Family Doctor Services

– in the House of Commons at 12:30 pm on 11th November 2004.

Alert me about debates like this

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health 1:25 pm, 11th November 2004

I beg to move,

That this House
places the highest importance on the role of general medical practitioners, working with allied healthcare professionals, constituting a family doctor service;
regards this service as the lynch-pin of NHS primary care services and central to public health promotion;
appreciates that general practitioners are best placed to provide care for patients, to facilitate their access to NHS services and to manage care of those suffering from chronic diseases and co-morbidities;
is concerned by the continuing level of general practitioner vacancies and workload pressures;
regrets the Government's devaluation of the family doctor's role in favour of an emphasis on diverse means of access to the NHS;
deplores the failure to maintain the out-of-hours service as a general practitioner-led service and the loss of Saturday morning surgeries;
calls on the Government to ensure that the NHS Programme for information technology delivers the choice of suppliers and functionality which general practitioners need;
further regards the Government's abandonment of general practitioner fundholding and commissioning as a severe misjudgement and urges the reintroduction of the benefits of fundholding through the adoption of practice-led commissioning;
and believes that the development of family doctor-led commissioning, alongside increasing patient choice, offers the best means of delivering an effective NHS which is responsive to patients' needs and wishes.

The origins of this debate lie in the many conversations that I and my colleagues have had in recent months with general practitioners and those who work in family doctor services. In the years since the 1999 legislation, when fundholding and GP commissioning were lost, GPs have become progressively divorced from the control of primary care as locality commissioning turned into primary care groups and then primary care trusts. The PCTs are no longer the local representative bodies for GPs and health professionals that they should be. Instead, they have become the local representatives of the Department of Health.

In my experience, one of the most depressing aspects of constituency health casework has been the decline in the influence that GPs can exert over the NHS services available to their patients.

Photo of Phyllis Starkey Phyllis Starkey PPS (Dr Denis MacShane, Minister of State), Foreign & Commonwealth Office

I rise to give the hon. Gentleman an opportunity to reflect on his remarks so far. Would not it be sensible for him to make it clear also that the role of the PCTs is to represent the needs of local people who rely on NHS services? The PCTs are not there to represent the needs of GPs, however worthy they may be.

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

The hon. Lady is completely wrong. As those of us who have visited GPs recently have been told time and time again, GPs represent the needs of those patients whose needs they are best equipped to represent. They find that PCTs respond not to the needs of patients, but to the diktat of the Department of Health.

The previous Conservative Government started GP fundholding in 1997, and we were developing locality commissioning. Immediately after the 1997 election, the Government said that they were going to develop locality commissioning. However, that did not result in the establishment of local commissioning groups responsive to local health professionals, and to GPs in particular. Instead, the outcome is that PCTs are dictated to by the Department of Health.

Many people working in PCTs want exactly what Dr. Starkey suggests—PCTs that are accountable to their local NHS, through local health professionals, for the needs and interests of their patients. However, that is not what is happening.

Photo of Chris Grayling Chris Grayling Shadow Minister (Education)

I should like to give a very practical example of that. I was visited by a constituent who wanted to talk about the problems faced by women with endometriosis. That is a major problem for sufferers, and it can cause significant disruption to their lives. My constituent asked me to find out from the local PCT what effort was being made to tackle the problem, and what support was available for people like her. The PCT told me that as the disease was not part of the Government's national service frameworks, no particular support could be provided. Does my hon. Friend agree that that is a perfect example of why he is right and Dr. Starkey is wrong?

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

I met my hon. Friend's constituents when I visited his constituency, and I know that he understands what is going on very well. He offers an excellent example. What I said in my opening remarks is born of experience. Recently, a constituent of mine was trying to access mental health services. She and I talked about her efforts for a considerable time, and in the course of our conversation I asked her what her GP had said. She told me that her doctor was fantastic and sympathetic, but that he had no say in the matter, nor any control over what services were available. That is dictated by the primary care trust. My hon. Friend is right and the hon. Lady needs to understand better what is happening in primary care.

This year, in the context of a new GP contract, GPs were looking for a more assured future and for a sense of support for and direction of family services, but unfortunately they have not found that. For example, the contract implies that GPs will take responsibility for the delivery of improved management of chronic disease. However, GPs then hear the Secretary of State say that regional chronic disease centres are to be established and that 3,000 community matrons are to be recruited to look after the elderly with chronic diseases. There was no mention of the role of GPs. They believe that they provide a service to patients as self-employed practitioners, contracted with the NHS. However, they are increasingly dictated to by PCTs and the Department of Health.

Photo of David Chaytor David Chaytor Labour, Bury North

On the specific point about matrons being appointed, does the hon. Gentleman agree that one of the problems for the NHS for many years has been that GPs have been required to carry out some basic functions that would be far more efficiently carried out by nurses? Is it not wholly positive that we are devolving responsibility in the NHS to different occupations in that way?

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

I shall come to that point in a moment. However, my point is not that we should not have additional community nurses. It is clear that they are necessary in order to provide improved chronic disease management, not least because in the years after 1997—up until the figures published by the Department of Health earlier this year—the number of community nurses fell. I shall come to the issue of the distribution of work in a moment.

The NHS programme for IT, to which I shall refer later in more detail, means that GPs are no longer the customers with control over the supply of their IT hardware, or the right to use the software that they have developed. They are told how to manage their patient booking systems. Out-of-hours services are now controlled by the PCT and, in some cases, they no longer deliver a GP service, nor even necessarily one where calls are handled locally.

Photo of David Drew David Drew Labour/Co-operative, Stroud

I have some concerns about how the out-of-hours service operates, but I am not sure that GPs would want to turn the clock back. Part of the reality of the new contract was that GPs wanted a new environment to work in. I would prefer it if GPs volunteered to join the out-of-hours services. Some will, but some have chosen not to do so. What would the hon. Gentleman do in the circumstances to try to encourage them to do so?

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

I shall deal with the issue of out-of-hours services in some detail later in my speech, but the short answer is that where the PCT continues to have a contract with a GP-led co-op that continues to have the support of local practitioners—as is happily the case in my area—much better results are seen than in other areas. That distinction points us in the right direction.

Despite the fact that a million patients visit their local family doctor practice each day—a far greater number than access NHS services by any other means—GPs see their service being diminished in importance. For example, I was on a bus in London recently—such is the nature of opposition that we cannot just get into the back of a car and hope that it moves. I saw an advert placed by a strategic health authority advertising options for care. The list included self-care, visiting a pharmacist, going to an NHS walk-in centre,calling NHS Direct, attending a minor injuries unit, going to accident and emergency or dialling 999 in an emergency. At the end of the list it said:

"For advice or a jab, go to your GP."

Is it any wonder that GPs feel devalued?

Increasing numbers of GPs are becoming salaried and controlled by their PCTs, and all GPs are being inspected, validated, performance-managed and target-driven to the point where they are concerned about their continuing clinical freedom. As Dr. Mayur Lakhani, the new chairman of the Royal College of General Practitioners, said in the most recent edition of the BMA News:

"I feel general practice is under threat—it is not valued . . . I want doctors to look forward to going to work in the morning. At the moment, people seem browbeaten."

Dr. Lakhani also suggested that the greatest threat to the profession—and this point is relevant to the intervention by Mr. Chaytor—is the

"inappropriate redistribution of medical work and role substitution."

He said:

"I do not buy this idea that others can do the work of GPs. GPs cannot be replaced. We cannot take the role of the GP and break it up into bits and say let provider X do that, provider Y do this and provider Z something else. You lose the essence."

Photo of Chris Bryant Chris Bryant Labour, Rhondda

The hon. Gentleman may think it odd that a Welsh Member of Parliament should intervene on this point, although much of what he has been talking about applies equally to Wales as it does to England, even though some of what he says applies only in England. He said that many more GPs are now salaried and he suggested that that was a problem. I represent a valleys constituency that has found it very difficult to recruit traditional-style GPs, so the advent of the salaried GP has led to a dramatic improvement in provision locally.

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

Far be it from me ever to think that what the hon. Gentleman says is odd. However, to introduce salaried GPs in circumstances in which it is difficult to recruit self-employed practitioners is very different from trying deliberately to introduce salaried GPs in place of self-employed practitioners, as PCTs are attempting to do in many areas.

Dr. Lakhani is right in what he says and right to say it. The Government cannot have it both ways. If, as I suspect, they know that they will achieve their aims only through recreating the innovation, energy and responsiveness of GP fundholding, they cannot at the same time put GPs on to a treadmill of providing services as dictated by the Department of Health. The Government cannot seek to recreate the benefits of fundholding and, at the same time, devalue the leading role of family doctor services in primary care.

Photo of David Chaytor David Chaytor Labour, Bury North

Does the hon. Gentleman accept that one of the by-products of the introduction of GP fundholding by the previous Government was that it encouraged many GPs to devolve responsibilities to nursing staff for the first time ever? With no disrespect to Dr. Lakhani, there are many GPs who have actively argued for that to happen for many years. Does the hon. Gentleman seriously object to initiatives such as NHS Direct, which gives ordinary patients faster access to the health service?

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

The point is not that NHS Direct is undesirable as a means of accessing NHS services, nor that walk-in centres are undesirable as a means of improving diversity of provision. We are in favour of diversity of provision. I have spoken about the importance of extending the role of nurses, for example. However, it is important for GPs to be focused on the things that they do best, such as diagnosis and the management of chronic disease. My objection was—and the hon. Gentleman will recall that this was the subject of his first intervention—that the Secretary of State announces that, for example, the NHS will recruit community matrons who will be responsible for the provision of services to the most elderly, who have a range of co-morbidities and who suffer from chronic diseases. Those are precisely the patients whose care GPs, as family doctors, are best equipped to manage. The relationship between community nursing and GPs is at the heart of the issue, but that is not what the Secretary of State said. It is not that diversity of provision is wrong—far from it—but we need to understand the central role of the GP and family doctor service.

We saw another example last week when the Minister of State, Mr. Hutton announced the establishment of seven walk-in centres for commuters. Fine. Okay. By all means, let us offer access to health care services. But that is the same Government who eroded the very access to family doctors that people who commute to city centres need. Commuters and office workers want to be able to visit their own GP practice in the evening or on Saturday morning, but those opportunities have gone. The consequence of the contract and the unwillingness of PCTs to commission those services from GPs has meant the abandonment of Saturday morning surgeries across the country.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

The hon. Gentleman is being generous in giving way and I am extremely grateful to him. May I take him back to the question put by my hon. Friend Mr. Drew? The hon. Gentleman has again raised concerns about the new GP contract and criticised those aspects that relate to the definition of out-of-hours services. Would he go back on the contract?

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

What GPs want—[Interruption.] Do Labour Members want an answer? I am not sure. Let me give the Minister an example. As the Under-Secretary of State for Health, Miss Johnson, knows, I recently met GPs in Welwyn Garden City. They want their PCT to commission them to provide Saturday morning surgeries, but they are not being given the commission, so they have been forced to cancel Saturday morning surgeries. They regard that service as valuable and explained to me at considerable length the benefits it provides and the difficulties that will ensue in accessing services in its absence— the number of patients fetching up at surgeries on Monday mornings or going to accident and emergency departments or elsewhere. No doubt the hon. Lady knows about that.

It is not me who is saying that we want Saturday morning surgeries; it is general practitioners. They are not saying, "Scrap the contract", but, "Enable us to continue to provide the Saturday morning surgery that our patients want and that we are prepared to offer".

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

I will be well behaved, Mr. Deputy Speaker. This is the last time that I shall intervene on the hon. Gentleman.

It is fundamentally untrue to say that GPs have been forced to do any of those things. The GPs were offered a contract and negotiated it. They wanted to be relieved of those responsibilities and chose to be relieved of them.

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

The Minister knows perfectly well that, under the terms of the contract, out of hours was defined such that if a continuing level of access to service was required it would have to be commissioned as a locally enhanced service. That is all we seek—a locally enhanced service. We discussed the GP contract on 8 July 2003 for the sum total of one and a half hours—such is the nature of parliamentary proceedings. On that occasion, the Minister said:

"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. I can give the hon. Member for South Staffordshire the assurances he seeks: we will implement the agreement to ensure that there is no loss of access to out-of-hours services."—[Hansard, 8 July 2003; Vol. 408, c. 1050.]

He said that there would be no loss of access to out-of-hours services, but the agreement was not implemented on that basis, as I shall explain later.

For the reasons I have given, we need to be clear about the future of the family doctor service. My colleagues and I are clear. We believe that the relationship between patient and doctor is vital. That does not mean that a patient should necessarily see their own GP every time they visit a practice; nor does it mean that they have to see a doctor if that is not necessary, as the hon. Member for Bury, North pointed out in his intervention. The role of nurses and other health professionals is expanding and it makes good sense to focus scarce medical time on the tasks for which medics are actually needed. However, what that relationship means is that patients want to know that their health needs are understood, seen in context and that one illness is not treated without an understanding of the range of further illnesses and complications that they may experience. That is what patients are concerned about. It is clear that patients value knowing, and being known by, their GP.

Photo of Andrew Selous Andrew Selous Opposition Whip (Commons)

My hon. Friend mentioned practice nurses. Is it not rather extraordinary that the Government's definition of those eligible for key worker housing does not include practice nurses in GP surgeries? They may have been in the NHS pension scheme for 35 years, yet because some of their salary is paid directly by the GP they are not included.

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

I do find that strange. Our constituencies are almost neighbouring, so my hon. Friend and I are both aware of the pressures on health workers and of their need to access affordable housing. I was not previously aware of that exclusion, but the Minister will know of it and I hope that he will take note of my hon. Friend's point and perhaps discuss it with the Office of the Deputy Prime Minister. In the past, I have had occasion to press for the extension of the definition of key workers, and my hon. Friend makes a good case in that regard.

Photo of Andy Burnham Andy Burnham PPS (Rt Hon David Blunkett, Secretary of State), Home Office

I am listening to the argument that the hon. Gentleman is developing. He has mounted a critique in opposition to the concept of salaried GPs. He seems to want to uphold the principle that GPs are independent contractors. What would he say to deprived communities, such as the one I represent, where for many years GPs have not wanted to invest their capital and commit themselves? Consequently, GP vacancies are higher in such areas. If he is denying us the right to salaried GPs, what will the Conservative party do for communities such as Leigh?

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

It will come as a surprise to some of my colleagues—for example, in Hertfordshire—to hear that significant numbers of GP vacancies are experienced only in urban areas. In fact, they occur in many areas.

The hon. Gentleman asked what we would do. Of course, we need measures to try to support GPs. I have held discussions with GPs, so I know of the difficulties for a young GP, especially in some urban areas, of taking on the necessary mortgage not only to live in the area, but to buy practice premises. That is not easy as it once was, so of course support is needed. There could be a range of options, such as the PCT purchasing the premises and, in some cases, as I acknowledged to Chris Bryant, it will be right to employ salaried GPs. I do not dispute that. My point is about the desirability of creating opportunities for GPs actually to be independent contractors. That is the best basis on which to establish the service.

The relationship between GPs and patients is one of the benefits that small practices offer patients, but which well-run practices of all sizes can achieve. It is more than simply a matter of service standards; it has a positive impact on the treatment of patients. We should not underestimate the need for effective management of co-morbidities or the benefits that flow from giving patients a framework of information and advice in the management of chronic disease. In both respects, the patient-GP relationship may be instrumental.

We should also be aware that every GP is an advocate for public health promotion and has the opportunity to make early interventions to combat disease. That will be maximised if GPs know their patients, take responsibility for their patients, assist them in exercising choice and influencing the management of their care, and are progressively able to commission services on their behalf.

The value of GPs and the family doctor service in terms of health benefits is clear. As Dr. John Chisholm, a former chairman of the BMA's GP committee, said in his speech to local medical committees in June:

"Health systems based on effective primary care with highly trained generalist physicians practising in the community provide more cost-effective and clinically effective care than other health systems that are less oriented to primary care. Furthermore, the higher is the ratio of family physicians to the population, the lower the hospitalisation rates."

Central to the role of family doctors should be the opportunity for practices to commission services on behalf of patients. Fundholding was taken up by many GPs and we should look to all practices progressively to take responsibility for commissioning decisions on behalf of their patients. Whenever possible, patients should exercise choice. All patients should have influence and a voice in the management of their care, but we should never underestimate the value of GPs as advisers and commissioners on behalf of patients.

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health


If we can be clear about the central role of GPs, why cannot the Government also be clear? In part, of course, it is because their focus is elsewhere. They have talked of hospitals and waiting list targets to the exclusion of all else. It is a condemnation of the Government that it is only now that they are acknowledging the need for the NHS to focus on improved chronic disease management.

Another reason is that the Government cannot let go of central control. Let us take that example of out-of-hours services, which we have discussed briefly. Eighteen months ago, I and my Opposition colleagues sought certain assurances. The Minister, as I quoted earlier, said that there would be no loss of access to out-of-hours services. What did we get? In seven areas, with a population totalling 1.2 million, including South Lincolnshire, we got a service with no GPs at all, and the Minister had to be brought to the House by my hon. Friend Mr. Davies to answer that point. Saturday morning surgeries have gone. MedEconomics reported recently that the bill for new out-of-hours services is likely to reveal a frightening level of underfunding, which will have a detrimental effect on the quality of out-of-hours services. We were promised that more would be spent and access would be maintained.

Photo of Mr David Hinchliffe Mr David Hinchliffe Labour, Wakefield

I am grateful to the hon. Gentleman for giving way and I apologise for not being present for the first few minutes of his speech. I am particularly interested in the points that he is making about out-of-hours services and I have noted that the Conservative motion talks about deploring

"the failure to maintain the out-of-hours service as a general practitioner-led service".

I do not know whether he has had the opportunity to study the Health Committee's report on out-of-hours provision, published as recently as July, in which we actually said:

"We are impressed with the potential of some models of GP out-of-hours service provision, including integration with ambulance services and creative use of skill mix" which we thought was a very important development. That report was signed up to by the entire Committee, which of course includes colleagues on his own Front Bench who agree with that particular point.

The hon. Gentleman seems to be harking back to a golden age of out-of-hours cover, which, in my experience, never existed. I worked alongside GPs in an out-of-hours service on mental health care; frankly, many of them were knackered—if that is not an unparliamentary term—and should not have been practising because they were exhausted. The hon. Gentleman really needs to address that point.

Photo of Alan Haselhurst Alan Haselhurst Deputy Speaker and Chairman of Ways and Means

Order. The distinguished Member, the Chairman of the Select Committee, has a lot of knowledge on these matters, but we do not want it all at once.

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

You are absolutely right, Mr. Deputy Speaker, but as a former member of the Select Committee under the hon. Gentleman's chairmanship, I would not diminish the value that we can get from hearing from him. I would sign up to what he says and I am not surprised that my hon. Friend Mr. Burns did as a Member of the Committee, because there are some models from which we can learn.

In my region, the ambulance trust has taken responsibility for the provision of out-of-hours services in Norfolk. However I know—because it has been recruiting doctors from Germany to meet its requirements—that it is having difficulty in getting GPs involved. Among the things that we need to be clear about is the fact that GPs in particular will subscribe to an out-of-hours service if they feel that it is structured around their needs, that it will manage risk and take clinical judgments on a basis with which they are happy, and that it will provide a service that is complementary to them. Of course, it must be seen as part of a more integrated service of unscheduled, unplanned care, but that does not mean that it becomes part of a bureaucracy that is no longer accountable to GPs. It is the out-of-hours GP service and it must be seen as such.

NHS Direct was mentioned. It is important to understand how this will work because NHS Direct is gearing up to take over call handling nationally, and that could undermine GP out-of-hours providers locally. It could substitute clinical assessment software for GPs' management and judgment and it could mean handling calls at centres where staff simply do not know local services.

Photo of Christopher Chope Christopher Chope Shadow Spokesperson (Environment, Food and Rural Affairs)

Will my hon. Friend comment about the situation relating to Egton Medical Information Services? The Government are centralising and imposing upon GPs a system of medical information that they do not want. Fifty-five per cent. of GPs are using Egton but the Government are going to prevent them from doing so in future. Is that not ludicrous?

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

I shall deal with that point directly; I am grateful to my hon. Friend. As he says, out of hours is not the only area where GPs feel let down. For many GPs, the implementation of the NHS programme for IT is indeed a matter of deep concern. The Government originally said that it was going to be a national strategy for local implementation. In June 2002, however, they said that they would centralise the IT programme. When we discussed this in July 2003, in the short debate to which I previously referred, I expressed concern—I shall quote myself if my hon. Friend will forgive me—

"about the extent to which information technology systems in the NHS are being centralised" and

"that the responsiveness of the IT system to individual customers was being removed".

I wondered, in the context of the negotiation of the contract,

"whether the BMA is entirely confident that GP practices will be able to exercise the same control over their service providers that they do at present".—[Hansard, 8 July 2003; Vol. 408, c. 1048.]

Since that warning back in July of last year, we have become aware of serious disquiet among general practitioners about the system that the Government are putting in place. As my hon. Friend Mr. Chope said, they have put a lot of investment into the EMIS system and 50 per cent. of GPs have adopted it, but this system is not the one that has secured a contract with a local service provider to provide GPs with their IT systems under the new arrangements. The GP contract says:

"Each practice will have guaranteed choice from a number of accredited systems that deliver the required functionality"— yet GPs are not getting the choice that they want, nor the required functionality.

It is also my understanding that the Department of Health has assured GPs that they will not be forced to change systems, but—with this Government there is always a but—GPs are being told that if they wish to keep their existing system and it is not one of those offered by their local service provider, they may have to pay for it from their own budget. Not only do GPs have cost concerns about the new system, but they are rightly concerned about moving from a system in which they have invested, that they and their staff are trained to use, and that they trust, to a system that is unfamiliar and untested.

Will the Minister today take the opportunity to tell us what consultation he has had with GPs about the IT programme? If a GP wishes to remain with an existing IT system that is compatible with the NHS system but which is not offered by their local service provider, will they be able to do so at no extra cost? Can the Minister assure the House that all new accredited systems can deliver the same functionality as existing systems? What assurance can he give the House that safeguards have been put in place that ensure that GPs who transfer to a new accredited system will not lose any confidential patient data in the process?

It is clear that the Government have a long way to go to convince doctors and the public—and, indeed, many of us—that they were right to take central control of the NHS IT programme, to explain why they have not secured the buy-in from GPs and users that is vital to any IT project, and especially to show that the IT programme will in fact deliver the service and the functionality that GPs require.

The NHS needs to be a primary care-led service, and the family doctor service is the lynchpin to primary care. In GPs we have 35,000 advocates of better public health who are best placed to intervene early and effectively—but it is a service under stress. GP numbers in the five years after 1997 rose by less than in the preceding five years. The number of applicants for GP training places is way down on five years ago. Vacancies reported in the last recruitment and retention survey were over 40 per cent. higher than during the previous year.

The Government's amendment to our motion demonstrates their failure. They are forced to recognise the value of a return to GP fundholding, although they will not admit it. They admit the lack of clinical engagement, as they term it, which actually means that they are admitting the lack of ability for GPs to control clinical services provided to their patients. They still fail in their amendment to express their appreciation of the central role of the family doctor service. The Government are clearly in denial over the problems experienced with out-of-hours services and the NHS IT programme. The Government's priority in their amendment seems to be to promote walk-in centres and NHS Direct. Our priority is to promote the family doctor service and GPs as the lynchpin of successful primary care.

I commend our motion to the House.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health) 2:00 pm, 11th November 2004

I beg to move, To leave out from "House" to the end of the Question, and to add instead thereof:

"welcomes the increase in general practitioner numbers;
supports the expansion of primary care provision through walk-in centres and NHS Direct to meet the needs of patients;
welcomes the new arrangements for the National Health Service out-of-hours services that provide an opportunity to integrate primary, secondary and social care, whilst guaranteeing high quality urgent care across the country including Saturday mornings and improving the quality of life for general practitioners;
acknowledges the progress made on the NHS Programme for information technology;
supports the introduction of practice-based commissioning which fosters clinical engagement whilst mitigating the worst excesses of general practitioner fundholding;
and believes that the general development of practice-based commissioning will deliver improved patient care."

I agree with Mr. Lansley about one thing at least—it is important that where we agree, we make that clear. I agree with him about the importance of primary care and delivering high-quality health care services to NHS patients. Primary care has always been the cornerstone of the national health service, and our family doctors have always been at the forefront of change and innovation. Primary care is the cornerstone of the NHS because it is where the vast majority of patients are seen and receive their treatment. Ninety per cent. of all patient journeys in the NHS begin and end in a primary care setting. Some 300 million appointments are made in general practice every year. Every fortnight, one in four people in Britain will see their GP or practice nurse.

It is for those reasons and others that primary care has played a critical role in advancing the health of every single person and every community in Britain, so it is not a surprise that GPs are the most respected and trusted professionals in our country or that primary care always gets and continues to get—despite the impression given by the hon. Gentleman—the highest levels of patient satisfaction of any part of the NHS. It is a proud record, deservedly so, and despite all of its detractors, I believe that our primary care model is admired across the world.

GPs have played an important role in bringing about some significant improvements in the health of our population in recent years, none of them documented by the hon. Member for South Cambridgeshire. For example, death rates from cancer are down by more than 12 per cent.; death rates from cardiovascular disease have fallen by more than 23 per cent. That is real and solid progress. I disagree strongly with the hon. Gentleman on both his analysis of the present state of primary care and on the best way to secure its future.

Photo of David Drew David Drew Labour/Co-operative, Stroud

I wonder whether my right hon. Friend will respond to something that the Opposition spokesman said. One of the arguments for freeing up the time of GPs is that it allows them to develop sub-specialisms. By chance, yesterday the all-party health group held a session on primary approaches to pain control. It was abundantly clear that GPs had to develop specialisms in order to make early diagnoses and pass their patients on for treatment. Unless we can free up time for GPs, which the Opposition do not seem to have any idea how they would do, it will not be practicable for them to develop such specialisms. Does my right hon. Friend care to say something about that in terms of the logic of what the Government are doing?

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

I want to come back to that issue in a moment. It is important to recognise that much of the skill mix and much of the change that has taken place in primary care and the increasing role of other health care workers in supporting primary care and family doctors has been welcomed by GPs. They see it as an important part of making sure that their expertise is concentrated on those parts of their work that they need to do.

In relation to specialisation in general practice, we have seen some welcome and significant progress—progress that was not seen in the 18 years to which the hon. Member for South Cambridgeshire conveniently forgot to refer. His vision of primary care is very much the "Dr. Finlay's Casebook" version, and with great respect, I do not think that anyone in the Chamber today can recall those times. Times have changed and things have moved on. One of my problems with the hon. Gentleman's argument today is that, sadly, he does not appear to be in that process of change.

The essence of the hon. Gentleman's argument today has been that the Government have failed to support primary care services in our national health service. That is simply untrue. It is a claim that cannot be justified by reference to the facts. He has chosen to ignore every indicator that points in the direction of the progress that is being made. He has ignored the views of Britain's GPs, having appointed himself today as their national champion. They have signalled in opinion poll after opinion poll conducted by the British Medical Association that their view of the quality of patient care that they are providing is that it is improving, not decreasing. He showed a blissful and wonderful disregard for his party's record on primary care when it was in government.

I am not surprised that the hon. Gentleman chose to say nothing about the previous 18 years, but let me remind him and his hon. Friends of one or two of the facts, because they reveal a different story from the one that the hon. Gentleman tried to tell. For example, between 1991 and 1996 there was a fall of 20 per cent. in the number of GPs in training, with a reduction in every single year. So much for his claim to value the role of primary care. Average list sizes are lower today than they were both in 1997 and in 1992. That undermines his claim that we have failed to address work load issues.

In relation to the new contract, about which the hon. Gentleman spoke at length, let me remind him of one rather interesting fact. The previous Administration imposed a new contract on GPs in 1990, having failed to negotiate an agreement with them. That rather puts paid to his argument that we are the ones who are not listening to the views of general practitioners. He has yet again completely failed to establish a clear alternative, which I think is a pretty important yardstick by which people reading and listening to his contribution today are likely to form a view. He does not plan to spend any additional resources on primary care. We know that he has no plans to change the new primary care contracts.

What the hon. Gentleman has said would make matters worse, not better. He intends to scrap our plans to improve GP premises, because he is against all those national targets. He would take away the right of the patient to be seen by a GP or practice nurse within 24 or 48 hours, because he is against that target as well and would not take any measures to implement it. There would be no targets for recruiting more doctors or nurses in the NHS. He would return the NHS—we know this from the Opposition motion and from what he said today—to the bureaucracy and unfairness of GP fundholding. All that would be a huge step backwards for our national health service. That is why his contribution will be seen as shallow and superficial and devoid of serious proposals.

I want to set out what I believe are the important facts, but I want to make one thing clear at the beginning. It is not my argument today that every problem facing our family doctor services has been solved. We all know that that is not the case. Neither is it my contention that we cannot improve the quality and range of services on offer to patients. We all know that we can. My argument today is that we are making real progress in expanding primary care services and in the process giving patients a wider range of services to choose from; in short that primary care is heading in the right direction.

Photo of David Taylor David Taylor Labour/Co-operative, North West Leicestershire

The House will agree that an NHS without targets could not possibly work efficiently or effectively. Does my right hon. Friend agree that those who supervise the delivery of general practice should apply their role in a sensitive and intelligent fashion to avoid the extra stress that is placed on GPs? Will he see me immediately the inquiry report is published into the suicide of Dr. Stephen Farley, a doctor in my practice in North-West Leicestershire? The report is due on 2 December, and the issue of stress may feature in its recommendations.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

I give my hon. Friend that assurance. The death of Dr. Farley was a terrible tragedy for his family and his patients, and we want to study carefully what the report says. The best way to deal with some of the work load pressures is to continue with the reforms and expansions that we are making in primary care, so that we can recruit more GPs and practice staff and the undoubted pressures that affect GP surgeries up and down the country can be managed more seriously.

We have been able to make progress, first, because of the additional investment that we have been able to put into the NHS—something that, of course, the Conservative party opposed at the time and described as reckless and irresponsible—and, secondly, because we have been prepared to challenge, which the hon. Member for South Cambridgeshire clearly has not today, some of the traditional assumptions about what primary care services should look like in the modern day and age.

The hon. Gentleman continues to define primary care largely in organisational terms—that is very much what I took from his comments today—and in terms of the services provided by doctors. That is a mistake on his part because primary care is much more than that. Primary care represents instead a concept of care that can be provided perfectly well by different professionals and organisations. What matters is the quality of care that is provided, not the organisational structure of the care provider who delivers it.

Primary care has benefited from new services led by nurses, such as walk-in centres and NHS Direct. Clearly, the hon. Gentleman takes a very different view. For example, both those services are viewed in the motion as undermining primary care because they are not led by GPs. He is completely wrong on that point, and I want to return to that in a moment.

Photo of Phyllis Starkey Phyllis Starkey PPS (Dr Denis MacShane, Minister of State), Foreign & Commonwealth Office

May I draw my right hon. Friend's attention to a scheme that is being implemented by the Co-op Pharmacy in my constituency that involves going to working men's clubs, measuring people's blood pressure and cholesterol levels and giving appropriate dietary advice? That is not GP led, but it is reaching men, in large part, who would never go near their GP and causing them to modify their behaviour and improve their health, so they are likely to be less of a burden on the NHS and their local GP. Should not those services be encouraged, not denigrated, as the hon. Member for South Cambridgeshire did? Most GPs would support exactly that sort of service.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

My hon. Friend is absolutely right. From my experience of working men's clubs, it is probably a pretty good idea to go into them fairly regularly to test blood pressure there. I am member of the Cemetery Cottages working men's club in my constituency, and blood pressure testing there is probably a quite a good idea. Of course, she speaks an awful lot of common sense, and she has made much more eloquently than I could the argument that I am trying to make.

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

The Minister is proceeding on a misrepresentation of not only what I said, but what he ought to know we have made clear in our policies. I do not define primary care in organisational terms. In fact, we wish to define care increasingly in terms of its being patient centred, with patents having individual care plans. I do not denigrate walk-in centres. I visited one in Loughborough recently, which was run not by GPs, but by emergency care practitioners and nurses, and it was run very well. The point, however, is to understand that patients need the relationship with their GPs to be able to structure the manner in which they gain access to services, to recognise the co-morbidities and to understand how such care is best put together.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

Of course, they do. That is why we are investing additional resources in primary care to ensure that that can happen. Walk-in centres are not a substitute for the relationship that registered patients will have with their own GP; they provide an additional service. If the hon. Gentleman had wanted to make that point, he should have chosen his words more carefully in his speech.

On investment, NHS primary care services are benefiting from the significant additional resources that we have made available. Funding for primary care services will increase from £5 billion to £6.8 billion next year—an increase of more than 30 per cent. over that period. That progress would be immediately undermined by the policies that the Conservative party now advocates.

The hon. Gentleman's patient's passport would take more than £1 billion away from the NHS to help well-off people jump the queue for NHS treatment by going private—a typical Tory policy of looking after the interests of the few at the expense of the many. If that money were taken away from the NHS, as he intends, it would be quite impossible for primary care trusts to maintain the investment that is going into the NHS front line. Primary care would suffer in the same way as hospitals from those reductions in resources. So there is no accuracy behind his claim that we are not properly investing in NHS primary care services—we are— and his proposals would make matters worse. [Interruption.] It is clear from his comments from a sedentary position that he thinks we are investing the right level of resources in primary care. If he is not clear about that, let him come to the Dispatch Box.

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

Clearly, the Minister wrote his speech before he heard my speech. He is referring to what he supposed I would say. He thought that I would criticise the Government's investment in primary care, but I did not do so. If I were to do so, I would say, for example, that between 2001 and 2002–03—let us look at the book, rather than into the crystal ball—investment in general medical services and personal medical service increased by just 9 per cent. As we would expect, the Minister is talking about what he will do in the future, but not holding himself accountable for what he has done in the past.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

I am happy to hold myself accountable for the actions of Ministers and my right hon. Friend the Secretary of State for Health. It is true that I wrote the speech in advance—I confess to doing so—and I can tell him why I did so: the hon. Gentleman makes exactly the same speech every time that he comes to the Dispatch Box. He makes exactly the same arguments, and we can see him coming from a very long way. It is ludicrous for him to say that he was not implying that we were not sufficiently investing in primary care because the motion is about our failure to support family doctor services. He is probably the only Member in the Chamber who thinks that the level of investment is not important to the support that we provide to our family doctors.

We are using those additional resources to invest more than ever before in our family health services. Our priorities are clear. We need more GPs and practice nurses. We need to improve as many surgeries as possible, so that patients can be treated in the best possible environment. We need to reward GPs and practice staff who are working hard to improve the quality of the care they provide. We need to improve access to primary care, so that patients can be seen wherever possible at a time of their own choosing and in a way that fits around their own needs and requirements. We need a wider range of services for patients to choose from, and we need to involve GPs and practice staff fully in the process of fashioning services around the needs of patients and shaping the key decisions that affect the design of local health services. In all those areas, we are making solid progress.

There are more GPs working in the NHS than ever before—over 3,000 more since 1997. We are increasing the number of GPs in the NHS at twice the rate achieved by the previous Administration. Vacancy rates for GPs, which were not even collected by the Conservative Government, are now falling, not rising, as the hon. Gentleman suggested. The number of doctors training to become GPs has increased by 80 per cent. compared with a 20 per cent. fall under the last Conservative Administration.

Photo of Mr David Rendel Mr David Rendel Shadow Minister (Higher Education), Education & Skills

I should declare an interest: my wife is a GP. Does the Minister agree that one of the troubles with the NHS is that there have been times of famine and times of good supply? What tends to happen is that a large number of doctors go into the GP service at one time, all of whom are roughly the same age, and then there is a period when many fewer go in because all the places are filled, followed by another period when a lot go in. Somehow, we need to smooth that out.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

I agree with the hon. Gentleman. The problem that he describes is the consequence of the boom and bust in NHS finances that we saw under that lot opposite. We are trying to ensure that the NHS has a steady path of increased resources, so that it can plan accordingly. It makes my blood boil—on the subject of blood pressure—to hear stories like that because that was the old NHS. That is precisely what used to happen: stop and go, start all over again. We can do better than that, which is what we are trying to do.

The hon. Member for South Cambridgeshire quoted a number of voices on primary care. Let me add a further one to the pot. I mentioned earlier that we are successfully recruiting GPs from other European countries. One such recent recruit was Dr. Lefeuvre from France who now works for the NHS in south-east London, and he said recently:

"When you have experience of the NHS, it is difficult to go back to France. We wanted to work in a different way, but unfortunately we didn't have the opportunity to do that in France. We decided to move over here because the NHS is more flexible than the system we had in France. Also my wife can work as a part time GP here. In France, that is impossible."

I very much welcome Dr. Lefeuvre's positive endorsement of NHS primary care, and I hope that the hon. Gentleman will be able to do the same.

As all my hon. Friends know, primary care is not just about doctors. There are also over 3,000 more practice nurses working in GP surgeries than in 1997—an 18 per cent. increase. The hon. Gentleman referred to a small fall in the number of community district nurses. It is true that there has been a fall of 800 or so, but the number of nurses who work in the community has risen by 25 per cent. in the same period.

Photo of Mark Todd Mark Todd PPS (Rt Hon Baroness Symons of Vernham Dean, Minister of State), Foreign & Commonwealth Office

When my right hon. Friend discusses that interface between nurses and GPs, will he reflect on the example of the nurse-led practice at Chellaston in my constituency, where the doctor is employed by a nurse who leads the practice, which is highly successful, fast growing and popular with patients?

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

That is a good example. I suspect that my hon. Friend is talking about a personal medical services practice in which all sorts of opportunities have opened up. That model points distinctly to the future of primary care. The situation will not be the same as that in "Dr. Finlay's Casebook"—most of the speech made by the hon. Member for South Cambridgeshire described Dr. Finlay in detail.

The hon. Member for South Cambridgeshire does not have a leg to stand on when he criticises our record investment and work force expansion. We have embarked on a major programme of investment in new GP surgeries and clinics. In the past four years, almost 2,500 GP surgeries have been replaced or substantially refurbished. Over the same period, more than 300 new one-stop primary care centres have been developed. There are 42 new NHS local improvement finance trusts—LIFT schemes—to help to boost investment in NHS primary care premises.

Photo of Liam Byrne Liam Byrne Labour, Birmingham, Hodge Hill

Does my right hon. Friend recognise that in my inner-city area—I know that many Opposition Members visited it during the recent by-election—it is critical for Eastern Birmingham primary care trust to work in conjunction with NHS LIFT if things are to operate at the necessary scale to transform services? Such work is offering us the prospect of transforming one of the worst eyesores in Birmingham, which is the Leyland club on Alum Rock road. Such plans would be impossible under the Conservative party.

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

I appreciate my hon. Friend's point. I was one of those who made the journey to his constituency; I thoroughly enjoyed my visit. He makes a good point. The NHS LIFT scheme gives us an important new opportunity to expand primary care imaginatively. We must ensure that while we also plan acute sector re-provision and build up new hospitals—there are 100-plus schemes in the NHS—we look critically at how many of the services traditionally provided in a hospital can be relocated to a primary care environment. I agree with the president of the Royal College of General Practitioners and John Chisholm that it would be good to locate many traditional hospital-based services in primary care, and I would be pleased, as I am sure that my hon. Friend would be, if we could make such progress in his constituency.

The NHS LIFT scheme offers a significant opportunity for primary care, with a total capital value in excess of £700 million. The Conservative party cannot point to similar investment in primary care premises throughout its entire period in office between 1979 and 1997.

The new primary care contracts will provide a better way to reward health care professionals for their commitment to improving patient care. They represent an important movement away from payments based largely on capitation to rewards that direct reflect the quality of care provided and primary care professionals' hard work. All the clinical indicators in the new contracts have been chosen by an independent expert group and are based on the best available evidence. GPs agreed to them when they voted overwhelmingly in favour of the new contracts last year. That situation is in stark contrast to that under the previous Administration, who imposed a new contract on GPs after failing to reach agreement with them.

I do not believe that the new contracts devalue the role of doctors working in primary care. Quite the opposite is the case because they properly reflect the hugely important role that doctors play. We inherited a situation in which only half of NHS patients could get a prompt appointment to see their GP—many had to wait for a long time. Some 97 per cent. of patients are now able to see a GP within two days, which is a huge improvement on the situation that we inherited. The improvement has been led by the pioneering work of GP practices throughout the country, including in South Cambridgeshire, where 100 per cent. of the constituents of the hon. Member for South Cambridgeshire are now able to get an appointment within 48 hours. It was disappointing, although not altogether surprising, that he failed to mention that improvement.

People can now choose from a wider range of primary care services, such as the new NHS walk-in centres, 57 of which are now open with a further 25 in development. More than 5 million people have attended NHS walk-in centres since they first opened in 2000. That confirms the value of the new services to the public, as does the support expressed for them by the Patients Association. They operate on a drop-in basis and can help to ease pressure in other parts of the NHS. They filled a gap in primary care that needed to be plugged.

As I said earlier, and as my hon. Friends have rightly noticed, the hon. Gentleman made a big mistake when he claimed that because such services are nurse-led, they somehow devalue the role of doctors. Of course they do not do that, in the same way in which the work of paramedics in accident and emergency departments does not undermine the role of hospital consultants. Such work can complement and support the contribution of other health care professionals who work as part of a wider team. Such work is being performed within properly agreed protocols. The service is safe and effective—it is nonsense to imply otherwise.

We have always been clear about the need to involve fully GPs and practice staff in local decision making in the NHS. In our first White Paper on the NHS in 1998, which was presented to the House by my right hon. Friend Mr. Dobson, we made it clear that we wanted to

"extend to all patients the benefits, but not the disadvantages of GP fundholding."

That is the aim of practice-based commissioning. It is not a return to the fundholding arrangements of the past. We have consistently made our intentions on the matter clear since 1998, so it is a pity that the hon. Gentleman and his colleagues have not been listening. Unlike under fundholding, no extra resources will go to practices that take up practice-based commissioning. There will be a level playing field for all practices irrespective of whether they take advantage of practice-based commissioning. Patients will not be unfairly disadvantaged if their practices decide not to take up the new opportunities, but that was not the case under GP fundholding.

Unlike fundholding, practice-based commissioning will not usher in a huge expansion of bureaucracy because primary care trusts will retain legal responsibility for the contracting process. We will not return to the situation under fundholding when decisions often came down to which hospital could provide a service at the lowest price because the single national tariff will prevent that from arising. Practice-based commissioning will instead focus on quality and efficiency, which will put patients' interests first, as it should be.

My hon. Friends and I believed that it was right to end fundholding because it unfairly discriminated against the patients of practices that chose not to take it up and because it spawned a giant bureaucracy. We will not repeat those mistakes as we take practice-based commissioning forward.

Photo of Andrew Murrison Andrew Murrison Shadow Minister (Health)

Is the Minister aware of a report of a study published in the British Medical Journal today showing that fundholders reduced admission rates for elective procedures considerably? That must be a major consideration when comparing different forms of primary care delivery. Was he aware of that study?

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

We made it clear that there were benefits of fundholding—that is not revolutionary or rocket science. We rejected the fundholding scheme because of its associated bureaucracy and because it was unfair. We did not reject it because it empowered GPs to make local decisions, and we made that absolutely clear in the 1998 White Paper. I shall send a copy of it to Dr. Murrison and perhaps we can have a discussion in the House about it another time.

Labour Members can safely disregard the comments made by the hon. Member for South Cambridgeshire because they bear no resemblance to the realities of the present or the past.

The final thrust of the motion relates to the changes being made to out-of-hours services. We have previously debated those proposals, but let me make our position clear to Conservative Members again. The new contracts will not lead to the end of GP-led out-of-hours services. They simply move responsibility for organising such services from individual GPs to the primary care trust. Let me remind the hon. Member for South Cambridgeshire of the important facts. The changes have been agreed with GPs, although he failed to mention that in his speech. Would he go back on the new contracts? Would he restore the legal obligation for GPs to organise and deliver out-of-hours care? It is transparent to everyone that he would not, which confirms the hollow nature of his criticisms of the new arrangements.

The hon. Gentleman complains about GP work loads, but the new contracts are an attempt to address that for the first time. He cannot have his cake and eat it. GPs have cited the heavy burden of responsibility for organising out-of-hours care as a barrier to recruitment to general practice. We agree with GPs, which is why we agreed to the changes in responsibility. Does he agree with the GPs or not? It is not true to say that out-of-hours service will not be GP-led—they will be. However, over time, there will be a wider role for other health care professionals in the delivery of out-of-hours services. Is he suggesting that that should not happen?

If the hon. Gentleman thinks that the changes should not happen, he needs to explain the difference between, for example, a trained emergency care practitioner working an out-of-hours rota one night and in an accident and emergency department another night. He will need to explain the difference between a trained district nurse working in the community and a trained first-contact nurse visiting a sick patient at home out of hours. The truth is that there is no difference in those scenarios. Other health care professionals can help in the delivery of out-of-hours services, and it would be absurd to argue that they should not.

It makes sense to—[Interruption.] The hon. Members for South Cambridgeshire and for Westbury (Dr. Murrison) chunter away. I have tried to make it clear, but the hon. Member for South Cambridgeshire does not listen, that the services will be GP led. I hope that that deals with his uncertainty.

It makes sense to draw on the widest range of skills available to provide out-of-hours care efficiently, to ease the work-load burden faced by busy GPs and to meet the needs of patients. That is what we are trying to do with the profession. The hon. Gentleman has proposed no alternative whatsoever. That says it all.

The hon. Gentleman's approach can be described as totally predictable. He is a shroud-waver, and that is what he did today. He wants to claim that the out-of-hours services are disappearing and people will not be able to see a GP out of hours any more. His position is ridiculous. We are investing heavily in maintaining those vital services. GPs will still make home visits out of hours. His central argument is without foundation. We all know why he makes those allegations: it is pure opportunism and nothing more.

The hon. Gentleman referred to investment in new IT systems in the NHS. Let me remind him of one or two of the things that have happened over the past 20 years. The NHS has spent a significant amount on information technology over that period, but it has made that investment in a piecemeal fashion, with no strategic vision and oversight. As a result, we have ended up with thousands of different operating systems but no central data network. Compatibility and interoperability have often played second fiddle to local preferences. As a consequence, it is not uncommon for one hospital to be unable to transfer data to another or for one GP practice to be unable to send patient records electronically to another. There are no systematic patient records. So a doctor in Cornwall who has to look after a patient from my constituency who is admitted to A and E while on holiday will not have access to that person's medical history. It does not add up to a positive endorsement of the idea that small is beautiful.

Although historically there may have been good local IT initiatives, sponsored by enthusiastic visionaries, those were often inhibited by the overall lack of funding and development priority given to IT at all levels of the service. Typically, good experiences were not highlighted and successful implementations were not scaled from their local beginnings to NHS-wide applications. Even after procurement and implementation was over, there was no guarantee that different local systems would be compatible or scaleable to support patient care across different organisational boundaries. That is the reality, and it is that reality that we are trying to address in the national programme for IT.

The experience of allowing individual trusts to specify and procure their own systems was slow and hugely costly. Having a national programme, which the hon. Gentleman criticised—if I understood him correctly, he doubted the value in having a national programme—makes it possible to harness the massive buying power of the NHS to achieve huge financial as well as clinical benefits. Implementation of the national programme does not, however, mean that all the systems that are currently providing value will be scrapped. The national programme strategy makes it clear that best use must be made of the existing IT asset base. Nor will GPs be expected to change clinical systems while their current system is compliant with the NHS care records service and continues to serve them well.

The national programme has adopted an incremental approach to building up any new applications or systems. That approach is intended to ensure that implementation is achievable and minimises disruption to the day-to-day business of the NHS. Similarly, it does not imply a wholesale replacement of one primary care system by another. EMIS supply a significant number of systems to primary care practitioners and we would prefer it to be part of the ongoing national programme. The national programme has sought to ensure that EMIS engages with local service providers, and I am aware that the company is continuing to work with the national programme to make its systems compliant. For example, it co-operated with the recent upgrade to GP IT systems to support the quality and outcomes framework, which from next April will drive the GP reimbursement arrangements.

The Department's policy on local choice on IT provision, to which the hon. Gentleman referred, remains as stated in the guidance that we agreed with the British Medical Association last year, which is that each GP practice should have a choice of more than one system. Those systems will need to be accredited against national standards and deliver the required functionality. Guidance published on the national programme website makes it clear that existing suppliers play an important role in current and future NHS IT service provision.

I am aware that in some areas, following consultation with local clinicians and representative bodies, a consensus has emerged that it is sometimes in the best interests of the whole local health community if choice were exercised on a community rather than an individual practice basis. However, LSPs have been informed of the national programme position that GPs must not be forced to change systems, and I understand that individual practices will continue to be supported if they have expressed a wish not to begin migrating in the short term to the preferred local system.

We are acting to preserve choice for GPs on which IT system they use, but it is absolutely right and proper—this is where I take issue with the Opposition—to ensure that those choices support the important objectives of the national programme itself. Those objectives are that in future the NHS IT network is effectively integrated and capable of providing a smooth flow of information around the system as a whole. That is important because patient lives can depend on it. So we will not be departing from that basic requirement in relation to local IT solutions.

I have set out the steps that we are taking to support the development of primary care services in the NHS. It is a substantial record of investment, growth and improvement. It is a record we intend to build on in future years so that primary care retains the very special role it plays in our nation's health care system. The motion proposed by the hon. Gentleman is an empty and vacuous collection of opportunistic, inaccurate and simplistic assertions. He has jumped on to every conceivable bandwagon he could find. He has presented no meaningful alternative. That is why I invite my hon. Friends to reject it in the Lobby.

Photo of Paul Burstow Paul Burstow Shadow Secretary of State for Health 2:37 pm, 11th November 2004

As I listened to the exchanges across the Dispatch Box, it occurred to me that the proposition is either GP family services on the Finlay model or primary care services on the "Peak Practice" model, as favoured by the Government. The Minister was a little hard on Dr. Finlay, but perhaps he needed to make those points because Mr. Lansley sounded like an advocate not so much of the consumer of health care, but of producer interests in the health care system. It is essential that the patient be kept at the forefront of our minds and at the heart of our thinking. It was not clear from some of the points about the GP contract whether that was the key consideration.

There can be no doubt that GPs are the backbone of the primary care system. It is right that we are debating the state of family doctor services and their pivotal role. It is also right to acknowledge that there have been improvements. The extra investment is beginning to give us additional capacity. I hasten to add that Liberal Democrats were happy to go through the Lobby in support of that extra investment. Changes such as the new GP contract and the development of practitioners with specialist interests are rightly placing even greater emphasis on the role of primary care in general and GPs in particular. As the Conservative motion and the unselected amendment standing in my name and those of my right hon. and hon. Friends rightly document, areas of concern remain. It is not my job—or any Opposition Member's—to act as cheerleaders for the Government's record. Our role is to analyse, criticise and point out areas of concern, which there are in relation to the development of primary care services in this country.

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

The hon. Gentleman talked about investment in national health services, but can he clear up a point about which I am slightly confused? The Liberal Democrats appear to be proposing hypothecation to the NHS of the proceeds of national insurance, but the relationship between the two in the coming financial year would result in NHS expenditure having to be reduced by £4 billion if one simply did that hypothecation. I do not understand from where that £4 billion would come if not from national insurance, and it is not hypothecation if money is brought in from elsewhere.

Photo of Paul Burstow Paul Burstow Shadow Secretary of State for Health

The hon. Gentleman was right to say, "if one simply" hypothecated. I shall happily send him the working paper on which the policy is based, so that he can read it in detail. The paper makes it clear that the hypothecation is spread over an economic cycle, not done one year to the next. That is how the policy would work. It seems an appropriate way to ensure that people see far more clearly how much they pay in taxes for the NHS. I would be surprised if the hon. Gentleman did not want to sign up to that, given that people would understand better how much they were paying into the health service and therefore would be more likely to engage at local level and question whether priorities were correct and whether resources were going to the right areas.

The most recent staffing figures available— I understand that new ones are due to be published fairly soon—suggest that there were 3,435 GP vacancies, a 31 per cent. increase on the previous year. The Minister said that that was no longer the case but did not quote any figure, so I hope that he can tell us today what the most up-to-date survey reveals the number of GP vacancies to be. More telling than the vacancy rate is the fall in each of the last three years for which figures are available in the number of applicants for GP posts. In 2001, there were 6.9 applicants for every vacancy, but that number had more than halved, to 3.3 applicants, by 2003.

Furthermore, the position will worsen before it improves. There is a demographic time bomb ticking away under the NHS work force; the number of GPs who will reach the mandatory retirement age—70— in the next five years will increase rapidly, especially in London and the west midlands. It is clear that there are recruitment and retention issues to be addressed. A change in working patterns has also been noted. Many more GPs are choosing to work part time. As a result, although the headcount of GPs has increased by 4,237 since 1997—a welcome increase—the full-time equivalent has increased by only 2,913.

One of the pressures on the system is the number of people who do not get a choice in which GP they sign up to. Patients in many areas struggle to get easy access to a local GP. Many GPs have lists much larger than the national average, which is about 1,850 per GP; for example, the average Westminster GP is coping with 2,500 patients, and areas such as Barking, Newham and Birmingham also have among the busiest GPs in terms of the number of people on their lists. No wonder many GPs are having to close their lists to new patients and patients are finding it ever harder to register with or change their GP.

Earlier this year, in its "Transforming Primary Care" report, the Audit Commission found that 0.5 per cent. of people every year are assigned to a GP. That might not sound like a large number when described as a percentage, but a significant number of people are affected; about 250,000 people each year are unable to find a GP because of list closures and other difficulties and are assigned to a GP by their primary care trust. The Audit Commission rightly said that this

"can be a significant issue for patients."

Of course it can. People should be able to choose their GP and get care closer to their home; they should not be allocated a GP, which might entail longer journeys away from where they live. Where is the choice for those 250,000 people every year?

Such shortages give cause for concern about how patient choice will work in practice, especially in the "choose and book" programme. I have no problem with patients having more choice and more control over their health care, but I am concerned about the Government's choice agenda being too narrow and its basis being on rather over-optimistic assessments of the capacity available to introduce choice. We believe that patients need to have more control over their health care; they should not just be faced with an array of choices—a choice of five hospitals, say, or—

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

I am confused by what the hon. Gentleman just said. He said that our choice agenda is too narrow, but then described it as over-optimistic. Will he explain?

Photo of Paul Burstow Paul Burstow Shadow Secretary of State for Health

I described as over-optimistic the assessment of the capacity available to make the policy a reality in practice.

Photo of Paul Burstow Paul Burstow Shadow Secretary of State for Health

I ask the hon. Gentleman to allow me to develop my point before intervening. In my view, patients should be regarded as partners in their care and involved in decision making about their treatment. If that is to become a reality, it must be not be something that is available only to the articulate few. When the NHS improvement plan was published earlier this year, the way in which PCTs and primary care professionals provided support to everyone in their community in exercising choice was left as a matter of local detail, so although the Government have targets for the implementation of the choice programme, there will be variations throughout the country in the support available to make choice a reality for everyone, not just for the articulate few.

The argument about choice between the Government and the Opposition is advanced in terms of, "My choice is bigger than your choice," but Ministers must give serious consideration to the extra time that GPs will have to take to make choice a reality for all patients. I wonder whether Ministers have undertaken any assessment or evaluation of how much additional time GPs will require to support patients in making choices at the point of referral.

Photo of Siôn Simon Siôn Simon Labour, Birmingham, Erdington

As one of the inarticulate many on this side of the Chamber, and bowing as we do to the articulate few on the other, I have to say that I am not following the hon. Gentleman's argument. It sounds articulate, but I am not getting the details. For the benefit of those of us who are finding his speech baffling, will he speak more slowly and even more articulately?

Photo of Paul Burstow Paul Burstow Shadow Secretary of State for Health

I am grateful to the hon. Gentleman for his constructive criticism of my remarks so far. He has clearly been struggling, but I shall endeavour to improve my performance, so that he can follow the rest of the argument.

I was exploring whether the patient choice programme will have an impact on GP consultation times and what assessment the Government have made of how much extra time GPs will need to provide the advice and support necessary to make that choice a reality. It is essential that the best use is made of GPs' time, so the roles of other members of the primary care team will have to be expanded. I do not buy the argument advanced by the hon. Member for South Cambridgeshire, that it is not possible to examine critically the range of tasks for which GPs have historically been responsible and determine whether some might more appropriately be discharged by others in the primary care team. I do not know whether that is his view or whether he was quoting the view of others, but my impression was that it is his own view.

It is estimated that one fifth of GP appointments are made in relation to minor ailments that could be handled by pharmacists. The development of minor ailment services in high street-based community pharmacists could help to ease the pressure on GP surgeries. That is a sensible proposal and one that I think will emerge from the new pharmacy contract. The Liberal Democrats would support such a move.

Photo of Mr David Rendel Mr David Rendel Shadow Minister (Higher Education), Education & Skills

Is not it the case that not only would the Liberal Democrats support it, but so would most of the best GPs?

Photo of Paul Burstow Paul Burstow Shadow Secretary of State for Health

I am sure that is so. We need to re-examine the role of the GP and how some of the tasks hitherto undertaken by a GP can be taken on by others who have a great deal to contribute. For many years community pharmacists have felt undermined and undervalued within the system and as though they were not seen as part of the primary care team. There are now opportunities to overcome that.

It is not just the role of pharmacists that can be expanded. There is also scope, for example, to develop the role of therapists, particularly physiotherapists. I was struck by a pilot scheme undertaken in the Forth Valley primary care trust over a 30-month period, which looked at opportunities for self-referral to NHS physiotherapy services in a primary care-led setting. The study found that that had significantly reduced GP workloads. People were choosing to go not to the GP but to the physio, possibly to deal with problems of back pain. That had a marked impact on individuals' quality of life and reduced GPs' work load so that they could concentrate on other tasks, not least issues relating to the management of chronic disease.

Other possibilities such as nurse prescribing, nurse-led practices and therapist-led clinics are providing new career paths for professions that we need to attract into primary care, and are freeing up GP time. These changes in the roles of nurses and therapists are crucial to ensuring that we start to tackle the shortages in these professions.

What is being done with the time that GPs have? The Government's obsession with targets is of real concern to GPs. For example, follow-up appointments are delayed and deferred to ensure that first appointment waiting time targets are hit. Diseases with a target attached take priority over those without a target. GPs end up playing piggy in the middle as frustrated patients turn up at the surgery asking for their appointment with consultants and others to be expedited. It is not just targets in secondary care that need to be scrapped. The 48-hour access target is leading to all sorts of wheezes to game the system.

Photo of Sarah Teather Sarah Teather Liberal Democrat, Brent East

Despite repeated assurances from my local primary care trust that the 48-hour access target should have no impact on forward-planned appointments, I have had a continuous run of complaints from two groups of patients in particular. The first is those who are chronically ill and find it impossible to book repeat appointments with the same doctor, and the second is those who work and want to book an appointment for, say, next Wednesday, so that they can take a little time off work. They find that the only way they can get an appointment is by starting to jam the phones at 8.30 am, book the whole day off and hope that they can get to see the doctor by the end of the day. That has huge implications for going to see a doctor when the situation is not urgent and people simply want to talk something through.

Photo of Paul Burstow Paul Burstow Shadow Secretary of State for Health

I thank my hon. Friend for her intervention. Those experiences are reflected in MPs' mailbags. Perhaps the good intentions behind the target are not being translated into reality. My hon. Friend's example of patients not being able to see the same GP at their next appointment raises concerns about the continuity of care, and there are increasing concerns about access to the GP by those who work away from the area where their GP surgery is located and not being able to get an appointment when they want one.

Other wheezes that are being used to game the system have been drawn to my attention by GPs, such as restricting patients to one problem per consultation. I do not know how that works in practice, but it is being tried. Another wheeze involves setting limits on times when patients can call for an appointment and, as my hon. Friend Sarah Teather mentioned, rationing access because the telephone is engaged all the time. So many people are phoning in that they cannot get through to book an appointment. The selective release of appointment slots is a further wheeze. Appointments should be booked to meet the patient's need, not to hit an arbitrary target. All too often it seems that the target is shaping the way the system is working.

The motion refers to out-of-hours services. There is still much confusion about how such services will work after 1 January. The Select Committee on Health, whose Chairman intervened earlier, rightly raised concerns about the costs, planning and implementation of a huge change to the provision of family doctor services out of hours. I support the change. [Interruption.] If the Minister would not chunter from a sedentary position, I would be happy to outline my concerns. Hopefully, there will be a response to some of those.

It is evident from my mailbag and that of many other hon. Members that people are worried about the loss of Saturday morning surgeries and the difficulties that that will cause. How did the Government arrive at their estimate of £6,000 per GP to provide out-of-hours and Saturday morning services? According to the results of a survey by the NHS Alliance, PCTs are struggling with the logistics, staffing and finances necessary to deliver out-of-hours services. One in five PCTs say that they will restrict services on the basis of quantity or quality or both. On what basis does the Minister reject the findings of the NHS Alliance's survey? I wonder whether he has looked at it and why he does not consider it an acceptable basis on which to criticise the Government's approach to the provision of out-of-hours services in the new form under the new contract.

Where will all the extra doctors come from to staff the out-of-hours services? How much reliance will PCTs have to place on locum and overseas doctors to fill the gap? Many PCTs plan to use NHS Direct services as the front end of their out-of-hours services. However, that will need to be monitored closely in the light of recent research in the British Medical Journal. A study published on 17 September looked at the effects on consultation workload and costs of off-site triage by NHS Direct compared to on-site nurse triage in general practice. Patients in the NHS Direct group were less likely to have their call resolved by a nurse and were more likely to have an appointment with a general practitioner. In other words, it was costing more to use NHS Direct. Perhaps that explains one of the cost pressures that PCTs are grappling with. Half of PCTs have said that they will contain the extra costs by delaying investment in new services. How long will they delay investment in much-needed new services?

Ministers have said that the recent increases in accident and emergency attendances have nothing to do with the change to out-of-hours services. Certainly some of the figures suggest that the increase predates the changes. I accept that, yet reports from the front line tell another story. The Nursing Times recently quoted an accident and emergency sister at Norfolk and Norwich university hospital as saying that her department had seen a 13 per cent. rise in attendances since January. She is quoted as saying:

"People tell me they are here because it is convenient and because they cannot get an appointment at the GP's."

Perhaps that is another unintended consequence of the 48-hour access target. To what do the Government attribute the increase in accident and emergency attendance?

Photo of John Hutton John Hutton Minister of State, Department of Health, Minister of State (Department of Health) (Health)

I have tried to resist intervening on the hon. Gentleman, but it has got too much for me. He has repeatedly attacked the 48-hour target, as did Sarah Teather. I understand the criticism, but under the hon. Gentleman's proposals, how quickly would one of his constituents be able to get an appointment to see a GP if he scrapped the target?

Photo of Paul Burstow Paul Burstow Shadow Secretary of State for Health

I am not proposing a target. I am proposing to scrap a target, because it gets in the way of people being treated quickly. The problem is that with the target, people are not getting treatment as quickly as they need because they are unable to get an appointment when they want it. An arbitrary target misses the point. That is my criticism of the Government's target culture.

Photo of Paul Burstow Paul Burstow Shadow Secretary of State for Health

I will not give way again, if the right hon. Gentleman does not mind. I wish to make some progress and move on to NHS IT procurement, which is mentioned in the motion. Well designed business processes delivered by well implemented systems can save GPs and other primary care professionals time previously spent on administration, but there are real concerns about how the procurement is proceeding and how the end users are being engaged in the process. What control do GPs have over the process?

Photo of Paul Burstow Paul Burstow Shadow Secretary of State for Health

No, I shall make progress, if the hon. Gentleman will forgive me. Without GPs' engagement and without their enthusiastic support, delivering a system that is fit for purpose will be a challenge. It is far from clear who in the national team is responsible for leading on this aspect of the programme's work. How will the full costs of the procurement be met? It has been reported that the total cost of IT procurement could be anything from £18 billion to £30 billion. Most of the extra costs will have to come out of existing budgets, increasing the average spend on IT; yet another cost pressure for PCTs to grapple with.

A further issue not mentioned in the motion but relevant to the working conditions of family doctors and the quality of care that patients receive is the standard of practice premises. According to a written answer that I received there are 700 GP practices operating in sub-standard accommodation; that is, accommodation below the Department's minimum standard, such as surgeries that lack sufficient consultation space, have access difficulties or pose questions about patient confidentiality. What is the timetable for tackling such sub-standard premises?

Many GPs face the serious problem of the affordability of premises, a particular concern in areas with extremely high property prices such as London. In some areas, GPs are retiring and selling their premises at residential rates to recover their investments, and those doctors are not being replaced because prospective GPs cannot afford to set up premises in such areas.

Andy Burnham mentioned the difficulty of getting doctors to set up in other areas, and I sign up to his view that salaried GPs have a role to play in ensuring good primary care across the whole country.

Photo of Sarah Teather Sarah Teather Liberal Democrat, Brent East

That is a particular problem in Brent, East, where underdeveloped land is scarce and property prices are high. The only way in which doctors can solve the problem is to buy a Victorian property and convert it. However, if one adds the cost of the property to the investment required to convert it, the cost is greater than its overall value, and the PCT will only reimburse GPs up to market value.

Photo of Paul Burstow Paul Burstow Shadow Secretary of State for Health

My hon. Friend is right to raise that concern, which I know that she has raised with her PCT. GPs often wind up in negative equity as part of acquiring a property, which cannot be sensible. Although NHS LIFT is certainly part of improving existing accommodation and providing new accommodation, PCTs should surely have the freedom and flexibility to find solutions that fit local circumstances.

The motion refers in misty-eyed terms to GP fundholding. Many GPs whom I talk to do not have fond memories of how Conservative proposals on fundholding worked in practice. Fundholding caused a huge equity deficit in the way in which NHS care was accessed; whether one's GP was a fundholder determined how fast one was treated, which was not an acceptable basis on which to provide health care. Serious questions also remain over the cost-effectiveness of the fundholding experiment. Practice-led commissioning must avoid that pitfall, and some of the Minister's comments this afternoon have reassured me on that point. No patient should be left behind in the new system.

A balance must be struck between freeing the frontline to innovate—the reason why I would scrap targets and support practice-led commissioning—and the need to develop and maintain coherent community health services from one part of the country to another. To date, little research has been conducted into the impact of practice-led commissioning, and as that policy is rolled out, I hope that how it works in practice will be carefully evaluated.

I have already said that the Government are obsessed with targets and handing out tick boxes. When it comes to family doctor services and primary care, "Shifting the Balance of Power" has not resulted in a bonfire of targets and red tape.

Photo of Paul Burstow Paul Burstow Shadow Secretary of State for Health

I have already said that I will not give way to the hon. Gentleman.

A PCT executive board member recently told me that after all the spending commitments tied to Government targets, the trust had already allocated 105 per cent. of its budget. That leaves no room for local innovation and no scope to ensure that services are aligned to the health needs of the local population, in which case unmet need remains just that. The NHS needs good local performance management; it does not need poor national political targets.

We carefully examined the Conservative motion, but we cannot support it because it does not offer the right vision of primary care service, while the Government amendment pats the Government on the back, and we will therefore vote against both of them tonight.

GPs are the backbone of the system in this country and are vital to delivering closer-to-home health care, and this debate is an important contribution to that vision. I urge my hon. Friends to vote against both the Government amendment and the Conservative motion, neither of which offers a coherent vision for the future.

Photo of Andy Burnham Andy Burnham PPS (Rt Hon David Blunkett, Secretary of State), Home Office 3:04 pm, 11th November 2004

To be fair to the Conservative party—I am not often inclined to do so—I congratulate it on securing today's debate and focusing our attention on primary care services, because the debate about health and the NHS in this country too often focuses on secondary care and hospitals, rather than primary care.

The motion describes family doctor services as the lynchpin—perhaps it is the bedrock or backbone—but whatever word we use, they are crucial to all our constituents. Given that the Conservative party has focused on the issue today, why on earth did it not prioritise family doctor services and primary care during its 18 years in power?

The Conservative Government left primary care in a sorry state, particularly in our more deprived communities and inner cities. Between 1991 and 1996, GP registrars fell by 20 per cent., which is why we now have a problem with GP vacancies. Let us make no bones about it: the motion discusses problems with GP vacancies and we can lay the blame at the Conservative party's door—GP numbers were slashed between 1991 and 1996. This Government have barely been in power long enough to see a GP through his training, which takes six or seven years, so we must make that point plain from the start.

The Conservative Government left GP practices in many communities in a terrible state—for example, located in old terraced houses without consulting rooms. The primary care estate, if we can call it that, was in a terrible mess. What are the answers in the motion? The motion discusses the reintroduction of fundholding, but is that really the answer to the problems facing primary care today? Fundholding placed an arbitrary label on patients, which dictated how they went through the system. Treatment was provided not on the basis of how urgently it was required, but according to funding status. Fundholding is incoherent. The motion mentions providing more Saturday surgeries, but it bemoans GPs being told what to do and being subject to targets. How can one want Saturday morning surgeries and also defend GPs' independence as contractors who can dictate their own work load?

The motion says nothing—not a word—about the state of primary care premises, on which I shall concentrate for a moment. In some of the more deprived communities, the state of the facilities led to general practice becoming moribund and lacking a clear vision for the future. The Government's vision for primary care is beginning to emerge in my constituency. That vision includes high class, modern facilities where GPs want to come and work, in all the towns in my constituency. GPs can obtain professional satisfaction from working in such facilities because space is available to deliver new services and because they can locally develop services previously provided by secondary care. The future of primary care involves GPs developing their skills and their role, which is linked to the quality of premises.

My constituency contains one of the 42 LIFT pilot areas, and it is probably true to say that our scheme is one of the most developed. A couple of weeks ago, I visited the Atherton site, where a brand new facility for GPs has already been built. The facility is huge and looks like a cottage hospital: it has ample space and includes consulting rooms, while the facility is first class and looks lovely, too. LIFT will take services out of secondary care sites such as Wigan infirmary and Leigh infirmary and put them on the doorsteps of mining communities, where transport is not good and people must travel to access services. That can only be good.

The Atherton scheme was one of the first, but a scheme is also in progress in Golborne. The first phase of the Golborne scheme, Leigh health park, has already opened. A new GPs clinic is planned for Hindley in my constituency—it will be located next to the Sure Start building and the swimming baths. Those developments will transform the quality of primary care at a local level.

The Minister of State, my hon. Friend Ms Winterton, knows that primary care is particularly important in communities that have a legacy of ill health from mining, because she kindly visited my constituency earlier this year. We have much higher levels of chronic long-term illness than other parts of the country and people find it harder to travel because they have mobility problems. That is why it is crucial that these services are developed and improved locally and people are saved from making needless trips to hospital.

General practitioners will be enthused if they are given modern facilities in which to work. That will tell them that they can begin to develop their careers and interests and to deliver far more than they are able to deliver in the cramped and poor conditions that they often have at the moment. The quality of the estate is crucially linked to tackling GP vacancies. Moreover, the improvements that have taken place in secondary care are linked to general practice. As GPs can begin to navigate their patients around the system as capacity is opened up and waiting lists fall, they can once again become the true advocates, or champions, of their patients, because they will be able to assert themselves on their behalf to secure the best of the care that they think they need. The role of the GP is about to flourish again, and it could become a very rewarding job.

In my constituency we face problems with GP vacancies and, as I have told the Minister before, with dentist vacancies. Contrary to Conservative Members, I would make a plea for salaried GPs and dentists in our communities, because they can provide services when patients want them at a time that they find convenient. That is the answer. My hon. Friend should reject the calls about "Dr. Finlay's Casebook" and give us salaried employees who can deliver services to my constituents.

I wholeheartedly endorse the Government's vision and direction, but funding is also required. As I say, health in my constituency is poorer than in many other parts of the country. The Minister talked about the increases in funding that have gone into primary care. That is indisputable, and they are welcome, but from the viewpoint of a PCT such as mine the imminent three-year spending round must go further in taking all PCTs as close to their target funding as possible. Otherwise, it will not be possible to deliver the desired improvements in general practice and family doctor services in areas such as mine. My PCT is some £12 million below its target funding in this financial year. I am led to believe that in PCTs in other areas where health is even poorer—such as Easington, central Manchester and parts of Liverpool—funding is even further below target. Yet many other PCTs in leafier parts of the country are significantly over the target that the Department of Health says that they need in order to tackle the health needs of their communities.

The Healthcare Commission recently recommended that the Government should move much more quickly towards bringing all PCTs up to balanced funding. That is because a couple of years ago the chief medical officer said that death rates in some communities in the north-west and the north-east have not improved since the 1950s. That shames every person involved in public policy, because it has not delivered the health gains to the communities that it should have done—health gains that other parts of the country are enjoying.

This spending round, in which a significant amount of extra money is going into primary care, gives us the chance to take a great leap forward in lifting the baseline of PCT funding in areas where the need is greatest. [Interruption.] Mr. Lansley may laugh, but that is morally the right thing to do. Extra health care revenue—new money—should be spent in the areas where need is greatest. There is no point in continuing to overfund areas that are already well provided for when we have serious health care problems in areas that are below their target funding allocation.

Photo of Andrew Murrison Andrew Murrison Shadow Minister (Health)

Would the hon. Gentleman like to comment on whether health inequalities have widened or narrowed since 1997?

Photo of Andy Burnham Andy Burnham PPS (Rt Hon David Blunkett, Secretary of State), Home Office

I would confidently assert that serious inroads have been made into some of the problems that scarred my constituency. For instance, deaths from coronary heart disease have been reduced by the prescription of statins under the national service framework. If the hon. Gentleman wants to argue that the Conservatives are in favour of tackling health care in the poorest communities, why on earth do not they say so, and why have they never shown any willingness to tackle the issue head on? I am proud to stand behind a Minister and a Government who are doing something about it. I urge them to take one more leap forward in this spending round, because many PCTs are some way below their target funding.

Photo of Siôn Simon Siôn Simon Labour, Birmingham, Erdington

Is my hon. Friend aware that my own PCT is in eastern Birmingham, which is another traditional working-class community that is not projected to be funded as it had expected and as we would like?

Photo of Andy Burnham Andy Burnham PPS (Rt Hon David Blunkett, Secretary of State), Home Office

I do recognise that. In many cases, inner cities and communities such as mine are suffering the most.

Photo of Andy Burnham Andy Burnham PPS (Rt Hon David Blunkett, Secretary of State), Home Office

I want to draw my remarks to a close, because other hon. Members want to speak.

We should not take money away from places that are well provided for—they should at least keep in line with NHS inflation so that there are no cuts to services—but we should put the new money into areas where health care needs are greatest. The Government are doing great things in health and I can see their vision emerging. All power to the Minister in what she is doing, but I ask her to give us that extra bit more money so that we can improve the health of those who are most in need.

Several hon. Members:


Photo of Sylvia Heal Sylvia Heal Deputy Speaker

Order. Several Members are hoping to catch my eye. If hon. Members can be concise in their remarks, more may be successful.

Photo of Desmond Swayne Desmond Swayne Parliamentary Private Secretaries To Leader of the Opposition 3:16 pm, 11th November 2004

In July this year, my primary care trust took on the out-of-hours care for the New Forest, and together with other local PCTs contracted Primecare to carry out the service. Let me give those Members who do not have that new system a taste of what they are in for.

I discovered that something was radically wrong right at the outset when a retired doctor contacted me to say that he was being telephoned by his former patients, asking him if he could do anything for them because they could not get anything out of the out-of-hours service. I have here the minutes of a meeting at a doctors' surgery—I shall not give its name, but it is in God's own town of Lymington. Dr. X introduced the meeting as follows:

"This meeting is to make clear our serious concern for our patients' welfare — and to highlight some of the causes so that they may be addressed without delay, thereby avoiding serious trouble."

He goes on to list some of the problems:

"Triage delay . . . Lack of feedback from doctor to doctor . . . Inadequate feedback, slow and poor quality . . . Hopeless record-keeping and doctor contact . . . Poor car-organisation . . . To this I would add . . . Low standard of triage, which is unsafe . . . Poor quality of outcome . . . Poor communication . . . Cavalier attitude regarding handing-on of work . . . Dire cost-effectiveness".

Photo of Desmond Swayne Desmond Swayne Parliamentary Private Secretaries To Leader of the Opposition

No, I will not.

He concludes:

"The Forest GPs have an enviable and hard-won reputation for looking after their patients' properly, and are deeply unhappy to find that this is already being undermined. We will not tolerate this, finding ourselves in the situation of being blamed by patients for inexcusably bad service from the new"— out-of-hours—"system." So that is what the doctors think.

Let me give a vignette from my postbag as to what the patients think about this service. I received a letter from a lady in Milford-on-Sea who turned out to be suffering from a severe bladder infection. She did not know that at the time—she was simply in pain when she rang up at 8.30 in the morning only to get a robot voice telling her that no operators were available. After 10 minutes, she gave up and rang the other number, on which she reached an operative who could not understand what she was telling him and handed her to another operator who also could not understand. The call took 15 minutes, and as it was an 0845 number she was paying a premium rate. Eventually a nurse called back and the problem was sorted out with a visit to the local hospital, after she had been in pain for 10 hours.

Another wonderful example came from the other end of my constituency, in Ringwood. A lady's father had his toe amputated and came to stay with her to be looked after, but the dressing fell off, so she telephoned for some assistance. She wrote that at

"approximately 10.30 pm his dressing came off his foot—I phoned Prime Care and after the telephonist spoke to someone I was told he needed to see a nurse and they would phone me back and give this 'top' priority. Three quarters of an hour later I phoned again and I was told it was 'top' priority and someone would be phoning shortly. I am still waiting!!!"

Photo of Desmond Swayne Desmond Swayne Parliamentary Private Secretaries To Leader of the Opposition

No, I will not.

Another example came to me from Diabetes UK, which is making representations on behalf of one of my constituents. The woman in question had shingles—she did not know that at the time, but she suspected it—and diabetic complications. She rang up at 10 am, and eventually, 12 hours later, she got to see a doctor— 12 hours later for an out-of-hours service.

Another example came from Fordingbridge. It was a case of suspected stroke, in which the district nurse was contacted and handled the contact with Primecare. That contact began at 7 o'clock in the evening, with repeated calls at 9 pm and 10 pm, and the person was told that a doctor was coming. At a quarter past midnight, a doctor rang to say that he would not call after all.

Then there was a lady in Milford-on-Sea who rang up with her problem, got a foreign-sounding man on the phone, and could not get any sense out of the conversation. Eventually, a nurse rang back, who, having offered the woman the option of being treated at Bournemouth or Southampton, and having been told that that would involve either a 50 mile or a 30 mile round trip, said that she did not know where either of those towns were, because she was phoning from Sheffield. After further considerable delay—

Photo of Desmond Swayne Desmond Swayne Parliamentary Private Secretaries To Leader of the Opposition

The hon. Gentleman is so persistent that I cannot resist.

Photo of Kelvin Hopkins Kelvin Hopkins Labour, Luton North

Could the hon. Gentleman inform me whether Primecare is a private company? Is this what private health care is like?

Photo of Desmond Swayne Desmond Swayne Parliamentary Private Secretaries To Leader of the Opposition

I will come to why it is like this in a moment. Let me finish with this particular lady's difficulties.

After four hours' delay, and having got to a centre—having been offered in the interlude Brighton, Winchester and Andover, moving in an elliptical orbit of increasing distances away from the caller—she finally got to a doctor. After telling the story of what was wrong and giving her name, address and medical history so many times, she then found that the doctor had the wrong name and no other information about her.

Finally, I shall give the example of a lady in Ringwood, who wrote:

"The nurse asked my father a lot of questions which were unsuitable as he could not get his breath, let alone talk."

Eventually, they got to a treatment centre, where her father

"was seen by a German doctor, he was good but my father needed oxygen and the cylinder was empty."

I sympathise with the point on which she finished her letter:

"My father has worked hard all his life. It is only now he needs medical help and this is what he has to put up with."

That is just a small selection of the complaints that I have been receiving from the New Forest. Ministers may live in planet Richmond house, but the reality of people's experience of primary care, and particularly of the out-of-hours service, is as I have described.

Mr. Hopkins asked whether a private company was involved. As I understand it, the problem is—I will meet the primary care trust again tomorrow, so see whether this is the case—that the service is costing vastly more than it is being reimbursed by the NHS for providing it. With respect to it being a private company, the reality is that most of the provision is by the people who have always provided it—the doctors in the New Forest. The chaos is engendered by the fact that this has been taken over by the primary care trust and then subcontracted to someone else. Were it still being run and led by the doctors of the New Forest, we would not be exposed to this problem.

I want to abide by your strictures about being brief, Madam Deputy Speaker, but I want to address one other problem about which doctors in the New Forest have been complaining to me. That is their fear that the system used by about 60 per cent. of them—EMIS—is going to be discontinued, and that they will have to abandon their tried and tested system and adopt something that will be expensive, unfamiliar and unhelpful. I have made a number of representations on their behalf. The story that we have got is that it will not work like that at all, and that EMIS might survive. During my research, I have found that that is not the case.

The Minister referred to the guidance. I have examined the document on the internet—"NPfITsuppliersguide.pdf"—which says:

"Following the final selection of LSPs"— local service providers—

"and the two 'core' clinical applications for the NHS, it has been implicit that these systems will ultimately replace existing NHS clinical systems over time".

The reality is that the systems that our GPs are using now will be discontinued. During my research, I came across a very interesting document—the minutes of a board meeting of the Surrey and Sussex strategic health authority, which stated:

"Professor Lawrenson raised the issue of the pressure being placed on surgeries to conform with NPfIT, when funds and culture were perhaps adverse."

Photo of Desmond Swayne Desmond Swayne Parliamentary Private Secretaries To Leader of the Opposition

No, I will not.

The minutes continued:

"The chief executive replied that the nature of the new . . . contract would effectively see the demise of all other systems and their current suppliers. Professor Lawrenson also observed that the traditional benefits associated with suppliers going to great lengths . . . to meet NHS requirements was in danger of disappearing . . . GPs . . . were currently able to exercise some choice in terms of the systems they used".

That choice would not be available, "once IDX . . . was introduced". The minutes continued:

"The Chairman acknowledged these concerns but remarked that the NHS was undergoing a process of 'ruthless standardisation' as far as IT was concerned and that there were clear advantages to that strategy."

Well, we have not seen any advantages.

Photo of Doug Henderson Doug Henderson Labour, Newcastle upon Tyne North 3:27 pm, 11th November 2004

I promise the House that my speech will be short. I want to raise a constituency issue, which also raises a point of general principle about the way in which the primary care trust operates, certainly in Newcastle and perhaps elsewhere.

To the south-west of my constituency is a community called Lemington, which has a population of about 9,000. At the bottom end of Lemington, right on the banks of the Tyne, is a relatively underprivileged area where a lot of elderly people live. Because of the private housing that is let, a lot of young single mothers live there too.

Until a couple of years ago, there was one doctor working in Lemington. He then left the practice. Having been approached by local people, I asked the health authority how people in Lemington were to gain access to primary care. The health authority told me that there was a perfectly adequate, indeed very good, practice about two miles west of Lemington, in a community called Newburn. In fact, the nearest practice is at the top of the hill. Anyone who has ever walked up the banks of the Tyne will know how steep they are. The hill leading from Lemington to the nearest community, about three quarters of a mile away, rises 300 or 400 ft. That is not the kind of gradient that an elderly person should be expected to negotiate.

At the top of the hill, on a plateau, is a relatively more affluent area called Chapel House and Chapel Park. There are two doctors' practices within 50 m of one another, each with about six partners. I asked the health authority "Do you think this is the right distribution of resources? Would it not be better if at least one or two of the partners in the two practices at the top of the hill moved a little of their operation to the bottom, where the poorest people live?" The health authority said "We will do what we can, but we cannot compel doctors' practices to locate themselves in any specific place." In that case, I asked, could the authority employ a doctor directly? The authority said that there was a limit to the number of doctors that it could employ directly, and that Lemington did not warrant the appointment of an employed doctor because there were enough doctors in the overall outer-west area. I could not disagree with that in statistical terms.

The question is, why does the authority not have power to require the two practices at the top of the hill at least to provide some facility at the bottom, where the need is greatest? The irony is that far more people own cars at the top of the hill than at the bottom, where there are elderly people and young mothers, many of them single.

The Government should look at the regulations governing the primary care trust. I do not think it right that we cannot require people who are publicly funded to locate themselves in areas of greatest need. The people of Lemington did not expect six doctors to go down to the bottom of the hill, but it would be an improvement if just one or two of the partners were prepared to work from a centre for at least some of the day, or some of the week.

There is, in fact, a new centre at the bottom of the hill in Lemington. It is one of those projects funded partly by regeneration money. There will be some nurses there. That great new facility could be financed because of the increase in health resources, but there is still no doctor for it. That is ridiculous, but the PCT tells me that it can do nothing.

I think that this is a real problem. I hope that the Minister will address it, if necessary taking advice from the health authority in Newcastle. If it turns out that the authority has interpreted its own regulations accurately, I hope that the Minister will consider the possibility of change to provide more flexibility, so that the authority can reallocate resources as circumstances and priorities change.

Photo of Sir David Amess Sir David Amess Conservative, Southend West 3:32 pm, 11th November 2004

I congratulate my hon. Friend Mr. Lansley on his speech. I agreed with everything that he said. My only criticism would be of his moderate language. There is no doubt that this is a centralising Government: there is not one aspect of our daily lives in which they are not prepared to interfere.

The first thing I ask the Minister to do is stop bashing doctors. The Government bash teachers, they bash the police, they bash our defence forces, they bash doctors, and the professionals find it absolutely repugnant. Labour Members recently started bashing each other. That I am not too bothered about—in fact I rather enjoy it—but I do think that bashing the professionals is deeply repugnant.

The Minister of State, Mr. Hutton, who is no longer present, spoke about the marvellous atmosphere among GPs. He comes from the area that I represent. Were he to meet GPs in Southend, West, he would find that morale is currently pretty low. Let me give an example. I have received a letter from a local GP. On the "target culture", he said that

"everything we are being asked to do is dominated by collecting numbers and reaching targets. This means that clinical priority is often put behind reaching targets. This is difficult for both primary care physicians as well as hospital doctors.

This government is obsessed by the need for patients to be seen in 24 hours by a nurse and within 48 hours by a GP. To reach these targets the Modernisation Agency has introduced 'advanced access'. This means that in many surgeries patients who need urgent help in fact end up phoning or contacting the surgery for several days before getting an appointment. This means that they are waiting much longer than they used to. It is particularly difficult for elderly people. Doctors should decide when patients are seen and in what priority and should be left to run their own businesses."

On information technology, I do not want to be too unfair to the Minister, given that the Health Select Committee has been graciously invited to Richmond house on Tuesday. I am informed that we will be given

"a demonstration of the Choose and Book software which will enable GPs to make direct referrals to Secondary Care and a demonstration of the NHS Care Records Service which will allow the sharing of consenting patients' records across the NHS".

We look forward to that.

However, another GP wrote to me saying:

"Primary care doctors now feel more like data input clerks than general practitioners, spending much more time than ever inputting information into computer systems in order to reach targets that achieve points that have no proven clinical basis. Doctors striving to reach these unrealistic targets solely to reap the financial rewards that this brings, are compromising good standards of clinical care and 'Points mean prizes' are now the watchwords . . . . The data input requirements that are part of the Quality Outcome Framework mean doctors spend much time staring at their computer screens during what should be 'face-to-face' consultations. There is a general feeling of frustration that the data collection is detrimental to patient care. The public, who are ultimately funding the massive increase in health spending, frequently complain to primary care providers that they are seeing little in the way of improvement and know full well that there are lies, damn lies and statistics and do not believe the figures put out by the Department of Health."

As the Health Committee Chairman said, the Committee produced a report on this issue in July; indeed, the Minister of State, the right hon. Member for Barrow and Furness, gave evidence to us on it. This issue is obviously important. Approximately 9 million patients receive urgent primary care out of hours, and as the report states,

"the 'out-of-hours' period, as it is now defined, accounts for two-thirds of every week."

We took evidence from a number of organisations, and again to be fair to the Minister, as the report states,

"West Hull and East Anglia . . . both . . . appeared to be well advanced in developing innovate solutions to providing GP out-of-hours services for their local populations."

However, it appeared to us that the preparedness of primary care trusts was not uniform across the country. In giving evidence, the NHS Confederation expressed the view that

"PCT readiness is not consistent across England".

Having listened to the contribution of my hon. Friend Mr. Swayne, one can see the extent of that inconsistency. The NHS Confederation felt that PCTs displayed a lack of understanding of out-of-hours issues and in general were not ready for the responsibility that they are being given. That is very worrying. It also said that PCTs are seen as being reactive rather than proactive. Few primary care trusts were working positively with GP co-operatives, which were mentioned earlier. Indeed, often, instead of being adversarial, they were actually in conflict. Dr. Mark Reynolds gave evidence, saying that people in PCTs were taking on the job "with no real experience". If we consider how important the service is, that is very worrying. The Health Committee felt strongly that PCTs across the country were not universally prepared. The Government certainly need to do something about that.

A local GP wrote to me recently to advise me that there was "considerable concern" about the out-of-hours services being taken over by primary care trusts. He said:

"Many are starting a new service with no previous experience. They have not really consulted the GPs in the locality about how the service will run. They have not asked for advice in setting up the service. The whole thing is being rushed and is a recipe for disaster".

I end with those thoughts: as we all know, everything is driven by primary care trusts now.

Unlike any other hon. Member present, I attended the Committee stage of the Bill that introduced primary care trusts. If anyone took the time to read the Committee proceedings, they would see that every single point raised by Opposition Members has, sadly, come to pass. A GP who wrote to me said:

"General practitioners were conned with the set up of PCTs. Some five years down the line, the ability of local practitioners to have any influence whatsoever on how services are commissioned or run in their area is minimal. They have no power on any PCT board and are often totally ignored."

That was not how the idea was sold to the country five years ago. I hope that the Minister, Ms Winterton, will take the opportunity when replying to the debate to praise the work of our GPs, stop bashing them and reassure the public that they will be given good quality out-of-hours services. Let us hope that the information technology on which the Health Committee is to be educated on Tuesday will not prove as deficient as it appears to be at the moment.

Photo of Kelvin Hopkins Kelvin Hopkins Labour, Luton North 3:42 pm, 11th November 2004

First, I advise Mr. Lansley to visit his own GP. If he did, he might find that he has an injured foot where he shot himself. Whenever Conservative Members speak about health, I am reminded of the level of health spending when we came to office in 1997. I have the approximate figures: Britain spent 3 per cent. less of its gross domestic product on health than France, and 3 per cent. of GDP is equivalent to about £50 million per constituency every single year.

It is no surprise that we still have problems now, because we are still dealing with the legacy of the Conservative years. The Government are certainly making real progress now—it is evident in my constituency—because they have increased spending on health. We cannot have a good health service unless we spend the money on it. I accept that it must be spent efficiently, and we can argue about different systems, but we will never have a good health service without providing the resources. When the Minister said that the Conservatives do not have a leg to stand on, perhaps it is because they keep shooting themselves in the foot, though I shall not pursue that any further.

My Luton constituency has seen significant progress, although there are still undoubted problems. We still have "single-handed" GPs who are quite elderly and have long lists and they over-refer to hospitals perhaps because they cannot cope with the number of patients or perhaps because they are worried about diagnosis. My own GP practice is a group one and it is extremely good. It is now embarking on screening for blood pressure and other risk factors for the over-50s. That is new and did not happen a few years ago. It is also easier to get an appointment at short notice these days.

However, there is still a serious shortage of GPs in Luton. When PCTs were set up, I was a little dubious, but the PCT in Luton is truly excellent and making substantial progress in introducing new systems. Only a few weeks ago, my right hon. Friend the Secretary of State opened a new walk-in centre, and I was also present when my hon. Friend the Minister for Public Health opened another superb health centre just this week. The new centre was initiated by our PCT, which shows that it is working well with local GPs and doing really good things.

We also have an excellent hospital in the area, which is making a great contribution. It is working together with the PCT, and I am very pleased about that.

At one time, I was seriously worried that there might be an extension of contracting to private companies. That has not happened, at least not yet. I hope that Ministers will resist that temptation, otherwise we might fall into the problems described by Mr. Swayne. I want an integrated health service whose component parts work coherently together. I do not want a health service that is disparate, subcontracted, and the province of competing private companies.

As I said, there has been tremendous progress in Luton. From the day it opened, the walk-in centre in town has attracted many patients. It is always full and does a great job. It attracts people—for example, the classic male—who are normally reluctant to see their GP and who feel uncomfortable about seeing a doctor. It is much easier for such people to drop into the walk-in centre and talk, for example, about the pain that they may have in their leg. Making it easier for people to see doctors is part of the way forward.

It is obvious that we need to train more doctors. As Alistair Burt said in Health questions last week, Bedfordshire faces a serious problem with its GPs. That problem is especially severe in Luton, but we are moving gradually to a world in which there is greater direct employment.

Mention has been made of salaried doctors. The doctors in Luton's walk-in centre are employed directly, and that is the direction that we should follow. Indeed, I believe that Nye Bevan would have preferred to create a service based on directly employed doctors in 1948, but he had to make some unavoidable compromises. I think that he would have been very pleased to see the move towards direct employment and the establishment of a coherent health service in the public sector. I hope to push my Government in that direction if I possibly can.

Group practices and centres such as I have described can afford to have specialisms and to employ a range of doctors. In my constituency, there are a number of minority ethnic communities, whose members might prefer to see a doctor who comes from their community and speaks their language. Moreover, women might prefer to be examined by a woman doctor rather than by a man. Group practices in a modern health service can provide such things.

I do not criticise GPs, as they do a tremendous job, but the old, single-handed practices run by a Dr. Finlay-type figure are a bit of a dying breed now. They did a wonderful job in their day, but we are moving to a new era. We should aim to provide what people need, and not try to match the folksy image that appears on television.

Photo of Andrew Murrison Andrew Murrison Shadow Minister (Health)

Does the hon. Gentleman think that his constituents would prefer to see Dr. Finlay, or go to a walk-in centre?

Photo of Kelvin Hopkins Kelvin Hopkins Labour, Luton North

We all want to have a personal relationship with a doctor, but I think that there will be a gradual convergence and that walk-in centres and medical centres such as I have described will offer services very similar to those available in the past. Patients will have a permanent relationship with one doctor, or with a group of doctors. For instance, I am not concerned about which doctor at my group practice I see. The practice has all my records and the doctors know me well, so there is no problem.

Photo of Doug Henderson Doug Henderson Labour, Newcastle upon Tyne North

Does my hon. Friend accept that the practice run by Dr. Finlay and Dr. Cameron was virtually a walk-in centre?

Photo of Kelvin Hopkins Kelvin Hopkins Labour, Luton North

Yes, but I suspect that in those days only those who could pay were able to walk in. We are talking about a free health service, and there is a big difference.

My next point has to do with funding. As is the case in the constituency of my hon. Friend Andy Burnham, Luton is millions of pounds below its fair funding target. We have serious health problems with diabetes and heart disease, because of the nature of the population. We have a growing problem of HIV in Luton, partly because of people coming in from elsewhere. Those factors cause enormous pressure on our local health service and we need considerably greater funding.

Mental health services are also substantially underfunded across the country. Indeed, mental health provision is a Cinderella service, certainly in Luton. We have superb facilities and great doctors, but there are not enough of them. As a result, serious mental health problems in Luton are going undetected and untreated for lack of resources. That lack of resources stems from what the Conservatives did in their time in government, not from what our Government are doing now.

Photo of Richard Bacon Richard Bacon Conservative, South Norfolk 3:50 pm, 11th November 2004

I am pleased to have the chance to speak in this debate. The motion calls on the Government

"to ensure that the NHS Programme for information technology delivers the choice of suppliers and functionality which general practitioners need".

I wish to focus specifically on that issue. The IT programme in the NHS is undoubtedly of huge importance, but GPs have serious concerns about it, not least because they are, at the moment, the controllers of information about patients. Eventually, under the proposals, it is likely that most information will be held centrally and a wider range of people will have access to it.

Worryingly, many of the characteristics of the most famous IT fiascos in the public sector—there are examples almost everywhere one looks—are exhibited by the national programme. The first is what the elder George Bush called "the vision thing". While for most undertakings some sense of where one is going is necessary, a grand vision for IT projects can be the most dangerous thing to have. Tony Collins, the specialist computer journalist, writes in his book "Crash: Ten Easy Ways to Avoid a Computer Disaster":

"In computer disaster terms a vision is an essential first step".

Photo of Richard Bacon Richard Bacon Conservative, South Norfolk

No, time is limited and I know that others wish to speak.

All the evidence and reports that the Public Accounts Committee sees suggest that failed IT projects have in common the failure to take things step by step, the failure to build on what is already known, the failure to be incremental and infection by the vision thing. The national programme exhibits the vision thing in huge measure. It will cost £6.2 billion with an unknown amount on top for implementation.

The second problem is lack of consultation. In the Criminal Records Bureau fiasco, there was a huge lack of consultation. An August issue of Computer Weekly contained a survey by Medix that found that

"Doctors feel left out of NHS IT plans".

In answer to a question about how much information they had had about the IT project, 3 per cent. said that they had had a lot of information, 26 per cent. had had some information, but 31 per cent. had had not much information, 29 per cent. had had no information but had heard of it, and a further 11 per cent. said that it was the first they had heard of it. In other words, 71 per cent. of those responding had had little or no information. In answer to a question about what consultation they had experienced personally about the IT project, 10 per cent. said that it had been barely adequate, 15 per cent. said it had been inadequate and 70 per cent. said that they had experienced none—a total of 95 per cent. of the respondents.

The third characteristic of IT disasters, which will be worryingly familiar to students of such matters, is a high turnover of staff involved. Sir John Pattison, one of the original architects and the first senior responsible owner of the programme, has gone. Lord Hunt, who was the Minister in charge, has gone. Richard Granger, the director general of IT in the health service, slums along on a salary of £200,000 and is the highest paid civil servant in the UK, but he earns a lot less than he would in the private sector. I attended a conference recently that had promotion stands for local service providers and I mentioned to one of them that I had heard that Richard Granger would be moving on soon and they said that they had heard that too. We shall watch eagerly to see how long Mr. Granger remains in his job now that the LSP contracts have been let. Of course, he was never responsible for clinical buy-in to the programme; it was explicit that he had no responsibility for getting clinicians involved. The Department of Health suddenly noticed that that was a bit of a problem, so rather late in the day—in March 2004, two years after the announcement of the programme—it appointed Dr. Aidan Halligan, the deputy chief medical officer, as the joint senior responsible owner of the programme. Yet six months later, in September, we found that Dr. Halligan was to return to his native country to take up a post as the head of the health service in Ireland, having achieved more or less nothing in terms of clinical buy-in during his six months in the job.

The fourth characteristic is indeed buy-in and most projects that do not work fail in that respect. That is where the alarm bells really start to ring. What must be, even for students of IT disasters, the locus classicus of such disasters was the Wessex regional health authority, where there was a Department of Health project for a central system that had to be imposed regionally, and a key issue was the failure to achieve clinical buy-in. It simply did not happen, so the district health authorities refused to fund the project and the Department had no choice but to cancel it. The fear is that primary care trusts will be put in a similar position and will not have sufficient funding to make the programme work, especially when their clinicians do not want it, do not like it and do not trust it anyway.

Clinical buy-in is incredibly important, because clinicians need to understand who has put the data into the system. They are unlikely to trust data unless they know how it was acquired and whether it is reliable. There is also a huge question about who will have access to such data. Are the proposed controls on access and the security protocols adequate to the task? Do they meet the concerns of GPs and patients about maintaining the privacy of what is often sensitive information? There is implied consent in data going up to the national spine in the programme; even if patients do not give consent, the data will be wrapped so that it is not easily readable. I was told today that consultants can look at any data, including that of patients who are not their own, and change the consent tag without obtaining the patient's permission. There are serious concerns about access to data, as well as about clinical buy-in generally.

The fifth characteristic often found in failed IT projects relates to funding. The Minister of State, who, sadly, is not in the Chamber at the moment, did what can only be described as a magnificent job in adding to the confusion in an interview on Radio 4 a couple of weeks ago, which was lovingly and forensically reproduced in Computer Weekly under the headline, "Health Minister adds to uncertainty over implementation costs of the NHS IT plan". It included a photograph of the Minister in which he is gesturing. I think that he is trying to explain something but unfortunately his expression makes him look like a white rabbit caught in a headlight, so whether he is on the receiving end of something or trying to give an explanation is not clear. What is certain, however, is that he did not make things easier to understand when he said:

"We think it is going to cost the same".

In other words, the £1 billion currently being spent on IT in the health service will cover all the changes required, taking no account of the fact that there is a series of IT issues in the health service, such as finance, payroll, manpower, staff rostering and the procurement of food and clinical and other services, as well as specialist equipment for immunisation programmes, none of which has anything to do with the national programme for IT.

Mr. Burstow received a little more clarity when pursuing a question put by my hon. Friend Dr. Murrison. The Minister said:

"Future funding to the NHS determined by the SR2004 expenditure settlement will enable trusts to achieve the target of 4 per cent. for total NHS spending on IT, set by the 2002 Wanless Report."—[Hansard, 4 November 2004; Vol. 426, c. 393W.]

Four per cent. is much higher than the current figure so that is not consistent with the statement, "We think it is going to cost the same". Any light that the Minister of State can shed in the wind-up will be most welcome.

To summarise, we have a massive vision, even though we know that in IT the vision thing is one of the most dangerous elements; indeed, it is a key ingredient of any computer disaster. We have lack of consultation on a spectacular scale. We have a high rate of staff turnover, although it has not yet reached the rate achieved during the implementation of the national probation service information systems strategy, which had seven programme managers in seven years, five of whom knew nothing about project management. One fears that we may be reaching that point. We also have a lack of buy-in—always a key worry, and in this case buy-in by clinicians, the people who matter the most—and we have huge questions about funding. This is a hardly a recipe for certainty or confidence and it is hardly surprising that GP magazine has said of the national programme for IT in the health service that it is likely to be more of a fiasco than the dome.

All of this is before one takes into account the effects of the new GP contract, and the way that it interlocks and dovetails, or, rather, does not interlock and dovetail, with the local service provider contracts that Mr. Granger has been so busy letting at such a high speed. As my hon. Friend Mr. Lansley mentioned, the GMS contract says in paragraph 4.34:

"Each practice will have guaranteed choice from a number of accredited systems", but the local service provider contracts, which are roughly £1 billion apiece across the country, say more or less the opposite; that LSPs can impose a main system on local commissions with one alternative.

This brings us back to a point that was made earlier about the EMIS system, which is currently used by 55 per cent. of general practitioners, which is not involved in any of the local service provider contracts, unfortunately; mainly because the company could not get professional indemnity insurance because of the risks that insurers thought that it, as a relatively small company compared with the very large contractors who are LSP contractors, would have to take on. So we have the ludicrous situation in which GPs are in some cases having to turn away from a system that works, the EMIS system, and turn towards a system that in some cases has not even been written yet.

Until recently I was not familiar with the phrase "vapourware", but I am told that it means a system that exists, so far, only in someone's head; it has not even reached the back-of-the-envelope stage. No one who knows anything about EMIS or Vision or any of the other systems would say that they are perfect, but at least they were incrementally developed. They were not infected by the vision thing, they responded to what local clinicians wanted, they have continued to change in response to the needs of GPs in helping their patients, and GPs like the systems and want to carry on using them.

The Department reckons that, given the choice between getting something for free and having to pay for a system like EMIS, GPs will choose to go for something that is free. The Department is probably right that some of them will, but I think that it will be surprised, and I predict that many GPs will choose a system that they know, trust and understand, even if they have to pay for it. The point is that they should not have to pay for it; there should be no discrimination in funding between systems that GPs can rely on and ones that are still in the ether.

The areas that I would like to see the Minister focus on in the wind-up are as follows. First, specifically in relation to EMIS, will the Minister give a guarantee that there will not be an imbalance in the funding between systems such as EMIS and systems provided by the national programme for IT? Will Ministers listen to GPs' ongoing concerns about the potentially huge problems of data transfer? The other day I received a letter about that from a GP in Suffolk; the problems are potentially enormous. Can the Minister say whether the national programme understands better the benefits of the project rather than the risks, because where things go wrong it is nearly always the case that people have underestimated the risks?

Should £6 billion of contracts have been signed before it was known what the overall costs would be, including the costs of local implementation, before it was known what changes in business processes would be necessary, before it was known whether clinicians would use systems that were sought to be imposed centrally, before it was known how the benefits would be measured, before it was known whether GPs would oppose any handover of control of the confidentiality of their patient records and before it was known whether there were enough in-house skills to translate national plans into local action?

Finally, the National Audit Office, interestingly, has already announced an investigation into the national programme, which may shed light on some of these questions. But in the meantime I look to the Minister for an assurance that GPs will not be forced to replace trusted, well developed, well understood systems that provide what they want and enable them to help patients, with distrusted, less well developed, less well understood systems that may end up costing taxpayers a fortune without delivering what is required.

Photo of Andrew Murrison Andrew Murrison Shadow Minister (Health) 4:04 pm, 11th November 2004

We have had a good debate this afternoon. We have had a total of six Back-Bench speeches and some very good contributions indeed. It is regrettable that the speech made by my hon. Friend Mr. Lansley was not listened to more closely by the Minister who replied to him. The Minister gave us a rendition that he had clearly written some time ago. My hon. Friend was trying to be helpful, as always, and it is a pity that his remarks were not reflected on more closely when the Minister came to make his speech. I am sure that his colleague will not fall into that trap when she comes to make her comments.

It is a time of enormous change for general practice. It is arguably the time of greatest change since the inception of the national health service—in many respects, perhaps even greater than that. Many practitioners and certainly the general public are perhaps not aware of the enormity of what is going on. The bedrock of primary care is shifting. Doctors will no longer have a 24/7 commitment to patients; patients arguably will no longer have a doctor whom they can truly call their own. Functions previously carried out by physicians are now being carried out by others.

General practice was once the lynchpin of British health care and one of its most attractive features; it was unique in the world and renowned throughout the world. It may be that the changes that are under way will improve health outcomes. We must always be on the lookout for how we might improve services, but change brings risk and the risk is that a unique and cherished part of health care delivery in this country is beginning to decline. That is certainly the impression that one gains from talking to many medical colleagues. They have the feeling that perhaps they have seen the best. We have heard some humorous references in the debate to "Peak Practice" and "Dr. Finlay's Casebook". We can joke and laugh about it, but in truth I suppose most people's ideal vision of a general practitioner is someone who has time to listen, to manage chronic conditions and to have a long-term relationship sometimes over many generations with a family.

With so much change, there is little wonder that many in the medical profession are struggling to determine where they will fit into the new scheme of things. Many have accepted the new contract, but privately they fear for their future and that of their calling.

Andy Burnham gave us his impression of how things were, especially in urban areas. The Labour party does not have a monopoly on concern for those who live in urban areas or for the underprivileged. We shall have a White Paper next week on public health. I hope that the Minister will tell us how Ministers feel that they might improve the health of those who are worst off. I am happy to send the hon. Member for Leigh some figures that may be of interest to him on improvements in health that have happened among the less well-off since l997. We briefly exchanged some comments across the Floor of the House on that, and I think that he will be interested in the figures that the Department of Health has produced in that respect.

The hon. Member for Leigh may also be interested in the figures for recruitment in deprived urban areas, which have fallen in recent years. The number of applicants for positions in general practices has declined in deprived urban areas. I am more than happy to send him those figures.

Photo of Linda Gilroy Linda Gilroy PPS (Rt Hon Nick Raynsford, Minister of State), Office of the Deputy Prime Minister

Mr. Bacon took 14 minutes, which denied me the opportunity to contribute. It is the legacy of my Tory predecessor that I represent the poorest ward in England. We do not have a recruitment problem. Will the hon. Gentleman look at how the primary care trust in Plymouth is performing? The chair of the professional executive committee, Dr. Pete Williams, said to me only this morning—he has been doing a surgery this afternoon as we speak—

"I've been a GP for 17 years and never enjoyed the job more."

Photo of Andrew Murrison Andrew Murrison Shadow Minister (Health)

I am grateful for that intervention. Plymouth is a city that I know well, and I fully acknowledge that it has its own particular problems. I am delighted that the gentleman enjoys his job. Until recently, I enjoyed being a general practitioner. It is a unique calling, and I am pleased to hear that good news.

My hon. Friend Mr. Swayne talked about Primecare and EMIS, which is used by 60 per cent. of GPs in the New Forest—slightly above the national average. I will say a little about IT if I have a few moments presently.

Mr. Henderson wants his PCT to be a little more assertive in determining where general practices are located. Given that many PCTs appear to be an arm of central Government, perhaps he might want to have a word with his right hon. Friend the Minister about that.

My hon. Friend Mr. Amess—a member of the Health Committee whose remarks were, as ever, robust and knowledgeable—was worried about the collection of data and referred to the fact that points mean prizes in connection with the quality and outcomes framework.

Mr. Hopkins focused on spending, rather than outcomes. Of course, spending is relatively straightforward—we can all do that—but getting results is more difficult.

My hon. Friend Mr. Bacon is, by now, an expert on the national programme for IT in the NHS, given his membership of the Public Accounts Committee. Again, I should like to make a few comments about NPFIT.

The new GP contract has thrown up a number of what are, I think, unintended consequences. We have heard about the demise of the Saturday morning surgery. It is perhaps ironic that, when we are seeing a reduction in out-of-hours services and Saturday morning services, we see the creation of walk-in, quick and easy clinics at railway stations. Most of our constituents want to see their own doctor if they possibly can, and I wonder about the Government's priority in that respect.

I should like to talk briefly about community hospitals. Again, an unintended consequence and perhaps something that the Government have not thought through properly is the threat to community hospitals. I have four such hospitals in my constituency, two of which have been badly affected by the new GP contract and threatened. Previously, GPs have given their services more or less for free to community hospitals because they have been on call out of hours and can bolt on their services to community hospitals relatively easily. Now that they no longer work out of hours, they are looking again at that commitment to community hospitals. Community care cannot be provided without out-of-hours cover. GPs would like to cover community hospitals in most cases; but, frankly, they are more or less doing so for free, and I very much hope that the Minister will consider that and reflect on the fact that the framework document for the new GP contract referred to the need to negotiate terms for GPs who work in community hospitals, but that was the last that we heard of it.

I should like to mention health MOTs because I suspect that they will become a large part of general practice in the future. Certainly, that is the hint that we get in the media. I have no doubt that the Minister will probably want to discuss that at some length next Tuesday, but I should like to sound a cautionary note. All hon. Members would like to see a wellness service—that is for sure—but those health MOTs and health checks should be based on evidence. We do not want gimmicks, because they are likely to divert resources from where they can be arguably better used.

This week, Doctor magazine felt that, under Government plans,

"Sick people will be treated by NHS Direct, walk-in centres and pharmacists" while

"Proper doctors— by which I think that it means traditional GPs—

"will spend all of their time devising health plans for well people."

Unless health plans are grounded in evidence and targeted properly, there is a real risk that they will be gimmicks and do very little to improve the health of the population. Health inequalities are growing under the Government. Such non-targeted schemes risk diverting resources from where they might have maximum impact.

NPFIT continues to be rolled out. We all agree that better IT is needed in the NHS, but we are perhaps at risk of indulging in some "group think". We are committed to a greater or lesser extent to that approach, so we are not prepared to think of alternatives. The predecessor programme—information for health—was bottom up, rather than top down, and we have perhaps lost some of the good points of that earlier proposal. I very much hope that Ministers will listen to GPs, who feel very badly let down, especially in relation to EMIS.

Photo of Rosie Winterton Rosie Winterton The Minister of State, Department of Health 4:15 pm, 11th November 2004

Opposition Members have asserted that the Government have failed to support family doctors. However, as the Minister of State, my right hon. Friend Mr. Hutton, ably demonstrated in response to Mr. Lansley, the exact opposite is true. Support for NHS general practice has never been greater.

There has been an unprecedented increase in investment in primary care under this Government. Expenditure will have risen by £6.8 billion in England by next year and by £8 billion in the UK as a whole. We have fostered innovation, with a greater range of services being offered to patients. We have increased the importance of primary care in the NHS and we have improved the rewards for NHS workers in primary care, both financially and in terms of professional responsibility.

Mr. Amess said that we were bashing doctors, but since July 2000, almost 2,500 general practice surgeries have been replaced or refurbished as we modernise the NHS infrastructure after years of under-investment. There are already some 1,300 GPs with special interests who are delivering a range of extended services in local settings that are convenient to patients. There are 1,169 more general practitioners than in 1997, and 3,280 more practice nurses. Record numbers of doctors are training to be GPs—almost 80 per cent. more than in 1997. We have introduced the new contract for GPs—unlike the previous Administration who imposed one—, which will considerably improve their quality of life and increase recruitment and retention. That is hardly bashing doctors.

The proof that our policies are working is the fact that more doctors are joining the NHS and staying within the NHS. They recognise that Labour is offering them a professional career in which they can concentrate on providing the best patient care. We are seeing an NHS that is becoming more local, not less. It is an NHS in which general practitioners and nurses have a greater say on how their patients are treated, and an NHS that is tailored to the needs of individual patients.

Let me briefly deal with several points made by hon. Members. I welcome the fact that Mr. Burstow acknowledged that there was extra investment in the NHS and that the new pharmacy contract presented an exciting opportunity to extend the role of pharmacists. He asked about GP vacancy rates. The vacancy rate in 2003 was 3.4 per cent., but that had reduced to 3 per cent. in 2004. The rest of his speech, however, was frankly a typical Lib-Dem whinge.

My hon. Friend Andy Burnham presented the vision of high-quality services that his constituency wants. He pointed out the importance of linking high-quality premises so that some of the GP vacancy problems that he was experiencing could be overcome. He talked about the way in which the LIFT scheme in his constituency was giving easier access to services. It was a great pleasure to visit his constituency and see how local people are working to improve services. He asked about funding, which we know that we need to address in some areas. He knows that we are considering allocations at the moment.

Mr. Swayne gave a graphic description of his complaints about Primecare. We launched new guidelines on 14 October, which set out quality requirements for out-of-hours services, and I hope that those are useful in the meeting with his primary care trust.

My hon. Friend Mr. Henderson referred to the difficulty in his constituency with the location of GPs in a particular area. The PCT can establish services under PMS where there is the greatest patient need. That may be a solution. However, I shall raise his specific point with the strategic health authority. My hon. Friend Mr. Hopkins talked about the new health centres and walk-in centres in his constituency. He rightly drew attention to the importance of training and the provision of mental health services.

Mr. Bacon raised the issue of IT. Of course we will listen to GPs' concerns. I also understand that my right hon. Friend the Minister of State has written to him about his specific points. If those are not dealt with in his correspondence, we will follow that up.

Dr. Murrison mentioned Saturday morning services. PCTs can commission them as a matter of local discretion. Saturday morning surgeries are covered by out-of-hours services, as agreed in the new contract.

The Opposition motion says that we are failing to support family doctor services. The debate has demonstrated that nothing could be further from the truth or the reality of what is happening on the ground. The Conservatives had their chance to run the NHS. We know what happened when they were in control. Nurse training places were cut by 25 per cent. and GP training places were cut by 20 per cent. The fact is that under the Labour Government the NHS is getting better. We have record investment, 100,000 more doctors and nurses, the largest ever hospital building and equipment programme, better working conditions for all NHS staff and better treatment for NHS patients. Labour will keep the NHS free at the point of need. The increased investment that we are providing benefits the many, not the few. In our NHS, access is based on clinical need, not on how much people can afford.

The Conservatives have consistently voted against increased investment in the NHS. They voted against the increase in national insurance contributions to fund the health service. This Government will never remove £1.2 billion from the NHS to subsidise the well-off few who pay to go private. That is exactly what the Tories' patient's passport would do. The vast majority of Britain's hard-working families cannot afford £9,000 for a heart bypass operation or £5,000 for a hip replacement, and they would face the prospect of unlimited waits under the Conservatives.

The Government believe that primary care is the cornerstone of the NHS and we are committed to supporting it. NHS primary care consistently scores 90 per cent. in patient satisfaction surveys. That is not the achievement of an unsupported service. It is a fantastic tribute to the hard work and dedication of GPs and NHS primary care staff. It shows that the public support the NHS, and so do the Government. I urge the House to reject the Opposition motion and support the Government's amendment.

Question put, That the original words stand part of the Question:—

The House divided: Ayes 118, Noes 286.

Division number 317 Family Doctor Services

Aye: 118 MPs

No: 286 MPs

Ayes: A-Z by last name


Nos: A-Z by last name


Question accordingly negatived.

Question, That the proposed words be there added, put forthwith, pursuant to Standing Order No. 31 (Questions on amendments):—

The House divided: Ayes 257, Noes 149.

Division number 318 Family Doctor Services

Aye: 257 MPs

No: 149 MPs

Ayes: A-Z by last name


Nos: A-Z by last name


Question accordingly agreed to.

Madam Deputy Speaker forthwith declared the main Question, as amended, to be agreed to.


That this House welcomes the increase in general practitioner numbers; supports the expansion of primary care provision through walk-in centres and NHS Direct to meet the needs of patients; welcomes the new arrrangements for the National Health Service out-of-hours services that provide an opportunity to integrate primary, secondary and social care, whilst guaranteeing high quality urgent care across the country including Saturday mornings and improving the quality of life for general practitioners; acknowledges the progress made on the NHS Programme for information technology; supports the introduction of practice-based commissioning which fosters clinical engagement whilst mitigating the worst excesses of general practitioner fundholding; and believes that the general development of practice-based commissioning will deliver improved patient care.