This has been an interesting debate. I come to it from the Northamptonshire perspective, but there are variations around the country, which worries me when it comes to the top-down approach of saying that every area must have a health centre or a polyclinic.
I asked my staff to trawl through all our letters to see how many people wanted a centre that was open 12 hours a day, seven days a week, but I have not had a single request for that by telephone or e-mail or at my advice surgery. However, I have had a number of letters from constituents stating their concerns about polyclinics. My staff summarise it as follows:
"Worried about loss of patient-doctor relationship. Seems to be older generation that are particularly concerned—value relationship with doctor, see same one frequently and they trust and are at ease with the same doctor."
Those are the views coming from my patch.
I have had a number of briefings from doctors on this subject. I went to a town hall-style meeting in the village of Great Doddington that was attended by 100 people, where the local GP spoke with great passion about her worry that the result would be that the village surgery would close. I can see the appeal of having many services on one site, but there is a real concern that centralising provision and making facilities bigger may result in the loss of village practices, which would be to the detriment of my constituents.
I tried to intervene earlier on the Secretary of State. I think that he said that no practices would close as a result of this initiative. The Guardian said that there would be a substantial loss of surgeries if the policy was to proceed, so when the Minister replies will he say whether I understood the Secretary of State correctly? That is an important issue.
My second detailed explanation from a GP occurred last Tuesday, and I should explain the circumstances. Last Monday during the recess I did what every good Conservative should do and went out campaigning for Boris for the election, and I got a very good reception on the doorstep. Unfortunately when I had finished that electioneering I fell flat on my face, did my leg in and cracked my ribs and I was covered in blood. I finished up at the GP's surgery, and while she prodded and poked me she had a great opportunity to explain her concerns in some detail. In all the time that I have been a Member of Parliament, when I have been told something by those who are highly respected in the community, I have always taken on board their concerns. In that regard, I have a slight worry about Dr. Stoate. He must have a split personality. Being an MP he is not trusted by anyone, but being a GP he is trusted by everyone.
In Northamptonshire, we have already arranged GP out-of-hours availability at two sites. The one that most of my constituents go to is Keydoc, so there is no problem about seeing a GP out of hours, although one could not see one's own GP. No one seems to want to see a change in that system.
The hon. Gentleman raises an interesting point, because precisely that situation has arisen in many areas other than in Northamptonshire. It works well and there is a service there if people want it. I have been surprised by the number of GPs locally who have written to me saying that they can make a provision, but they object to being told exactly what to do, for how many hours and in what format.
That is exactly the feeling in my area. Despite the fact that we have one of the worst ratios of GPs to population in the country, we have made rather a good fist of our arrangements, and our GPs are highly regarded.
My constituents' real fear seems to be the loss of the relationship with the family doctor. Hon. Members say that that will not happen, which is good news if that is so, but I want to give a very real example that affected my family. My wife went to see her local GP, but saw another instead who said she had nothing to worry about. She did not get better, so she saw her own doctor, who knew her history intimately. She had liver cancer; she was immediately referred to the acute hospital and, thanks to the NHS, she was saved. This happened five years ago. My concern is if that situation had involved a polyclinic where she did not know the doctor, I am not sure whether she would have bothered to go back to get a second opinion.
I am interested to hear the hon. Gentleman's examples and am sorry to hear about his cut leg and cracked ribs. If the hon. Gentleman's GP had decided that he needed an X-ray, or if his wife's GP had decided to order a liver ultrasound scan, it would have been far better to have that X-ray or ultrasound scan then and there in the same clinic, rather than waiting for two or three weeks for provision in one of the local hospitals, which might be 20 miles away. Surely it is better to have the ultrasound scanner and the X-ray machine on the same site to deal with such matters as one-stop events?
I am grateful to the hon. Gentleman for his intervention, because it takes me to my final point. Everybody in my constituency wants a hospital in the Wellingborough and Rushden area. I have found no one who does not want this. We must travel miles to get to a hospital, and we are in an expansion area where 52,000 new homes are about to be built. We want a hospital. Listening to this debate, my fear is that somebody will say, "They can have a polyclinic, because then we will not have to provide them with a hospital," which would be totally and utterly unacceptable. There are significant variations around the country, so I do not believe in one centrally imposed system. There may be great merit to those health centres, but they should not be centrally imposed everywhere.
At times, the debate has been stimulating, and it has been interesting and necessary throughout. Many well-informed contributions highlighted the concerns in many different parts of the country. The key issues to come out of the debate are the disparity in existing provision, the nervousness about future provision and the potential for a break in the important GP-patient relationship. Any decision to improve provision and services should be taken locally and should not be imposed centrally.
My hon. Friend Mr. Lansley opened the debate. He provided a thorough analysis and a detailed, comprehensive and authoritative explanation and understanding of the issues. He was right to highlight his support for family doctors, the importance of GP contracts, the need for GPs to remain as independent contractors and the tensions between primary and secondary care. He was also right to highlight the concerns about the imposition of polyclinics or GP-led health centres—it is whatever the Government have chosen to call them today—which will be centralised, top-down structures that will be unresponsive to local needs in some circumstances and undermine access in rural areas. The issue is about centralising primary care. The Opposition do not oppose polyclinics or GP-led centres, when local needs desire and require them.
The Secretary of State for Health is a disarming man with a charming and calming manner, which is why, I suspect, he has been put in that job.
Sadly, the Secretary of State is not in his place. Unusually for him, the issue has clearly rattled him. He did not set out how he will explain to his constituents that the PCT that covers his constituency has admitted that it sees the imposition of a polyclinic as an opportunity to reconfigure GP services, thereby possibly closing existing practitioners. He did not support the family GP, and, interestingly enough, he did not defend the imposition of health care centres or polyclinics.
In response to my intervention—it will be interesting to see whether he confirms this later—he stated that primary care trusts do not have to have a polyclinic or a GP-led health centre and can therefore use the resources that would have been allocated for other, locally driven services. We will wait and see whether he substantiates that point outside this House.
Norman Lamb once again explained how his party plans to politicise PCTs' expenditure decisions by direct, local political interference. He rightly highlighted low morale among GPs and the need to review the quality assessment framework. He was also right to highlight the importance of preventive health care and the link to health inequalities. We need greater emphasis on public health. The PCTs with the greatest level of deprivation often spend the least resources on public health.
My hon. Friend Mrs. Dorries expressed her genuine concerns on behalf of GPs in Bedfordshire and about the imposition of GP-led health care centres in her constituency based on the potential breakdown of the GP-patient relationship. She rightly highlighted the importance of decisions being made locally in Bedfordshire in response to local community needs and questioned the logic behind the imposition of such schemes against local wishes. It will be interesting to hear what the Minister says in response to her points.
Dr. Taylor is a distinguished and knowledgeable Member of this House who always makes an interesting contribution to health debates, and today was no exception. He was correct to highlight the fact that GPs are independent contractors, but it must be right to harness the independent sector to drive improvements in the provision of health care, which should always take place through the prism of patients rather than through the prism of the delivery mechanism. It is right that the Opposition support any willing provider. I can give the hon. Gentleman the assurance that he seeks: the Opposition passionately believe that the NHS should be free at the point of delivery, and we are completely committed to the objectives and ethos of the NHS.
As the House knows, Dr. Stoate is a practising general practitioner, and he is extremely knowledgeable about these matters. However, I wish he would use that expertise and knowledge constructively rather than unconditionally supporting Health Ministers in whatever they are trying to do, regardless of whether those things are in patients' interests. He is right to highlight the additional pressure on accident and emergency departments, which was initially a direct result of the Government contracting both extended and out-of-hours services under the GP contract, which came into operation in 2004. Before I move on, I also want to know whether the hon. Member for Dartford is one of the 3 per cent. of GPs who are happy with the Government's handling of the NHS, or whether he is part of the 97 per cent.
Mr. Barron is a distinguished Chairman of the Health Committee, and his contributions are always thoughtful and serious. He was right to say that GPs are the backbone of the NHS and that less well-represented areas often face serious problems with health inequalities. There is no political difference between the three main political parties that that needs to be addressed. However, the Government amendment deliberately obfuscates and confuses two particular central Government initiatives, which need to be separated and debated independently. As the right hon. Gentleman said, patients demand greater access, and we support that demand where it is necessary. However, we also need to consider why it is there. The reason Members of Parliament found significant constituency concern when the contract was changed was that patients found that access to their GPs was not as it had been before. That concern has died down because patients have found a way of circumventing the problem, by going to accident and emergency and putting additional pressure on ambulance trusts. We need to make sure that the decision in respect of services used is with the patient, not with central Government.
We then heard from my hon. Friend Mr. Bone, who made a significant contribution based on experience in Northamptonshire. He was absolutely right to highlight the possible loss of the relationship between GPs and their patients.
I missed out my hon. Friend Mr. Jackson, but I should not have done—he is an assiduous and tireless defender of his constituency's interests. He was right to highlight the Government's failure to deliver improvements, particularly in the context of the significant amount of taxpayers' money that has been invested in the national health service. He was also right to point out the important requirement for GPs and their patients to be consulted properly about the central Government proposals.
My hon. Friend was right, again, to point out the benefits of consultation when Governments listen to what local people want. He gave a direct example of how that had benefited his constituents in Peterborough. My hon. Friend was correct to put on the record the significant inward economic migration, which has affected his constituency and mine and put great stress on public sector services in Peterborough and Boston.
In the time that remains, I want to highlight some of the key issues. I turn first to the GP contract. We should not allow the Government to get away with the view that GPs are somehow responsible for the reduction in out-of-hours and extended hours provision. That reduction was the direct result of the GP contract that was imposed by the Government and effectively led to reduced patient access. Furthermore, the cost of out-of-hours provision has increased by two or three times because the Government have insisted that it should be provided by primary care trusts rather than general practitioners. That has led to announcements, even last week, of cuts in out-of-hours services by contractors to primary care trusts.
The subsequent Government reversal, as they attempted to reinstate what they were responsible for withdrawing, has shattered the relationship between the Government and GPs, resulting in GPs being very upset. In a poll, 98 per cent. of them said that they thought that the Government's methods of negotiation were unacceptable and 97 per cent. said that they had no confidence in the Government's handling of the national health service.
All that is not the responsibility of the current Secretary of State. However, he has exacerbated the problems through his Department's tactics. The Government seriously miscalculated the number of points that GPs would earn. They rewarded GPs for a level of activity that was already in place, and that has been a significant contributory factor in the drop in productivity, leading to an additional cost of £1.76 billion to the taxpayer.
We Conservatives are not against polyclinics or GP health centres; in fact, when they are supported by the local community, via GPs and patients, we support them. However, we are deeply concerned about the Government's plans to impose polyclinics or GP health centres in every primary care trust. That is imposition without consultation or evidence. According to the Department of Health website, the consultation process is supposed to finish on
The House must understand that we are not talking about some minor tweak to primary care. The establishment of GP-led health centres and polyclinics will be the largest change to primary care since the establishment of the NHS 60 years ago. We have heard stories about how polyclinics and GP-led health centres will be inconvenient for some individuals. They will be suitable for some, particularly in urban areas, but there is real concern among GPs—and, more importantly, their patients—in rural communities.
The framework for action, which was specifically about London, set out that polyclinics will be cheaper and more convenient. There are arguments against the contention that they will be more convenient, particularly in respect of rural areas. In fact, polyclinics are more expensive than traditional GP surgeries, in respect of not only infrastructure, but the occupancy costs per patient. In addition, the Government must not underestimate the importance of GPs acting as gatekeepers controlling access to expensive secondary care. We Conservatives will not coerce GPs and their patients into polyclinics against their will.
Other mechanisms and structures could be put in place and need to be considered. For example, an innovative system is operating in the floor above the Boots store in the centre of Poole, where a consortium of GPs is providing a range of services that are proving much more accessible than those at the traditional GP practice.
Let me ask a few brief questions. Ministers are not—or were not until the Secretary of State seemed to change the policy earlier—allowing PCTs to consider the appropriateness of a polyclinic or GP-led health centre for their area. Will the Minister confirm his view? Ministers are not insisting on consultation, ensuring consideration of the impact on patient care or basing their decisions on evidence. Ministers are not allowing PCTs to use their money instead to improve the provision of health care through existing practices. Why, for example, will they not allow PCTs to use this money to invest in community hospitals rather than GP-led health centres—the point made by my hon. Friend Mr. Stuart? Why will not they allow non-spearhead PCTs to invest this money for smaller GP practices in socio-economically deprived areas, thereby reducing health inequalities? Why will they not allow this money, if desired by a primary care trust, to be invested in, for example, occupational health?
In short, the Government have been holed below the waterline as regards any suggestion that the central command and control era is over—in fact, it is going in exactly the opposite direction under this Prime Minister. At a time when the Government are closing and downgrading rural services such as post offices, local schools and police stations, we cannot have yet another local service under threat. Local accountability, local decision making, local consultation and local needs and requirements are all being overridden by Ministers. We will change that. We will empower local GPs and patients to reflect local communities' needs and requirements, driven by quality of service and by patient outcomes. Our plans will drive improvement in the provision of health care and deliver a better, more effective, more efficient and patient-focused national health service.
We have had a good debate, and I will try in the time that is left to respond to some of the specific points that hon. Members have made.
Before I do so, I should like to reaffirm the importance that we place on family doctors. The relationship between a patient and their local GP is one of the most important features of the NHS. As Nye Bevan said,
"The family doctor is in many ways the most important person in the Service."
We recognise the vital importance of the GP as provider and commissioner of care and as a strong advocate for their patients' health and well-being. The primary care system in this country is the envy of the world. I therefore reject the accusation contained in the Opposition's motion that GPs are undervalued and under-appreciated. In fact, there are today more than 5,000 more GPs than there were in 1997, and their average pay has increased from £46,000 in 1997 to £110,000 in 2005-06. Investment in primary care services has more than doubled from £3 billion in 1997 to £8 billion in 2005-06, and GPs as a whole do a fantastic job.
However, health care can never stand still. Sixty years on, the NHS must react to 21st century challenges, offering services that are responsive to what patients want and need. The NHS next stage review interim report, "Our NHS, our future", which we published last autumn, recognised the need to improve access to primary care and community services, and it set out a number of proposals to make services more equitable and to ensure that patients have real choice. Those included £250 million of new money for new GP practices in the most under-doctored areas, benefiting patients in 50 primary care trust areas, and for more than 150 new GP-run health centres—one in each primary care trust area in England.
I will not, because I have only a few minutes to respond. The Opposition Front-Bench spokesman took rather longer than I was expecting.
Those health centres will allow any member of the public to pre-book or simply to walk in and be seen by a GP from 8 am to 8 pm every day of the week. They will all have a strong focus on promoting health, particularly to hard-to-reach groups, and on preventing health inequalities. When we talk about developing health centres or when some local parts of the health service describe plans for polyclinics, we are not referring to a single, fixed model of care. These terms describe flexible models for bringing primary care together with a range of other services, be they diagnostic services, specialist care for patients with long-term conditions such as diabetes, or social care. Research shows that the public want services that are more joined up, and it shows that more integrated care produces better health outcomes. But there is no one-size-fits-all solution. What matters is doctors, nurses and other clinicians working with the public to design integrated care to meet local circumstances. That is why the Government are providing investment for the new health centres, and why we have given the local NHS the flexibility to design the services that will be based in those centres.
Although we are not prescribing specifications for the new services—it will be up to SHAs and PCTs to design those with local communities—we are saying that there needs to be a small number of core requirements, which are expected by the public. For GP practices in under-doctored areas, those requirements include extended opening hours, engagement in practice-based commissioning and wide practice boundaries to secure the maximum level of access. For the health centres in every primary care trust area, those include: an easily accessible location; being open from 8 in the morning until 8 in the evening, seven days a week; bookable GP appointments and walk-in services; services for registered and non-registered patients; and a maximisation of the opportunities to integrate and co-locate with other community-based services.
To respond to the question put by Dr. Taylor about the role of the independent sector, even if every one of the new health centres and all of the extra capacity that we are creating in the NHS at primary care level were won by the independent sector—and that is not what is happening—the proportion of provision of primary care run by the independent sector would amount to only 3 per cent. of the national total. I would add that existing GPs are private contractors.
It was suggested by a number of Conservative Members that the public were not interested in more flexible opening hours for GPs. They claimed that there was no demand for them. I have to tell them that every single poll—not just those done by the Department, but those carried out recently by MORI and by Which—shows that it is a priority for the public. When record investment is going into GP services, they do not consider it unreasonable to be able to visit a GP at a time that is more convenient for them.
"I know that many GPs and others have difficulty with the word 'polyclinic'...but the concept of bringing practices together and providing a greater range of integrated services in the community has to be right...It might be true that small is beautiful, but professional isolation and poorly integrated services are not...Practices need increasingly to work with each other and with other partners in primary care, whether as virtual partners or on one site".
Dr. Dixon, whom I visited with the Secretary of State last week, practises not in inner London or inner Manchester but in rural Devon. His fantastic health centre in Cullompton, far from making it harder for local people to access services, means that many people in the surrounding villages and Cullompton no longer have to travel to Tiverton or further afield to Exeter for treatment. Instead, they can receive them on their doorstep, in their local market town. Moreover, his surgery is about to embrace evening and Saturday morning opening.
When one looks at the London model, one finds that 29 out of the 31 primary care trusts in London are already working on proposals—bottom-up, not top-down—for health centres in their areas. A recent survey by the British Medical Association, no less, found that 70 per cent. of GPs in London said that their premises were "inadequate".
No I will not give way, I am afraid.
Mr. Jackson suggests that extended opening will be used only by yuppies in four-wheel drive cars who are about to fly off on holiday. I have to say that where we have had extended opening, whether it is in Barking and Dagenham or Tower Hamlets, the patients accessing services in the evenings and Saturday mornings are not four-wheel-car-driving yuppies, but blue-collar workers, who otherwise have to take time off work and lose money from their pay packets.
Some are families with young children, and some of them are pensioners, and they appreciate the extended hours delivered by this Labour Government. [Hon. Members: "Give way!"] It is not just in Devon or in London—
The services are proving popular not only in London and Devon. In South Cambridgeshire, the constituents of Mr. Lansley will get a new GP-led health centre in St. Neots. The Sawston medical centre already offers integrated services, including minor operations and audiology as well as general practice. In Eddisbury, the constituency of my opposite number, the Dene Drive primary care centre has three GP practices, which offer integrated services under one roof. [Interruption.] From a sedentary position, Mr. O'Brien admits to opening it in February.
Sheringham, in the constituency of Norman Lamb, houses eight GPs, with expanded services, and it recently benefited from a £1.2 million extension under the Government's LIFT programme. In response to a question from the hon. Gentleman, it is not true that the money was conditional on its being spent on extended opening, as he alleged.
As part of our current negotiations with the BMA about the new contract arrangements, we have agreed to invest up to £105 million in new GP services. That will include money to fund the pay recommendations. We reached broad agreement with the BMA on the new services, but I am afraid that I cannot announce them to the House today because the BMA is still challenging the pay recommendations. However, I share the hope of the hon. Member for North Norfolk that we can make a positive announcement along the lines that he said he would like.
The hon. Gentleman is right about the minimum practice income guarantee. As my right hon. Friend the Secretary of State made clear in his opening remarks, we will tackle that when Lord Darzi publishes his final report in the summer. I have asked Westminster primary care trust for an explanation of the arrangements that the hon. Gentleman described at Buckingham palace and Westminster school, but he will accept that they may result from the minimum income guarantee rather than anything less acceptable.
The hon. Gentleman knows that we have been involved in an intensive six-month period of work on practice-based commissioning to encourage better commissioning. The primary care trusts are now responsible for ensuring that practices are properly supported, and we will hold them to account to ensure that they give practices the necessary support to realise practice-based commissioning, to which we remain committed.
The motion must be one of the most extraordinary motions on health tabled by the Conservative party. It follows an astonishing speech by the Leader of the Opposition on Monday, which advocated giving GPs a veto over more convenient opening times, and a Conservative-supported GP petition, which states:
"We...believe that we should be free to determine the opening hours, size and locations of our practices".
"Mr. Cameron's speech contains disappointing echoes of the arguments of those who have long opposed any reform of the...public sector".
The speech and the motion could have been written at BMA headquarters.
The motion is accompanied by an equally ludicrous press release from Conservative central office, with the headline, "Labour's secret blueprint for polyclinics". The Tories claim to have uncovered guidance that amounted to a threat to family doctors' services throughout the country. The only problem is that my fellow Health Minister, Lord Darzi, announced the guidance in a speech at a national conference in December and it has been publicly available on the Department's website ever since.
Far from being a threat to family doctors' services, our plans will provide 265 new GP practices and GP-led health services throughout the country, on top of the existing 8,500 GP practices, with £250 million of new money. A new health centre that is open from 8 am until 8 pm, seven days a week, will be set up in every PCT area, and 103 new GP practices will be established in 50 of the least well-served areas of the country.
The public say that the ability to see a GP at a time that is more convenient to them is the one further improvement that they would like in the health service. With record investment going into GP surgeries, we on the Government Benches do not believe it unreasonable of the public to expect that improvement, and that is what our proposals will deliver.
It is extraordinary, although not surprising, that the Conservative party is aligning itself so firmly with the forces of conservatism against improving health services for the public. That might curry it some favour with the BMA, but most people can spot producer interest capture when they see it. What an astonishing—and from our point of view welcome—set of affairs that the Conservatives should be positioning themselves so firmly on the wrong side of the health argument. That is why their motion will be defeated. I commend our amendment to the House.
Question accordingly negatived.
Question, That the proposed words be there added, put forthwith, pursuant to
Madam Deputy Speaker forthwith declared the main Question, as amended, to be agreed to.
That this House welcomes the fact that the Government is providing £250 million, in addition to existing GP services, for 152 new state-of-the-art GP-led health centres open from 8 a.m. to 8 p.m., seven days a week; notes that these will offer a wide range of health services including prebookable GP appointments and walk-in services; further notes that where patients previously had trouble seeing their GP or had to make numerous visits to a variety of health professionals, they will now be able to see a doctor more quickly, collect their prescriptions, get their eyes tested, have a variety of diagnostic tests or see a physiotherapist in the same building and at times convenient to the patient; further welcomes the additional centrally funded 100 GP practices to be located in the most deprived areas which will have a strong focus on promoting health and reducing inequalities; acknowledges the landmark agreement with GPs to extend surgery hours in evenings and on Saturdays and agrees that extended access will benefit hardworking families; further welcomes the extension of the role of pharmacies to be able to prescribe for and deal with minor ailments on the NHS, as well as promoting good health, supporting those with long-term conditions and preventing illnesses through additional screening and advice; recognises that the Government is on the side of patients; and agrees that extending access to GP services through extended hours and new GP health centres can have a real impact on health inequalities.