§ 10.8 p.m.
§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Harper.]
§ Mr. Speaker
Order. I would remind the hon. Gentleman that his point of order is taking time out of an hon. Member's Adjournment debate.
§ 10.9 p.m.
§ Mr. Edward du Cann (Taunton)
There comes a matter now which I hope we can, with the help of the Joint Under-Secretary, who I am glad to see here, answer in the affirmative. I am grateful for the opportunity to raise tonight the subject of the provision of medical centres, that is premises where three or four doctors work in association from a main surgery on the usual group practice basis, with additional accommodation for local authority nurses, health workers, social visitors and the like. This may seem a pedestrian subject, but it is none the less of great topical interest to the medical profession as the hon. Gentleman will know. Regrettably, it is also a subject which at present involves uncertainty and also inevitably some anxiety. This is unfortunate and I believe unnecessary. I hope that it will be possible for these Parliamentary Secretary to dissolve the clouds of uncertainty and difficulty.
To put the subject in context, I am sure the Parliamentary Secretary would agree with me when I say that good practice premises are a valuable aid towards the organisation of a high standard of medicine. I would go further and say that they are invaluable.
During the negotiations on the "Charter for the Family Doctor Service" in 1965 and 1966, the profession's representatives expressed to the then Ministry of Health the need for the family doctor 548 to have adequate, up-to-date premises to enable him to provide the standard of service he wished to give the public. As a result the Ministry agreed to introduce a scheme of direct payments for rent and rates intended to secure reimbursement by reference to what each doctor paid or was deemed to pay. In certain cases there are notional assessments. All this was instead of undifferentiated gross fees on a per capita basis. In addition, the Government agree to establish the General Practice Finance Corporation to lend money to doctors to enable them to purchase their own premises. The rate of interest now charged by the Corporation is 10 per cent.
At the conference of representatives of local medical committees in June last year, there was some discussion of this matter and a good deal of emphasis was given to problems connected with the provision of premises. I recall in particular, as I am sure will the Parliamentary Secretary, Dr. Cameron's speech. However, the total amount of money lent to doctors by the General Practice Finance Corporation since it was established in 1966 is very substantial. I understand that it has now reached some £5¼ million to nearly 1,000 practices, which means that in excess of 3,000 general practitioners are involved. It demonstrates the continuing involvement of the general practitioner in the provision of capital for their practice premises. This will be in addition to money they raise privately from building societies, bank loans, or from their own capital resources. I suggest this demonstrates the wish of general practitioners to attempt to improve their premises.
I am sure the Parliamentary Secretary will agree that it has been generally recognised for years that the encouragement of group practices with the obvious advantages of doctors working closely together in circumstances in which it is easier to provide for the adequate and optimum use of ancillary staff and facilities, must be right.
In theory, all this is wholly admirable But how does it work in practice? I have already inferred that there have been some difficulties which have been raised in various public discussions. The fact is that the scheme of direct payments for rent and rates has proved to involve anomalies in many cases. I have no doubt that the Ministry 549 is aware of those anomalies and I suggest that it has been aware of them for a long time. Equally I am in no doubt that the profession as a whole is seeing to it, and will see to it, that the Ministry is aware, and will he made aware, of these anomalies in all their various forms. But I am concerned to get action in this matter, and hence am raising this subject tonight. Again I express my gratitude for the opportunity to do so.
My special interest in the subject derives from the wish of four doctors in my constituency to establish a medical centre, that is to say modern group premises in Taunton. Dr. Dodson came to see me on their behalf as long ago as August, 1967, some 2½ years ago. At that time he and his colleagues had the agreement of a developer to build, they had a site, planning permission and they had the executive council's agreement. They also had the backing of our local medical officer of health, Dr. Parry Jones, who is an excellent and practical man, and the co-operation of the town clerk and local town council.
So far so good, it may be thought. All they needed was a meeting with the district valuer to establish what should be a reasonable rent for the premises assuming they were equipped to the required standard. This was in order that they could make their calculations and evaluate the financial consequences of the decision which they had taken, and so on.
To take the story a little ahead, the premises were opened on 7th July, 1969. I visited them on 1st August and I found —and this is agreed on all sides—that they were first class. They were well equipped, practical and efficient. They were involving public health staff as well as the staff of the doctors—Drs. Dodson, Skene and Collins.
All this was described in an issue of the magazine "Pulse" on 18th October, 1969, so I need not go into detail. It was a good plan, and it was well executed. Yet they have still not met the district valuer. They still do not know what reimbursement they will receive—two and a half years after I first saw them and two and a half years after I first put the matter to the Minister, the last time on 3rd February, and seven months after the centre came into operation. My point is 550 simple: these delays are not good enough. However, your decision, Mr. Speaker, to allow me to raise the subject on the Adjournment has provoked the Ministry to some activity.
I am grateful to the Parliamentary Secretary for the correspondence which I have received from him. One paragraph is worth quoting. He said that the Ministerreceived a deputation last August from the representatives of the medical profession about many aspects of the rental payments made by Executive Councils and, since then, the Department has been actively engaged on the matter.I hope that the Parliamentary Secretary will not mind if I ask, why only "since then" when the matter had been raised by me much earlier? If this is activityseven months with no result—I wonder what would hapen if the Department had not been so "activity engaged on the matter.The letter continued:…these questions are very involved and affect more than our own Department and any changes possible will be changes in the remuneration system and as such will have to be negotiated with the representatives of the profession".That is absolutely true. The letter continues:We hope it will not be long now before we have some proposals to discuss with them, but meanwhile I am afraid that I cannot say what these are likely to be".All that is required is a simple administrative process. I hope that no one will think me pompous when I say that I have had responsibility in the Treasury and as a Minister in another spending Department. I am a director of a property development company. There is nothing in these matters which could not be settled in the course of an afternoon or less than that.
The House may think, as I do, that the financial risk which Dr. Dawson and his colleagues have accepted, and are still accepting seven months after they opened their centre, is an unreasonable and poor comment on their initiative, public spiritedness and keenness on higher standards. Had it not been for these qualities the people of Taunton, or at any rate those associated with this practice and patients of it, would certainly have been the poorer and would inevitably have received less good treatment.
551 My argument in effect is an argument for higher medical standards in general practice and the acceleration of their provision. When doctors enter into a long term capital commitment, it is not satisfactory if they cannot obtain in advance an indication of payments likely to be made to them under the repayment scheme. These are not people asking for profits. All that we are concerned to do is, if possible, to improve standards in the Health Service.
I turn from the particular to the general. As at the end of last year, there were 148 health centres provided by local authorities in use and 95 were being built. Plans had been approved or accepted for 201 but building had not started or been authorised. That is a total of 444. This leads one to the conclusion that when they have all been finished in three or four years time they will accommodate, at the most, between 4,000 and 5,000 doctors out of a total population of 20,000—in other words, at most, 25 per cent. That means that 75 per cent. of doctors will not be accommodated in that time. It is therefore certain that problems connected with servicing and financing general practitioner premises will be with us for a long time. This is all the more reason perhaps for encouraging self-help.
Indeed, the case of Dr. Dodson and his partners is by no means unique or isolated. I am astonished that I have had, in correspondence, pleas from 20 or more practices—in the West Country from Helston, Exeter and Taunton. I am grateful to the Parliamentary Secretary for dealing, in advance of the debate, with the case of Dr. Spare and Dr. Crosby. From Basingstoke to Blyth, from Great Missenden to Glasgow, and from Breconshire to Welwyn Garden City letters have come to me, to my astonishment, showing the concern of the medical profession.
I quote from one letter from three doctors in Wickford, Essex:We feel that we have made an act of faith with the N.H.S. by going out on a limb financially and should have the right to know to what extend we are expected to subsidise it. In the event of the District Valuer deciding on a figure lower than 11 per cent., we could find ourselves with a substantial sum to pay yearly from our own pockets. We would, therefore, be most grateful for your assistance in helping us to solve this situation.552 Frankly, this correspondence has not only surprised me, but to a degree, it has moved me.
If there has been some demonstration, as I hope, of the need for speed, for more realism and co-operation on the part of the Minister, I would argue, too that the quality of service by general practitioners in the next twenty years really depends on a favourable decision being made as a result of tonight's debate, either now, if possible, or, at any rate, shortly. The profession has already waited a long time.
Yet it is not only a matter of speed and certainty. It is essential that the district valuers—we know how hard worked they are at presentx2014;produce realistic and fair rents. There is evidence that this is not happening. I ask the Parliamentary Secretary, together with the Minister, to see that they are given a new or, at any rate, a particular brief.
There are problems here and I will mention some quickly.
There is no doubt that good medical premises have a high unit cost. They have to be purpose-made, and this involves certain difficulties. The high costs are well out of line with the much lower costs of building ordinary office accommodation because of soundproofing, the need for privacy, heat, special lighting, plumbing and the rest. From evidence that I have seen, it appears that rent assessments by district valuers have sometimes been based on cheap office accommodation. That is quite wrong.
It appears, too, that district valuers sometimes assess a rent by working out the net usuable area. This can be very unfair, especially in rural areas.
Perhaps the Minister, his colleagues and officials will have a good look at the position relating to owner-occupied premises where rents do not always cover the interest charges.
Again, district valuers sometimes compare unlike with like when they compare medical centres with local authority-owned health centres. These are not comparable, the latter sometimes involving a degree of subsidy.
We probably need a new system, but we also need some of these special factors to be taken into account.
I was somewhat sweeping a moment ago when I said that I was certain that 553 the problem could be solved in an afternoon. I still think that is right, and I will suggest a modus operandi to the Minister. At the planning stage could not final detailed plans be submitted to the executive council for approval having regard to local conditions—it is always important to remember them—and advice from the Ministry of room area standards in general?
Could not competitive tenders then be sought, and these again submitted to the executive council for approval?
After that, could there not be a round table conference and negotiations between the parties allowing them to be reconciled and allowing agreement to be reached before work is commenced? I hope that that might be possible. I hope, also, that those special factors, some of which I have mentioned, will be taken into account.
It may be thought, from what I have said, that the standards of general practice are, alas, lower today than they could or should be. If so, there is a golden opportunity now to provide a new impetus to improvement—indeed, to make a great step forward.
General practitioners have already shown their eagerness, as always, to serve the public, and to serve the public well. I hope very much that they will receive new backing and new encouragement from the Ministry.
§ 10.25 p.m.
§ The Joint Under-Secretary of State for the Department of Health and Social Security (Dr. John Dunwoody)
I am pleased to be able to take nail in a debate on the matters raised by the right hon. Member for Taunton (Mr. du Cann) as it affects the provision of general practitioners' practice premises and therefore the development of medical services in the community. Even if the matter affected only a few general practitioners in the right hon. Member's constituency, it would be important, but other general practitioners, too, are affected and the implications spread wider still.
General practice is changing in that more and more general practitioners are working in groups. We, in the Department and the profession see this as the pattern of the future and I welcome this trend, first, because it breaks down the isolation of the individual general prac- 554 titioner and makes it easier for general practitioners to keep up to date with developments in medicine. Each member of the group can take a special interest in some field, perhaps geriatrics or obstetrics, and the whole group benefits from each practitioner bringing his special knowledge to bear in the consultations between the doctors on the treatment of their patients.
§ Dr. M. P. Winstanley (Cheadle)
It may be true that in a group practice different practitioners can specialise in different subjects, but is it not the essence of general practice that practitioners are not specialists in different subjects? Is not the actual fact of the matter that the practitioners specialise in that Dr. A. specialises in having Mondays off and Dr. B. in having Tuesdays off? I am not against this, but is not this administrative, welcome though it may be, rather than clinical specialisation?
§ Dr. Dunwoody
I cannot accept this. I was careful about the words I used. I did not use the word "specialise". I said that they could take a special interest, and there is a difference. I was not trying to make general practitioners into second-grade specialists, but it is right for them to be able to take a special interest in sonic part of their work.
Secondly, and no less important, it enables doctors to work more closely with health visitors, nurses and midwives in the local authority services and to bring them into the consultations about patients. This way of practising medicine is best conducted in premises designed for, or adapted for, the purpose and we regard the provision of such premises as something we should do all we can to encourage.
The right hon. Member wrote to the then Minister of Health in 1967 and more recently to my right hon. Friend asking that the district valuer should give an estimate of the payments the executive council would make in respect of rent for surgery premises that were or are being planned by his constituents, two different groups of doctors. In both cases, the premises are purpose-built and are have been given very serious consideration planned to the doctors' specifications, and seem to be admirable developments. I can assure him that his representations by both us and the Inland Revenue, whose 555 concern in the matter I will explain shortly.
I want to say a few words about the rent and rates scheme for general practitioners and the reasons for it. The point of departure—and this is fundamental—is that the general practitioner is an independent contractor. For a long time, the remuneration paid to general practitioners, first under the old insurance scheme and, since 1948, under the National Health Service, has included reimbursement of practice expenses as well as payment for services.
Until 1966, the expenses were reimbursed through fees. The total expenses of all general practitioners were estimated from a sample and included in an aggregate amount for the profession as a whole, this aggregate amount being distributed to individual practitioners through the fees. Each general practitioner therefore received an amount for reimbursement of expenses related to the fees he earned and not necessarily to the actual expenses he bore. If he spent more than average on his practice, his net remuneration was reduced.
Since premises are expensive, the reduction in his net income could be considerable if he spent above average on them, so that this method of payment tended to discourage, instead of acting as an incentive to, modernising premises. During the discussions with the profession in 1965–66, it was decided, therefore, to reimburse the cost of premises directly, relating the payments as far as possible to the actual expense incurred.
Giving this decision practical effect was not so easy. To begin with, as the general practitioner is an independent contractor, it is his responsihilty and right to run his practice in the way that seems best to him. On the other hand, the National Health Service could not be expected to foot any bill presented by the practitioner without consideration of the need for, and the value for money represented by, the premises. So the scheme adopted had to leave the general practitioner as free as possible to please himself without removing the incentive to get good value for money. The system also had to cover many different circumstances. Location plays a big part in the cost of premises. Some of 556 the premises were brand new and some old. Some were separate premises, others houses or shop or office premises converted to surgeries and some were houses partly used for practice and partly as a residence either for the doctor himself or someone else, like a caretaker. The property might be rented or it might be owned by the practitioner, the partnership, one member of the partnership or a relative. It was not practicable to devise different schemes for all these different circumstances and it did not seem equitable that the payments by the Executive Councils in respect of rent should vary depending on the form of tenure between one practitioner and another. A single solution which would meet all these requirements was therefore sought and the answer found was to base payments by the Executive Councils on current market rent.
I shall not go into the procedure of the rent and rates scheme in detail. It is sufficient for the purpose of this debate that the aim of all the mechanics of the system is for the location, size and so on of the premises to be approved by the Executive Council in consultation with the Local Medical Committee and for payment of the current market rent of the premises as assessed by the district valuer of the Inland Revenue. This can only be firmly assessed when the building is ready for occupation by the doctor. Current market rent is the rent which might reasonably be expected to be paid for the practice premises following negotiation at the date when the assessment becomes operative.
I hope I have made the point that we want to encourage in full such developments as the medical centre at Taunton and to help general practitioners who are providing them. However there are sometimes practical difficulties some of which are related to the method I mentioned earlier of paying expenses directly.
I can understand that when a general practitioner is acquiring new practice premises he wants to know before he commits himself how much the Executive Council will pay under the rent and rates scheme. The possibility of the district valuer giving an estimate of the current market rent has been discussed very thoroughly and on a number 557 of occasions between the Department and the Inland Revenue. As a result the Inland Revenue agreed to authorise district valuers to give estimates of current market rent in connection with loans made by the General Practice Finance Corporation.
I should like to confirm the figures mentioned by the right hon. Gentleman. In England and Wales alone this corporation, in a period of just over three years, has loaned more than £5 million, which has provided a significant improvement in doctors' working conditions, very much improved conditions for patients, and, I believe, a higher quality of service and higher standards of care for the patients. This is a record of which both the profession and the Government can be proud. This corporation was set up as a statutory body under the National Health Service Act, 1966, to provide finance for these purposes, and these loans are made at the stage when the site and the plans for the building had been approved by the executive council. It did not, however, feel able to extend this facility to other premises.
The main distinction between these and other cases is that in the G.P.F.C. case the site and plans have already been approved, so that the district valuer is dealing with something pretty concrete and definite and is moreover advising a public body. In the other cases he is likely to be faced with more tentative proposals in respect of premises which may or may not be suitable, and proposals which may be modified in any case, but may well be altered also in the light of what he has to say about the possible market rent.
In these cases the district valuer is likely therefore to be drawn in consequence into providing an advisory service for doctors who are planning new premises, which is not only more appropriate to a private professional surveyor, but would impose on him a considerable extra burden of work. However, I am considering, in conjunction with the Inland Revenue, whether estimates could be provided in other cases where the premises are in fact available and the doctor clearly intends to go ahead with the scheme.
One has to bear in mind that the district valuer is already very heavily burdened. The rent and rates scheme 558 placed a considerable extra load on the Valuation Office of the Inland Revenue, which nevertheless has gone out of its way to be as helpful as possible. The service is stretched over the country as a whole, and if a facility is given to general practitioners in one place, general practioners in other parts of the country will, quite rightly, expect the facility to be afforded them as well.
There is a feeling, which the right hon. Gentleman has expressed, that only the district valuer's estimate is a realistic basis on which to proceed, as perhaps a local valuer's estimate might differ greatly from the district valuer's and it is the district valuer's assessment which determines how much the executive council will pay. I can understand the feeling, but any estimate of the probable value of premises which is made before they are put up is bound to be tentative whether it is given by a local valuer or the district valuer.
The right hon. Gentleman wrote to the Minister of Health in 1967 about group practice premises being erected by a developer for renting to Dr. Dodson and his partners. His request was discussed with the Inland Revenue, and it was a matter of regret to the Inland Revenue and to the Minister that it was not possible to agree to it.
He has also written recently supporting a similar request from two other doctors in his constituency, Dr. Spare and Dr. Crosby. We have made enquiries of the executive council about this case and it appears that the doctors have already applied for a loan from the General Practice Finance Corporation, in connection with these premises. If this is so, the situation is different from that of Dr. Dodson and his partners so far as con-concerns the district valuer's ability to give an estimate on the plans, and I am glad to say that Dr. Spare and Dr. Crosby's proposal falls within the class for which an estimate can be given.
A part of these premises is to be used for dental suites and these are not covered by the rent and rates scheme, which applies only to doctors' premises. If our information is correct, therefore, Dr. Spare and Dr. Crosby should submit their plans for the centre to the executive council for approval of the portion to be 559 be used for medical services, and ask the council to approach the district valuer for an estimate of the rent payable under the scheme. I should emphasise that the estimate will be provisional and the district valuer will need to reassess the premises when they have been completed to arrive at his final figure.
There are other issues relating to the rent payable under the scheme for rented premises and for those owned by the practitioners and the position of doctors in health centres. All these matters are included in the representations which the profession raised with my right hon. Friend in August last year. The Department has been working with the other Departments concerned on proposals designed to meet certain deficiencies which the profession found in the scheme as it stands.
560 The Department had in fact been considering some of the points the representatives made before the meeting with my right hon. Friend, and matters are now well advanced. The Department's ideas will, however, have to be presented first to the representatives of the profession, and we hope to reach this stage in the very near future. I cannot anticipate tonight what might be the results of these discussions and I have therefore had to confine myself to the scheme as it actually operates.
Despite this, I myself have found this debate useful and of interest. The right hon. Member can be sure that I have taken note of what he has said and that his views will be taken into account in the discussions that are proceeding.
§ Question put and agreed to.
§ Adjourned accordingly at twenty-two minutes to Eleven o'clock.