect upon that.
We should also put the issue into its proper context, because the hon. Gentleman failed to do that. At present, fewer than 5 per cent. of GPs provide their own out-of-hours cover. Most practices have already delegated that function, prior to the new contract, to GP co-ops or have contracts with private providers, but that has not stopped GPs deciding to work additional out-of-hours shifts. I believe that that will continue to be the case.
I am sorry that Mr. Turner is not here, because I was struck by the comments of one GP on the Isle of Wight recently. His practice recently decided to opt out of its statutory out-of-hours responsibilities, but he, along with his colleagues, is working additional out-of-hours shifts. That is being made possible because of the extra investment that we are making in those services.
I had quite a lot of sympathy for the Minister's arguments until he said, "because of the extra investment that we are making in these services". I have spoken to the three primary care trusts covering my constituency and they all say that they are having to find extra money to introduce the type of service that they think the public expect and deserve. The amount that will be clawed back from GPs themselves will cover only about half the cost of the services that have been designed, and those services have been cut from the original gold-plated services. Will he assure me that, if my local primary care trusts need extra resources, something will be available?
It is always good, in these debates, to hear from a Liberal Democrat because clearly, for Liberal Democrats, there is no such thing as an NHS budget. On out-of-hours services, the hon. Lady is right: to opt out, a practice has to pay a proportion of its income back to the primary care trust, but that is only half of the investment available to trusts to fund out-of-hours services. We have doubled, in overall terms, the investment going into those services, and we have ring-fenced that money. It is one of the very few parts of the NHS budget that is ring-fenced, and that is precisely to avoid the difficulty, which the hon. Lady and others will, I am sure, speak about in a minute, of PCTs not having additional investment. It is up to trusts to make effective use of the resources that we have given them.
I agree with my hon. Friend Dr. Stoate that we should make wider use of specialist nurses, and we should integrate out-of-hours services with walk-in centres and accident and emergency ambulance services. That is not a step backwards, as the hon. Member for South Cambridgeshire implied, but exactly the opposite. Out-of-hours services will continue to make full use of the services of GPs. The contractual vehicle will be different, but that is what GPs and the BMA have asked us to provide. We are working with them and with the National Association of GP Co-operatives to ensure that the new arrangements work well and in the interests of patients.
I am not at all clear what the hon. Gentleman's position is. His motive, however, is crystal clear: to undermine public confidence in the arrangements that are being made by PCTs to provide out-of-hours cover. To give him some credit—I want to be even-handed—he has not wasted any time in setting about that task. The contract only came into operation three weeks ago, and only 10 per cent. of trusts have so far taken on responsibilities for out-of-hours services from their GP practices. He certainly got his shroud-waving in at the earliest opportunity.
On community hospitals, the hon. Gentleman completely missed the point. The new contract for GPs has no bearing on the arrangements whereby GPs may provide medical cover for patients occupying beds in community hospitals; neither were those arrangements covered by the previous contract. Changes to the out-of-hours obligations in the new contract are therefore nothing to do with any instances where there may be a local dispute about payment for such cover.
Will the Minister reflect on Warminster, where wards in the cottage hospital have closed because GPs have withdrawn their services, having taken the view that, although they are very happy to provide cover in the hospital as a bolt-on extra to their out-of-hours contractual obligations, they will certainly not do so in the absence of those obligations? That is happening right across the country. I am surprised that he does not know that.
No, it is not happening right across the country. There certainly was a problem in Warminster, and there have been problems in one or two other community hospitals—I acknowledge that. However, they are not to do with the out-of-hours arrangements under the new contract. The hon. Gentleman is wrong about that. The Minister of State, my hon. Friend Ms Winterton, will address that point in her winding-up speech, and I am sure that the hon. Gentleman will want further to reflect on his arguments.
Agreements that GPs may have with a community hospital are separate from their primary medical services contract and it has always been up to PCTs to decide locally how to commission that work as part of their broader commissioning strategy. The doctors and dentists review body itself expressed the view that the matter should form part of the wider review of staff and associate specialist grades that the Department is committed to undertaking. That is very much in line with how we would like to proceed. From
The Opposition's case is misplaced, misinformed, opportunistic and completely devoid of any practical alternatives to the path that we are pursuing, on both the working time directive and the provisions of out-of-hours services. It is not clear to me or, I suspect, anyone who heard the hon. Member for South Cambridgeshire whether the Opposition are in favour of the new contracts for GPs, whether they support the provisions in the contracts for out-of-hours services, or whether junior doctors should be covered by the directive. In that sense the hon. Gentleman was at least consistent in ensuring that his arguments lacked any substance, any sense of proportion or any recognition of what is happening on the ground. That is another reason why my right hon. and hon. Friends should reject the motion standing in the name of the Leader of the Opposition.
I start by referring to a speech that the Minister of State gave in January at a gathering organised by the Royal College of Surgeons. He said—[Interruption.] That is not this particular quote; I am afraid that the Minister of State will have to listen because this is a new quote from that interesting speech. On the working time directive, he said:
"We have all analysed the size and scale of the difficulties ahead of us. They are real and obvious. But we need to do more than this. And we need to start taking the necessary steps now to secure implementation."
The deadline for introducing the maximum average working time of 58 hours per week is
The hon. Gentleman would have made a fair debating point if we had taken no action prior to my making that speech to the Royal College of Surgeons. I hope that he is prepared to be fair and acknowledge that.
That was a very early intervention, and I hope to explore in a little more detail some of the steps, and their adequacy, that the Government have taken since the working time directive first appeared on the horizon in 1998 and they made a commitment to implement it over the following few years. I take no lessons from the Minister at this stage, but I am sure that if he does not agree with other things that I have to say he will take the opportunity to catch your eye, Mr. Speaker, and intervene.
The January speech is proof, if proof were needed, of the dither and delay that was exposed, and dealt with in detail, in the examination by the House of Lords European Union Committee. I shall outline my reasons for that conclusion. It is not as if the directive has come out of the blue. The Minister and his colleagues have had five years to grapple with its implications for the NHS. Ministers have known about the SIMAP judgment since October 2000. The NHS is now having to deal with the interactions of a whole series of decisions taken by this Government over the past five years. Both the GP and consultant contracts start to kick in just when the directive begins to bite. In combination, those three major changes have a huge effect on the medical work force and their capacity to sustain current levels of activity and, indeed, to deliver ever higher standards.
In their submission to the European Commission the Government stated that the UK requires between 6,250 and 12,550 more doctors to comply with the directive—a lot of extra doctors. The Minister outlined, both in his speech and in the amendment to the motion, the Government's progress on recruiting and training more doctors. The BMA says that compliance with the directive will result in the loss of the full-time equivalent of 3,700 junior doctors. I know that that figure is contested, but the Minister did not, in his speech, demonstrate why it is not an accurate assessment.
All that has to be seen against a backdrop of the poor, even non-existent, work force planning of the 1980s and 1990s and the legacy cost of neglect and under-investment by an earlier Administration. The failure of the last Conservative Government to expand medical training places and the current Government's decision to stick to Conservative spending plans for their first two years in office have undoubtedly exacerbated capacity constraints and the Government's ability to be in the right position to ensure full compliance with the directive by August. Even now, the Royal College of Physicians says that there are insufficient junior doctors in training. Some might say, "Of course it would say that," but it is nevertheless worrying that it flags that as a serious concern.
I agree with the Minister that the answer to the working time directive is not simply more doctors; it is about doing things differently. The hospital at night project, which has been discussed across the Dispatch Box, is one measure that needs to be taken. Whether it was suggested by the BMA or the royal colleges, or whether it was a Government initiative, does not much matter; it is what comes out of it that matters and whether it delivers the additional capacity to allow us to deal with the consequences of the directive
The 32 pilot schemes that are being trialled through the country provide opportunities to innovate and experiment in different ways of working, to manage demand and so on. However, although local initiatives such as the ones that are being implemented to change the skill mix, expanding the roles of nurses, midwives, therapists, pharmacists and others, point a way forward, and although there has undoubtedly been an improvement in the work force size over the last few years, the most recent work force survey suggests that we still have shortages of midwives and some of the key therapist roles that are key to making a reality of the individual initiatives being implemented throughout the country. Such initiatives have a part to play, but it is far from clear whether they can be implemented across the NHS before the
The Committee went on to report that no more than 50 hospitals will be in a position to implement the methods trialled in the pilots. Do the Government accept that conclusion and, if not, why not? How do their conclusions differ from the Committee's? The Government acknowledged in their submission to the European Commission that the alternatives, as we have heard in today's debate, may not cost more than employing extra doctors but will certainly cost as much, so it is not a cheaper option for the NHS to get round the problem with upskilling, changes and skill mixes. In its brief for today's debate, the NHS Confederation states that it will not be possible for many NHS organisations to meet the compliance requirements by August 2004. The Government clearly agree, given what the Minister of State, Mr. Hutton told the House today. Indeed, the confederation goes on to warn that some trusts will not be able to provide safe medical care in some specialties if they introduce compliant rotas. Trusts face an invidious choice between damaging patient care and failing to comply with the directive. The confederation urges the Government not to adopt a punitive approach when dealing with non-compliance. It would be useful if the hon. Member for Doncaster, Central explained in her reply to the debate how the Government intend to deal with trusts that are not in compliance with the directive, not least because the right hon. Member for Barrow and Furness said that many trusts will not be compliant. Presumably, those trusts will be dealt with case by case.
According to the Royal College of Physicians, six out of 10 hospitals still do not have the 10 middle-grade staff necessary for a compliant rota. More worrying still, almost four out of 10 hospitals say that they have fewer than eight middle-grade staff, so they are well short of what is needed to deliver compliant rotas. In the speech that the right hon. Member for Barrow and Furness made in January he said that
Why, in January, did the right hon. Gentleman think it necessary to say that such a process should be in place? Surely it should have been in place for a long time.
The Government have issued inadequate and vague guidance to hospitals on the implementation of the directive. To start to develop a road map just months before the deadline for implementation is breathtakingly incompetent. Ministers say that the directive could have been complied with were it not for the European Court rulings in the SIMAP and Jaeger judgments. The SIMAP judgment, however, was made in October 2000, and dealt with the issue of what is meant by working time. That was further complicated last summer, as the right hon. Member for Barrow and Furness said, by the Jaeger judgment, which gave an unworkable definition of when compensatory rest should be taken. The European Commission made a welcome announcement on
The motion also deals with community hospitals and the link between their capacity and the GP contract. The right hon. Member for Barrow and Furness was right that there is not a direct causal link between the GP contract and the issues affecting community hospitals, but there is undoubtedly some interaction that is causing GPs who work in community hospitals to abandon that work. There are 400 community hospitals in the United Kingdom that provide 10,000 beds and rely on about 4,000 GPs to provide key services. Those hospitals are crucial to the system. They provide a safety valve for district general hospitals, and are increasingly becoming centres for rehabilitation and intermediate care. There is a genuine possibility that the new GP contract will have the unintended effect of causing GPs to withdraw from work in community hospitals, as has already happened in Bolsover, Clay Cross and, as we have heard, Warminster. Wherever that happens, salaried medical staff are used as an alternative, but when they take on GP roles in community hospitals they are subject to the working time directive, so costs increase. That has not been factored into the Government's costings, and is connected to the point made by my hon. Friend Sandra Gidley about the inadequacy of resources to implement changes in the contract.
Will the Minister explain why her Welsh and Scottish counterparts have embarked on negotiations on community hospitals? They are more concerned about the issue than the Government in England, and have started negotiations to ensure continuity of care and to enable GPs to continue to fulfil that role. There is no similar process, however, in England to avoid the fallout after
The new consultant contract, which aligns pay with sessions worked, is a welcome innovation in the NHS. However, the Government appear to have underestimated the amount of work that consultants have undertaken in their costings, plans and implementation of change. If those hours are not funded, they will not be worked. If they are not worked, the extra consultants trumpeted in the amendment will not provide extra services, and the Government will merely be treading water as a consequence.
I apologise for intervening on the hon. Gentleman, but there are some things that I must correct. The British Medical Association agreed the funding envelope for the consultant contract.
That was not part of my argument, but I am grateful for that additional information. I do not think that I uttered "BMA" at all in the context of the consultant contract. There appears to have been an underestimate of the work done by consultants. The BMA may have agreed to something, but that does not necessarily invalidate my assertion and the evidence in the Health Service Journal and other journals that this growing problem is causing severe budgetary problems, especially at year-end. Strategic health authorities put it at the top of their list of financial pressures. The right hon. Member for Barrow and Furness may say that the contract is fully funded, but time will tell. I hope that the hon. Member for Doncaster, Central will explain that the Government are satisfied that there is no mismatch between consultants' historic work load and the work load that they will undertake under the new contract, as that may well have a serious impact in future.
In conclusion, there is very little time in which to implement the working time directive. The scale of the task, as has been outlined, is huge. Ministers have had ample time to plan and prepare for the implementation of the directive, but have failed to realise the impact of a range of measures that they are implementing this year on the working time directive. As a result, Ministers will have to rely on the hard work, professionalism and good will of front-line staff to get them out of a hole that they dug and that they will now expect the staff to bail them out of.
Order. Before I call the next hon. Member to speak, I remind the House that Mr. Speaker has placed a 12-minute limit on Back-Bench speeches, which applies from now.
I welcome the debate and feel reassured that doctors' hours in the NHS are being reduced. When I or any member of my family or any constituent of mine needs to be treated through a scheduled operation or as an emergency, the last thing I want is for them to be treated by a tired doctor. Even though doctors are dedicated to the task in hand, when they get tired they might not be as sharp as they could be. We must remember that it takes seven years to train a doctor, and probably as long to open a medical training school. I am pleased that a medical training school has been opened in my region, the east of England, at Norwich, and will no doubt be turning out doctors very quickly.
We have excellent GPs in St. Albans. My own practice, Midway surgery, sees patients within 48 hours. It carries out minor operations and runs many clinics. Another, the Kedia practice, has just had a brand-new surgery built that will provide state of the art services to the people of London Colney, a village in my constituency. I have written to my right hon. Friend the Minister to see whether he can come to open the new surgery shortly. In addition, we operate a collective stand-by service in St. Albans, StaDoc, which covers the whole constituency. It is hoped that this group will provide doctor cover to enhance the service at the minor injuries unit at our city hospital, which is nurse-led and is wonderful. I visit the place regularly. Staff there can deal with all but the most serious injuries, and they deal with them in minutes, not hours.
Many people seem to delight in knocking our health service. Recently, our local newspaper did so on its front page with banner headlines attacking the failure to meet accident and emergency targets for waiting times. One week later I discovered that, on average, 5 per cent. of people booked in for operations do not turn up. They do not ring up to let the hospital know; they just do not bother to attend. That appeared on page 17 of the local paper with a modest headline and received little coverage.
As I said, having been given an appointment for treatment, some people do not turn up. They give no reason and no advance warning. A leading surgeon told me that he had known the rate to be as high as 25 per cent., but the average was about 5 per cent. In the day surgery unit, which does 100 operations each week, 5 per cent. is the equivalent of two and a half weeks of operations not carried out when theatre space had been allocated and clinical staff were ready to operate. That is a waste of resources. If those operations had been performed, many people could have been taken off the waiting list.
Measures are in hand to ensure that, as far as possible, the figure of 5 per cent. is reduced. For example, hospital staff ring the patient, where possible, a few days before the due day to ensure that the patient will turn up. In addition, a list is being compiled of people who can be called at short notice to fill possible vacancies. It is still outrageous that people who have been examined, had an operating slot scheduled and had preparatory work done do not show up. There is a two-way bargain, with the health service scheduling operations and doing preparatory work. The patient's side of the bargain is to turn up on the right day at the right time, ready for the operation.
I recently spent a morning in our city hospital day surgery unit, where I was told about the non-attendance. I was due to meet the morning list of patients and follow one patient from pre-med to operation, post-operative care and then home. The patient chosen was a young man who had been suffering extensive back pain for some time. He was programmed for a cortisone injection in his spinal area. That sounds simple, but it is fraught with danger. The man had a local anaesthetic and was fully conscious through the entire procedure. The nurse responsible chatted to him throughout, reassuring him. The whole procedure was facilitated by the use of X-ray photography to enable precise positioning of the injection site. That meant that all of us had to wear lead aprons, which are extremely heavy.
The surgeon and the anaesthetist explained the whole procedure to me in detail throughout the operation. The procedure did not take long but was carried out very carefully indeed—an impressive performance, nothing like "ER" or "Casualty". I observed the patient in recovery and joined him later back in the ward, where he had some tea and toast and was then discharged. I have spoken to him since and he tells me that his back pain is much eased. As well as being a recently appointed fellow of the Royal College of Midwives, I now feel emboldened to apply to become a fellow of the Royal College of Surgeons.
Emboldened by the Minister speaking about his sister, I want to mention my mum, who will be 84 next Monday. I wish her many happy returns. For the past two years, she has spent much time in and out of hospital, and in the main has been treated very well.
I may well do that, Mr. Deputy Speaker, now that you point it out. Doctors' hours are extremely important and my right hon. Friend the Minister alluded to the steps that will need to be taken so that we have the right number of doctors. We need more training places, and I am pleased to say that we are working with the university of Hertfordshire to try to set up a medical training school there, which will ensure that we get the right number of doctors. I know that the university vice-chancellor, Professor Tim Wilson, and his team are keen to provide such a facility. With the large new state of the art hospital, which we hope will be built in Hatfield, close to the university, we should be able to link the two together—a new hospital and a medical training school to provide the doctors we need, to ensure that we can comply with the working time directive, and to ensure that operations are carried out properly, doctors are not too tired, and a full and efficient service is available to our constituents as patients.
I am grateful for the opportunity to take part in the debate. I do not intend to follow my hon. Friend Mr. Lansley and the Minister down all the wider issues, or to bring up any relatives, as the House will be relieved to hear. I want to make a brief and simple point about the problems of rural areas. Of course, I have in mind my constituency, Richmond in Yorkshire, and issues that have arisen in Wensleydale in my constituency. I know that the Minister who is to reply to the debate, Ms Winterton, knows Yorkshire, so she may well be able to visualise the area about which I am talking.
I fear that changes in GPs' hours and possibly the working time directive, which I shall mention briefly, impact particularly hard on rural areas. Health service resources are spread more thinly and, of course, GPs are spread more thinly in those areas. I am referring to very rural areas—in my constituency, the top end of Wensleydale, where ambulances do not arrive as rapidly as they do in the rest of the country. Everybody understands that that is a problem and something is being done about it, but it will probably continue to be a problem. The accident and emergency department of the hospital in Northallerton is over 40 miles away for my constituents—an hour's drive and more, in many cases, and much more in bad weather and difficult road conditions.
My constituents feel remote from the health service in any case, so GP practices are particularly important in such an area—disproportionately so. People feel they rely on GPs even more than in the rest of the country. They rely on them heavily because there are more elderly people than in the country as a whole. Vast numbers of tourists come in and quadruple the size of the population, which is not usually taken into account, as far as I can see, in the way that resources are deployed. Many people work with machinery on farms, and roads are particularly winding and difficult, so there are more accidents than in the country as a whole. The reliance on GP services in those areas is considerable.
The contract that has been agreed, which has many merits, which is right in principle—as everybody has said—and which is important for the recruitment of GPs into the health service, applies as much to rural areas as to everywhere else. I make no criticism of the local doctors who are taking part in the contract, which will lead to new out-of-hours arrangements. I make no criticism of the local trust, the Hambleton and Richmondshire primary care trust, which is doing its utmost to work with the new situation and has assured people that it believes there will be no reduction in the quality of their out-of-hours service. Nevertheless, it is unarguable that that is a major challenge for the trust. I do not believe that when these things are negotiated between the British Medical Association, GPs and the Department of Health, and when they are considered in the Department, the needs of very sparsely populated rural areas are considered.
Let us consider what the situation means in practice for my constituents. If they live in upper Wensleydale, they have to telephone the local surgery and get another number to telephone York or Catterick. That is like telling someone who lives in central London that if they think that they need a doctor in the night, they must telephone Northampton and a doctor might be able to come from Luton. The same sort of distance and travelling time are involved, except that in this case there are hills in the way. There is often heavy snow on them in winter, and fog or ice can make journeys almost impossible. In those circumstances, it is not surprising that people are anxious about the implementation of the new contract.
As I said, the primary care trust is doing its utmost to make the arrangements work and is putting resources into that. Four-wheel-drive vehicles are being purchased with every type of cell phone and satellite navigation. That is the subject of some local cynicism, as the locals all know where the telephones will not work and that satellite navigation can reliably deliver people to a field at the top of Wensleydale and will not necessarily bear any relation to where the houses are. With all the technology available on earth, finding a cottage on top of the dales on a dark night in bad weather is still an extremely difficult thing to do. People are worried that the doctors who know the immediate locality will not be attending them in the night, and that if doctors are called out to make a 30-mile journey and a 60-mile round trip, they will not be available to other people at the same time.
The anxiety about this matter in rural areas is wholly understandable. There is a good deal of resentment. Last week, a farmer put it to me that if he has a sheep that is ill in the night, it will be attended to by a vet who lives locally—vets are still a principal part of our community in the Yorkshire dales—and who already knows the medical history of that sheep and its relations, whereas if one of his family is ill in the night, that service will certainly no longer be available. That is how people regard the situation, which is understandable, even though great efforts are being made to ensure that an out-of-hours service works for that part of the country. I reiterate that I am making no criticism of all the people who are trying to make that service work.
We do not know how the issue will work out. The Minister pointed out extremely fairly that we are in the early days of these new out-of-hours services. That is certainly the case with regard to how they will apply to remote areas such as upper Wensleydale. The jury is out and we do not know how the services will work. In the past 10 days, there has been some controversy in my constituency about how they are working. There is dissatisfaction about the fact that, on a bank holiday such as Easter Monday, large numbers of tourists visit the area, but in an out-of-hours time. When people have road accidents after 6 o'clock, the local GP service is not available to them, and neither are the air ambulances for which we have raised large sums at charitable occasions in my constituency precisely because of the remote nature of the locations.
There is a feeling that access to health care has been reduced. I hope that that feeling will prove to be misplaced, but it is the feeling and suspicion of many of my constituents in areas such as Wensleydale. When these matters are considered in future, the needs of sparsely populated rural areas must be given greater weight. The people who live in such areas have paid their taxes and national insurance. Yes, they understand that there are difficulties in providing services in particularly remote rural areas, but they are entitled to have their particular needs taken into account. When the application of general rules and agreements starts to mean that care and resources are more thinly spread geographically, the needs of sparsely populated areas really come into play.
I am grateful to the right hon. Gentleman for giving way and for the tone of his remarks, with which I have a great deal of sympathy. He might not be aware that we have recently announced some additional resources for primary care trusts serving constituencies such as his, in rural areas where out-of-hours service providers will undoubtedly face additional costs. We are trying very hard to ensure that those additional costs are reflected in the allocations.
Yes, I am aware of that. I do not know whether the Minister was in the Chamber when I spoke about the resources going into vehicles, cell phones and satellite navigation. Those resources are certainly being deployed. We do not know whether they will be sufficient to deal with the task, but it is necessary to have additional resources for sparsely populated rural areas, and I think that it is necessary to consider whether exactly the same rules should be applied to such areas in negotiating contracts and working hours or whether exceptions should be made.
The working time directive leads to a wider debate that I do not want to go into, except by joining many people in the country in expressing astonishment that the European Union should make any such rules at all. I do not see why it is in the interests of people living in France, Germany or Italy to regulate the working hours of doctors in this country, and I do not see why such decisions should be made in any other place than this country. When the Minister has to come to the House and say how much the Government are trying to fight court judgments that we all agree are manifestly not in the interests of this country, it shows how much power has passed to unaccountable institutions. That is a wider debate, however; the Prime Minister wants us to have it in great detail over the next 18 months, and we will enjoy that.
My point about the working time directive is simply that it is another of the forces that makes things more difficult for sparsely populated areas. The Minister spoke about the small hospital trusts and the attention that has been given to them, and recognised that the problem is more difficult for them. In terms of rotas, it is more difficult for hospitals that have access to a limited number of consultants and junior doctors to cope with such issues. He is trying to give them particular help, but my point is that such issues accumulate over the years. Changes in the training requirements that may be set by royal colleges and agreed with the Department of Health have made things more difficult for small hospitals. It continually becomes more difficult for small hospitals to continue their existence. I am not being alarmist about that—there is no threat whatever to the Friarage hospital in Northallerton—but I know that it gets harder every year for people to run a small hospital. That requires either that exceptions be made or that greater resources be given to such hospitals.
Notwithstanding the point that the Minister has just made, account of population sparsity is not systematically taken in the allocation of health service resources. If we are to continue to apply sweeping national or supranational rules to situations that are unusual and needs that are difficult to satisfy many miles from the nearest hospital, we will have to take into account in funding allocations the needs of the particular rural areas involved.
I hope that that will be borne in mind in future. I do not think that any changes can be made to the contract now and I am not proposing any such changes. Obviously, that contract is signed and done, so I am not saying that any immediate action can be taken. However, I think that we will have to address these issues and that the Department of Health should be conscious that, when it considers matters from an urban and suburban point of view, as is often the tendency in Whitehall and in this House in what is mainly an urban and suburban country, we need to give increasing attention to the particular problems of rural areas.
It is always a pleasure to take part in health debates, especially because, as the House knows, I still carry on a certain amount of medical practice myself.
We are debating a very serious issue and, as Mr. Hague rightly highlighted, it will cause a certain amount of anxiety among constituents. I acknowledge his point about thinly populated rural areas where services are sometimes difficult to provide. None the less, debates such as this give us the opportunity to debate some of the issues in public so that people can be reassured about what the Government are doing to address them.
We have to balance the needs of service provision—ensuring that patients have access to appropriately trained, alert and awake medical personnel of all types, specialties and subjects—against the need for training requirements of a high standard and teaching requirements to ensure that personnel pass on their knowledge to others, as well as the need to ensure that they can carry out research and have a decent family and out-of-work life. All those things require a delicate balance that it is sometimes very difficult to achieve. Of course, we must also ensure that we balance all those issues against financial management and the best possible use of resources for the taxpayer.
This afternoon, we have talked extensively about the new GP contract, which I welcome and which, for the first time, allows GPs to provide a wide range of evidence-based services. One of the main advantages of the new GP contract compared with the old GP contract is the enhanced, additional services that GPs can provide. The evidence-based services are based on evaluated research and proper evidence, so GPs can be sure that when they carry out, for example, diabetes care, care for people with hypertension or care for people with Alzheimer's, it is based on research-based evidence, and they can be sure that the care is worth while. That improves GPs' morale enormously, because they know their work has a measurable benefit and a measurable outcome.
The old GP contract was full of what the people who wrote it may have perceived to be good ideas, but the ideas were not evidence-based. Many GPs found the contract extremely difficult to understand, and they often felt that they were wasting their time, which had a serious deleterious effect on the morale and recruitment of GPs. During my career as a GP, I noticed recruitment falling, with fewer good quality young people coming forward to be GPs. Young doctors often said that they could not understand the way general practice was going, that a GP's work was not based on sound science and that becoming a GP did not seem to be a good career progression, and they therefore turned away from general practice into the hospital sector, which was regrettable.
The new GP contract has improved morale and recruitment, and John Chisholm, who chairs the GP committee of the British Medical Association, is enthusiastic that it will produce the GP recruitment drive that we need. The BMA rightly points out that the country is short of GPs, and there is serious under-recruitment for general practice. It is vital that we attract the best quality graduates into general practice as a career choice—and, for the first time in many years, the new GP contract provides hope that that will be the case.
If GPs are to provide enhanced services during the day to allow patients to see them within 24 hours, where they feel that that is necessary, and to access services within their communities in GP surgeries, we must use other health professionals to fill in the gaps. It is not credible that we can expand the work load indefinitely without asking other health professionals to share it. I am pleased that we are working on a new pharmacy contract, which will allow pharmacists to take away much of the burden currently carried by GPs.
Pharmacists are highly motivated, highly trained professionals, who do not always use their skills to the best of their abilities because the current pharmacy contract does not allow them to do so. The pharmacy work force will be acknowledged by the new contract that Ministers are currently negotiating with the profession, which will add enormous extra depth to the health care provision. The new contract will apply equally to out-of-hours and in-hours services because many pharmacists already provide an extended-hours service at weekends and in the evenings, and they are accessible without an appointment simply by patients dropping in to see them. That is one more strand of improved health care provision to which we can look forward.
I am also pleased that the BMA has negotiated a new consultant contract with the Government. I am concerned that many trusts have not yet implemented the new consultant contract, and I have recently met BMA members who share my concern that there are serious local implementation issues. Some trusts have not taken up the new consultant contract in the right way, and I would like to know what the Minister can do to make sure that the new consultant contract is developed to the maximum and that all consultants will benefit from it. The consultant contract allows extra resources and more productive career development patterns for consultants, but it requires local negotiation.
If we look back a few years, we can see what the medical work force used to be like. I was a junior doctor not that many years ago—it is certainly within living memory. When I was a junior houseman, I worked a "one in two", which meant that my contract for a fortnight was 208 hours—one week I worked 136 hours, and the following week I worked a mere 72 hours. Those were my contracted hours, but the work often overran because of sickness, holidays or study leave, so the situation was even worse than that. When I was a junior doctor, a one-in-two contract was the norm, and most doctors were working those hours. I am pleased that those days are long gone because I do not want to see such contracts again.
Even when I was a junior GP, I was expected to work a full night shift, which often meant getting out of bed several times during the night, and to get into work at 8 o'clock in the morning to carry out a full morning surgery. It was unrealistic to expect doctors to undergo such pressure and provide good care to patients. After a night on call, for example, I was on a ward round in the morning and was confronted by the consultant, who said, "Would you like to explain this new patient who arrived last night?" I said, "What new patient?" He said, "This one in this bed." I said, "I am sorry. I have not seen this patient before." The nurse jabbed me in the ribs and handed me the notes. I had clerked in the patient during the night—I had made extensive notes that turned out to be quite good—but I could not recollect the case in the morning because I was so tired. That sort of thing is clearly bad for patient care, and I am glad that those days are long gone. Things have moved on tremendously in the health service, and I am pleased that doctors' hours now allow them to undergo the right training and research and to have lives of their own, which ensures that they are not overtired and do not potentially put patient care at risk.
I should like to address one or two local issues in my constituency. Yesterday, I visited my local hospital, the Darent Valley hospital in Dartford, to witness the opening of the first new operating theatre of its type in the country. It is called OR1, and it is a state of the art, brand new, fully automated, computerised operating theatre, where the entire range of medical instruments and equipment hangs from the ceiling and the consultant has a fully computerised control panel. While the world's media watched via a video link to the hospital's postgraduate centre, Mike Parker, the surgeon, carried out an operation with the new equipment while Andrew McIrvine, his colleague, relayed information to us in the postgraduate centre as we watched an interesting operation to remove a patient's gall bladder.
The new equipment is fantastic, and it is wonderful to see Dartford at the forefront of the process, because the technology is brand new and Darent Valley hospital is the first hospital in the country to use it. The resources, commitment and investment are going into the health service, and future patients will benefit from that. I am sure that such equipment will be installed in hospitals around the country because of the Government's investment.
There have been enormous improvements in NHS training and patient care, and there have also been improvements in general practice. Many general practices are being rebuilt to improve access to care for patients, and many GPs are taking on extra medical and nursing staff to allow them to provide extra care. However, the work force's needs must be balanced against patients' needs and taxpayers' needs to ensure that we get best value. Adjusting the skill mix to use the right profession in the right way is clearly the bedrock of ensuring the delivery of best quality care.
I welcome new initiatives such as the GP contracts, and I welcome the working time directive, which allows us to rethink how we provide medical care in this country. The working time directive is a challenge and, as the Minister says, it presents significant problems in some parts of the country. I am sure that all hon. Members recognise that there are difficulties in some areas and that the new arrangements must be bedded in before we can make the best use of them.
The situation has improved so much in the past few years. We look forward to sustained growth, development and investment, which will allow hospitals to improve their facilities, and GPs and pharmacists to improve their range of services, which must be the way forward to ensure that everybody in this country has increased health care and life expectancy. I welcome the debate, I am pleased to have had the opportunity to address the House this afternoon, and I look forward to the Minister's reply.
Most of what I have to say this afternoon concerns junior doctors' hours, but before moving on to that question, I must say that I agree with almost everything that Dr. Stoate has just said. In particular, I agree that it will be possible to develop primary care under the new general medical services contract.
One might have hoped that he would take a view back into history, to before 1997 in his remarks about making out-of-hours services more flexible so as to reflect the needs of the medical profession, as well as of the patient; the development of a more flexible local definition of what general medical services means, including local contracting through the practice management system; the development of a broader range for pharmacists; and the development of services that are available through GP surgeries. The development of primary care did not begin miraculously in 1997, or even, I hasten to add, in 1979—it has been carried through by Governments of all political complexions over a long period, and is an important success story for the national health service, whatever the political label of the Government at its head at any particular moment in time. I agree with what the hon. Gentleman said, but he is not entitled to claim exclusive credit for the process as one that started on
That is a broadly non-partisan comment. I hope that what I am about to say about junior doctors' hours is also non-partisan, but I suspect that it will lead to rather less agreement across the Floor of the House. Anyone who has attended health service debates over many years knows that the whole subject of junior doctors' hours in the NHS is a very long-standing issue. In the period before 1990, in particular, and cumulatively over several years, it got seriously out of control. There is no argument about the fact that the position before the introduction of the new deal could not be defended in the modern world. Doctors were being asked to work in circumstances that did not provide high-quality training for them or high-quality care for their patients.
I was a junior Minister when the new deal was signed and Secretary of State for two years during its implementation. That process started in 1991 and went on regardless of the change of Government that took place in 1997. The commitment first to recognise that there was a real problem with junior doctors' hours, then to do something about it, was shared across the political divide. More importantly from the point of view of both doctor and patient, it was being addressed by the health service as employers and by doctors' representative organisations—the British Medical Association and the royal colleges—without the need for a legislative framework to oblige them to do so. The situation had clearly become insupportable—action needed to be taken, and it was.
That is why I asked the Minister whether he felt that the adoption of the legislative framework of the working time directive makes the delivery of the shared objective of better management of doctors' hours easier or more difficult. As there was a clear commitment to do something about it, and action was being taken by the employer in agreement with the profession, I genuinely do not understand why the Government see no conflict between delivering that desirable objective—which is shared across the House—and the adoption of a legislative framework that, as the Minister recognises, makes it more difficult for him to do so.
In understanding that conundrum, it is important to understand why addressing the issue of junior doctors' hours is extremely difficult for the health service management and for the training authorities of the royal colleges. If it were simply a matter of saying, "People should not work ridiculous hours—let's change the law and do something about it," it is reasonable to assume that somebody would have done something about it before the situation got as serious as it had by the late 1980s.
There are difficulties in ensuring that the medical work force have sufficiently diverse training to deal with the wide range of circumstances that they will need to be able to cope with in their professional practice. My right hon. Friend Mr. Hague talked about the difficulties involved in delivering medical cover in community hospitals. That applies not only to very remote rural areas, but in relation to, for example, the delivery of maternity services and minor accident cover in community hospitals, which is an issue that regularly arises in the life of a health Minister. That is compounded by the—entirely benign—move in the medical profession towards increasingly specific sub-specialisms.
All those factors make it hard to deliver a proper training regime for doctors alongside a commitment to reduce working hours. The fact that the issue is complex and difficult, and is recognised as such, adds extra point to the question of why it is necessary to introduce a legislative framework that complicates the delivery of a shared, if admittedly difficult, policy objective, given that the only result of introducing that framework is to make the delivery of the objective even more difficult. The Minister stressed that we should not seek to adopt a one-size-fits-all approach, but that is precisely the result of introducing an unnecessary legislative framework, because history demonstrates that the issue was being resolved before that framework, which will make it more difficult, was introduced.
As my right hon. Friend the Member for Richmond, Yorks said, the difficulty is compounded by the fact that we are talking not only about a legislative framework but about a legislative framework that is being introduced in a European context. That means that the Government as the employer cannot ultimately introduce the changes that are necessary to make the policy deliverable. It is worth remembering that the working time directive was introduced by the authorities in Brussels under the single market legislation because it was felt to be necessary to deliver a single market. It is perverse to imagine that the free movement of goods and services around the European Union is promoted by confusing the problem with the delivery of junior doctors' hours in our, or indeed anybody else's, health service. That is why I do not understand why the Government welcome the introduction of a legislative straitjacket the result of which is to make the delivery of their policy objective, which I share, more difficult.
The Government are entitled to some sympathy, given that—to employ the much-used cliché—we are where we are. We have a legislative framework, and the Government have to try to obey the law and to deliver their policy objectives within the health service. They have to try to square that circle. Mr. Burstow pointed out that the legislative framework has been in existence since 2000, and we are now talking about August 2004, but we have a very unclear idea about how the circle is to be squared—we are simply asked to rely on the words of the Minister, who is sure that it will be all right on the night.
It really is not good enough to say that that European working time directive might have been okay, but the problem was compounded by the SIMAP judgment. The SIMAP judgment concerned the definition of the phrase "working time" as it applies in the medical profession, and it was about a very simple question: does time that is spent on call count as working time? One does not have to know much about the history of this issue to know that that question goes to the heart of the management of doctors' hours during their training. That is what all the arguments were about throughout the 1980s and 1990s. In 2000, legislation was introduced, as far as we know without active disagreement by the Government, on the extension of the working time directive to cover the medical profession, but without having decided, and leaving it to the courts to decide, the fundamental question of whether "working time" refers to time on call or time treating patients. It is a pretty broad-brush measure. Although it deals with extending working time legislation to junior doctors' hours, it does not define working time.
The charge against the Government is that they were content to allow the measure to be introduced without properly considering the implications and the definition at its heart. It has been in force, complete with the interpretative judgment, for three and a half years, and we still await any clear idea about the way in which the Government intend to interpret it. They have been caught asleep on the watch during an important health service development and consequently patients are at risk.
I welcome this debate. The issues that it raises are serious issues that local health care professionals have drawn to my attention, and we now have a welcome opportunity to discuss them in the Chamber.
Having said that, I think that the motion is alarmist and concentrates narrowly on specific aspects of the subject. It is designed not to shed light but to cloud the positive benefits that have accrued from the Government's health policies and to spread an impression of impending doom and gloom. It also reflects one significant failure in Government health policy—the inability to cure the parliamentary Conservative party's collective amnesia about its record in government.
There is a debate about the robustness of the British Medical Association statistics, but let us assume that they are robust. Conservative Members' reaction to them, as reflected in the motion, is out of all proportion when compared with the predicament in which they left the health service in 1997, when there were 224,000 fewer staff, including 60,000 fewer nurses and 19,000 fewer doctors. The amendment outlines other figures, which I am told are understated and therefore not spun. To continue the cricketing metaphor, it is a question of reverse spin. Even on the Opposition's gloomiest prognostications, the staffing and ability in the NHS to meet the challenges that the debate covers are hugely improved since the Government came to power in 1997.
Let us consider one or two specific matters. General medical services contracts and the European working time directive and its impact on junior hospital doctors' hours have been discussed. Although I do not contest the difficulties that those policies may cause in some circumstances, their overall thrust accords with recognised priorities that have existed, as some Opposition Members said, for a long time. The effect in reducing junior hospital doctors' hours and giving general practitioners betters hours, more flexible working and greater reward will hugely enhance the attractiveness of the medical profession to would-be trainees and help to realise the Government's objectives for the doctor provision that is necessary for the nation's growing health needs.
I was surprised by the weight that the Opposition attached in the motion to out-of-hours services. In my discussions with my local primary care trust, the issue has not been raised. The gloomy forebodings in the motion do not appear to be reflected in reactions on the ground. I checked with my local doctors' surgery and was told that the service would continue as it had done previously and that there would be no deterioration.
My constituency is in a traditional inner-city area, Sandwell, which has historically suffered a range of health problems. Even now, life expectancy is considerably below average and the area has historically been provided with too few doctors. However, if one examines what is happening on the ground, the motion does no justice to the true picture in an area that has suffered from under-provision and deals with a greater range of health problems than the average. My surgery, which is less than 300 yards from where I live, is expanding. It is due to have two extra doctors, is extending its premises and will become a university training centre.
The Neptune health centre in the middle of Tipton deals with one of our most deprived communities. It intends to take on a range of services that the local acute hospital previously provided. The Tipton care organisation and the Great Bridge partnership for health have pioneered new, joined-up and flexible working, which has involved GPs working with physicians' assistants and a range of nursing support. That has meant taking on roles and responsibilities that only specialist doctors undertook hitherto. In Sandwell, there is a pioneering flexibility in the provision of health care, which, by having multi-skilled groups dealing with a much wider range of health needs than under the former model, epitomises the Government's approach.
The motion fails to convey exactly what is happening on the ground and is therefore misleading. The Minister and all hon. Members can cite statistics, but they do not do justice to what is happening, either. When talking to local health professionals in my area, I have been impressed not so much by statistics as by the almost evangelical spirit that they have displayed in meeting the sort of challenges that the area presents, and by the way in which the new structures, working methods and funding have boosted their morale. They recognise that measures such as the European working time directive are a challenge and that there are problems in recruiting doctors. Such problems have always existed in my area and the retirement of the first generation of Asian doctors will present further problems.
However, health professionals not only recognise the problems but know that they can deal with them. The potential funding exists and there is an opportunity to make the case to meet the challenges ahead. I have been hugely impressed by the way in which they have sought to embrace the Government's agenda. Consequently, health care is improving in my locality.
The European working time directive presents challenges and the European Court of Justice judgment creates difficulties. However, the extra funding, staffing, new ways of working and missionary zeal that I have noticed in so many local health care professionals means that the challenges will be met. The health care professionals are much better placed to do that through the Government's policies. We should reject the motion because it fails to recognise that that is the reality on the ground.
My one fear and regret about this debate is that I might not be as welcome as I believe that I am at the moment to sit on this side of the House after I have said what I am going to say, and that the kind Opposition Whips who alerted me to the debate might not do so again.
I had an Adjournment debate on this very subject last November and the Minister who responded was all too aware of the worries resulting from the European working time directive. Also in November, the all-party group on local hospitals held a meeting which was addressed by the Minister of State, Department of Health, Mr. Hutton. We were impressed by the amount of work that he had done on this matter and the urgency with which he viewed the situation. I am, therefore, slightly encouraged, as I was encouraged by some of the things that the Minister said.
The Minister said that the Department of Health was giving priority, when implementing the working time directive, to maintaining quality and access to care. That is crucial. He also said that redesign—not relocation—would take place around the needs of local people. He added that we must not substitute tired consultants for tired junior doctors. I sympathise with the comments made by Dr. Stoate. I was a junior doctor rather before he was. He was on a one-in-two rota, but I was on a one-in-one rota at a hospital that used to exist about half a mile from here. That really went far beyond a joke. I did not just forget things like he did—I actually cracked up in the middle of the job. It is therefore essential that we do not substitute tired consultants for tired juniors, and that we take note of the working hours involved.
The Minister also said that the role of the Department was to support the NHS to meet the requirements of the directive. I want to take a few minutes to emphasise that I believe that the Government have another supremely important role to play. They have to take the part of citizens and patients, in some cases almost against the doctors. I want to draw to the attention of the House a letter in a recent edition of the British Medical Journal from a Scottish consultant neurosurgeon who was writing on the ills that afflict the NHS. He wrote:
"These include the new deal, the consultants' contract, the general practitioners' contract, the European Working Time Directive—all man-made artefacts and all preoccupied with the welfare of doctors, not patients."
I want to bring that letter to the attention of the Government so that they can be aware of how some people might look at the changes and to note some of the snags involved, some of which have already been mentioned today and on other occasions. They are worth mentioning. The first—and, to me, the biggest—involves the risk to the continuity of care. With full-shift systems, the same doctor never looks after a patient for any length of time, and, given the pressure of work, handover processes can sometimes be rushed. Continuity of care is therefore crucial.
The second snag involves training. Junior doctors, particularly surgeons, and trainers are questioning whether the reduced hours are giving them enough exposure to the practical procedures and operations in which they have to be supremely competent when they achieve consultant status.
The third involves lifestyle. The Royal College of Physicians recently studied 57 hospitals across England and Wales, and found that 63 per cent. of the medical specialist registrars on full shifts were working seven nights in a row. That cannot be comfortable for family life and it is not popular. Certainly, trainee obstetricians have found cover on full shifts very unpopular. Particular problems have been raised in relation to anaesthetics, obstetrics and paediatrics, which are services that cannot be covered in hospital at night by a generic doctor. Those specialisms pose extra problems. The answers obviously involve employing more doctors and the Government have given us figures to prove the numbers that are coming on stream. We have also heard a lot about doing things differently and there are some very good plans in that respect.
It appeared from what the Minister said in his opening remarks—I hope that the Minister of State, Ms Winterton will confirm this—that the review being carried out in Europe might well lead to some delay in the implementation of the changes. The British Medical Association warns that, even if there is a suggestion of delay, implementing legislation to bring it about could cause further delay. The NHS Confederation makes a good point in a recent briefing note, saying:
"We recognise that it is the Government's responsibility to ensure that the working time directive is implemented but where despite trusts' best efforts it is not possible to achieve compliance, it is vital that there is a positive and supportive rather than a punitive response from the Department of Health and SHAs."
Given the snags with the new deal that I have mentioned, the working time directive and the new contract, hospitals are at risk, particularly certain large hospitals that are situated relatively close together. I am thinking of some in my own part of the country, including those in Telford and Shrewsbury and those in Gloucester and Cheltenham. The Government must ensure that it is possible for all those hospitals to preserve the emergency facilities that the people in those areas require. There is a particularly worrying triangle in the north-east of England, around Hartlepool, Middlesbrough and Stockton. Their hospitals are all close together and are all providing all the services at the moment. As we are well known in my part of the country for campaigning, Hartlepool has already been in touch with us to ask what it can do to protect its hospital.
There are also many smaller hospitals throughout the country that are somehow managing to maintain accident and emergency services. One has only to think of Banbury, Hexham, Workington, Bridlington, Newark and Louth. I could provide a long list of others. Those hospitals must be at risk. All this is taking place against the background of the Department of Health's paper published in February last year, "Keeping the NHS local: a new direction of travel", which I welcomed. It expressed the intent of Government policy to keep the NHS local, which is certainly compatible with local wishes. The Government will recognise that, if that is not possible, there will be a risk of political flak from various communities.
An excellent leader appeared in the British Medical Journal recently, written by Andy Black, the well-known health service management consultant. He stressed the political risks involved in downgrading emergency services and made two useful recommendations. The first was that the Royal Colleges should find a way of connecting with the public perception of the need for local access to emergency services. The second was the use of real "managed clinical networks", which would result in a real sharing of services. It is no good having an accident and emergency unit, and, 20 miles away, as is the case in Worcestershire, a minor injuries unit that is totally separated from it. If they worked together, with the same staff rotating between them, the staff working in the major unit would know the problems of the minor unit and the sorts of cases that the minor unit could see, which would avoid unnecessary journeys. Andy Black put his finger right on it when he said:
"If the price of moving the complex emergency to an appropriate centre of expertise is that this patient is accompanied by another nine or 10 patients who are not complex acute cases then another set of problems is launched."
That is exactly what we are seeing in Worcestershire—those nine or 10 patients who did not need to be moved are causing tremendous other problems.
On the GP contract, I was puzzled by the Minister's comments on community hospitals and I hope that his hon. Friend will return to the matter in her wind-up. I must admit that I thought that community hospitals were going to be at risk with the new contract.
I will say little about the consultant contract. I am slightly worried about today's announcement of 25,000 extra orthopaedic operations. Will that take NHS consultants away from NHS duty and make continuity of care even worse?
I ask the Government to remember that the NHS is for the patients. It is up to the Government to be the ordinary citizen's advocate and to ensure that changes are acceptable to the public, not bulldozed through as some previous changes have been.
It is a pleasure to follow Dr. Taylor, who speaks with such authority on this subject and whose very presence in the Chamber is a reminder to us all of the potency of health as a political issue in our constituencies. He mentioned that he was approached by Hartlepool, whose local hospital is threatened, for advice. I hope that he advised that an independent candidate should stand against the Labour Member there to achieve some results.
I want to speak briefly about the new GP contract, which I broadly welcome. Of course, it makes sense to reduce the number of hours that doctors work. If it makes no sense for MPs to be up all night and then be expected to do a proper day's work, it makes less sense for the country's doctors and GPs to have to attend to their patients when they have not had a decent night's rest.
I sound a brief note of caution before Ministers make claims about the impact of the new contract on patients. The Minister of State, who is normally alert and fleet of foot, does not understand the depth of concern in constituencies about what will happen when the new out-of-hours contract is introduced. The evidence that I have seen is that patients in my constituency will feel worse off because the level of service will be manifestly less than it is at the moment. If steps are not taken before
There are three areas of concern on which I want to touch: first, cover at Andover hospital—the position is the same at other smaller or cottage hospitals; secondly, the loss of Saturday surgeries; and thirdly, the operation of the new out-of-hours contract, which in my case is with Primecare. None of that is the fault of the local PCT or the local GPs. Simply, the money saved by not paying GPs to provide out-of-hours cover, even when topped up by new money from the Department, is not enough to replicate the service that GPs currently provide, mainly because it was provided on the cheap.
Let me begin with Saturday surgeries, which have not really featured in this debate. At the moment, I can see my GP in Andover on a Saturday. For those who commute from Andover or who work long hours, that may be the only time that they can see their GP without taking time off work. Last Saturday, my GP saw 15 patients and processed a number of repeat prescriptions. With the new contract, Saturday is out of hours, so the local GPs are not contracted to provide any service on that day. They could do so if the local PCT bought it in as a local enhanced service, but my PCT does not have the resources to do so, a point to which I will return in a moment.
My PCT is struggling with funding for taking over the out-of-hours service. It has been allocated 6 per cent. of what is called the global sum, part of the GP income stream, and GPs have taken a commensurate reduction. But that is simply not enough to replace the service. I know of only one GP practice that is going to open extra-contractually on a Saturday and that is a dispensing practice in a neighbouring constituency that can do so from the dispensing surplus. None of the surgeries in Andover will be accessible on a Saturday.
In fairness, there are plans for a replacement GP service. On Saturday and Sunday, there will be five sessions at Andover hospital operated by a GP or GP registrar. It may be bookable, but, basically, it is open house. Of course, one will not see one's own GP and the GP whom one sees will not have access to one's records. For most people, the hospital is more difficult to access then their local medical centre, so by any definition, the service offered on a Saturday will be seen by my constituents as reduced.
Then we have the position of Andover hospital. Andover is the largest town in my constituency, with a population of 40,000 and growing. The Andover War Memorial hospital hosts a range of services, including out-patients, diagnostic imaging, day surgery and so on. For anything more serious, one must go 15 miles to Winchester. At the moment, out-of-hours cover at that hospital is provided by local GPs, so one can go to the minor injuries unit at any time and be treated. A nurse deals with the patient and, if required, a GP will be called out. Although details of the contract after
Finally, there is the operation of the new out-of-hours service to be provided by Primecare and funded through the PCT. At the moment, calls from patients in Andover are answered by a local nurse until 11 pm and thereafter by the on-call doctor in person. In future, the plans are to route calls initially to Birmingham and then to Southampton—the local hub—and if a GP is required, he will drive from Southampton or possibly Winchester. At the moment, cover in Andover is provided by a rota of local doctors and the response is obviously much quicker. However that is presented, it will be seen locally as a reduction in service.
I want to end on a theme that, I am afraid, I have mentioned previously. The reason for all this is that Hampshire, and particularly Mid Hampshire PCT, is simply underfunded. For every £100 that the average patient in England gets, Mid Hampshire gets £80. At that level, it is simply not possible to provide the quality of service that Ministers and I, as the local MP, want. That is why in all the debates on heath services in Hampshire, whether primary care or secondary care, we return to the underlying structural imbalance in the way that funds are distributed. Until Ministers address that fundamental point, they will continue to have difficulty persuading my constituents that the NHS is as good as they make out.
This has been a good debate, throughout which excellent speeches have been made. I was particularly struck by the quality of the Conservative speakers, who included no fewer than three Privy Councillors.
A number of interesting points have been raised. It is a pity that the Minister was ever so slightly prickly in his opening remarks, for he had no need to be. Our motion was tabled in good faith. While we broadly support much of what has been discussed today, we have problems—problems raised with us by our constituents. It is right and proper for us to counsel caution when it comes to matters that affect a vast work force, one of the biggest in the western world. I hope that Ministers will take that in good spirit, and will do their level best to respond to the genuine concerns that have been expressed.
The Opposition believe that the health and safety of doctors and their patients should not be compromised. Doctors should not be forced to work unacceptably long hours. We have heard from two doctors today, who spoke of one-in-two and even one-in-one rotas. I worked a one-in-two rota for two years. I would like to say, in a curmudgeonly sort of way, that it did me no harm; but I will not say that, because I suspect that it did harm me, and I am sure that it did not do my patients any good at all.
I think back to 1991, when a Conservative Government produced "The New Deal for Junior Doctors". It was a good piece of work but, sadly, by March 2002 the BMA was complaining that a third of juniors were still working beyond the limits set by it. During the intervening time, we had failed to get to grips with what I consider to have been a very positive measure. That leaves me somewhat concerned about the future of the working time directive, and Ministers' sincere and well-meant efforts to improve things for junior doctors and, most important, the patients in their charge.
In January the Minister of State told us:
"Complying with the Working Time Directive need be neither costly nor a burden."
I trust the Minister implicitly, but I have sought a second opinion. I have written to 170 acute trust chief executives asking for their views on how things stand. I asked them what problems they envisage in the meeting of deadlines, what assistance they are being given by Government, and how they think it will all pan out in the months ahead. I have received good, if mixed, responses. As might be expected, those from people making their careers in the health service are fairly positive. In general, they constitute measured and reasonable attempts to address the big problem that all the respondents clearly face.
One word occurs time and time again—"challenging". All the respondents feel challenged by the directive. "Challenging" can mean many things, not necessarily bad, but I believe that in the context of my inquiry those people really do feel up against it. I am not surprised that no one now seriously believes that the targets that have been set will be met throughout the NHS—the Minister said as much today. It would be interesting to know where the trusts stand in terms of the penalties that may apply if they do not meet those targets; I should like to hear what the Minister thinks.
The Minister says that trusts have been given £46 million to meet the costs of compliance. I must press him on that. The matter was debated in European Standing Committee C, but, as my hon. Friend Mr. Francois pointed out earlier, we have not been given all the answers that we would like to have been given. It is all to do with quantifying the costs. Last month, in the Committee, we finally managed to elicit from the Minister the fact that compliance could cost up to £780 million and require between 6,000 and 12,000 more doctors. The upper limit exceeds even my estimate, based on my poll of acute trust chief executives. It also exceeds the BMA's estimate. If the Minister genuinely believes that the cost will reach that level, we need more details—in writing.
I was further confused by a written answer, which I received only yesterday, to a parliamentary question that I tabled 10 days ago about the methodology used by Ministers to arrive at these figures. I was told:
"Actual costs or numbers of additional staff required are not held centrally and could not in any case be disaggregated from the overall cost of NHS growth and modernisation."
That is rather odd, coming from a Government with an insatiable demand for data relating to targets they have set with a view to the generation of politically obliging headlines, which we see all the time. I really must press Ministers on whether they are sticking to the figures of up to £780 million and between 6,000 and 12,000 doctors—and, if so, on how those figures are derived.
The Minister of State made a confusing statement concerning the guidance that was issued to European Standing Committee C about the possibility that that upper figure might be shifted downward if we used alternative means of providing the cover currently provided by doctors. I hope that the Minister will clarify that in her closing speech because, if it is wrong, we should know about it.
Paragraph 3.1 of the guidance says:
"The cost of recruiting the several thousand extra middle grade doctors required for the UK would run into hundreds of millions of pounds per annum. This includes on costs, overheads and training costs. The alternatives to employing additional doctors as set out above are likely to cost approximately the same as recruiting more doctors."
Are we saying that £780 million is a reasonable reflection, or are we seriously saying that by changing working practices and using other health care professionals the figure can be brought down, because that is not what the Department's own written guidance says? I seek clarification from the Minister.
The Government have rightly increased the number of places at medical schools, but I would like to know how they arrived at the figures that they think are required. We have heard that they feel that between 6,000 and 12,000 more doctors will be needed to satisfy the working time directive, but I cannot believe that the number of places provided at medical schools has been calculated on an empirical basis. I hope that the directive and its strictures have been factored into the assessment that Ministers have presumably made of how many doctors we will need in the future.
An historical example emphasises the point in a cautionary way. In the 1970s, consecutive Governments predicted the number of dentists that we might need now, based on the incidence of dental caries and the fact that fluoridation was predicted to reduce it. Unfortunately, they got it wrong, and that is at the heart of our current problems with NHS dentistry. We do not want to repeat such a mistake, do we?
The working time directive was incorporated into domestic legislation in 1998, yet it was 2002 before invitations were issued to undertake pilot schemes in the NHS. It is not good enough for Ministers to say that the problem with the roll-out of those schemes has been anyone's fault but the Government's. It is unreasonable to say to trusts that they have not got their act together, as it is clear when one considers the time scales involved that the fault does not lie with them at all. Indeed, contrary to Ministers' assertions, many of them have been quite enthusiastic about the schemes. I cite in particular the hospital at night schemes, which many of them have warmly embraced, and rightly so. Of course they favour the more efficient use of human resources, but none of the ones that I consulted is under any illusion that hospital at night or any other piloted scheme could address the staffing shortfall. One trust said:
"None of the projects has achieved working time compliance and they have required central funding which may not be available when the initial project ends."
Yesterday, we saw the most extraordinary three-point turn in recent political history. The Prime Minister might have set something of a trend. If so, in the new spirit of openness, it would be refreshing to hear whether Ministers, in retrospect, are content with the way in which they have handled the implementation of the European working time directive, or whether on reflection they share the obvious concerns expressed by the trusts that I have consulted.
As EUROSTAT has shown, our health service is fundamentally different from those in Europe. We have 1.4 junior doctors for every senior doctor, while Europe has one junior for every four seniors—it is turned on its head. We have the fewest doctors per head of population in Europe. Because of the slack in Europe and because it has proportionally far fewer juniors, it is arguably better placed to implement the directive with relative ease, while our NHS will clearly struggle with it. The NHS will clearly feel challenged by the directive; "challenging" is the word that has come across time and time again in the consultation exercise that we have undertaken.
That is surely all the more reason for the early pilot schemes that we simply have not had. There were four wasted years between the implementation of the directive in 1998 and the invitation to conduct pilots in 2002.
The hon. Gentleman has just tried to make the argument that only the UK faces that particular pressure for additional doctors. I do not know whether he has read the submissions that all the other member states of the European Union have made to the Commission, itemising the difficulties that they face in implementing the directive, but if he has, he will have seen the long list of additional doctors that Germany, France, Sweden, Holland and Italy all require to meet the terms of the SIMAP and Jaeger judgments. This is not just an English problem.
Of course it is not just an English problem. The point that I was trying to make by giving EUROSTAT statistics is that our NHS is fundamentally different from systems that operate on the continent. I am sure that the Minister accepts that and, in particular, the statistics on the ratio of junior doctors to senior doctors. Clearly this matter primarily involves junior doctors, and if the Minister cannot understand that, he merely underscores my concerns. We know that there are far more doctors per head of population in Europe than in this country. Clearly, the employment environment in the health service in this country is fundamentally different from that which applies in Europe, which makes the roll-out of the European working time directive far easier in Europe than in this country. I am sure that the Minister must admit that.
Several right hon. and hon. Members have rightly discussed cottage hospitals, and I am worried, from the Minister's remarks, that he perhaps does not fully appreciate the impact that the GP contract might have on community hospitals. I have cited my specific example and from the conversations that I have had, I am sure that it is mirrored up and down the country.
It is just not good enough to say that the new GP contract has nothing to do with any contractual arrangements that GPs may have with community hospitals. There are clearly bolt-on effects. Although I accept that there is limited direct linkage between GPs' contracts to provide out-of-hours cover to their patients and their arrangements with community hospitals, in practice, as I am sure other hon. Members will bear out, GPs facing the removal of their out-of-hours obligation will not then subscribe to the knock-on obligation to community hospitals to which they currently subscribe. That is the current problem for community hospitals. If the Minister does not appreciate that, he must go back and examine the matter, which is a real concern in my area and many others. We have heard about it in other contributions today.
"Keeping the NHS Local", published in February 2003, was a good document that Ministers perhaps need to dust down and remind themselves of. They need to remind themselves—I hope that they will be reminded of this in the big conversation—that people want their health care delivered locally. Will Ministers please dust down "Keeping the NHS Local" and apply it to the current problem of GPs opting out of their community hospital cover? Two of my community hospitals, in Warminster and Westbury, have already sustained closures this year, in the stroke unit and one of the general wards. Those closures are directly related to the current debate on GPs' hours.
We have heard about Saturday morning surgeries, and we might also have heard about the problems that GPs will face on Monday mornings. If there is perceived to be inadequate or patchy cover over the weekend, people might be queueing up on a Monday morning to get the treatment that they want from their doctor. I hope that Ministers are looking into that.
The Government have known since 1998, and arguably earlier, that the European working time directive would pose serious problems to the NHS. They should have known about the potentially devastating implications of the new GP contract for community hospitals. Ministers knew that staffing costs would rise, and that the supply of doctors would be insufficient for needs. They knew that any extra money for the NHS would be mopped up by some of the extra costs brought about by a series of initiatives—not only the European working time directive—introduced since 1997. Disingenuously, they have referred to extra doctors when they should have been talking about the likely reduction in doctor hours available to the service by 2009. They have over-hyped cash flow, knowing full well that much of that will not reach the front line. It is little wonder that our constituents stand aghast as Ministers deliver evermore upbeat assessments of improvements in the NHS.
In introducing this afternoon's debate, the Opposition have alleged that Ministers are somehow complacent about the implementation of the European working time directive in respect of junior doctors' hours and have failed to anticipate the effect of the new GP contract on out-of-hours cover. On the Government side, we have shown that that is plainly not the case.
The starting point of the debate is whether doctors ought to be working excessive hours. We believe that, whether they are working in hospitals or general practice, it is bad for doctors to have to take critical decisions while overtired and overworked. That was eloquently described by my hon. Friend Mr. Pollard.
My fellow Minister of State made it clear in his opening contribution that on the issue of out-of-hours cover, the Opposition have ignored both the statutory duty of primary care trusts to provide it and what is actually happening on the ground. As my right hon. Friend said, at the moment only 5 per cent. of GPs provide their own out-of-hours cover. GP co-operatives and private providers already carry out most of the cover and we are continuing to work to ensure that the new arrangements work well and in the best interests of patients.
The right hon. Members for Richmond, Yorks (Mr. Hague) and for North-West Hampshire (Sir George Young) drew attention to some of the difficulties in bringing about out-of-hours cover and the right hon. Member for Richmond, Yorks particularly drew attention to what is happening in rural areas and to the challenges that they face. I was pleased that both Members drew attention to the hard work being put in to ensure that there is no reduction in services, and they received assurances that that would not be the case as more resources were going in. As my right hon. Friend said, specific allocations have been made to rural areas on top of the extra £350 million targeted to support out-of-hours services.
With regard to the working time directive and junior doctors hours, my right hon. Friend told the House that because of the recent decisions of the European Court of Justice, implementation of the directive will be very demanding for the NHS. Mr. Dorrell also referred to that. We agree about the difficulties, which is why, together with other European countries, we have made clear our concerns—and the Commission has accepted that the directive needs to be amended. My right hon. Friend gave the House an assurance that he would keep it fully informed of developments in that respect.
Will the hon. Lady also emphasise that Ministers have constantly been in touch with the small hospitals group and that meetings have taken place with those hospitals and with the Royal College of Physicians to discuss the working time directive and the European dimension?
Yes, my right hon. Friend has certainly met them and continues to engage in discussions with them.
At the same time as successfully making representations to the Commission, we have put in train a number of measures to reduce junior doctors' hours, to increase the numbers of doctors in training, and to establish pilot schemes to look into the implementation of the working time directive. In doing so, we have made it clear that our priority is to implement the directive in a way that maintains both the quality and accessibility of NHS services—a commitment praised by Dr. Taylor, who also praised the work of my right hon. Friend the Minister of State. I mention that because my right hon. Friend was not in his place at the time.
My hon. Friend Mr. Watson referred to new ways of working that will be necessary to ensure that we maintain service provision. For example, he highlighted in his area the better use of nurses' time and skills. My hon. Friend Dr. Stoate mentioned that as well, and referred particularly to the role that pharmacists can play. We need to consider the role that they can play under the new contract, and my hon. Friend knows that I strongly support such a move.
Mr. Burstow raised the issue of what would happen if trusts were not compliant. Pilots spread best practice, as we know from the results so far, and it is unlikely that the whole of a trust will be not compliant. Certain areas will have particular difficulties, including, for example, obstetrics—as the hon. Member for Wyre Forest pointed out—and, possibly, paediatrics.My right hon. Friend the Minister of State meets regularly with the BMA and others and will issue guidance on problems that may arise in such specialties.
Dr. Murrison raised the issue of cost. As my right hon. Friend said, some £46 million has been provided to assist with compliance, but it is impossible to disentangle plans for compliance from trust plans to modernise and improve services generally, as well to meet other key NHS priorities. We have not asked trusts to quantify costs separately as that would be an added burden. Planning for working time directive compliance forms part of overall NHS planning, but in each trust the solutions will need to fit local circumstances, which will differ from place to place.
The hon. Members for Westbury, for Wyre Forest and for Sutton and Cheam raised the issue of community hospitals and out-of-hours services. I reiterate that the new general medical services contracts have no bearing on the arrangements whereby GPs provide medical cover for patients occupying beds in community hospitals. Agreements that GPs may have with a community hospital are separate from their primary medical services contracts, and PCTs should decide locally how to commission such work as part of their broader commissioning strategy. Discussions have taken place in Warminster, and continue to take place. Three months cover has now been provided, as the hon. Member for Westbury knows—we have corresponded on the matter—and the minor injuries unit has been reallocated to Westbury.
Yet again, the Opposition have shown us that they are less interested in solutions and what is best for patients, staff and those who make our health service work, and more interested in sniping about the NHS and undermining those who work in it. That is not surprising, because when they were in power the attempts they made to reduce working hours for junior doctors were too little, too late. When in power, they also cut trainee numbers. This Government have reduced the hours of doctors in training: 95 per cent. of them now work for 56 hours or fewer a week. This Government have increased work force numbers so that there are almost 7,300 more consultants and 67,500 more nurses than there were in 1997. This Government have increased the number of medical school places so that 6,030 students entered medical school in 2003.
Also, this Government's new GP contract has been welcomed by the BMA as being
"better for patients and better for everyone working in general practice".
The Government welcome the overall aims of the working time directive to ensure humane working hours for doctors, but those on the Opposition Front Bench have not learned any lessons. They have not said that they would recruit more health staff than we are recruiting already; nor have they said what reforms to contracts and working practices they would introduce. In fact, they have said very little of substance—but perhaps I am being slightly unfair, as they said that they would support the agenda for change.
"The Conservative Party put itself on a collision course with doctors and nurses last night by announcing plans to scrap national pay agreements in favour of local hospital deals with staff."
"The policy has been condemned by the British Medical Association as 'divisive', while the Royal College of Nurses said that it would do nothing to solve recruitment problems."
The hon. Gentleman insisted:
"What we want is for hospitals to be able to reflect local conditions and have the freedom to negotiate with their staff. That is one of the characteristics of independence in our view. Clearly the more independence you bestow on an employer, the less scope there is for uniform national contracts."
Of course the Government appreciate that the Opposition are still tying down certain aspects of their health policy—in fact, most of it—but we had hoped for something more constructive and less muddled from them when they decided on the topic for today's debate.
The Government are working with patients and staff to deliver real improvements in the NHS for the benefit of everyone. Only the Conservative party does down the NHS, because it does not share our belief that the NHS is the best way to deliver decent health care to everyone in this country. That has always been the case, and we have heard today that, despite all the Conservative party's rhetoric and protestations, it really does not believe in the health service. Not only are 166 Conservative MPs sending out that message, but we now know that a whole gang of prospective parliamentary candidates, highlighted today, are also going out and undermining NHS staff.
We believe in the NHS, which is why I urge the House to vote against the Opposition motion and for the Government amendment.
Question accordingly negatived.
Question, That the proposed words be there added, put forthwith, pursuant to
Madam Deputy Speaker forthwith declared the main Question, as amended, to be agreed to.
That this House welcomes the overall aims of the European Working Time Directive (EWTD) to ensure humane working hours for doctors in training; further welcomes the Government's lobbying of the European Commission and other EU Member States which has resulted in the Commission's giving assurances that they will bring forward legislative proposals on the EWTD before the summer; notes the dramatic reduction in the hours of doctors in training which means that 95 per cent. of them now work for 56 hours or fewer; congratulates the Government on the increases in workforce numbers and medical school places, which mean there are now almost 7,000 more consultants and 55,000 more nurses than there were in 1997, and that 6,030 students entered medical school in England in autumn 2003; welcomes the work being done in the National Health Service in implementing new ways of working that contribute to modernising and improving services and meeting the obligations of the Directive; and joins the Chairman of the BMA's General Practitioners Committee in welcoming the new GP contract as being "better for patients and better for everyone working in general practice" and notes that it will allow primary care trusts to offer patients a safe, high quality service, with care delivered by the most appropriate professional, through better use of more joined-up services.