I beg to move,
That this House
opposes the Government's plans to impose a polyclinic, or GP-led health centre, in every primary care trust;
regrets that this could result in the closure of up to 1,700 GP surgeries;
is concerned that the imposition of polyclinics against the will of patients and GPs could be detrimental to standards of care, particularly for the elderly and vulnerable, by breaking the vital GP/patient link;
further regrets that these plans are being imposed without consultation;
is alarmed at the prospective loss of patient access to local GP services at a time when care closer to home should be strengthened;
believes that the Government's plans would jeopardise the independence and commissioning capability of general practice in the future;
supports the strengthening of access to diagnostic and therapeutic services without undermining the structure of GP services;
and calls on the Government to reconsider its plans for polyclinics.
Last Thursday, the local medical committees, which are the statutory bodies required to represent GPs across the country, met in conference and passed a vote of no confidence in the Secretary of State and the policies of the Labour Government. On the same day, the British Medical Association delivered to Downing street a petition against the Government's polyclinic proposals consisting of 1.2 million signatures. Patients care about the future of their local surgeries and about their GP services. They and GPs are concerned that the Government's top-down, one-size-fits-all imposition of polyclinics in London and in each primary care trust across the country will reduce access to their GP services and undermine the GP-patient relationship, which is at the heart of the successful delivery of health care.
Today's motion is very simple. It urges the Government to think again. If the Government had offered additional funding to support the creation of extra GP practices in under-doctored areas, we would have supported them.
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My local primary care trust has announced that we are to have an additional clinic, funded with additional money, in an area where some of the GP lists are full, which is an area of deprivation. The clinic will be open from 8 am to 8 pm and will provide drop-in services not only for the local community but for the whole area. Is the hon. Gentleman saying that he would deny the people of Crosby that clinic?
No. The right hon. Gentleman should remember that back in January 2006, the Government promised to provide additional general practitioner services in under-doctored areas such as his. The fact that they are doing that two and a half years on should not be a cause for congratulation; it should be a cause for regret that it has taken so long. My point is simple—
No, I will answer the right hon. Gentleman's first question before I come on to the next one. The point is that we need additional GP services in under-doctored areas, and the decision on where and how those services are structured must be the product of local consultation and agreement, based on local needs and circumstances. For some time—for two and a half years—the Government have been saying that they will provide additional GP services in under-doctored areas, and we are not disputing the need to do so.
The hon. Gentleman mentioned petitions; I went to see my GP the other day, and the receptionist was giving out petition forms. Someone asked what the forms were for, and the receptionist said, "They're going to close all the local surgeries down." That is complete nonsense, and the hon. Gentleman knows it, so why does he go along with it?
It is the British Medical Association's petition, not mine. The Secretary of State and the Minister of State, Mr. Bradshaw, are suggesting that 1.2 million people across the country are being conned by their GPs, but that is not true. The Minister of State pops up and says that the Department had one e-mail from someone saying that they did not really believe in the petition, so I have asked the Minister whether he will publish all the e-mails presented, and every representation made, to the Department of Health. The fact is that across the country doctors have been voicing their concerns that their practice will be undermined to their patients, and I will explain in my speech why those concerns are valid. Doctors have concerns about the impact that the imposition of a polyclinic will have on their practices.
I will come to the hon. Lady in a minute. The first point to make clear is that the Government could have gone ahead in a far simpler, better fashion. They could have offered primary care trusts extra funding to provide additional practices in under-doctored areas. They could have offered funding to each primary care trust across the country to enable them to provide access to diagnostics and additional therapies in each area, in places that would have made sense from the point of view of local GPs. Everywhere that I have been—that is quite a lot of places—GPs would very happily have got together and agreed where it would be appropriate for such diagnostics and therapies to be available.
Is not the point that over the past 10 years the Government have set up a system for commissioning, and are now going outside it, and that any PCT that declines to put a polyclinic somewhere in its area will get disciplined? Is that not shocking?
Yes, it is, and that is the way in which the Government now work. It is simple to say why GPs and patients across the country are angry: it is because, contrary to the Government's rhetoric about local decision making, and contrary to the Minister's rhetoric about all the proposals coming from primary care trusts, it is an imposed plan, generated inside the Department of Health and adopted by Ministers who should have known better.
To go back to the first intervention, the people of Crosby may be delighted that there is to be a polyclinic there, but the people of Bournemouth are concerned, and doctors are worried about the patient-doctor relationship being eroded as a result of polyclinics being created. Does my hon. Friend agree that it would have been better to have allowed Bournemouth and doctors an opportunity to have a say in the matter, and then to have determined whether a polyclinic was appropriate?
I absolutely agree with my hon. Friend, and he rightly reflects precisely the kind of points that are being made to all Members of the House. Labour Members may not admit it, but they know that GPs are telling them that they cannot see the rationale for many of the proposed imposed polyclinics across the country.
The Government were not content to bring forward proposals that would have made sense and could have been adapted and used locally. Gripped by a desire for the latest imported ideology of polyclinics, they first told London that there would have to be 150 polyclinics in the capital, and then told every primary care trust that they should have one each.
Of course, we need to strengthen primary care—no one disputes that—but Martin Roland, who is director of the National Primary Care Research and Development Centre in Manchester, said in the British Medical Journal in March:
"Increased patient choice requires more high-quality practices, not the small number of large practices that some polyclinic models suggest. We know that patients in small practices rate their care more highly in terms of both access and continuity. Indeed, although small practices show more variation in quality, on average, they achieved slightly higher levels of clinical quality than larger practices in the quality and outcomes framework."
I will give way to Shona McIsaac, but perhaps Ms Buck will explain later why smaller practices that get better outcomes on the quality and outcomes framework will be shut down in favour of larger practices.
I ask the hon. Gentleman to follow up what was said by my right hon. Friend Mr. Morley. I represent the rural part of north Lincolnshire. We will get a new clinic in north Lincolnshire, but the PCT has told us that that is a local decision to meet local need, and not one rural GP practice will close as a result of these plans. So why is the hon. Gentleman and his hon. Friends scaremongering to the extent that my residents think that their practices will close?
That is quite interesting, but the hon. Lady needs to look at the material published by the North East Lincolnshire PCT to accompany its memorandum of information, which sets out 34 practices that will be in the proximity of the new polyclinic in Grimsby, with all the implications that might flow from that. That is what we have seen across the country. We are not scaremongering; people are looking at the material published by PCTs across the country. The Secretary of State for Health peddles the same line as the hon. Lady in saying that no GP practice will be affected and closed, but his own PCT in Hull says that the process will be used as a lever for the reconfiguration of GP services and that, at the end of the day, there will be fewer GP sites.
The hon. Gentleman has twice mentioned my constituency. What Hull is doing of its own volition is going out to consultation at the moment, and the proposal is additional to the proposals for the new centres that will come to under-doctored areas and additional to the GP-led health centre that we are putting into Hull. It is consulting on three additional health centres to deal with three problems: first, a preponderance of single-handed GPs; secondly, facilities and services that do not even meet the Disability Discrimination Act 2005; and thirdly, the fact that it has no women doctors whatsoever. So the PCT has gone out to consult the people of Hull, quite separately from what we are doing nationally, to seek to address those problems, and so it should.
The Secretary of State is getting desperate. I have here the presentation document from Hull PCT. If it devised the proposal, why does the powerpoint presentation say, "Darzi GP-led health centre"? It does not say that it is something that the PCT thought up. The proposal's criteria are exactly those that the Department of Health have specified. The document's conclusion says:
"The number of GP sites will reduce."
[ Interruption. ] Labour Members should listen. If the Secretary of State is saying that Hull PCT will provide three additional GP health centres, how come the impact will be that the number of GP surgeries will reduce? We know exactly what that means.
Is not the central point that we are very happy to see polyclinics if they are additional and wanted by the local community? The element of compulsion is quite wrong, and Labour Members have got a real shock coming to them when they discover that, in their areas, GPs will dislike it but be dragooned and that they will lose their current practices.
I agree, and my right hon. Friend has a reasonable complaint if the Government are providing additional money in his area only on the basis that it will be spent in a certain way. If I recall correctly, his PCT is the lowest funded per capita in the whole country. If anywhere in the country should be given the opportunity to spend the money as it sees fit, it is his constituency.
I assure my hon. Friend that certainly GPs in Chelmsford do not think that he is scaremongering in any way. Mid Essex PCT is being forced to have a polyclinic in Chelmsford and GPs in the area are extremely worried that it will have a serious and negative impact on their practices, because of the nature of the things being imposed on them.
I am grateful to my hon. Friend, who has gone to the heart of the issue. At the moment, the Government require PCTs to publish memorandums of information before in effect tendering for the new polyclinics. We have seen the tender documents from 58 PCTs, which identify 608 GP surgeries in proximity to proposed polyclinic locations. Because the Government have insisted that the new polyclinics should register patients, the local practices identified in those documents will see their patient lists undermined, some of them potentially fatally.
The Secretary of State has said that no GP surgery will be closed as a consequence of opening polyclinics, but how can that be true? The Government amendment does not refer to the polyclinics proposal for London, which we should address for a second. The Prime Minister got up at the Dispatch Box and said that there would be 150 polyclinics, that each polyclinic would have 25 GPs and that each polyclinic would serve 50,000 people. The consequence of that would be the closure of more than 70 per cent. of existing GP surgeries in London.
Documents from half the PCTs refer to 600 GP surgeries in proximity to potential polyclinics. If the polyclinics are not additional and the GPs in them are the same GPs who currently work in their own surgeries—or, for that matter, salaried doctors in PCTs—then a number of surgeries will have to close. That was the clear implication of the Government's proposals for London. If that is not the case and the GPs are genuinely additional GPs in additional GP practices, where will the money come from? We have done that calculation, too. If the Secretary of State is to be believed and the provision is all additional, the cost of that number of GPs in that number of surgeries would be £1.6 billion a year. However, the Government have allocated £250 million over three years, so the situation simply does not add up. One of two things must be true. Either the GPs will be moved and the practices will be moved from their present locations into larger polyclinics, or additional services will be provided and additional costs will be incurred. The Government have not answered the question about which one of those two things it will be.
In my PCT, the thinking concerns creating a polyclinic based on a hospital. That would reduce inappropriate accident and emergency attendances by people who are not registered with doctors, which hammers the hon. Gentleman's argument that there is a one-size-fits-all solution. Is it not true that in 1981 the Acheson report addressed the issue of single-handed practices, particularly in London, where single-handed practices were over-represented? For 16 years, Conservative Governments made progress—not enough in my view—on reducing single-handed practices. Although there is good practice in some single-handed practices, by and large the quality of care is not as good as that provided by other practices. Is the hon. Gentleman saying that his party stands four-square behind all single-handed practices, regardless of the quality of care?
Nobody could responsibly say that "regardless of the quality of care". The hon. Lady has said that we have suggested that there is a central plan, but I did not make that suggestion. Ara Darzi produced "A Framework for Action" for London, which set out the specific design for a polyclinic—25 GPs, 50,000 people, £800,000 a year rent, a number of out-patient attendances, the employment of a consultant and the provision of a number of nurses. I did not make that up; the Prime Minister stood at the Dispatch Box and paraded the fact that there would be 150 polyclinics in London. It is absurd that the hon. Member for Regent's Park and Kensington, North has challenged us on single-handed GPs when the evidence is clear that the best quality and outcomes framework results are achieved by practices with two or three GPs. [ Interruption. ] I know that they are not single-handed practices. Why do the Government propose to push GPs from across London into large polyclinics, when the evidence is clear that accessible local surgeries with two or three GPs achieve the best results?
My hon. Friend has said that the situation is absurd, but there is a further bizarre twist. Is he aware that the Darzi clinics will not be subject to monitoring by health overview and scrutiny committees? The Government are introducing a two-tier NHS: parts of the NHS are subject to scrutiny by health overview and scrutiny committees, whereas independent treatment centres and Darzi clinics will not be subject to scrutiny and monitoring by health overview and scrutiny committees, which seems fundamentally wrong.
I agree with my hon. Friend. Pulse recently looked at the proposals in PCTs, and only a tiny proportion of those that it looked at had been subject to even a semblance of a public consultation. The reason is precisely the same as the reason that my hon. Friend gave: the Government are determined that the proposal should not be subject to scrutiny. Why? Because it will not stand up to that scrutiny, it is not locally determined, it does not arise out of the needs and circumstances of the area and, on the quality of care that will be provided, it is not even evidence-based.
If the aim of the proposal is to force the closure of single-handed practices, why are the Government going to parachute a polyclinic into the middle of Scarborough, where we have a number of good group practices, but not into rural areas, where we have some very good single-handed practices? It does not even follow the logic of Ms Buck.
The Secretary of State says that my hon. Friend can work it out. The reason may be that the chairman of the BMA council is a GP in Scarborough, but there we go. We will see whether the Government's conspiracy extends even to that. What my hon. Friend says is absolutely true. I have been to rural areas and talked to the head of the local medical committee in north Yorkshire, and it is completely absurd that a town such as Scarborough, which has many health needs but is not under-doctored in terms of GPs, should have money spent on it in that way. Throughout north Yorkshire, it is perfectly clear that access to diagnostics and therapies is required in a range of market towns and centres, not in one centre at the furthest extremities of the area. That is absurd. As it happens, north Yorkshire is technically among the most-doctored areas in the country.
May I thank my hon. Friend for supporting my right hon. Friend Mr. Knight in his campaign to defend health services in Bridlington, and share with my hon. Friend the concern of people along the east Yorkshire coast about polyclinics being imposed on the area? Bridlington, while its hospital services are being devastated, is having a polyclinic imposed and being told that it represents an improvement in its health care.
It is risible. My hon. Friend will know that from his experience, as will my right hon. Friend Mr. Knight, who represents Bridlington. We visited Bridlington and District hospital together, and it is outrageous that the Government appear set on downgrading its services and then, in pursuit of a "care closer to home" philosophy, on undertaking re-provision on the same site—dressing it up as a polyclinic. We live in bizarre times.
No, I shall not give way.
The hon. Member for Regent's Park and Kensington, North was quite right to talk about London earlier, but it is important to understand that, far beyond that, there are considerable implications in rural areas. My hon. Friend Mr. Goodwill, and my hon. Friend Mr. Stuart in the East Riding, made it clear that there are rural areas where spending such money, so that a polyclinic is established in a place that is already well doctored, is not only wasteful of resources and prejudicial to the GP practices in the area, but, if it threatens other surgeries, could have serious implications for access.
We have done the calculation on access to GP surgeries, and NHS London made a calculation in its consultation document. It says that it has done high-level modelling, meaning that people in London will be on average only 1.5 miles away from their GP surgery. That is quite interesting, because NHS London did not go on to say that, currently, people in London are on average just half a mile away from their GP surgery. So when the Secretary of State says that he is perfectly willing to campaign on the issue, perhaps he would like to tell all the people of London that the distance to their GP surgery will triple. It is quite clear: we have done the calculation and NHS London said that the distance would be 1.5 miles. [ Interruption. ] It is quite clear. It is a good one. Don't you worry, it is. [ Interruption. ] Actually, Ministers should know that the distance will triple in Hull and in Exeter.
In places such as North Cornwall, the distance to a GP would more than triple, rising to more than 9 miles on average. The Government are parading their belief that they can improve access to primary care, but nobody, anywhere in the country, will be able to believe the Government's arguments if their access to a local surgery is so prejudiced. There is an enormous difference in London between going half a mile and going a mile and a half. Someone who is elderly, vulnerable, frail or a mother with children, without access to a car, becomes reliant on public transport. In rural areas, access to public transport over many of these distances is difficult to contemplate.
I agree with the hon. Gentleman in so far as the Government will end up with another independent treatment centre-type fiasco if they continue with the top-down restructuring of the type that he is criticising. He said earlier that these services should be largely designed by GPs. May I seek a reassurance that he is really trying to tell us that patients and local communities should have a big say in how primary care is designed—that it should not be designed by central Government and imposed on the local community or by those who are contracted to provide the service but designed by the local community itself?
I commend to the hon. Gentleman our document, "The patient will see you now, doctor", published last September, which clearly set out how we would seek to empower patient choice and involvement, the effect of which would be increasingly to design primary care services around the needs of patients.
The Government and primary care trusts have gone ahead without the semblance of a public consultation. Where, in all this, is the evidence to justify the Government's imposition of this plan? Since they published their proposals, the King's Fund, which I am sure that Ministers will acknowledge is independent and respected, looked at the evidence for polyclinics under three criteria—quality, cost and access. On quality, it said:
"The co-location of multiple services presents opportunities for delivering more integrated care, particularly for people with chronic diseases. However, the evidence suggests that in practice these opportunities are often lost."
On cost, it said:
"Expectations that community-based services will be less costly than hospital-based equivalents are frequently not met."
On access, it said:
"If a substantial centralisation of primary care were pursued, the consequent reduction in access to these services would be a major sacrifice."
Overall, it concluded:
"A major centralisation of primary care is unlikely to be beneficial for patients, particularly in rural areas."
I think that the hon. Gentleman is concentrating too much on one particular type of polyclinic. There are many models. There is nothing to say that a polyclinic has to include every local GP. There is plenty of opportunity for hub and spoke models whereby the local GPs can remain and the polyclinic can provide central services such as X-ray, physiotherapy, consultant services and so on. There are also models where individual practices can co-locate into polyclinics and remain as individual practices. There are many examples around the country of that happening. The opportunity exists for primary care trusts to negotiate and discuss with local GPs and other providers how that type of model can benefit their area, thereby allowing patients to get the benefit of small practices and central services in one locality.
I have heard that before. The fact is that if there were going to be a hub and spoke model in London, why did the framework for action describe a polyclinic model of 25 GPs and 50,000 people? Why did the Prime Minister refer at the Dispatch Box to 150 polyclinics? Why are GPs in north London telling me that the primary care trust is saying that if they do not move into the polyclinic, their rent reimbursement will be stopped? A GP wrote to me and said that he knew what was about to happen to him because the primary care trust published a map of primary care services in his area and he was left off.
The official Opposition are coming rather late to this issue. People such as myself tabled early-day motion 1465, which flags up the more fundamental flaws with polyclinics outside London and the metropolitan areas. A fatal flaw of the Conservative motion is that it does not consider the potential of free market competition to inflict serious damage to patient access to general practice and public services. No wonder firms such as Serco, UnitedHealth and Virgin Healthcare are lining up outside the Department of Health just outside this place, licking their lips at the prospect of extracting vast sums from the NHS. Why is that not referred to in the Opposition motion? It deserves to fail because of that.
It is not there because when I have talked to, for example, GPs in Islington who were very unhappy about the way in which a tender was awarded to a commercial organisation, I found that they were willing to enter into competition as long as it was fair, and as long as it was based on a level playing field. I am not opposed to personal medical services or alternative, commercially run, providers of medical services practices, but I am opposed to the top-down system of imposing polyclinics, which is undermining the existing GP structure.
It is interesting that the Prime Minister, when challenged at his press conference last week, retorted that there would be thousands of additional GPs. I think that he said that there are already thousands of additional GPs—[Hon. Members: "There are."] Of course there are more GPs since 1997, and so there should be. But in the last year for which figures are available, 2006-07, there were only six additional GPs in the whole country, so the Government are not in a position to make much progress on that issue. The predictions from the King's Fund in its recent document show that we would be short of 2,000 full-time equivalent GPs by 2016. Where is the flow of additional GPs who are to fill the polyclinics?
If polyclinics take over existing GP services, local practices cannot be maintained. If primary care trusts provide the funding for polyclinics, they will, as a consequence, force the closure of many other local GP services because it is not possible to use the same money twice. The Secretary of State knows that, but he will not admit it. There is a long-term agenda in his Department to undermine the independent contractor status of most GPs and to compel them to become part of a PCT-controlled primary care structure. That is why a GP in London said the other day that the PCT was
"bending everyone's arms very strongly. Life will be very difficult if we don't go in."
It is interesting to note that the Government's amendment to the motion does not actually mention polyclinics. I suppose that the Secretary of State is going to pretend that they are health centres, not polyclinics. The Minister of State, the hon. Member for Exeter, is constantly saying that people get confused because those centres are health centres, not polyclinics. I received two answers from the Minister of State on this subject. On
"'Health centre' is a term used to describe a range of health services characterised by the co-location and integration of different services, including those traditionally provided in a hospital setting."—[ Hansard, 15 May 2008; Vol. 475, c. 1666W.]
A month later, on
"'Polyclinic' is usually a term used to describe a range of possible health service models characterised by the co-location and integration of different services, including those traditionally provided in a hospital setting."—[ Hansard, 16 June 2008; Vol. 477, c. 767W.]
Those definitions are absolutely the same. As far as I am concerned, if it walks like a duck and quacks like a duck, it is a duck.
No, I shall finish now, if my hon. Friend will forgive me.
If the structure proposed forces local GP surgeries to close, forces GPs into becoming salaried employees of their primary care trusts instead of independent contractors and turns patients into through-puts rather than people, it is a polyclinic. We should follow the evidence, which says that smaller practices are often of higher quality. We know that they are more accessible. We know that patient choice and preference show that they value continuity of care even more highly than rapid access to care. We know that integrated care is about a lot more than putting all the services in one large building. How can access and care closer to home be improved if hospital services are closed down while polyclinics are built on the same site? Why are the Government so obsessed with the ideology that they have brought in, when they should understand that primary care in Britain is one of our comparative strengths? We should develop and strengthen our structure of primary care, not replace it with a German or a US-style polyclinic system.
All hon. Members should be aware of the concern raised throughout the country because of the Government's top-down imposition of polyclinics. There is a better way. We can strengthen access to community services and strengthen the existing GP structures. We can extend GPs' commissioning and their responsibility for providing integrated care for their patients. We can use those additional resources to improve access to community services while maintaining access to GPs locally. We can empower patients to choose their general practice and to drive up quality and access improvements through their choices. That would be a better way. The Government should reconsider their polyclinic plans. The motion would require them to do so, and I commend it to the House.
I beg to move, To leave out from "House" to the end of the Question, and to add instead thereof:
"welcomes the Government's support for primary care and proposals to invest £250 million in 113 new GP practices in the most deprived communities and 152 new state-of-the-art GP-led health centres open from 8 a.m. to 8 p.m., seven days a week, in every part of the country;
notes that these centres will offer a wide range of health services including pre-bookable GP appointments and walk-in services for registered and non-registered patients;
recognises that the exact format and location of each GP-led centre will be decided locally in consultation with patients;
notes that GPs will not be forced to work in the new GP-led centres and where that is the case patients will still be able to remain registered with their GPs at their existing location and premises;
acknowledges that the expansion of primary care is essential if the overall health of the population is to improve, and inequalities in health are to be addressed;
and welcomes plans to ensure enhanced primary care services are capable of meeting the new challenges facing the NHS including tackling lifestyle diseases such as obesity and through more effective screening programmes for the general population."
We are delighted that Mr. Lansley has used up another of his party's Opposition day debates to allow us to reiterate our commitment to primary care, set out our record of investment and reform, and explain in detail our exciting plans to expand capacity in primary care.
No previous Government have more clearly demonstrated their commitment to primary care and those who work in it. Let us examine the record since 1997: investment in primary care has more than doubled; there are more than 5,000 more GPs and more than 4,400 more practice nurses; GP pay has increased by around 55 per cent. in real terms; GP hours have reduced by 17 per cent., and the time spent on each patient is up by 50 per cent. That is hardly the record of a Government who are hostile to the role of primary care in the NHS.
I want to set out as clearly as possible exactly what the Government propose throughout the country, what the NHS is seeking to do in London, and to mention briefly other separate developments that clinicians, patients and managers in local PCT areas, including—I am pleased to say—Hull, are leading.
Let me begin by stating firmly what we do not propose. According to the BMA and its political wing opposite, the Government have not one but three evil ulterior motives: to privatise primary care by allowing companies such as Boots to run GP services; to nationalise primary care by making GPs state employees; and to destroy family practices by breaking the GP-patient link.
Conservative Members claim that the accusation of privatisation comes from behind me, but it appears in every BMA leaflet that I have read, at the same time as that of trying to make GPs do what Bevan could never make them do—become state employees. So we are trying to privatise and nationalise simultaneously.
The GPs of Hastings and Rye are not persuaded that the BMA has got it right. Not one has complained. They are delighted with the £15 million that my right hon. Friend has made available for a new health centre in the town centre. Patients are not compiling petitions, either.
My hon. Friend's experience is replicated throughout the country.
We are supposed to have three ulterior motives. All that is arrant nonsense. It is possibly the most ludicrous misrepresentation made in the House since the equally ludicrous attempts to distort the principles behind the establishment of the NHS 60 years ago, and it derives from exactly the same source.
The motion refers to a Government plan to "impose" "polyclinics." Opposition Members deliberately use that term because of its impersonal and biomedical connotations. There is a perfectly valid argument for polyclinics. There is no argument for imposing them centrally on every locality as a replacement for GP practices—that is why we do not have such a plan. A polyclinic combines primary and secondary care. The only part of the country where a network of polyclinics is proposed is London, where a comprehensive review of health services took place last year, and the Government had no say in its outcome. It was a London consultation, which the NHS in London led.
Mr. Lansley mentioned north London. In my constituency, the chairman of the local medical committee, who is a local GP, made it clear that premises are limiting the advantages that GPs can offer patients. A plan that provides GP centres is therefore important. It is likely to give us a GP centre in Enfield Lock and in Enfield town—exactly what Sir George Alberti, a leading clinician, said that we need. The people of Enfield, North will not be deprived of that huge investment by the Conservative party's propaganda.
My right hon. Friend makes an important point about health services in London. We had no role in the outcome of that review; however, like the population of London, we support NHS London's proposals. I want to take a minute to explain to the House why the proposals, which those on the Opposition Front Bench oppose, are right for London.
If the footfall of a centralised primary care centre is 50,000 people, that adds up to about 50 per cent. of all the GP practices in any one constituency. As a south-east London MP, I should be grateful if the Secretary of State said whether he is seriously proposing that 50 per cent. of our constituents go to one place for their primary care?
I am suggesting that the hon. Lady, like her colleagues on overview and scrutiny committees throughout London, participate in the London consultation, the outcome of which has shown wide support from both the public and politicians of all political persuasions for what is being proposed in London, and well it might.
We hear the trite comments from the Opposition Front Bench, but people in London do not have access to the quality of primary care that they deserve. There are particular problems with access in this city. An Ipsos MORI poll of Londoners revealed significantly lower satisfaction ratings than the national average, and that 54 per cent. of GP practices in London have only one or two GPs, compared with 40 per cent. elsewhere, that nearly 20 per cent. of GP practices in London are unable to offer an appointment 48 hours in advance, that demand for longer opening hours is even higher than in the rest of the country, that 50 per cent. of all patients who attend A and E departments in London can be better treated elsewhere, and that more people clog up A and E in London than in any other city.
One of the justifications for polyclinics is the extension of GP availability. Healthcare for London quotes the patient survey of 2007 as saying that the majority of patients are dissatisfied with their GP's opening hours. However, the British Medical Association quotes the same survey as saying that 84 out of 100 people are satisfied with their GP opening hours, so is it not better to listen to individual patients and individual GPs? I have not had one GP or patient from my constituency contact me to say that they are in favour of polyclinics.
The hon. Lady is referring to the Healthcare Commission report, which was not a London-only survey and which showed a high level of satisfaction with GP opening hours. However, the 84 per cent. in favour left some 6 million people throughout the country who were dissatisfied. When one looked into the figures, one found that people from black and minority ethnic communities, such as the Bangladeshi community, those from poorer backgrounds and, in particular, those from London were much less satisfied than the rest of the country. According to a BMA survey, 60 per cent. of London GPs say that their facilities are unsuitable for current needs, 75 per cent. think that they cannot meet future needs and 36 per cent. doubt whether their facilities could be adapted to meet the access requirements of the Disability Discrimination Act 2005. Those are the problems in London, which London is seeking to resolve.
The Secretary of State is talking to a large extent about London. Can he tell my constituents why he wishes to impose a polyclinic on the East Riding of Yorkshire PCT, where I assure him there is very little appetite for one? This morning, a GP from Beverley told me:
"Polyclinics will lead to the end of personalised care which current patients enjoy."
That GP, who is nearing the end of his career, also said—perhaps this will rock the Secretary of State most—that he has voted Labour all his life, but will not do so at the next election, because he has lost confidence in the Government on health.
The total cost is estimated at around £150 million, which will be money well spent and a crucial investment in improving the situation in London.
The term polyclinic has been used in London to describe a range of models that allow primary and some secondary care services, such as diagnostics, to be available in each local community, reducing travelling time and making services more convenient for patients. In some cases, that may involve bringing services together under one roof. In other cases, as my right hon. Friend Joan Ryan mentioned—this is a specific option that is part of the London proposals—it involves having a network of GP practices linked to a hub that provides more specialist services. Both of those are available in London.
Interestingly, in the one part of the country where polyclinics are being proposed, Conservative politicians support the proposals, as, indeed, do the public. Every local authority overview and scrutiny committee, including those that are Tory-led, backs the exciting plans to resolve NHS problems in the capital—problems that probably should have been dealt with 20 or 30 years ago.
I certainly welcome the additional investment in primary care, but whatever the problems in London, they are not the same in Birmingham. The report to the PCT on implementing the measures said that there was
"no clear geographical area which warranted investment in an additional three partner practice" and no real pattern to highlight a need for the GP-led health centre to be located in one particular place. A place was chosen because accommodation was potentially available, even though there are low levels of under-doctoring there. I therefore ask my right hon. Friend please to give this money to the PCTs and to let them decide how to spend it in the interests of the people they serve.
I think that that is the Opposition's policy—give the money to the BMA and it will decide how to spend it. It is also their policy for GPs to be allowed to set up where they want to, for GPs to be allowed to open when they want to and for GPs who work in disadvantaged areas to get more money. I do not agree with that policy. I believe that when we move on from London and talk about other parts of the country, including the west midlands, my hon. Friend will agree that our proposals are the most sensible way forward.
The Secretary of State accused a Member on his own side of the House of adopting the policy of the BMA, but Lynne Jones actually said was that she wanted to give power to the local area so that decisions could be taken locally. Surely that is what should be done, as it is local people who know what the needs are in any particular area.
That is what we are doing— [Interruption.] I am talking about what is happening in London; I will come on to the rest of the country in a minute. London has had its own analysis of problems, which have been the subject of many reports over the last 20 years. Politicians refused to implement the proposals. We are implementing the proposals, with London's support.
Is it not interesting to note that the BMA—when not campaigning and producing petitions—wrote a few weeks ago to all GPs and local medical committees describing the new proposals in what it called a "factual guide"? It talked about the key differences between the health centre proposals and the polyclinic proposals; and of the polyclinic proposals it said, "mostly in London".
I have not seen that particular circular, but that is exactly what I am trying to explain. In London, there is a specific proposal about polyclinics. That is opposed by the Conservative party, despite the fact that the project has been worked up locally by people in London and has been the subject of full consultation with the public and GPs.
In my constituency, we are about to rebuild a new local hospital which will be a 24/7, GP-led urgent care centre with 40 respite beds and diagnostic services that are to be brought right into the heart of our community in Eltham. Mr. Lansley has proposed that any vested interests in the local health economy could scupper that in the face of widespread local support for the scheme. That is not bringing the service back to local people; it is taking it away from them and putting it in the hands of vested interests.
Unlike the proposals for London, the 150 GP-led health centres that my Department has asked the NHS to develop across the country are not, and have never been, designed to alter the way in which existing GP services operate. The London proposals are so designed, for all the reasons that I have discussed. The proposals for the rest of the country are not seeking to change GP services at all. They are designed purely and simply to increase capacity. The average primary care trust has around 55 GP practices that will continue to provide services to their patients as they do today. In addition to those practices, each PCT will also now have a GP-led health centre, funded from ongoing additional investment, attached to which are only three conditions. No. 1 is that the centre should be in a central location; it should be accessible. No. 2 is that it should be open from 8 am to 8 pm, 365 days a year. The third is that any member of the public must be able to use the centre either to book a GP appointment or to turn up to see a GP or nurse without the need to be registered at the centre—in other words, people can continue to be registered with their local family doctor and benefit from the continuity of care that is provided.
The Secretary of State says that those are the only requirements, but surely it is a requirement that the Department has laid down that these centres—these clinics—should register patients. By extension, therefore, patients will no longer be registered with other GP surgeries.
I just mentioned that— [Interruption.] I did. I said that the third condition allows patients to be registered or to walk in and receive GP services because they are in a more convenient location. Let us consider the logical extension of the hon. Gentleman's argument. Yes of course members of the public can decide to leave their existing surgery and register at this GP-led health centre. It is called patient choice. They are perfectly entitled to do that. What we expect is that this additional resource will be used to mix and match, as I mentioned. Most patients will want to stay with their existing GP because of the particular benefits that gives them, but they will also want to use the GP-led health service on Christmas day or on a Sunday afternoon knowing that they do not have to be registered there to use its services.
The Secretary of State is trying to share as much information with the House as possible. Is it not true that there are two other conditions? One is that no primary care trust can say, "No, we don't want to do it." The second is that there is a rule that no existing GP-led health centre—that is to say, a wide practice—can turn itself into one of these new GP-led health centres.
It is absolutely the case that we are saying that in the interests of greater capacity, greater patient choice and the public being able to access primary care, this is not a zero-sum game. There will be a greater need to access primary care in the future, particularly with the plans that we have for prevention being as important as diagnosis and cure, and there must be one of these centres in each location.
I have set out the three conditions. Beyond those, it is for local GPs and the PCT to discuss exactly how the service is provided.
I thank the Secretary of State for his courtesy in giving way again. I suspect that hon. Members on both sides of the House would agree that many patients are naturally very loyal to their general practitioner. That being the case, does the right hon. Gentleman accept that if there were to be any attempts by financial mechanisms or otherwise to compel general practitioners to move into polyclinics against their will, that would be resisted by the GPs, very likely by their patients, and not least by local Members of Parliament as well?
Further to the point raised by Lynne Jones, if the Secretary of State looks at areas such as Cornwall and the Isles of Scilly, he will see that there is a geographical problem. If he is simply imposing a top-down restructuring of the type that he is describing, a single polyclinic in just one area in a place the shape and size of Cornwall will clearly have a destabilising and destructive impact. Why does he not allow that local community to design services that best meet its needs, rather than imposing this top-down, centralised restructuring? Why will he not allow the local community to design its own services and achieve the aims that I think he desires?
We have specified three conditions. The centres must be centrally located, must be open from 8 am until 8 pm seven days a week, and must allow people to use their services on a drop-in basis as well as to be registered if they wish. The money that will be invested is additional money, provided not by the local primary care trust but from the centre, to improve access throughout the country. I think that that is the right thing for a Government to do.
Members of the BMA are not the only people to comment on the proposals. The Royal College of Midwives, of which I am an honorary vice-president, tells me that it is interested in the potential of polyclinics and larger health centres to provide better midwifery services—better antenatal and post-natal care. That means, however, that the centres should provide accommodation for midwifery. Will Ministers and local NHS chiefs encourage the decision makers to provide such accommodation?
My hon. Friend has reminded me why the proposals are so exciting for London. It will be possible to provide services such as diagnostics and maternity care, and to achieve a fundamental advance in primary care in the capital. My hon. Friend has also reminded me that we should listen to the views of Age Concern. The hon. Member for South Cambridgeshire said how dreadful the new arrangements would be for elderly people. This is what Age Concern said in a briefing for today's debate:
"For many, especially carers and those with mobility issues, the super surgery or polyclinic could be preferable to what they currently have on offer. For those without transport, it can take a whole day to get to the doctor and back, via the pharmacy. If then, they are required to visit the hospital for blood tests, x-rays or anything else, that will take them another day. There is a tentatively enthusiastic welcome to a super surgery or polyclinic that will allow them to do all these things on one day, under one roof."
When we talk to the public and to patients, they see the attraction. Obviously they listen to the horror stories that are being peddled, because they trust their local GPs, as well they should, but when what we are proposing is contrasted with what Her Majesty's official Opposition are suggesting that we are proposing, it can be seen that what we are doing is improving primary care throughout the country.
What would my right hon. Friend say to the GPs from the local medical committee in Sunderland who came to see us last week? They welcome the extra investment, but believe that the money could be spent more efficiently if it were spent via existing doctors' surgeries. When asked why, they say that some of the previous reforms, such as independent treatment centres, have proved quite wasteful.
I would tell those GPs that this is not the only investment being made in primary care. About £500 million is going into primary care this year from one source or another. In Sunderland, as well as in my city of Hull, GPs will have their own plans, but we will ensure that nowhere in the country is there a single patient who cannot gain access to primary care seven days a week, 365 days a year, between 8 am and 8 pm. God forbid that I should make the link between Newcastle and Sunderland, but people who work in Newcastle and live in Sunderland will now be able to go to a GP-led health centre in Newcastle. This is about patient convenience and patient choice.
May I play devil's advocate, and suggest that my right hon. Friend is not going anywhere near far enough? While I support his plans for super-surgeries that will be open seven days a week—I think that that will really help patient care—my real desire is for them not just to provide GP care seven days a week but to provide visiting consultants, X-rays, physiotherapy and occupational therapy. I want patients to have access to a whole range of services that people in smaller towns and rural communities currently have to travel many miles to receive. I want the centres to provide those services so that patients will not have to travel 20, 30 or more miles to major centres to receive services that they could receive far more efficiently and cheaply in their local communities.
Order. Before the Secretary of State replies, may I just remark that the interventions have been getting steadily longer? I ask everyone to remember that the list of Members wishing to take part in the debate is quite long.
My hon. Friend Dr. Stoate is right. I am concentrating on primary care because of the attack that these proposals will somehow diminish primary care. Bevan, at this Dispatch Box in 1946 as the National Health Service Act was passing through the House, saw the integration of primary and acute care as one of the fundamental principles of the creation of health centres around the country, and we have an opportunity to revisit that.
We in Barnsley are looking forward to having a super-surgery—or polyclinic, or whatever it will be called. We have traditionally had too few GPs, to the point where one GP practice currently has a patient list of 8,000. Nobody can tell me that that is ideal. We are therefore quite looking forward to the extra capacity that will come with these super-surgeries.
It is stated that the Tories claim that 608 practices may close in 58 PCTs. [Interruption.] Well, I apologise for initially saying "will" instead of "may". Also, the procurement guidance that was "discovered" hidden away on our website was actually launched by Ministers in December at a public meeting.
Barnsley is cited as one of the Conservatives' examples; it is said that, because there are all these GP surgeries around the area where the GP-led health centre will be placed, somehow they will all close. However, my hon. Friend Mr. Illsley is absolutely right. Barnsley has 49.3 GPs and 25.4 nurses per head of population and all the resultant health problems, while Cambridgeshire—the hon. Gentleman's part of the world—has 74.6 GPs and twice as many nurses per 100,000 head of population. That is why, as another major part of this proposal, we are putting 130 new GP practices in under-doctored areas, which I presume the Conservative party also opposes. [Interruption.] Well, I am sorry, but it signed up to a petition saying that GPs should be allowed to set up where they want to set up, and if we want them to work in poorer areas, they should get more money. Not even the Brazilian Health Minister, who was talking to me the other week and who is introducing health centres in the favelas in Rio de Janeiro, was saying that the GPs who work there should get more money, but that is what the Conservatives are saying for towns such as Barnsley and Hull.
I will certainly give way to the hon. Gentleman shortly.
Many PCTs are looking to provide other services in these health centres, such as diagnostics or pharmacy services. However, that is a matter to be decided locally in consultation with patients, GPs and the public. We have no plans, no intention, no desire, no aspiration and no ambition to force a specific model of primary care on GPs or patients. These new services are designed not to replace existing GP surgeries, but to provide additional access and extra choice for patients.
Nor is this an attempt to get rid of single-practice GPs, which will continue to be an essential part of primary care, particularly in rural areas. However, there has undoubtedly been a general trend in recent years for GPs to come together to work in larger teams so that they can provide a better range of care and more integrated services. There are now more than 500 practices with nine GPs or more. This has been led and encouraged not by Government, but by GPs themselves, who increasingly find that it is more practical to work together in larger, more suitable premises, providing a greater range of integrated services.
No, I will not give way for a while
Therefore, having invested heavily in primary care and increased the number of staff and improved their conditions, the Government now propose to expand primary care capacity, including in the 25 per cent. of PCTs with the poorest GP provision, thereby addressing a major cause of health inequalities.
What have Her Majesty's official Opposition got to say? Last week, they claimed that there was a £1.6 billion black hole in our plans for GP-led health centres. I note that that ludicrous claim is missing from the catalogue of ludicrous claims masquerading as a motion for today's debate. Yet again, they mistakenly assume that what has been proposed for London will be transposed to the rest of the country, and there will be 25 GPs in each of the new health centres—in actual fact, the expected number is five not 25.
I think the Secretary of State gave a rather one-sided view of the Age Concern briefing that he mentioned. Does he acknowledge that older people have real concerns about these plans, particularly because, as we know, they are most reliant on family doctor services? There are real concerns that the relationship will be lost. There are also concerns about access during the day; people hope that the extended hours will not mean fewer opportunities to see family doctors during the day, because they are the sort of times on which older people are particularly reliant.
The hon. Gentleman is right to say that the elderly, who use health services more and, as Age Concern points out in the briefing, use primary care services much more, would be worried by any indication that their GP services were to be diminished. As Age Concern points out, the advantage of the polyclinic and the health centre for elderly people is that even if they have to go a little further to get to the polyclinic, they do not have then to go somewhere else to go to the pharmacy, to go somewhere else to get diagnostics and to go to the hospital for other services. That is a very important point.
Incidentally, we have been absolutely stringent in saying that increased access, which the Minister of State, Department of Health, my hon. Friend Mr. Bradshaw has mentioned has now reached 21 per cent. across the country—that is an 11 per cent. rise since we introduced the policy—must not be at the expense of existing hours. The pay that goes to GPs is only for their giving additional hours; it is not for putting in a Saturday morning and taking away a Thursday afternoon. Greg Mulholland is right to raise the point.
Perhaps the Secretary of State can clarify something for me. He is at pains to say that his proposals do not aim to replace GPs' surgeries, yet the proposal put forward by the Hampshire PCT to locate a polyclinic—or whatever he wants to call it—in my constituency talks about building
"capacity to absorb a growing population."
That sounds to me as if the polyclinic is replacing the need to build new surgeries when new houses are built.
I am not going to give way.
The allegation is made by the Conservative party that every one of these GP-led centres will have 25 GPs, and that is wrong, because we expect them to have, on average, about five new GPs. That rather silly misrepresentation is less pernicious than the way in which many patients are being deliberately misled by some in the profession about what our proposals to improve primary care actually mean.
I have here a leaflet produced by a group of GPs on Teesside entitled "Save our Surgeries". It has an NHS logo on it, when it should not have, it contains no address to which to write and it makes several unsubstantiated claims about what our proposals will mean. It is, by no means, an isolated leaflet; such leaflets are going right across the country. It says:
"This initiative will be the first stage in dismantling of traditional general practice in this country."
That is nonsense, because we are actually providing new investment and additional capacity.
The leaflet also states:
"You will have to de-register from your local surgery in order to register and be seen in a new one."
People will not have to do so, although, of course, anyone who chooses to change their GP, as is their right, will have to register with a new practice. That is the case for any patient now who chooses to change practice, but the same will not be true for those who use the new GP-led health centres. As I have explained, patients do not have to leave their existing GP to gain access to the new service.
Here is another one; the leaflet also states:
"This funding is only for a very short time. When it runs out, the PCT will have to use other funding to continue the new services."
That is not true. We have confirmed that it will be recurrent funding for primary care trusts. Finally, it states:
"The proposals will eventually force doctors to leave traditional general practices and work for private big companies like Tesco or Virgin...Doctors who work in these practices will have to follow company policy and protocols regarding prescribing expensive drugs and making referrals to hospitals."
This borders on hysteria. In the first instance, we expect many of the new contracts to go to GP-led consortiums, not private companies, and any GP practice, whoever runs it, has a professional duty to provide the best possible care for its patients and will already work to sensible protocols on prescribing and referral. In fact, Virgin has made it clear that it is not interested and will not even be bidding for these new practices. It will seek to get GPs—who are already, I remind hon. Members, in the private sector—to come into consortiums with it, and it will provide the building. That is nothing to do with the Government or the 150 new GP-led centres.
No, I will not.
Such scurrilous leaflets ignore or patronise the central player in this debate: the patient. While the vast majority of GP practices provide an excellent service, it must be acknowledged that many patients cannot access the services they need and that there is a very real need to improve the quality of primary care in some parts of the country, especially in London.
We have many examples of patients being dragooned into signing the BMA's petition, but when patients understand our proposals, they realise that we will not be taking away their GP services and that the relationship between the family doctor and the GP is sacrosanct and will be protected by this Government.
The Government believe that adding more than 270 new GP practices and GP-led health centres across the country, with the majority in under-doctored areas—some of which have been under-doctored for the past 60 years—will add extra capacity, provide more convenience and choice for patients, and allow the expansion of more preventive work such as vascular checks to proceed successfully. As we will not be removing existing GP surgeries, the time for the Opposition to criticise these proposals will be when and if these new facilities remain empty and unused once they have been established. I confidently predict that that will not be the outcome, and that historians of the health service will look back on this peculiar spat as the time when producer capture killed off the little credibility that the Conservatives ever had on health issues. I commend the amendment to the House.
It is surely a spectacular achievement by the Government to have taken a concept that is clearly worthy of consideration and development and, in the space of nine short months, turned so many people against it. The reason for that is the central imposition from Whitehall, which will require every PCT to introduce a GP-led health centre.
The Secretary of State draws a distinction between GP-led health centres and polyclinics, but the King's Fund—which is entirely independent of the BMA—says that they involve a model of care that is not dissimilar. GP-led health centres are, at the very least, embryonic polyclinics. They look to most independent observers very much like the same thing. As Lynne Jones and my hon. Friend Andrew George, who is no longer in his place, made clear, surely the decisions should be made by local commissioners, who are accountable to the communities they serve.
The frustrating aspect is that this all started so well. In July last year, the Secretary of State announced the Darzi review. He said:
"The review, the first of its kind, will directly engage patients, NHS staff and the public. I have written...to all NHS staff to explain the importance of this new approach. The success of the review will depend on gaining access to those relationships and stimulating a range of lively, local, provocative debates. Public services cannot be transformed by going against the grain of public service, or without support from the professionals who know the NHS best."
That was the stated ambition at the start of the process, but three short months later, when the interim Darzi report came out, it announced the 152 GP-led health centres, one for every PCT. Was that really the outcome of that great conversation with the NHS, or was it the imposition of a blueprint that had already been determined long before the launch of the review?
Does the hon. Gentleman share my concerns about the fact that Lord Darzi said in his report that many polyclinics would take the place of the care provision formerly provided by district general hospitals? Does he agree that that would be a detrimental step? We have all been fighting to save our district general hospitals, and anything that threatens them will be of great concern.
That might be a concern, but my argument is that these new mechanisms for delivering care should be piloted. They should be tried in various parts of the country so that we can learn the lessons, both positive and negative, and see what the implications are for district general hospitals and community hospitals. We ought to be developing a lot of these services in local community hospitals, which often serve very rural areas. For many communities, that would be a much better way forward than the Government's proposals.
The Secretary of State, who has left the Chamber remarkably quickly, claimed that this was not a central imposition, but it is. The operating framework for the NHS for 2008-09 states that
"all PCTs will complete procurements...for new GP-led health centres" within this year. What a stitch-up—a centrally imposed direction from Whitehall that must be carried out within such a short time.
One would have hoped that the Department and Ministers might have learned lessons from the debacle that was the Medical Training Application Service and from the whole business of modernising medical careers. We saw the consequences of imposing an entirely new system across the whole country, without proper piloting, and it ended in disaster, causing many problems for junior doctors. Did the Government learn their lesson from that gross error? No, they did not.
Here we are again, imposing a system from the centre despite all the evidence, which I shall come on to, from the King's Fund and many others, which ought to be enough to make the Government stop and think, and learn lessons before proceeding further. In future years, this case will provide us with yet another perfect case study of how rushed central imposition fails, with the waste of resources that always happens when attempts are made to impose a measure from Whitehall, with the failure to develop policy based on evidence, and, critically, with the alienation of professionals and communities.
Let me deal with the subject of the alienation of professionals. The Government have decided to pick a fight with the BMA, and with GPs in general. They quickly dismiss the BMA, accusing it of being luddite and resistant to any change, and saying that it always has been like that and always will be. That view results in the Government closing their mind to legitimate concerns from many doctors about the implications of the proposals. It also closes their mind to the risks of undermining what is already very good in our primary care system. Primary care in this country is the envy of much of the rest of the world. We must never be complacent about the need to improve primary care when it fails, but there is a real risk that the proposals will undermine much of what is so good about the system that we have.
Alienating communities is not the way to empower communities or local commissioners. The primary care trust in Birmingham mentioned by the hon. Member for Birmingham, Selly Oak might well have its own plans about how it wants to develop services in that community. In my county of Norfolk, the primary care trust has not even finished a review of its estate since it was created in the autumn of 2006, yet this change is being forced on it.
These decisions should surely be made locally, and should be based on what works best in the area. They should be based on what services are being developed to provide the services talked about in the proposal—such as the community hospitals, which are so critical in serving rural areas. They should be based on the quality of primary care. It is variable; surely that points to a need for local solutions, rather than having Whitehall simply impose its proposals. Surely local commissioners should make such decisions. What are the important principles that should apply, and what evidence is there that existing provision is failing? What evidence is there that polyclinics will provide solutions to any of the failures that we identify?
The principles behind the proposal are important. First, clearly there are real issues to be addressed in connection with the concept of breaking down the divide between primary and secondary care. The case for providing care closer to home is an important principle, as is the quality of care provided to the patient. As for whether there is a need to improve what we already have, as I have said, we must not be complacent. There is a divide between primary and secondary care, and we should consider all ways of reducing that divide, to ensure that there are better working arrangements between consultants in hospitals and GPs working in the community.
The quality of primary care is generally, but not universally, excellent. The Royal College of General Practitioners is aware of that; it recognises the variability of care across the country, and the fact that in deprived areas there are fewer GPs. There are concerns that some single-GP practices do not provide the quality of care available elsewhere. Some are very good, but others do not offer care of a sufficient quality. There are financial incentives that encourage GPs to work in the leafy suburbs, but not to work—or stay—in the poorest communities. Those financial incentives need to change.
There are also concerns about the patient experience. The Secretary of State made the point that if a person has to visit a GP, then a pharmacy elsewhere, and then a hospital for a further check-up, perhaps after an operation, they may make many long journeys. That can be extremely onerous for the elderly and people who live in rural areas. At the beginning of the week, I spoke to a constituent who described making a 60-mile round trip to the acute hospital in Norwich for what turned out to be a two-minute check-up appointment following an operation. None of us can be happy with that situation, so we must have open minds and be willing to consider ways of improving the patient experience.
It is worth while considering new models of care, looking at what works in other countries, and trying to learn the lessons. Last summer, I visited the Arches health centre in a poor, inner-city part of Belfast. It is, in essence, a polyclinic. It brings together health and social care, and there is a citizens advice bureau in there, too. To all intents and purposes, it looked like an incredibly impressive facility, so I am certainly not dismissive of the concept's potential to work in certain defined conditions, but when the King's Fund looked at the evidence, it raised serious concerns.
The King's Fund first looked at other countries. There is some bizarre cross-dressing going on; it talked about the original concept coming from the Soviet Union and being developed in many eastern European countries that were part of the Soviet bloc, yet those countries are now moving away from that model, and towards a much more open primary care market. Meanwhile the United States, Germany and Canada are very much moving in the direction of the polyclinic model. As two groups of countries are moving in diametrically opposite directions, the changing enthusiasm for polyclinics surely ought to make us wary.
The King's Fund also warns that what might look very attractive and work effectively in the States or Germany cannot be translated to this country. It makes the point that there are far more doctors per 1,000 people in Germany, for example, than in this country. So caution is required about simply adopting something that looks good elsewhere.
The King's Fund clearly recognised the potential for such new concepts of delivering care, but it found no systematic evaluations of polyclinic models in other countries. The Government, however, appear determined to proceed without that evidential base. The King's Fund had real concerns about what it saw overseas. It saw that, in many cases, the fact that professionals were working together under one roof did not automatically lead to integrated care; it saw a lack of integration between polyclinics and hospitals. It raised concerns about a lack of continuity of care, whereby the patient did not see the same doctor every time. That is one of the issues that cause elderly people a lot of concern.
The King's Fund found concerns about a decline in professional motivation and development, where consultants who might previously have been based in hospital centres of excellence end up in more remote settings away from professional colleagues.
Bizarrely, given the Government's claims, the King's Fund identified a lack of patient choice. Given some of the concerns that have been raised by the BMA and others about the ultimate position with small GP practices closing, the result could be that people in a local area end up with less choice about their primary care centre. They might have no choice but to go to the local polyclinic. That looks very likely to be the case in London.
The King's Fund also looked specifically at the local improvement finance trust schemes already operating in this country. It specifically examined 12 LIFT schemes that it considered bore all the hallmarks of the polyclinic model that the Government seek to pursue. It said:
"If anything were to demonstrate the benefits of the polyclinic model in England, it should in theory be evident in LIFT schemes."
What did the King's Fund find? Its conclusions should worry the Government. It found little evidence of innovation in this country's existing polyclinic model. It found that local authority social services, which were supposed to be integral to those centres, had "fallen by the wayside" and were not continuing to participate in them because of tight local funding streams.
Crucially, the King's Fund found a lack of clarity about responsibility for strategic development—no one in charge, determining the strategic development of those centres. It found a lack of clarity about who was responsible for overall clinical governance in those facilities. Surely that should disturb the Government. It found that payment by results—the Government's mechanism for funding care, which is a blunt instrument—is causing acute hospitals to have their funding streams undermined where such centres exist, because the polyclinics do the more routine procedures, thus leaving the acute hospitals to do the more expensive procedures, while receiving the same tariff. They are losing income for the simple procedures and receiving too low a tariff for the more complex procedures. All that is swept aside in the Government's determination to rush headlong down this route.
The King's Fund also found that none of the 12 existing schemes demonstrated savings or improvements in costs compared with previous models of care. They had struggled to persuade GPs to relocate, and had been developed because of a political imperative to introduce them, rather than being based on patient need. The report raised the specific fear that polyclinics would, in effect, become white elephants. It also noted the concern about access. It drew specific attention to the fact that if people have to travel further and for a longer time to their primary care centre—particularly in the more deprived communities, where people might not have access to cars—they are less likely to use that facility. Surely, again, that should be a concern in London, given the proposals that the Government are intent on pursuing.
When the King's Fund examined the 12 existing cases, it identified a failure to shift any care from remote acute hospitals to polyclinic settings. It is essential to secure local leadership and a shared ambition, which is usually lacking when a model is imposed on an area by Whitehall.
The King's Fund has stated that, critically, the Government have not answered the question about who will lead on either strategic direction or clinical governance. Until the Government clearly indicate their intentions on centrally imposed GP-led health centres, there will be massive concern that the fears identified by the King's Fund in the existing centres will be realised right across the country, because we have not learned the lessons from the pilots. Foreign evidence also points to the central importance of leadership in such centres. The existing LIFT schemes and the foreign experience should be enough to persuade the Government to pause for thought.
My plea to the Government is to develop pilots with proper investment. The King's Fund has stated that the focus is often on simply creating the building within which services are provided, without investing in change management, which involves changing services and the way in which patients are treated. We should develop those models, extend the evidence base, sort out the question of leadership and explore the range of models, which include hub and spoke, and locating all GPs in the same building.
The hon. Gentleman is discussing pilots and polyclinics. He may be interested to know, if he does not know already, that the only part of the country that currently proposes to develop polyclinics is London, where 10 pilots have been proposed.
I have the minutes of the North Yorkshire and York primary care trust clinical executive meeting in February, which considered a proposal for a polyclinic in Scarborough. The PCT thinks that it is going to have a polyclinic, even if the Minister does not.
I am grateful to the hon. Gentleman for that intervention. Everyone outside this place uses the terms interchangeably—for example, the King's Fund, the independent research body, uses the terms interchangeably. Everybody understands that what is happening is the introduction of something that looks very similar to a polyclinic: it may be embryonic, if that is the right way to describe it, but it has many of the characteristics of what the Government describe as a polyclinic.
We should watch the evidence develop and allow experiments with community hospitals to develop services in rural areas. We should listen to the warnings from the King's Fund and many others rather than the warnings from the BMA. Many independent bodies have expressed concern and oppose the central imposition of a new model of primary care. Even at this late stage, given all the evidence out there, the Government should make it clear to PCTs and to strategic health authorities which quietly do the Government's bidding, that PCTs are free to say that they will not introduce polyclinics, that PCTs can develop their own mechanisms for delivering care within the community, and that PCTs will not be disadvantaged as a result of taking such decisions. We should learn the lessons first, and allow locally accountable commissioners to make such decisions.
Order. Mr. Speaker placed a time limit of 12 minutes on Back-Bench speeches in this debate. It is now apparent that if that is maintained throughout the period, not everyone will be able to take part. I propose that the first two such speeches will be subject to the 12-minute limit, and then I shall review the situation in light of how much time we have left at that stage.
I am in no position to comment on the appropriateness or otherwise of polyclinics—or whatever the Government's term is in relation to other parts of the country. Polyclinics may turn out to be useful, successful and helpful, but I am here to speak up on behalf of patients and professionals in my constituency who are expressing a great deal of concern about our primary care trust's proposals. Most people in the locality approach the issue with great distrust, because they feel that our area has been used as a testing ground and my constituents as guinea pigs in new approaches to general practice and primary care.
Until now, our area has been well served with effective and very popular GP services, but it is being subjected to changes that, from the point of view of local people, are unasked for and untried. Recently, three GP practices were privatised—there is no other way to describe it. Three popular practices were required to bid to continue their existence. They met all the quality requirements, and in the assessment they did better than the private sector bidder on all of them, but the private sector bidder put in a lower bid in terms of costs. The bid was never quite clear, because when people inquired into how the situation had come about, they were told that the matter was commercial and in confidence.
UnitedHealthcare, a subsidiary of an American outfit, secured the contract. I expected—perhaps rather cynically—that it would put on an absolutely wondrous show in the three practices that it had taken over, so that they would serve as loss leaders and as an example of what a good job it could do. My cynicism was not justified, because although a man called Neil Bentley from the CBI has declared them to be a success, he obviously lives in an evidence-free zone. Since the new company took over, appointment times for each patient have been reduced from 15 minutes to 10. If the visit or appointment is unscheduled, people get only 5 minutes and are told that they can talk about only one problem, even if they have more. The new company has not complied with the extra opening hours that the contract specified, and which it undertook to deliver. It closed a baby clinic and then had to reopen it in response to a public outcry. There are rumours—although they are denied—that the company is in the process of going back to the primary care trust to ask for more money.
That is what has been happening in my constituency, and now we have proposals for polyclinics. These, we are told, will provide community-based diagnostics. There are apparently three proposals for polyclinics in my constituency, and as part of the move to community-based diagnostics, one will be at University College London hospital and another will be at the Royal Free hospital, so we will actually have hospital-based diagnostics and—this will be a novelty—hospital-based community and GP services. Originally, polyclinics were to be targeted at under-doctored areas and populations, which might be worth while if it were the only way to secure the extra doctors and better services required to meet people's needs. But those needs vary from place to place, depending on the geography and on the nature of the population. I have always believed in horses for courses, but I do not think that the Government do. In London, it is certainly not horses for courses but "Thou shalt have a polyclinic." I also believe that it would be a good idea for these things to be tried out in pilot schemes in various parts of the country.
I must remind Ministers that, generally speaking, GP services are very cost-effective, particularly in their role as gatekeeper for the rest of the national health service. I am sure that the Minister would have to confirm that when he talks to Health Ministers from abroad they are envious of the impact of GP services on keeping down costs. It looks, from such evidence as is available, as though where polyclinics, or something like them, exist, more investigations and tests are prescribed, often wastefully, as in the United States—perhaps less so in Germany—and more people are referred to hospital as in-patients. Both those developments may be a good thing from the point of view of patients, but they may also be on the excessive side.
I have some questions, to which I have not managed to get answers, about the proposed polyclinic at University College hospital. It appears that that scheme will involve everybody who goes there for GP services, as well as everybody who goes to accident and emergency and can walk into the place, as opposed to arriving by ambulance. In effect, far from there being a shift to community services, we are moving towards provision being increasingly concentrated in the hospital. Will the doctors there be able to refer people to other hospitals instead of University College hospital, where the polyclinic will be located?
Then there is the question of the impact on the area's existing GP services, which are convenient and familiar—two things that appeal particularly to older people, disabled people and families with children. It is also the case that nearly everyone looks for some continuity of care by seeing the same doctor, if at all possible.
Ministers have said that no one will be forced to join a polyclinic, but when the companies' contracts come up for renewal, will they get them renewed, will the same terms be available to them, and, more importantly, will they be entitled to apply to some of the practices outside the polyclinic? That is not clear at the moment.
That brings me to the question of who will own the polyclinic. Will it be a private sector outfit? Will UnitedHealthcare, which has already taken over the three GP practices in the area, be able to bid for and take over the polyclinic? If so, that will be despite the fact that its owners have been indicted for fraud and every form of swindling of taxpayers, patients and doctors in the United States. If it gets the polyclinic contract, will it also get the out-of-hours contract, for which it is believed to be bidding? If so, we would end up with a US company having something approaching a local monopoly in part of my area. I remind Ministers that the first priority and statutory duty of the people running a private sector company is to put the interests and needs of shareholders first. It is not just me who says that. Mr. David Worskett, director of the self-styled NHS Partners Network, which is in the private sector, has said:
"The independent sector has to protect shareholders' interests".
This company, as an American company, believes in turning diseases into a commodity; that is how it has made its money over the years.
Camden primary care trust is already putting a massive effort into promoting polyclinics at University College hospital and the Royal Free hospital, but it is not putting the same effort into two practices in Kentish Town that have put themselves forward as a possible polyclinic. They have not had the same level of involvement from officialdom, yet they have a fine track record. They have been providing primary care. They have arranged for consultants to come out and see their patients in their practices. They have run drug and alcohol clinics. They have helped people suffering from drug and alcohol problems to find employment. They have provided psychological medicine. They have provided help for children and families. Social workers have operated from their premises, and so have people from the voluntary sector. These people have a proven commitment and competence, and to develop what they are doing would be the sort of organic development to which the Government should be committed—going with the grain, from the point of view of patients and professionals.
The London polyclinic proposals are not like that. The Secretary of State and the London health lot say that the proposals are led by the NHS in London, not the Government. I do not understand that. Professor Ara Darzi, who is a most distinguished surgeon and a highly intelligent and charming man, put forward the polyclinic proposals for London. He is a Minister in this Government. Mr. Paul Corrigan, who used to work at Downing street, is the London director of strategy and commissioning in London, and the benighted Lord Warner is chair of the provider agency in London, following his departure from office as a Minister just before all the trouble arose over the problems of junior doctors. Let us assume for a minute that there is no Government influence in the matter. That means that the strategic health authority, which is not accountable to anyone, and the primary care trust, which is not accountable to anyone, are taking decisions. In the end, however, Ministers are responsible, and I believe that they ought to take a step back.
The next thing I have to say is something conservative: remember the cost of change. The process of change is immensely costly, in terms of money and the amount of time and effort that people have to put into the process of change. I believe that Ministers—
My constituents in Scarborough are perplexed, confused and angered by the proposals. If the Minister comes to Scarborough, as I hope he will very soon, to talk to people there, he will hear that they want more money to be spent on a number of areas in the health service, such as dentistry.
Scarborough hit the headlines two or three years ago when we had queues going round the block, reminiscent of the Soviet Union bread queues, when it was rumoured that an NHS dentistry practice was opening up. People are very concerned about out-of-hours services, and four years ago the local primary care trust upset the applecart when, by putting the out-of-hours service out to tender, local GPs who were covering those services and providing cover at the local community hospital found that they did not get the contract for such services in the countryside, which meant that they could not also cover the hospital. A lot of money was wasted in one case, when dentists from Germany were brought, at £700 a night for 10 nights at a time, to provide cover.
Whitby hospital in the north of my constituency is being subjected to death by a thousand cuts, according to many in that area. Services have been reduced. The accident and emergency service is under siege because of the list of incidents that ambulance drivers are told they must not take to Whitby—only the most minor of injuries and illnesses are dealt with there. Maternity is currently under review at Whitby because we are told there is no demand for maternity services. That could be something to do with the fact that maternity is open only from 9 until 5. The health service is under siege in my constituency, and the Government are coming up with a solution to a problem that many people do not see.
I would like to share with the House a letter that I recently received from one of my constituents, Mary Thompson. She writes:
"The last time I wrote to an M.P., it was to complain to Lawrie Quinn"— my predecessor—
"about the lack of N.H.S. dentists in Scarborough. The situation has got worse since then, but I must keep trying.
This time, it is still the N.H.S., but I would like to tell you about some of my husband Eric's experiences since being diagnosed with bowel cancer four years ago.
After two major operations, chemotherapy and radiotherapy, the cancer returned and Eric was referred to the Leeds General Infirmary by Scarborough Hospital, who were unable to do any more for him. We saw a Mr. Sagar who arranged for several tests, including a PET scan in London"—
250 miles away—
"for which we had to arrange and pay for transport ourselves—no mean feat for someone who had great difficulty sitting comfortably due to the nature of his illness. Eric's operation was arranged for August 18th, the long delay" of five months
"in part due to the fact that a urology team had to be on stand-by as well as the bowel team, and a high dependency bed was also needed as it was not certain that he would even stand the surgery, so big an operation was planned. On the day, Eric was gowned and ready for theatre when Mr. Sagar arrived to see him, extremely angry, to say that the operation would have to be cancelled, because of the two high dependency beds available to him, one had been given to a road accident victim, and the other was needed for the person whose operation was before Eric's—his need was deemed the greatest.
Apparently there is a shortage of high dependency beds due to government cuts. Eric was allowed to go home for the weekend, but had to return on the Monday to keep his bed."
That is a 120-mile round trip. The letter continues:
"The operation now took place the following Thursday, and though successful, was incomplete as he was left with two nephrostomies (tubes leading directly out of his back from his kidneys, emptying into two bags attached to his legs) instead of the urostomy which had been planned. We were never told whether this was due to the postponement of the operation and consequent changes of staff.
After going home, Eric became very ill on September 21st and our G.P. arranged for an ambulance to take him to the A&E at Scarborough Hospital. We waited two hours, then our son arrived, so we cancelled the ambulance and got Eric to the hospital in his car, where we had the usual long wait in A&E. Eric was unable to stand and found the chairs there very uncomfortable, given his condition. I remarked to a nurse that we had been waiting a long time and she snapped back 'Everyone has to wait—it's part of the system'"—
Order. I am sorry to interrupt the hon. Gentleman, but he is going into considerable detail on a matter that appears to lie outside the terms of the motion and the amendment, which are about primary care as opposed to the secondary sector, to which he is referring. May I suggest that he try to move back pretty quickly to the primary care sector?
I thank you for that guidance, Mr. Deputy Speaker. I am trying to show where we need better spending in the health service. Mrs. Thompson closes her letter by saying that better medical facilities are needed and that she does not know where all the money is being spent.
In Scarborough hospital, we need money to be spent on the deep clean which has still not been delivered. Last year, 600 jobs were going to be cut. I hope that the Minister will visit Scarborough and see where we need to spend money. We clearly do not need to spend it on a polyclinic.
In February, the PCT was told that there had to be a polyclinic somewhere in Yorkshire, and several sites were considered, including Selby and York, before it was decided that Scarborough would be the place for it. People in Scarborough feel strongly that they do not want it; they want services through their GP. Our local newspaper asked people on the streets what they thought. Mrs. Marcia Waddington said:
"I know change has to happen but I think change is not always for the better. This Government might think bigger is better but sometimes it is not."
He husband added:
"The older generation especially prefer to see a GP who knows them and their background. It just wouldn't be the same."
A lady from Colescliffe road said:
"I don't want to go to a super surgery. I want to go to my doctor's surgery. We don't need these types of surgeries. I know my doctors and like them."
I pay tribute to Mr. John Palethorpe, who led the campaign last year to save services at Scarborough hospital and has been leading the campaign this week to save our GP services. The relationship between the patient and the GP is the most valuable part of our health service. The proposal to parachute a polyclinic into Scarborough would jeopardise that important relationship. We already have a facility in Scarborough where a variety of services are available, but which is underfunded, namely Scarborough hospital. If the Minister has £1 million in his back pocket, may I suggest that he invest it in Scarborough hospital, rather than providing us with a polyclinic that neither the GPs nor the patients want?
Will the Minister clarify the situation when he winds up the debate? We were told that there would be a single unit in the middle of the old town in Scarborough, but only yesterday there was a report in the Scarborough Evening News of a meeting held on Saturday about the new super-surgery, at which the head of commissioning, Jane Marshall, said that
"the plans would likely encompass services in a number of locations rather than an all-under-one-roof service."
The Secretary of State was talking about clinics in one place. How will he deliver on the improvements that he claims he can, if services are provided in a number of locations? Will all those locations be open from 8 am to 8 pm, seven days a week, or is the local primary care trust, realising that what is proposed is not wanted, trying to come up with imaginative and innovative ways to spend the money?
The polyclinic in Scarborough is not wanted by patients or GPs. If the Minister has the money to invest in the health service in Scarborough, there are a number of areas, including dentistry, Whitby hospital and Scarborough hospital, where it could be better spent.
Order. In order to be fair to the seven hon. Members who are seeking to take part in the debate, I am making the time limit nine minutes. That should, I hope, meet everyone's needs.
The debate has shown that needs differ throughout the country. I cannot understand why the Government are not standing by their rhetoric that all change should be locally led. It is quite clear that change is not locally led, except in the sense that there is a lot of anticipatory compliance in the modern NHS.
When I started receiving communications from my local GPs and constituents about the new provision, which they felt threatened their existing surgeries, I immediately contacted the PCT to find out what it was all about. On the surface, providing additional services seemed an excellent idea, so I got hold of the PCT report about the proposal. As I mentioned in my intervention on the Secretary of State, it is quite clear that the PCT is not leading the proposals. Indeed, when I asked the PCT whether the proposal was one that it would chose to spend the additional resources on, in order to improve health inequalities in south Birmingham, it was clear that it was not.
We do not have an easily identifiable gap in services. The PCT proposes to locate the new 8 am to 8 pm health centre in the Selly Oak part of my constituency, for two reasons. First, it is on a main road. Secondly, because of the short time scale—the PCT has to have the centre up and running by
On the Bristol road in Selly Oak, where the health centre is proposed, there is a new £2 million investment by one of the local GP practices, which is set to double its GP list—it is expecting to take on an additional 4,000 patients. The development has been five years in the making, with full support from the PCT, and will provide services in addition to GP services. This GP approached me many years ago; he was concerned about the lack of services to combat osteoporosis, which is common in women, and he remains concerned about ill health prevention and equality of access to services.
In King's Heath, the currently favoured location for the GP-led practice, a new health centre has just opened, providing full GP and other services and an associated new pharmacy. The location of the proposed new practice is near at least three other GP practices. I know that very well, because it is where I live.
That is absolutely right. Obviously, the PCT would not earn brownie points if it failed to go along with these proposals.
When I heard about these proposals, I immediately thought, "Why should these new services threaten existing services?", but it is quite clear that the health centre is expected to take on 6,000 patients, as is the GP-led centre. Yes, they will also take people who are not registered and there is certainly a need for the proposed services, but the GPs say they would be delighted to provide those services if only there were an opportunity for them to expand existing provision. It seems, however, that the rules say that the premises have to be completely new, so they are not in accordance with the idea of expanding existing GP provision.
When I started to investigate these issues I was worried, so I went back to the Darzi interim report and tried to find the logic behind these proposals. I found that Darzi had noted that life expectancy was lower in areas where there were fewer GPs per head of population. That may well be the case, but I am not sure that the conclusion follows—that the way to deal with the problem is to develop 150 GP-led centres and to provide new GP practices in areas where there are health inequalities. It is not exactly logical to deduce that that is the way to deal with the problem. I read the report, but I could not understand the thinking that led Lord Darzi to decide that this was the solution to under-doctoring. I certainly could not understand why he should view it as a blueprint to be applied across all PCTs. The under-doctoring in my constituency, for example, is not particularly great and it is spread out—there is no single location where there is a problem.
It seems to me that the Government should stop portraying the debate over these issues in terms of the BMA and the Tory party being opposed to genuine locally led improvements in service. That is not the case. Two of the GPs who contacted me about this issue are members of the Labour party and they are actively interested in improving services to their patients and reducing inequalities. One made a submission to the Select Committee on Health and is active in the Socialist Health Association. These are not people who naturally look to the Conservative party to champion their cause. They are very worried—and their worries were confirmed by a conversation I had with the lead officer at the PCT—that this is just an excuse to bring in the private sector and provide competition, which is seen as the way to make GPs buck up their ideas and improve their services. I do not think that the GPs in my area need that kind of competition. They want improvements in service. They put in bids to expand their practices. They are outraged because they were told a year or two ago that they should cease providing Saturday morning services and are now being told that that is what they must provide.
Yes. A couple of my constituents recently changed practice. One of them has mental health problems and, having talked to the new GP, felt that he was more sympathetic to her. GPs are even willing to engage with patients when they want to find out whether it would be a good idea to move to their practice. That is already possible.
Many GPs would like to provide the proposed services, but they say that there is no level playing field. The new provision is being procured through the standard procedure, which gives large alternative provider medical services an administrative advantage. Those services are bidding for other contracts and are set up for that kind of work, which is not the case for GPs. Some GPs who have expressed an interest in bidding for the services were given 24 hours' notice of a bidder event day. Most of those who have looked into the possibility of tendering do not believe that they are in a position to do so. It would divert their attention from what they should be doing, which is providing high-quality services for their patients.
I ask the Government to look seriously at the criticisms made today, particularly by Labour Members. We believe that the Government have much to be proud of in terms of developments in the health service. There is no doubt that health services have improved dramatically since 1997. We have 5,000 more GPs, and GPs now have more time to spend with their patients. However, the Government should not simply dismiss the concerns of GPs because they think that they are being oppositionist for opposition's sake. There are many good reasons why the BMA in general and GPs in my constituency are concerned about the proposals. They believe that they will destabilise existing services. How will a practice that is expanding, taking on an additional 4,000 patients, continue when there is going to be a new health centre over the road, potentially taking on 6,000 patients? It will have to take on additional patients if it is to continue to receive funding beyond the five-year allocation. In the end, the money will be allocated to the general pot and there will be no specific allocation for the proposed services.
I urge my hon. Friend—
We are two hours into the debate and we have yet to hear anyone speak in support of the Government's policies on polyclinics. I am sure that the Whips are going around trying to find someone who will speak up in favour of what the Government are talking about.
It is a particular pleasure to follow Lynne Jones. I could not agree more that all the change in health care should be locally led. I am sure that the Minister will have paid close attention to Frank Dobson who, after all, was the Government's first Health Secretary and talks a great deal of common sense on these matters.
There is nothing more important than primary health care because it is the primary interface that patients have with the health care service. That is particularly so for older residents and the very young in our communities. GP surgeries are often the last community-based service that is available not just in villages but in the suburbs. It is a service that gives people access to the NHS at the heart of their communities, close to their homes, and its future should be driven and shaped by those communities to ensure that it meets their needs. Lord Darzi made great play of that recently when he visited the constituency next to mine, just outside Basingstoke, to talk about the future of polyclinics or GP-led health centres.
The problem we face in my constituency is that the Government have great house building targets for Basingstoke—with which many local people, including me, do not agree—that are not matched by a similar expansion of local surgeries, including GPs' surgeries. About 1,000 houses a year are being built, there has been a 13 per cent. increase in the number of babies born in our local hospital, and the fastest-growing group of people in my constituency are those aged 65 and over: the pensioners of north Hampshire. However, we are seeing a real lack of support for the development of those important primary health care services in my community.
Let me give three examples. Merton Rise is a family development north of Basingstoke. The plan was to have a GP's surgery at the heart of it, but that has been axed. Rooksdown, in the neighbouring constituency of North-East Hampshire, is also a family-based community. For four years, a portakabin has delivered important GP services to families who have produced not just one or two but as many as three babies while they have been living in that community. In the ward of South Ham, 25 per cent. of residents are over 65, and the largest number of 70-year-olds in the borough live there; however, its 1960s GP's surgery is bursting at the seams and long overdue for replacement.
Although it is clear that Basingstoke greatly needs investment in primary care, no money has been forthcoming. However, the town has been identified as the favoured location in Hampshire for a town-centre polyclinic. Our PCT has told us that we must have one—we know that it has little choice in the matter—and it will be a significant distance from the communities that I have described. Moreover, the main rationale for the polyclinic is that Basingstoke is a commuter town. Polyclinics may have a role to play in urban and metropolitan areas, but they do not meet the urgent and pressing needs of families and elderly people in the outlying suburbs of Basingstoke. There is a need for basic GP provision, not a centrally dictated solution to a problem that is not the first priority for local residents. It seems perverse to spend money on increased access for commuters rather than mothers with young babies and the over-70s.
Basingstoke's town centre already has plenty of GP provision, for historical reasons. We have a newly located GP's surgery, offering an extended range of services, right next door to our station. However, I understand that the present rules will not allow it to bid for a polyclinic, so there is a possibility of duplication where we really do not need it.
The Government have put great emphasis on new funding, but it is not altogether clear that the message has reached the PCT in Hampshire. The matter was discussed in some detail at a PCT board meeting in March. According to the board papers, the chairman of the PCT patient and public involvement forum asked whether any services would have to be cut
"to enable this requirement to progress"— that is, the requirement for a GP-led health centre. The PCT responded that the priorities would need to be "reassessed", which does not sound to me like a guarantee against cuts in health care services in the Hampshire area. Perhaps the Minister will clarify that when he winds up the debate.
If patients can register with an expensively laid-out new centre, they will take their money away from the GP's surgery—perhaps in the countryside, in an area such as the East Riding of Yorkshire—with which they are currently registered. That would undermine the funding of the surgery, and lead to the closure of GP services in areas such as Leven and Beeford in my constituency.
That is an excellent point. My constituency also contains rural areas. I have already received letters from areas north of Basingstoke such as Bramley, where it is feared that the viability of providing GP services will be undermined. It is not, however, just a question of money. My main worry is that Hampshire PCT's attention will be diverted from resolving Basingstoke's genuine primary care needs. The PCT has just undergone an enormous reorganisation, and is now the largest in the country. It is clear that it has been struggling to deal with specific local problems, including the delivery of primary care in Basingstoke.
During Health questions earlier today, the Secretary of State said that the Government had no intention of removing existing services, but by definition money will be diverted—whether it comes from the Secretary of State or the PCT—from solving the problems in existing services and ensuring that they can meet the needs of local residents. We must look after the elderly and families, those who need support the most, before turning our attention to other priorities that the Government may have—priorities that may be absolutely right for metropolitan and urban areas such as London, but do not hit the mark when it comes to our problems in Basingstoke.
There is something funny about this debate. I am the only practising GP left in the House of Commons, and apparently I am the only one with a good word to say about polyclinics. I honestly believe that they will give patients access to services that currently require some to travel many miles, and to which many others simply do not have adequate access.
In my view, Ministers have given sufficient reassurance that most of the new services will be in addition to the existing ones. GPs will be able to work on a hub and spoke model, retaining their own practices if that is what suits the locality, or to locate their practices in polyclinics, maintaining the integrity of those practices while having access to all the extra services that are currently not so accessible.
The idea of polyclinics is not new. A recent King's Fund paper on the subject refers to the Dawson report of 1920, which set out a vision of primary health centres that would focus on "curative and preventative medicine" and would provide an opportunity for GPs, nursing professionals, visiting consultants and specialists to work alongside one another. That model is exactly the same as the polyclinic model of today.
The King's Fund paper suggests that one of the reasons the concept has not made much headway since then is the
"singular lack of enthusiasm from the medical profession and in particular its BMA representatives".
The National Health Service Act 1946 allowed health centres along the lines proposed by Dawson to be set up but did not make their adoption mandatory, despite Bevan's enthusiasm for the idea, owing largely to opposition from the professionals. Their opposition stemmed from
"the BMA's hostility to any proposal which appeared to turn GPs into public servants".
Unsurprisingly, therefore, by 1963 only 18 purpose-built health centres were in place.
Vested professional interests were also partly to blame for the failure of the East German polyclinic model to survive reunification. In 2005, an article in the British Medical Journal by German academics explained:
"State owned policlinics were one component of primary health care in former East Germany, housing general and specialist doctors and dentists. This integrated model was efficient and cost saving: facilities and laboratories were shared, alternative treatment and prevention strategies were coordinated, and referrals to specialists were well monitored, as well as each patient's case. Policlinics did not conform to the West German concept of independently contracted doctors paid on the basis of an item of service, so they did not survive in East Germany after 1995."
However, five years later, in 2000, the polyclinic model was back on the agenda in Germany, having been reinstigated by German policy makers in a bid to
"increase cooperation between general doctors, specialists, and hospitals; to improve communication between institutions; and to reduce healthcare costs."
That illustrates that we need to be extremely wary about the opposition to the current polyclinics proposals expressed by professional trade unions such as the BMA. The BMA says that it is not opposed to the polyclinics model per se, but that they need to be introduced gradually over time and not be imposed centrally, and that proper regard must be paid to the specific character of each local health economy. That is a perfectly sensible position to adopt, except that the BMA has been saying exactly that from 1920 onwards.
As long as the polyclinic model remains an aspiration rather than a specific policy objective, the chances are that we will never see them in place across the country. As one speaker said last week at a meeting on polyclinics of the all-party group on pharmacy that I chaired, the irony is that the polyclinic model now being proposed has in fact existed for years in one branch of associated health care at least: veterinary care. In that field, large, one-stop, city centre clinics, comprising both generalists and specialists, and with impressive on-site diagnostic and treatment facilities, have been in place for years and have worked very well. It is a pity that the owners of the animals that are benefiting from that kind of one-stop, integrated care are still waiting for something similar to materialise in the NHS.
Other health care systems around the world have, of course, been using the polyclinic model for years. The polyclinic proposal is far from being the untried, untested, experimental model of care that many in the media have claimed. As the NHS Confederation has stated:
"The principles behind the idea of polyclinics are in line with the way in which healthcare is developing across the world. The design rules that underlie the idea of polyclinics appear to be fairly uncontroversial."
The case in favour of polyclinics is, in fact, unarguable. They provide an unrivalled opportunity to create larger groupings of primary care professionals, and to create a critical mass that will allow an enhanced range of services to be provided. They exploit economies of scale to provide greatly extended diagnostic support with rapid access and turnaround, and a range of other services that are difficult to offer in smaller practices. They reduce the need for patients to travel to hospital by relocating high volume work that does not require hospital infrastructure. They will integrate services to break down the traditional barrier between primary and secondary care and provide opportunities for specialists to work alongside their colleagues in primary care. They will also create space for other services, including community health services and other related health, social care, leisure, housing and benefits services that patients, professionals and the community will value.
There is, of course, a range of issues around how, where and why polyclinics are to be implemented, but none of the concerns that have been expressed is insuperable. The idea that they will inevitably undermine the direct relationship between a GP and their patient, for instance, is wide of the mark. The Berlin polyclinic, Polikum, uses a web-based scheduling system to ensure that patients who want to see their own primary care doctor can do so. They may only be able to see their GP during certain periods of the week, but that is no different from how the current system works. As now, patients have to weigh up whether a familiar face is more important to them than speed of access.
Nor is it necessarily true that patients will have to travel further to see a GP. The hub and spoke model suggested in the Healthcare for London plans offers the potential to preserve local access while at the same time providing a community health care hub that offers a broad range of diagnostic and treatment services. In Liverpool, for example, the local PCT has set up a network of neighbourhood health centres and NHS treatment centres. Under that system, no patient is more than 15 minutes' walking time from GP services while there has been a corresponding shift of services out of hospitals and into the community closer to where people live.
I suggest that the real issue is not whether the principle behind the polyclinics is the right one—I do not know of any serious commentator who fundamentally disagrees with them—but relates to their implementation, about which legitimate fears have been expressed. For example, the risk is that they could end up duplicating existing services provided in the community, and therefore waste money by creating overcapacity. If, however, their implementation is properly planned and managed and due regard is paid to current services, there is good evidence to suggest that they will help us make more efficient use of existing resources. Well-organised and integrated systems improve cost-effectiveness, reduce follow-up appointments and duplicated tests and improve the quality of care. The Kaiser Permanente model in the US shows us how this can be done, and provided that the polyclinic service contract is properly set and monitored, there is no reason to think that the advent of new providers will impact negatively on the quality of care offered to patients. After all, GPs are, and have always been, independent, for-profit contractors operating within the NHS. Those are the rules GPs elected to play by when the NHS was set up. With proper debate and consultation and due care taken in the commissioning process, there is every reason to think that polyclinics can lead to substantial benefits in terms of the quality of care offered to patients.
May I begin by declaring that I am a member of the British Medical Association and a fellow of the Royal College of Physicians? I am not speaking in order to give any official message from either of those organisations, however; I am speaking entirely on my own behalf, and on behalf of my constituents, local GPs and NHS professionals who have spoken to me.
The debate has produced a huge benefit already, in that we should all now know what we mean by a polyclinic and a GP-led health centre. To me, a polyclinic is a body that brings together GP services, investigative services, probably hospital consultant clinics and probably a headquarters for community services, as well as dental services. That could be perfectly satisfactory in certain areas, particularly in big cities, although I note what Lynne Jones said about her part of Birmingham.
As for GP-led health centres, the Secretary of State has made it absolutely clear that they need only have three characteristics: they have to be accessible, to be open from 8 am to 8 pm 365 days a year, and to be able to accommodate drop-in patients and registered patients.
I am grateful to the Minister for his reply to my parliamentary question of
"whether the decision to have a polyclinic in a primary care trust area is a decision to be made locally."
If I may, I want to take his answer apart, and agree with certain bits and ask further questions.
The first sentence of the answer is as follows:
"How primary care trusts...choose to configure or commission local primary medical care services is a local matter."
That is absolutely right; it certainly should be. I agree with that.
The second sentence of the answer is:
"However, all PCTs have been asked to commission additional general practitioner (GP)-led health centre services and have been given additional funding to secure those services."
The key word there is "additional". I met the chair and chief executive of my own PCT yesterday, and in their paper about their plans for future health services in Worcestershire they state that the Department of Health requires every PCT to establish a
"new GP-led Health Centre".
To my mind, the difference between "new" and "additional" is vital, and I will return to it. I am a little confused about the reference to extra funding; is it really new additional funding, or is it part of the growth money already announced and passed to PCTs?
The final sentence of the Minister's answer to my question is crucial:
"PCTs will decide after local consultation where and how these services should be provided and will carry out an open and fair procurement to secure the services they specify."
Deciding "where and how" is crucial. If extra hours and extra capacity are needed, some of the existing health centres around the country—this is certainly the case in my area—are closed from 6.30 pm and throughout every weekend, so spare capacity exists that could be used.
In Worcestershire, the GP-led health centre is likely to be in Worcester, the largest town. If only the money for such services were given to the PCTs without strings attached, it might be feasible in Worcestershire to put in place three of these health centres—one in each major town. That would spread the benefit of 8 am to 8 pm opening and the benefit of such centres being open for the entire weekend across the county, but, as it stands, only those who are near enough in the city of Worcester will benefit. Such an arrangement would almost certainly do away with the need for new premises, because that existing spare capacity could be used. That would lessen the worry about continuity of care, and about the lack of local knowledge and of previous knowledge about patients, and it could even mean a rotation between different practices within a given area. Such an arrangement would be ideal. I am asking the Government to get away from insisting that these must be new services, because they could be additional services in areas where there is the capacity to provide it.
Several right hon. and hon. Members have mentioned worries about the back door into commercialisation, and I share that fear. The last part of the answer to my written question stated:
"PCTs...will carry out an open and fair procurement to secure the services they specify."—[ Hansard, 16 June 2008; Vol. 477, c. 768W.]
If it really is open and fair, and if account is taken of the lack of need to build new premises if spare capacity in existing health centres is used, existing practices could probably compete on a fair basis with the huge commercial organisations that are gearing up to compete for the provision of such services.
The fears of commercialisation have been rehearsed by Labour Members, and, in the interests of speed, I shall not go into them. I just want to remind the House about the need for local consultation and for accountability to local people. I went to a lunchtime launch of the Local Government Association health commission's final report on accountability, the executive summary of which said:
"More recently, there has been a conscious effort to devolve decision-making, giving greater autonomy to NHS providers and setting a smaller number of national standards to sit alongside ones that are locally agreed."
That is how we should decide on GP-led health centres, where they will be and what they will provide. I am convinced that GPs in their existing practices in the health centres could provide accessible 8 am to 8 pm, 365 days a year, drop-in and registrable services.
There are alarms about commercialisation, and I wish to request a meeting with the Minister to rehearse with him some of the alarming allegations that I have received about how some of the commercial organisations function and to share with him two crucial letters in the medical press that sound warnings about commercialisation from the United States. I also wish to share the sensible points made by the organisation that is completely divorced from the BMA and is thoroughly rooted in the interests of patients: Keep our NHS public. I humbly request such a meeting.
One of the most disappointing things about this debate and the motion is that they are focused entirely on the providers and not on where they should be focused—on the patients. That says an awful lot about the stance of the Conservative party.
Mrs. Miller said that nobody had spoken in favour of polyclinics, although my hon. Friend Dr. Stoate just did so. One of the reasons why that has been the case is that nobody has a health centre in their constituency. Interestingly, Norman Lamb was calling for pilot schemes. I can tell him that we have quite a number of pilot schemes. In fact, he referred to some of them, in the sense that 12 areas have health centres, and Wigan is one of them. Indeed, Wigan was one of the first boroughs to have a local improvement finance trust—LIFT—centre. Parts of the borough have some of the worst health statistics in the north-west and, thus, in the whole country. It is also one of the most under-doctored areas in the country.
The King's Fund, which was cited by the hon. Member for North Norfolk, has made a number of comments about health centres. I do not recognise those comments in respect of how we run the health centres and our LIFT programme in Wigan. For instance, it mentioned poor management, but each of our six health centres has a manager in charge to ensure that the organisation within, and between, the services provided is properly carried out. The King's Fund also mentioned a lack of innovation, but Wigan has a new and important innovation—our "Find and Treat" approach, whereby local GPs, through the health centres, go into the community seeking people who are particularly vulnerable to strokes and cardiac problems and try to bring them into the health centres for treatment. Rather than waiting for people to come once they have had their stroke or heart attack, when it is often too late, GPs are going out to ensure that we can treat them before that happens.
Most of the speeches that I have heard today did not attack polyclinics per se and did not say that they cannot contribute to local health needs. The main issue taken up by those opposing the Government plan is that polyclinics are to be imposed from the centre on every area, even when there would be better ways of spending the money. Dr. Taylor talked very well about how the money could be used creatively, using existing assets to deliver much more benefit for patients.
I disagree with that analysis, because I do not think that is true. I think that health centres and polyclinics for the London area will provide better services and better outcomes for the patients. Our health centres in Wigan are doing that. They have the strong support of my three colleagues who also represent the borough—my right hon. Friends the Members for Makerfield (Mr. McCartney) and for Leigh (Andy Burnham), and my hon. Friend Barbara Keeley. They all support the health clinics and the extension of the health clinic principle throughout the borough. Our six centres are all large, modern, adaptable buildings. The primary care trust arranges the sub-leases and each local health centre provides a massive range of services. Fundamental to that is a GP practice—or in several cases, a number of GP practices, all of which are local and none of which is provided by Virgin or any of the other organisations that have been mentioned. They are all local GPs who have voluntarily gone into those health centres to ensure that they can provide a better service from a better facility.
Most of the centres also have a pharmacy, and the centres provide an enormous range of services. We are talking about child care, audiology, district nurses, community mental health, out-of-hours nurses, family planning advice, diabetic retinopathy—I am sure that my hon. Friend the Member for Dartford knows what that means—integrated therapy for children with special needs, minor surgery units, podiatry, physiotherapy, speech and language therapy, and older people's services. That list goes on and on, and many of those services are provided in most of the clinics.
I want to give a couple of examples of what is done in one or two of the health centres, particularly the Platt Bridge health centre, which is in the Makerfield constituency. It covers a former mining community with immense health and social problems, and severe deprivation—it is in the 3 per cent. most deprived super output areas in the country. The health centre is marked out not because of the services it provides, although those are excellent—they include a hydrotherapy service—but because of the way in which my right hon. Friend the Member for Makerfield managed to get the primary care trust and the local authority to work together so that this is not just a health centre. It is in a huge complex that includes a school, library and community centre, all of which work together to provide a major centre for that deprived community, which has been given a belief in itself and confidence in its future. That would not have been provided unless the LIFT programme had provided the PCT with the catalyst for that centre.
In Wigan, we have Boston House, named after Billy Boston, who was probably the greatest rugby league winger ever—as I am sure Greg Mulholland will agree. It has a GP facility and a pharmacy, and provides nurse training provision, health education, podiatry and audiology. It has a 19-bed physiotherapy unit, but what sets Boston House apart from all the others—and is especially important for the people of Wigan—is the fact that it has an 18-bed renal dialysis unit. People from Wigan who needed dialysis used to have to travel to Salford or Bolton, which took a full day. That was disruptive and in some cases distressing for the patients and their families. Now, they can have dialysis in Wigan, and that is much less disruptive. I have talked to the patients involved and I know that it has massively improved their quality of life.
If the hon. Gentleman wants to improve his health, it is not too late to register to play in the rugby league match a week on Saturday.
The hon. Gentleman describes a facility that is clearly popular and works. Does he agree that that might work in Wigan, but is not necessarily the answer in Leeds, North-West or other areas? The imposition by the Government is the heart of the problem.
One of the problems with this debate is that so many people say that it might not be the answer in their area, but not one of the hon. Members who has said that has had experience of it working in their constituencies. If hon. Members want to see how it works, I invite them to come to Wigan and talk to the people who provide the services in those health centres and, especially, to the patients, to see whether they like the centres. Instead of going along with the BMA's claims, hon. Members should come and see the reality on the ground. Then they might change their minds. The first three health centres in Wigan were not built in my constituency, and I knocked on the door of my PCT to ask when it would get one. Now it has.
We have two other health centres in Wigan. The Sherwood Drive health centre has GPs and provides minor surgery services, a pharmacy and, after a recent extension, a dental practice. The Beech Hill health centre, which is my local one, is a GP centre with a pharmacy attached, and it provides numerous other services.
Boston House health centre was provided by the LIFT programme, the Sherwood Drive health centre was provided by a private sector company, which has since sold it to the PCT, and the Beech Hill health centre was one of the very earliest health centres, built in the 1960s, and the GP practice has now moved into a modern centre. So there are many ways to provide those services. It is not a question of one size fits all.
We will not rest on what we have done, excellent though that is. We welcome the extra funding for the health centres and we hope to have more such centres in the future. For example, one will complement the walk-in centre in Leigh, a second will be based in Ashton and a third in the Whelley/Scholes area in my constituency. The PCT has plans for three further primary care centres, plus one GP-led health centre in Wigan town centre, which will provide the services that the Secretary of State described earlier. In addition, it will provide services for homeless people, which are important.
Because we have been so under-doctored, and GPs surgeries have been poor in the past, people have used accident and emergency at the hospital instead. Wigan A and E is a major trauma centre—it is next-door to the motorway—and has a high-dependency unit and an intensive care unit. Using doctors trained to provide those services for what is, in essence, primary care had a deleterious effect. The health centres, with their longer opening hours and wider range of services, have a beneficial effect. We need more such health centres, because we want to shift the NHS from being an organisation that treats ill health to one that intervenes to prevent people from getting ill.
I wished to speak only because I have been genuinely shocked by aspects of the campaign that has been waged on this issue. Perhaps I am too easily shocked, but there has been a dishonesty in some of the campaigning that has caused much anxiety and even illness in some people. I had an elderly lady phone my office this week, and she said that when she had gone to her GP surgery she had been told that it would close. I checked with the PCT which told me that the surgery had plans to expand. It may seem clever to campaign in that way, but for people who claim to be concerned with the health of others, it is having a serious and damaging effect.
"The Act is part of the nationalisation programme which is being steadily pursued by the Government."
Section 21 of that Act stated:
"It shall be the duty of every local health authority to provide, equip, and maintain to the satisfaction of the Ministry, premises which shall be called 'Health Centres'".
The BMA said that health centres would be introduced over its dead body and, indeed, 10 years after the NHS was established, there were only 10 health centres in this country. That was because the GPs, represented by the BMA, would not have them. It has taken us a long time to realise that having a network of well equipped and professional health centres will have an immeasurably beneficial effect on the health of the population.
When I was elected to Parliament in 1992, the report from the director of public health in Staffordshire said that my constituency, a former mining area, had the worst health, the greatest number of single-handed GPs and the highest incidence of secondary referrals from GPs to hospitals—usually an indicator of insecure medical practice—in the area. It was essential that that situation be transformed, and I can report that in many respects it has been. Because of investment, we now have a raft of state-of-the-art health centres across the district. Nobody would now claim that such developments are not beneficial to the health of the population. The idea that anybody could have resisted the development of health centres sounds so ludicrous now, and it will seem ludicrous in the future that anybody could resist the development of the next stage in health care, which is what we are talking about now.
I am a great admirer of the primary care system of traditional family doctors, but unfortunately it has to be said that it has been very difficult over the years to make the necessary reforms of that system. To compress a short history, I was alarmed for many years that there was no proper system for the clinical audit of general practitioners. It took the horrors of Shipman to produce that system. We have to be realistic and say that it has taken muscle from the centre and often deeply disturbing events to get the general practice system to reform in the ways that it should.
I was interested to hear the comments made by Dr. Taylor. I greatly respect him and his experience. I do not want to misinterpret him, but I think that he was effectively saying that if the primary care system had developed in the way that it might have, with extended services, the need for these proposals would never have arisen. However, that is not what has happened. The system has resisted all proposals to extend. We need only think of the arguments that we have had just to get a modest increment in evening or Saturday morning provision, which was standard when I was growing up—it was quite normal to have evening surgeries or Saturday morning surgeries. We have now had to pay the doctors more to return to a system that we once had.
It is bewildering that we cannot understand that it is possible to extend GP provision in a way that will genuinely extend choice and access for patients. We think about patient groups, and when my children were small we would have been heavy users of a super-surgery in our area. All we had, when children were inconvenient enough to get ill out of doctors' surgery times, was the prospect of a visit from an out-of-hours person who knew nothing about us and had no diagnostic back-up of any kind, or of taking the children down the local accident and emergency, which was probably inappropriate. The idea of having an intermediate centre for such situations, just so that tests could be done and people could be checked over, seems a genuine extension of patient choice.
I am sure that the hon. Gentleman would agree that we should be developing policy that is based on evidence. Does he not think that we should have serious concerns about the range of points made by the King's Fund and others? They show that the polyclinics and health centres already established under the LIFT scheme and the experience from abroad suggest that some of the conclusions that he wants to see are not happening.
I am grateful for that intervention, as it gives me the opportunity to make my final point, which is about what happens if we cut through some of the nonsense and look at what is being proposed.
As I mentioned in my intervention earlier, I had a very interesting document from the BMA, which was sent out to all GPs and local medical committees in May—just last month. The document is called "New NHS Primary Care procurements", and it is described as a "factual guide". It is an example of the BMA talking sensibly to its own people, rather than getting all excited about a public campaign against things that some people do not like.
The factual guide includes a very nice table that sets out what it calls the "key differences" between health centres and polyclinics. Hon. Members can read it. It then goes on to describe the background to the policy, which is exactly the point that has been made. It talks about the Darzi review, and says that a central tenet of it
"has been the importance of determining primary healthcare services locally."
It goes on to state that the review sets
"out a rigorous process requiring any change to be transparent, clinically evidenced, locally led and for the benefit of patients."
When the BMA is talking for grown-ups, it tells the truth about what is on offer, but when it is putting petitions around surgeries and telling people that all their local surgeries will close, it talks dishonestly.
The fact is that we have a proposal—it might not have been necessary if primary care services had reformed themselves in the way that they should have done over the years, but they have not—that will extend the range of services available to patients. That is a very good thing and it is dishonest to pretend otherwise.
Like my hon. Friend Dr. Wright, I think that the BMA's "Save our Surgeries" campaign has been disingenuous. It has created unnecessary fear and worry that GP surgeries around the country are about to close. That is simply not the case.
I want to talk briefly about the example from north Lincolnshire. My right hon. Friend Mr. Morley intervened earlier on this point. Parts of Scunthorpe are very deprived, and they also have few GPs, so there is a plan for a GP-led health centre in Scunthorpe. Doctors have been saying that because of that plan other GP surgeries are under threat, particularly in the rural parts of north Lincolnshire. North Lincolnshire MPs went to the primary care trusts to ask what that was all about, and they guaranteed that the money for the centre was additional and that there was no threat to any other GP practice in north Lincolnshire. In fact, they wanted to invest more money in those other practices. People will still have access to their GP, and it is wrong to tell those people that their GP surgeries are about to close.
If the hon. Lady has been following the debate, she will have heard that patients can register with the new centres. If they move their registration from their former rural practice to the new centre, the rural practice will lose that patient and the income and could therefore become non-viable. It is not true to say that this is pure additionality, and the hon. Lady should perhaps have picked up on that by now.
I think that I regret allowing the hon. Gentleman to intervene. He has been talking about people's GPs, the services that they provide and how much people appreciate those services—but people will stay with their GP if that GP provides a service that they want. If they want something else, they can transfer, as they can now. They can transfer from one GP practice to another if they want additional services.
Earlier this year, I went out and consulted my constituents at random about what they wanted to see in primary care, what they wanted from their GP and what type of opening hours they wanted. I wanted to ask 150 people, but through a quirk I ended up with 151. When I asked whether they wanted GPs to open at more convenient times to meet their needs and their lifestyles, only one person opposed that, while 150 wanted access to GP services for more hours. As for evening appointments, 150 people wanted them and one person did not. There was not such strong support for weekend appointments, which were wanted by only 144 out of the 151.
People wanted that increased access, which is what the GP-led health centres and polyclinics in London will provide, for a wide variety of reasons. One reason that struck me came from working women with young families. Although there is meant to be more equality in society, when it came to taking the kids to the doctor it was still the woman who had to do it. Generally speaking, she would have to take time off work, and the kids might also have to miss school. That was one reason why those women wanted early morning appointments or appointments later in the evening.
In the Cleethorpes constituency, there are still a number of single-handed GP practices. That was another factor in people wanting more access. For example, if women had an older male GP, they felt uneasy about seeing him about issues to do with sexual health and said that they would prefer a larger health centre so that they could have that choice and have access to the type of clinic that they would not necessarily get in a single or double-handed GP practice. Plenty of people are perfectly happy with that set-up, and no one is suggesting that it will change. However, in my area patients have demonstrated a desire for more than just those single-handed GP practices.
There are now health and medical centres in Cleethorpes and Immingham, just as there are in the area represented by my hon. Friend Mr. Turner. The people who can access those health clinics really appreciate being able to use their services. Immingham is quite isolated from other urban areas in the constituency. The town's GPs came together and relocated to one building. Some people in the area had a bit of a pop, saying, "Oh my God, we've got fewer GP surgeries now." Technically that was true, but only because the GPs had all moved out of dilapidated premises and into a brand-new purpose-built primary care centre, where people can use a variety of services. My hon. Friend gave a list of the services, so I will not go through the complete list again. People can have their blood tests and X-rays done there, which means that they do not have to travel to the hospital in Grimsby, which is not easy to do from Immingham.
The British Medical Association was therefore wrong to say that such health centres will always mean that people will have to travel further. That is rubbish; my constituents do not have to travel, because services are being provided on their doorstep. Recently, another GP-led health centre—the Beacon medical centre—opened in Cleethorpes constituency, and the people being treated there think that the wide range of services is excellent.
The Opposition are completely out of touch with the public mood on this issue. We are no longer in the days of Dr. Finlay and his sidekick, moody grumpy Dr. Cameron —perhaps it is the name that makes the Conservatives so keen on their old-fashioned ideas. Those days are long gone. People's lifestyles are pressured. They have many demands on their time, and we have to make sure that primary care evolves and adjusts to meet their needs. If we do that, the NHS will be around for another 60 years after celebrating its 60th year next month.
The motion is all about patients and the provision of health care for the maximum benefit of patient outcomes. This debate has been very revealing, in that the only speakers who supported the Government's policy came from that diminishing dying breed, the ultra-supporters of the Government.
The debate was opened by the shadow Secretary of State for Health, my hon. Friend Mr. Lansley, who gave a timely and devastating critique, mentioning the potential serious problem and the detrimental impact on patient care. He was right to highlight the problems of potential closures, the potential increase in travel distances, and the danger to the fundamental GP-patient relationship. In direct contradiction of what Shona McIsaac said, he mentioned the dynamic, strong feelings that patients and GPs have on the issue. He also highlighted the funding uncertainties: where will the money to support the policy come from? Even more importantly, he mentioned the fundamental lack of evidence to support the Government's policy, in relation to quality, access and service.
We then heard the Secretary of State's response. He is usually highly polished and has a Teflon quality to him, but today he was clearly slightly over-excited, rattled and very confused. I suspect that he does not really want to have to defend the policy, because he knows that it does not make sense, particularly in the context of localised decision making—an idea that the Government trumpet—and clearly he was not enjoying himself. He tried to make a difference in definition between polyclinics and GP health centres, but it was clear from other contributions that they are the same. He quoted a London MORI poll in an attempt to support his policy, but the only recent poll that matters in London is the mayoral election, which was clearly won by Boris Johnson.
The Secretary of State took an extraordinary, uncharacteristic and slightly sarcastic sideswipe at Lynne Jones, who made an extremely thoughtful and balanced contribution. Like us and, I suspect, the Liberal Democrats, she is trying to argue for more devolved decision making on how the money is spent. The Secretary of State's response to her contribution was extraordinary. Tellingly, he confirmed that primary care trusts would not be allowed to convert and expand existing practices, even if that was in patients' interests; there had to be a new polyclinic or GP-led health centre in every primary care trust, and even more in London. He made a bizarre attack on Conservative party policy, which is to try to find ways of improving primary care in socio-economically deprived areas, so that we can reduce health inequalities and improve things for those who do not have sufficient access.
A significant contribution was made by Norman Lamb, who rightly confirmed the necessity of local decision making. He made a critical point about the importance of continuity of care, and about the danger that GPs' understanding of individual patients' medical histories could be eroded by the policy direction being taken. We next heard from Frank Dobson who, let us not forget, is an ex-Secretary of State for Health. The current Secretary of State's view is that there is uniformity of opinion in London that polyclinics are a good idea, but that view was clearly shot to pieces by the right hon. Gentleman's contribution. The right hon. Gentleman was right to highlight the fact that the drivers of the polyclinics policy are Ministers in the Department of Health. The policy is not a response to patients' needs, to the NHS in London or to primary care trusts' desires elsewhere in the country.
My hon. Friend Mr. Goodwill made a significant contribution. He was right to challenge the idea that the proposals would be the best use of resources in his constituency. In a lucid, considered contribution, my hon. Friend Mrs. Miller highlighted concerns in her constituency. At the time of his speech, Dr. Stoate was the only Member to have supported the Government line. He is clearly very knowledgeable about the health service as a result of his professional qualification and his career, so it is sad that he always rises to defend Government policy, irrespective of what it is. He does not, perhaps, use his expertise and knowledge to make constructive suggestions for the Government. Dr. Taylor made a telling contribution, as always. He made one particularly good point: the policy should not be about buildings, but about patient services and pathways. That is one of the fundamental errors in the direction of Government policy.
I will not allow Conservative Members to be painted into a corner and seen as the representatives of the British Medical Association. We are not its representatives; we are here to fight for patients and the improvement of patient services. We are not against polyclinics or GP-led health centres per se. In fact, when they are supported by patients, GPs and the local community, we will be supportive and will facilitate them and enable them to be introduced. However, the decision should be taken locally, and should be based on clinical evidence, and evidence on health inequalities and prevention measures. There should also be a comprehensive understanding of the impact on existing provision.
The House needs to understand that we are not talking about a minor tweak to primary care. The establishment of polyclinics and GP-led health centres will be the largest change to primary care since the establishment of the NHS. In many places, including the Secretary of State's constituency, it has been said that the change would act as a catalyst for the reconfiguration of local GP services. It should be for local primary care trusts and patients, not Ministers in the Department of Health, to make the decision.
Of course the Secretary of State is right that there are circumstances in which health centres of polyclinics would have a beneficial impact. He rightly gave the example of preventing multiple appointments and additional travel, particularly for the elderly and the vulnerable. We also recognise that there should be greater access to diagnostics and follow-up appointments, and it may be that such centres are the appropriate place to provide those services, but not everywhere, not uniformly, and particularly not in rural areas.
Very specific criteria were set down by Darzi that the polyclinics and GP-led centres would be both cheaper and more accessible, but some hon. Members' contributions have demonstrated that that is not the case. The Government need to answer some specific questions. They do not seem to understand that there is a direct correlation between GPs and patient care and a threat to that relationship. Will the Minister also explain in winding up the debate whether a GP-led health centre means a GP presence all the time, from 8 am to 8 pm, seven days a week, 365 days a year? Why are there no pilots to produce evidence that the Department of Health can analyse?
The Secretary of State confirmed for the first time that, on average, there will be five GPs per centre outside London. That amounts to an additional 605 GPs. Where will those additional GPs come from, in the context that there were only six more last year, if they do not come from surgeries that are already in place? Why will Ministers not allow PCTs to invest instead, where appropriate, in community hospitals or other GP-led health centres—a point made by my hon. Friends the Members for Beverley and Holderness (Mr. Stuart) and for Scarborough and Whitby? Why will Ministers not allow additional facilities to operate in non-spearhead PCTs—for example, outreach services?
The policy is confusing. Lord Darzi said in his framework document that PCTs would not be allowed to reconfigure services until a PCT clinic review has taken place, giving evidence of the benefits. Where is the evidence—I hope that the Minister will explain this—to support the supposed benefits of a centrally prescriptive solution that is odds with locally determined reconfiguration? I suspect that the answer to those questions is that a one-size-fits-all proposal is not really about patient outcomes, but about political outcomes.
There is an inherent contradiction between devolving commissioning responsibilities to a PCT through practice-based commissioning, and proposing a centralised approach to service design, with plans for polyclinics or GP-led health centres in every PCT. The Opposition will not coerce doctors into polyclinics against their will. GP-led health centres should be able to offer additional services, such as physiotherapy and phlebotomy, but they can be provided in other facilities as well in the existing system. This is not just about new buildings. Under the next Conservative Government, primary care will be patient-centric, responsive to local communities and free to innovate, ultimately to drive better patient outcomes.
Our primary care system of family doctors has served this country very well and is the envy of the world, and the Government are investing record sums in it. Funding for GP services has increased from £3 billion in 1997-98 to £7.86 billion in 2006-07. There are 19 per cent. more GPs today than in 1997. Incidentally, there were 273 more, rather than the six more mentioned by the Conservative party, in 2006-07 alone. They are better rewarded than ever before. More doctors are in training to become GPs, and vacancy levels for jobs are the lowest for many years.
The new contract has also brought important benefits for patients: being able to see a GP within 48 hours or to book ahead, longer consultations and better outcomes. But in every recent survey of what the public would like improved in the health service, being able to see a GP at times that are more convenient for them comes top. That is part of the reason why in March we agreed with the BMA that surgeries offering opening in the evenings and weekends will be rewarded. I am pleased to tell the House that today 21 PCTs already have achieved the aim of at least 50 per cent. of GP surgeries opening in their areas either on a weekday evening or at weekends. We are confident that the rest of England will do so by the end of the year.
Even with more than half of GPs offering extended hours, there may still be some people whose GP, for whatever reason, does not wish to open in the evening or at weekends, and we think it only fair that those people, too, should have the possibility of getting to see a GP at more convenient times. That is why we announced last autumn an extra £250 million to enable the local NHS to establish a new GP-led health centre in every PCT in England and extra GP surgeries in the least well-served areas. That is additional money on top of, not instead of, the record sums already going into existing GP surgeries. No one will lose their current family doctor as a result.
In fact, one of the specific features of the new health centres is that people will be able to remain registered with their own doctors and see GPs in the new centres if they wish. The centres will be particularly welcome for people who work full time or commute, who currently find it hard to visit a GP, and they will also take pressure off accident and emergency departments, which deal with a lot of people who should see a GP. The only requirement we are placing on the centres is that they should be open seven days a week, 12 hours a day, and offer appointments and walk-in services.
Norman Lamb criticised the Government for moving too fast and predicted that we would live to regret our extra investment in primary care services. I suspect that when his constituents begin to enjoy the extended opening hours of GPs in Norfolk and the new 12/7 GP health centre in Norwich, or wherever Norfolk PCT decides to locate it, he will regret his opposition to those improved new services. He quoted the King's Fund report, which was much more balanced than the impression he gave—but of course, it was an analysis of a policy that is not being proposed.
Mr. Goodwill, like a number of Conservative Members, said he was opposed to the new investment in his constituency. I am sure that other parts of North Yorkshire, such as York and Selby, might welcome it. His local PCT, as he well knows, will have assessed the needs of Scarborough and Whitby, and I understand that a public meeting in his constituency this week supported the proposals. He also said he was concerned about the provision of dental services. He might like to suggest that the PCT considers including extra dental services in the new centre. That is exactly what many PCTs up and down the country are doing. He asked whether the services need to be provided under one roof. No, they need not.
Mrs. Miller also said that she opposed the extra investment, in spite of the very significant population growth in her area. I suggest to her that, as in North Yorkshire, there are plenty of people in Hampshire who would welcome that extra investment. It is also not the case, as she suggested, that the existing GPs whom she mentioned cannot bid to run the new health centre.
My hon. Friend Lynne Jones is due to get not only a new health centre but a new GP surgery in her constituency because it is one of the under-doctored areas. Her constituents do not enjoy the same access as people in neighbouring constituencies in the Heart of Birmingham PCT, which has reached 75 per cent. access for extended hours on behalf of its patients. There is nothing whatsoever to stop the GP practice that she mentioned bidding for the new health centre. It need not be a new building; it can be an expanded existing building, and we have repeatedly made that clear.
I make the same assurance to Dr. Taylor. The new services can be part of an existing system, and there is nothing to stop Worcestershire adopting the kind of model that he favours. If he wants to make that case to Worcestershire PCT, he is very welcome to do so. The current proposal is for Worcester, but if he wants to persuade the PCT that his model is better, I wish him good luck. Of course, I would be very happy to meet him, as I always am.
My hon. Friend Dr. Stoate made a very strong case in support of the improvements that we are making to primary care, as did my hon. Friend Mr. Turner. He well knows that he will get not only a new health centre but three new GP practices in one of the most under-doctored areas of the country. He also made an important point about the huge public health benefit of investment in primary care.
My hon. Friend Dr. Wright gave an example of some of the disgraceful and irresponsible scaremongering by the BMA and the Conservatives that has caused unnecessary anxiety to patients, including his constituents. My hon. Friend Shona McIsaac also welcomed the new investment and improvement in services.
My right hon. Friend Frank Dobson referred to a procurement that has nothing to do with the extra investment that we are announcing but is an ongoing process of PCTs procuring new GP services. His local PCT says that it is perfectly happy to defend the way the procurement was carried out. If it is not happy with the provider's performance, it can terminate or not renew the contract. I understand that the proposal for a new health centre in his area involves housing it in a local hospital because that is an accessible point locally, unlike in some other parts of the country where hospitals are not necessarily as accessible as other places.
It is not only patients who welcome the new services. Anna Waite, a Conservative councillor in Southend, told her local paper two weeks ago that
"this is a big step forward. A large surgery with easy access and in the right location will be ideal. To be open seven days is fantastic."
Labour Members are delighted to have been given another opportunity to defend the Government's record on the NHS and highlight the further improvements under way in primary care. We do not think it unreasonable, given the record sums going to GP practices, that people should be able to see a GP in the evening and at weekends. We will not reverse those improvements or give a veto over health policy to the doctors' trade union, the BMA. I recall a similar campaign by the Conservatives this time last year against what they claimed was a programme of hospital closures. That campaign was humiliatingly abandoned when they were forced to admit that they had got their facts wrong. I predict a similarly bruising fall from this bandwagon.
Question accordingly negatived.
Question, That the proposed words be there added , put forthwith, pursuant to
Mr. Deputy Speaker forthwith declared the main Question, as amended, to be agreed to.
That this House welcomes the Government's support for primary care and proposals to invest £250 million in 113 new GP practices in the most deprived communities and 152 new state-of-the-art GP-led health centres open from 8 a.m. to 8 p.m., seven days a week, in every part of the country; notes that these centres will offer a wide range of health services including pre-bookable GP appointments and walk-in services for registered and non-registered patients; recognises that the exact format and location of each GP-led centre will be decided locally in consultation with patients; notes that GPs will not be forced to work in the new GP-led centres and where that is the case patients will still be able to remain registered with their GPs at their existing location and premises; acknowledges that the expansion of primary care is essential if the overall health of the population is to improve, and inequalities in health are to be addressed; and welcomes plans to ensure enhanced primary care services are capable of meeting the new challenges facing the NHS including tackling lifestyle diseases such as obesity and through more effective screening programmes for the general population.