HC Deb 24 November 1972 vol 846 cc1839-48

4.4 p.m.

Dr. Edmund Marshall (Goole)

The town of Knottingley in my constituency is a major growth point of industrial Yorkshire. It has a wide variety of local industry, and in the past 10 years rapid growth has come about with the opening of Kellingley Colliery nearby. This has brought a steady influx of population, not only from elsewhere in Yorkshire but particularly from County Durham and parts of Scotland. Between 1961 and 1971 the population of the urban district increased from 11,184 to 16,355.

Most of the increase has been accommodated on an extensive new housing estate called the Warwick Estate, which now houses more than 5,000 people. This population is made up predominantly of young couples with small infants. They are people who have moved to this new area in many cases to set up their first homes. They are working people who are not well-endowed financially for whom private transport is a luxury which only a few can afford.

Such families have frequent need of the medical attention of general practitioners. Wives need to visit doctors' surgeries for matters relating to pregnancy and childbirth, while their youngsters are prone to all the usual illnesses of childhood. Despite this great need for general medical services, no doctor practises from surgery premises within ¾ mile of the edge of the estate.

There are two general practices which have premises in the urban district, comprising nine doctors altogether. But their surgeries are all in the older parts of the town, either at Cow Lane in old Knottingley or at Ferrybridge. The Ferrybridge surgeries are ¾ mile from the nearest part of the Warwick Estate and 1¼ miles from the furthest part. There is a direct bus service to those surgeries, but the bus runs only once an hour and the return adult fare is 10p. However, many mothers cannot attend the surgeries without taking their children in perambulators, which prevents them from travelling on the bus. For those who have to walk to the Ferrybridge surgeries there are difficulties caused at times by bad weather but at all times by the dangers of crossing the busy A645 main road along which there is a constant stream of heavy commercial vehicles throughout the day, and also the difficulties caused by the fact that the return journey is uphill.

The other surgery, at Cow Lane, is two miles from the Warwick Estate. There is no direct bus service. The available routes for pedestrians to Cow Lane involve negotiating a very awkward railway level crossing and either a muddy lane which becomes impassable in bad weather or a narrow road called Spawd Bone Lane which has inadequate pedestrian footways near the entrance to a major industrial works.

In view of these difficulties for residents on the estate the West Riding County Health Committee in 1967 built a new health centre close to the middle of the estate. That health centre replaced a clinic which had operated in the older part of the town. It was designed in part to provide all those health services which to date have been the responsibility of local authorities; for example, mother and baby clinics, child speech therapy and general welfare, including immunisation. In addition, a family planning service operates from the health centre, and a local probation officer attends one evening a week. In this way the health centre is well used, and this indicates a willingness on the part of local residents to attend the centre.

When the centre was planned and approved, assistance was given by the then Ministry of Health only on condition that general practitioner facilities should be incorporated in the building. As a result, the centre contains four suites of doctors' consulting rooms plus a central records room which, as I saw on a recent visit, already has the appropriate furniture for storing and securing patients' medical records. Everything is there, set up and ready for doctors, but so far no doctors have agreed to come. Consequently, the public resources put into the health centre remain to a degree under-utilised.

The simplest way for doctors' surgeries to commence at the health centre would be for one of the two practices operating already elsewhere in the town to set up a branch surgery there. Branch surgeries are not without administrative and practical problems, but these have been met in other parts of the country.

From the financial point of view, the cost for doctors to rent premises at the health centre would surely be no more than for conventional branch surgeries. Again, on this aspect satisfactory arrangements have been devised for financing doctors' surgeries operating from health centres by agreements worked out under Section 46 of the National Health Service Act 1946, as amended by Section 22 of the Health Services and Public Health Act 1968.

Nor can the absence of any nearby pharmaceutical chemist be a valid reason for deterring doctors operating from the health centre. Surely such a chemist would be more likely to set up shop on the Warwick Estate once it was known that surgeries were to begin there.

Why have the two local practices refused to open a branch surgery from the health centre? First, there is the practice which operates from Cow Lane; namely, Drs. Murphy, Scholey, Fox, Lee, Pal and Holmes, six general practitioners who between them have more than 20,000 patients in Knottingley and surrounding areas. They claim to have followed the advice of the British Medical Association over recent years by centralising their surgery accommodation in the interests of efficiency. They have spent over £25,000 on new premises at Cow Lane, including six individual surgeries, a modern dispensary and a huge car park. I agree that this development is to the benefit of my constituents in that part of Knottingley, but I wonder whether even these premises are sufficient for so large a practice. I am told that sometimes during surgery hours the queue of waiting patients spills out into the street.

I do not know how far the Department of Health has encouraged this policy of surgery centralisation, but it seems that Cow Lane represents a degree of over-centralisation to the overall social detriment. This policy may make for administrative sense and technical efficiency, it may make life easier for doctors themselves, but in this case it results in harassed mothers having to push heavy prams along narrow lanes in pouring rain. The logical outcome of the policy of centralisation would be to have all family doctor surgeries in hospitals. If general practitioners are to remain truly general and truly family doctors they should be prepared to consult their patients closer to their homes.

The second practice, which has a surgery in Ferrybridge, comprises Drs. Walton, Busson and Atkins, who already have other branch surgeries at Brotherton and in Castleford. This practice has shown some interest in starting a branch surgery at the health centre on the Warwick Estate, but so far has been unable to do so on the ground that it would need a fourth partner to help in such an extension of its work and it has not been able to recruit a new partner.

I readily appreciate that problem. I know the difficulties of recruiting new partners for practices in that part of the country, especially in the overall national shortage of doctors. The Medical Practices Committee recognises that Knotting-ley urban district, together with the surrounding Osgoldcross rural district, is an under-doctored area and would welcome additional doctors there. I hope that Drs. Walton, Busson and Atkins will renew their efforts to recruit a fourth partner. It may be that these words will reach some suitably qualified person interested in taking up such challenging work.

In the absence of any move by local practices to establish a branch surgery on the Warwick Estate, in May this year I requested the National Health Service Executive Council for the West Riding to consider advertising an entirely new practice to be based on the health centre. The response of the executive council, after due consideration, was an outright refusal. Nor would the council take action to encourage the use of the health centre as a branch surgery.

Perhaps this is not surprising, when one considers that half the membership of the council is composed of professional representatives, that it includes only eight local authority representatives out of a total membership of 30, and that there was at the time a vacancy for a member to be appointed by the Secretary of State. I do not believe that with this composition, executive councils can ever be expected to come to grips with any problems arising from professional reluctance to undertake changes within the National Health Service.

While I am perfectly ready to believe that professional sovereignty has to be paramount in all matters of technical or medical performance, questions of surgery location, numbers of doctors in a particular area, and so on, are social questions which should ultimately he settled by public representatives. The concept of a doctor within the National Health Service as an entirely independent contractor is something that I find difficult to reconcile with the overall purpose of the National Health Service.

If, for example, there were a similar situation in the education world on the Warwick Estate, I wonder what would happen if local education authorities found that teachers were able to prevent all teaching in some new school that had been specifically designed to serve a new area. We cannot have a truly public National Health Service if it is possible for professional representatives to take a dog-in-the-manger attitude towards the facilities provided for its use.

I do not want to stray too far into matters of National Health Service re- organisation, but there should be an opportunity within that reorganisation to get the right balance of power in these matters. At present, local authorities do not appear to have the power to represent the wishes of their public on questions like distribution of doctors' surgeries. It may be that the Government feel similarly without power in these matters.

Indeed, in a letter which I received, dated 18th August last, from the Under-Secretary of State, the hon. Member for Barkston Ash (Mr. Alison), who, incidentally, has kindly told me why he cannot be present today, he wrote: We have no power to intervene in such questions. That statement may be correct within the existing administrative framework of the National Health Service, but there may be ways for the Department to act to make better provision generally for bringing doctors' surgeries to areas of new housing development.

For instance, under Section 15 of the National Health Service Amendment Act 1949 it is possible for additional functions to be imposed by regulation on the Medical Practices Committee. I wonder whether we could explore in this way the possibility of requiring that committee to give urgent priority to the sending of doctors to areas of new housing, new towns and so on. Perhaps the committee could be required to decline to accept any applications for new doctors to practise within an executive council's area until the new housing areas in that area were adequately served. Of course, the Government could help by training more recruits for the profession, by opening more medical schools, for instance, at the University of Hull.

In general, the lack of general medical services on the Warwick Estate is a very good example of how the National Health Service needs some remodelling if it is to serve the general public above anything else and of how the Government have to expand the medical training facilities and bring new people into the profession if the country is to have all the doctors that it needs.

4.20 p.m.

The Under-Secretary of State for Health and Social Security (Mr. Paul Dean)

I am grateful to the hon. Member for Goole (Dr. Marshall) for raising this important matter concerning his constituents, and I hope that the appeal that he has sent out from the House this afternoon to doctors to come forward and help solve the problem will yield fruit.

The General Medical Services for Knottingley are provided by two partnerships of doctors. One, of six doctors, has a total or of about 15,400 patients in and around Knottingley, while the other, of three doctors, has about 8,000 patients. Both partnerships have main surgeries in Ferrybridge, which is at the north-west corner of Knottingley. The larger partnership also has a main surgery at Ash-grove, which is in Knottingley itself, while the other partnership has branch surgeries at Brotherton and Castleford.

As the hon. Gentleman said, a health centre has been provided by the local authority on the Warwick Estate, including provision for one general practitioner, but this accommodation has not been taken up. The intention was that the smaller partnership would bring in a fourth partner who would be accommodated on these premises, but so far it has been unable to find a suitable partner. The executive council has made it clear that if any independent doctor comes along who wishes to set up practice from the health centre it would give him every possible support.

The position in Knottingley, considered as a whole, cannot really be regarded as unsatisfactory. By comparison with other places the average lists are 2,547, compared with the average for the area of the West Riding Executive Council of 2,492 and the latest available national average of about 2,460. The trouble seems to be that in relation to the distribution of population within the town the surgeries of the existing doctors are not well placed. The hon. Gentleman said that perhaps the best solution, which he originally put to the executive council, would be the provision of a branch surgery within the area of the Warwick Estate, but the replies of the doctors concerned made the point that it has for many years been the policy of the profession to centralise surgery facilities. This enables better facilities to be provided and better use to be made of the time of doctors and their ancillary staffs. This policy has the support of the Department but, equally, we and everybody else concerned must, and do, take into account the convenience of the patients as a whole.

As an alternative to the provision of a branch surgery on the Warwick Estate, the hon. Gentleman has suggested that a new practice should be established in this area. The executive council considered this question in July and replied that, having regard to existing arrangements and facilities in the area, there was no justification for declaring a practice vacancy based on the Warwick Estate. The council made it clear, however, that if any independent doctor came along who was admitted to its medical list and wished to set up in practice from the health centre it would give him all possible assistance.

Following his correspondence with the executive council the hon. Gentleman wrote to the Department, and he has quoted the reply which he received from my hon. Friend. In reply we reminded the hon. Gentleman that one of the partnerships practising in Knottingley was still interested in taking a fourth partner and taking up the accommodation at the health centre. We understood that the executive council was doing its best to help by informing any doctor seeking a partnership in the area of the position, but very few doctors seem to be coming into the area, and so far there has been no result.

In our view this offered the best hope of getting an additional surgery in the near future on this estate. We did not rule out the possibility of an independent doctor setting up a practice on the estate, but this is not a likely solution of the problem. Even though the executive council has undertaken to give a new doctor every assistance, it is not easy for a doctor working on his own to build up a viable practice from nothing, and I think the hon. Gentleman accepts that there are difficulties here.

The hon. Gentleman went on to discuss the possibilities of new arrangements to try to persuade or encourage doctors to move into unadopted areas. The hon. Gentleman a little underestimated the measures which are available and which are used now. It is true, and the hon. Gentleman was not in any way denying the importance of this, that doctors are independent contractors, and as such they cannot be required to practice or open a surgery in a particular area. To alter this position would involve changing the basis on which general practitioners have served in the National Health Service since 1948.

The National Health Service Act 1946 provided—this is an important aspect which perhaps the hon. Gentleman did not fully take into account—for the setting up of the Medical Practices Committee as an independent body charged with the responsibility for ensuring the adequacy of the numbers of doctors in all parts of the country.

The method followed by the committee, working in collaboration with executive councils, is to determine conveniently—sized practice areas and to place each in one of four categories-restricted, intermediate, open and designated. There are 1,700 practice areas in England. The broad basis of the categorisation is the average number of patients per doctor, but various other factors are taken into account which influence the adequacy of the service provided—for example, doctors' other commitments, the nature of the area and so on.

Restricted areas have enough, or more than enough, doctors already. The Medical Practices Committee will rarely allow any new doctor to set up in practice in such areas. Intermediate areas are also adequately doctored. Here again, applications to establish new practices are unlikely to be successful. Open areas and, still more, designated areas are in need of additional doctors. Applications from doctors to set up in practice in such areas will normally be approved by the committee without question. About one-third of the general practitioners in England are practising in designated areas, and a further one-third in open areas.

In addition to this negative control, exercised by the Medical Practices Committee, the Department offers doctors financial inducements in the form of special allowances to set up in designated areas. These measures will ensure that proportionately more doctors are induced to go to those parts of the country where they are most needed.

There are still shortages of doctors in many areas. An executive council, such as that for the West Riding, which is responsible for the services for about 1¾ million people, must weigh and compare carefully the competing needs of the communities within its responsibility before deciding to recommend to the Medical Practices Committee the creation of a new practice vacancy.

The hon. Gentleman also mentioned the health service reorganisation. He asked what effect, if any, that will have. I will carefully consider the points which he has made, but all that I can say now is that it will be difficult to forecast what effect, if any, the coming reorganisation will have on situations such as at Knottingley. Undoubtedly the measures which we have already taken to increase the number of general practitioners in the country and to assist them to improve the service they give to their patients will help. The improved efficiency which we can expect to result from reorganisation will make an indirect contribution to situations such as the one which we have been discussing.

I am sorry that it has not been possible for me to be more specific. As the hon. Gentleman knows, these matters are largely in the hands of the local committees concerned. However, I hope that the fact that he has drawn attention to the problem and that we have had this short debate will do something to contribute to the coming into the area of the additional doctor which the hon. Gentleman clearly wishes to see, and which we would be glad to see.

Question put and agreed to.

Adjourned accordingly at twenty-nine minutes past Four o'clock.