§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Joseph Dean.]
§ 11.5 p.m.
§ Dr. Edmund Marshall (Goole)
I regret the necessity of having to raise yet again 1458 on the Floor of the House the subject of general medical service on the Warwick estate at Knottingley.
I have referred to this problem on two previous occasions, first in an Adjournment debate on 24 November 1972, and, secondly, in a general debate on the Health Service on 20 April 1978. I do not wish to repeat in detail what I said on those occasions, but I remind the House that the problem relates to a building now owned by the Wakefield area health authority. The building was constructed in 1967–68 to provide a health centre for a housing estate at Knottingley known as the Warwick estate, on which between 5,000 and 7,000 people now live.
Although the building was specifically designed to include consulting rooms for GPs, no family doctor surgeries have yet been held there. My constituents on the estate have to travel either a mile to the next nearest surgery at Ferrybridge or two miles to a surgery at Cow Lane in Knottingley, most of them passing the health centre on their way. This is a silly situation, which causes annoyance and frustration locally.
In August 1977, 1,040 adult residents from households, with an additional 1,260 children, signed a declaration saying that if a new practice was established at the health centre they would, in general, wish to be included on the panel of patients there. With that number of prospective patients, a viable practice, possibly consisting of two doctors, could be based at the health centre. Unfortunately, the medical profession, both locally and nationally, has acted in such a way as to prevent any doctor from holding surgeries at the health centre.
In the debate on 24 November 1972 the then Minister, the hon. Member for Somerset, North (Mr. Dean), indicated the view of the Department that the best hope of getting an additional surgery on the estate was by the recruitment of an additional partner to one of the practices operating at Ferrybridge, which could then open a branch surgery at the health centre. I was not aware of any efforts made by that practice, which then consisted of Drs. Walton, Busson and Atkins, to recruit an additional partner during the following five years, but apparently their intention to do so remained.
1459 In a meeting arranged with the chairman of the Wakefield AHA to discuss this problem with representatives of relevant local committees on 23 June 1978, the then chairman of the local medical committee for the Wakefield area, Dr. L. C. Grahame, of Badsworth, near Pontefract, assured me that the same practice, now consisting of Drs. Walton, Atkins and Gupta, was still anxious to recruit a fourth partner with a view to opening a branch surgery at the health centre on the Warwick estate.
That encouragement was fortified when I learnt that, with effect from 1 August 1978, a fourth partner had been recruited to the practice—a lady by the name of Dr. C. A. Pinder. Through the family practitioner committee for the Wakefield area, I therefore asked when the enlarged practice would open a branch surgery at the health centre. The response from the practice, dated 11 September 1978, was a bald refusal, stating that it was not the intention, either then or in the near future, to extend the practice arrangements to include branch surgery facilities at the Warwick estate health centre. So far as I am aware, that practice has in no way expanded with the recruitment of the fourth partner, who is simply serving to take some of the normal work load which would have been carried by Dr. Walton and Dr. Atkins, who are apparently advancing in years. In the case of Dr. Atkins, he is not in good health.
The additional partner, whose recruitment was made possible simply because Knottingley was classified as an open area with fewer doctors per head of population than the national average, had been absorbed into the previous work of an ageing practice. It seems that I was misled by the chairman of the local medical committee, Dr. Grahame, when we met on 23 June 1978. I understand that he has since retired.
It is, of course, open to any of the other existing practices of Knottingley or Pontefract to commence health surgeries at the centre, because the two towns are grouped together for the purposes of medical manpower. I therefore approached the six local practices with that in mind. Because the average number of patients per doctor is markedly less in Pontefract than in Knottingley, it would be appropriate for a Pontefract practice 1460 to open a branch surgery at the health centre.
Three of the six practices which I have approached have considered the position but find that they cannot expand their present practice arrangements. That includes the other Knottingley practice, which has the names of approximately 80 per cent. of the residents of the Warwick estate on its list of patients, but, for reasons which I do not find convincing, it is not willing to help its existing patients on the estate by holding branch surgeries there.
The members of other three practices in Ferrybridge and Pontefract—namely, Drs. Walton, Atkins and Gupta; Drs. Hough, Hewitt, Simpson and Smith; and Drs. Dewes, Kidd and Lewis—did not see fit even to reply to my letters on this subject, even though I enclosed prepaid reply envelopes for the last two of the practices that I have mentioned. Needless to say, my letters—of which I have copies here—were in friendly and reasonable terms.
Not only are the existing practices in the locality unwilling or unable to start a branch surgery at the health centre, but I am afraid that the recruitment of the fourth partner to the Ferrybridge practice has made it virtually impossible for any new practice to be set up based on the Warwick estate. This is because the addition of the doctor at Ferrybridge has so reduced the average number of patients per doctor in Knottingley and Ferrybridge that the classification of the area for medical manpower purposes has been altered from"open"to"intermediate ", and it would no longer be automatic for an application from a suitably qualified doctor to practise in the area to be approved.
The level of division between the two classes of area was raised by 100 patients per doctor in 1975. This means that Knottingley is now an intermediate area. According to a written answer given to me by my right hon. Friend the Minister of State on 5 March 1979 at column 498 of Hansard, applications to start new practices in intermediate areas are rarely granted. In any case, no such application in either an open or intermediate area could be approved with any additional financial allowance necessary to get a new practice off the ground while the list of 1461 patients builds up. Such an allowance is available only for areas classed as"designated ", where the average number of patients per doctor, including the new doctor, still exceeds 2,500.
Together with interested organisations in Knottingley, I have explored the possibility of raising funds locally to meet the initial expenses of a doctor setting up a new practice at the health centre in the absence of an initial practice allowance. It was very disappointing to learn in a letter from my right hon. Friend that any general practitioner who accepted such a payment from voluntary sources would be in breach of his terms of service under paragraph 32 of the NHS (General Medical and Pharmaceutical Services) Regulations 1974. In other words, although it is legal and very common for a member of the medical profession to practise both within the NHS and privately, often seeing the same patients under both sets of arrangements, it is apparently illegal for a community that badly wants a doctor to offer some extra financial incentive to help one to set up a new practice.
What all this boils down to is that the profession of general medical practitioners, at both local and national levels, is able to exercise rigid, self-protective power in situations such as Knottingley to prevent the community from obtaining the general medical services that it clearly wishes to receive. The local practices are able to operate a boycott of the health centre, refusing even to consider holding branch surgeries there for a trial period. This boycott is operated with impunity, because the administrative arrangements for general practitioners within the NHS are designed to suit the convenience of the profession far more than the convenience of the public. As long as general practitioners retain the status of independent contractors, even though paid out of public funds, they will avoid being publicly accountable in the true sense of the term.
Of course, it is only a small minority of general practitioners who behave in an anti-social fashion. For instance, everywhere else in my constituency family doctors have happily moved into health centres built for their use. But I am afraid that the present structure 1462 of the NHS helps and protects the antisocial minority among general practitioners.
I conclude by asking my right hon. Friend to consider pursuing three possible courses of action. First, will he consider amending the regulations of 1974, to which I have referred, to allow doctors to receive financial payments from public subscription in circumstances such as those I have described at Knottingley? Secondly, will he seek to reduce the dividing line between the open and intermediate classes of area for medical manpower purposes to what it was before 1975 so that Knottingley, for instance, would again become an open area? Thirdly, and more generally, will he use his influence wherever possible to make it less difficult for the thousands of my constituents who live on the Warwick estate to obtain the services of a general practitioner at this health centre, which was built for that purpose over 11 years ago right in the heart of their neighbourhood? Without some change in the situation in one of those ways, I am afraid that, reluctantly, at present I can see no way of making further progress towards a solution of this vexed problem.
§ 11.20 p.m.
§ The Minister of State, Department of Health and Social Security (Mr. Roland Moyle)
For a number of years my hon. Friend the Member for Goole (Dr. Marshall) has argued on behalf of his constituents for a doctor or doctors to practise from the clinic set up in the health centre on the Warwick estate at Knottingley. He raised the matter a year ago in a Supply debate on the National Health Service. He has since written to me and my Department. He has asked questions in the House and he has been in contact with the chairman and secretary of the medical practices committee to seek a solution, and I think that the best service that I can perform for him this evening is not only to explain how the Government see the situation but to set the whole problem in context.
One has to start with the status of the general medical practitioner, who is, as my hon. Friend said, an independent contractor. He is not a salaried employee of my Department or the Health Service and is not subject to any management or 1463 disciplinary controls as such. He provides general medical services in accordance with prescribed terms of service as set out in the appropriate National Health Service regulations, which are the general medical and pharmaceutical regulations 1974, as revised, and his contract is with his family practitioner committee.
That does not mean that there are no controls over the distribution of general medical practitioners. There are controls. They have existed since the NHS was set up, and I should like to explain how these controls operate because they have an important bearing on my hon. Friend's problem.
To provide general medical services under the National Health Service as a principal, a registered medical practitioner must first apply for admission to the medical list of the local family practitioner committee. That committee, after consulting its local medical committee, must refer the application to the medical practices committee.
That is now a national committee. It is empowered to refuse the application if it considers that the number of doctors already providing general medical services in the locality is adequate. By this control, the medical practices committee aims to prevent increases in the number of doctors in areas where there are sufficient doctors already and to encourage them to set up practice in the under-doctored areas. The committee is seeking to achieve an even distribution of doctors throughout England and Wales, so that everywhere patients will have reasonable access to a doctor.
To help the committee to judge the adequacy of the number of doctors, it divides the country into practice areas which it classifies according to the average number of patients per doctor. As my hon. Friend has already divined, the committee uses four classifications, designated, open—these are areas where applications to practise are normally granted—and intermediate or restricted areas. In those areas applications may be refused on the ground that the number of general medical practitioners already there is adequate.
There is another control exercised by the medical practices committee should a general medical practitioner in England and Wales resign or die. It is for the 1464 committee to decide whether a vacancy should be filled. If there are sufficient doctors there, an existing practice may take over the patients, or patients may be advised to choose a new doctor from among those already there.
Classification of areas is always subject to change as new doctors come into an area. Those who retire may or may not be replaced.
When deciding individual applications, the medical practices committee endeavours not to be too rigid in applying the classification of area list size. It tries to take account of local circumstances after consulting the family practitioner committee, which is an important channel for identifying the local circumstances.
Knottingley is part of the Knottingley, Pontefract and Osgoldcross practice area and, as my hon. Friend said, for many years it was classified as an open area. This meant that a doctor wishing to set up there would have had his application granted by the medical practitioner committee. But there have been recent increases in the number of doctors practising there and the classification has been altered to intermediate. That means that an application to practise in Knottingley will not now necessarily succeed. So far no one has applied to practise there. If someone did apply and the medical practices committee refused the application, the doctor concerned would have a right of appeal to the Secretary of State, who would obviously have to consider, in deciding the appeal, the adequacy or otherwise of the existing manpower in the practice area.
I should make it clear that the medical practices committee is an independent body. It is not part of my Department. It comprises practitioners, with two lay members. It is a hard-working body and meets twice a week for 48 weeks of the year. The committee undertakes difficult work. It is not easy to tell a medical colleague that he may not practise where he wants to, but that is what a great deal of the work often involves. The committee deserves more credit than it generally receives.
I turn to the local circumstances which concern my hon. Friend. I recognise that for some people in the area the distance to the nearest doctor's surgery may be up 1465 to two miles. This creates real problems, particularly for mothers with young children and for elderly or disabled people. In most parts of the country most people's homes are within less than a mile of a doctor's surgery, or, indeed, of several surgeries. But with just under 23,000 general practitioners to serve the whole of England and Wales it is not possible for everyone to have equally close geographical access.
The total number of doctors in general practice is steadily expanding. Doctors necessarily tend to be concentrated in relatively densely populated areas and close to locations to which people travel for other purposes. Some medical practices have branch surgeries and—this was the solution advocated by my hon. Friend—there must be compromises. The principle of taking the service to the patient may sometimes be in conflict with the ideal that all surgeries should have full equipment and full support from various services which form part of the primary care team. The family practitioner committee and the medical practices committee have these considerations in mind. They try to balance them, but it has not been possible to come up with an ideal solution in Knottingley and the Warwick estate.
The health premises on the Warwick estate already provide, of course, a wide range of health care. It was always intended to use them for mothercraft and relaxation classes, chiropody, speech therapy and baby clinics. These are in full swing. In addition, this centre provides a base and office for health visitors, home nurses and domiciliary midwives. A dental wing to replace old premises in Knottingley is being added and will provide new facilities which will be completed towards May.
I turn to the regulations that apply to the provision of services by individual practices. Doctors are independent contractors. They decide where they would like to practise and then proceed, as I have already explained, to obtain the approval of the medical practices committee in the area. The new doctor gives to the family practitioner committee details of the premises from which he proposes to practise, his surgery hours and the limits of his practice area. The family practitioner committee must consult the 1466 local medical committee before it gives its decision. Approval cannot be unnecessarily withheld.
The doctor is responsible for providing his patients with general medical services at his surgery, at their homes or elsewhere in his practice area. When doctors in a practice are considering how many surgeries they should provide and where they should be, they should take full account of the needs of all their patients, but they cannot ignore the effect of their decisions on their own financial position.
They can expect to receive from the family practitioner committee a fair reimbursement of the rent and rates element and a proportion of the costs of their staff. The amount that they receive indirectly in this way for expenses varies broadly with the size of their practice, but not in accordance with their actual expenses. The profession as a whole accepts the drawbacks in this arrangement—which has an element of swings and roundabouts—as part of the price of maintaining its independent status. The same terms of service apply to a family doctor in a health centre, and he has freedom of choice in deciding where he sets up his surgery, whether that applies to a health centre or to the more traditional forms of surgery.
In general, health centres are not provided unless the local doctors have expressed an interest in working from them, and doctors are not legally committed to moving into the health centres when they are built. Doctors can change their minds. For example, while a health centre is being built there might be a change in the membership of a practice, which might affect the decision to move in. Other enforced changes in health practice, such as increases in proposed health centre charges or fears about jeopardising independence and security of tenure, may also persuade doctors during the construction period not to go ahead with their originally expressed intention of practising from the health centre.
In the Knottingley case, the four-doctor partnership which had expressed an interest in a health centre on the estate has been reduced to three doctors. It is accepted, as my hon. Friend said, that this partnership had said that it would consider working from the clinic if it got a fourth partner. It recruited a fourth partner in the middle of last year. The family 1467 practitioner committee reminded the practice of its undertaking. In reply, the practice said that it had considered carefully the position but had decided against providing a branch surgery in the clinic.
I can well understand the disappointment of my hon. Friend at this outcome after all his endeavours and hard work. As I have tried to indicate, the initiative in these matters remains with the doctors. My hon. Friend will recall from previous correspondence between us that I was not aware of any failure by this practice to provide general medical services for patients living on the estate. It is generally a question of convenience and travelling time.
I can well understand my hon. Friend's concern for his constituents on the Warwick estate and the difficulties which face, for example, young mothers having to make their way some distance to a doctor's surgery. I have no doubt that he was disappointed that the local partnership, when it got its additional partner, concluded that it was unable to open a branch surgery on the estate. The pattern 1468 of general medical care is tending to group general medical practitioners in a pattern which provides better services for individuals on a more centralised basis and therefore involves some more travelling for the public.
Given this pattern of care and the need to use limited medical manpower to the best purpose, it is impossible to arrange for all residents within semi-urban areas to be within a mile of a surgery, convenient though that might be. If there is any comfort for my hon. Friend to take from the current situation, it will be from the knowledge that there has been some improvement recently in the number of doctors serving the locality—even if their distribution is somewhat distorted—and that the medical practices committee considers that Knottingley is now better supplied with doctors than many other parts of the country. That is cold comfort, I am afraid, but it is all I have to offer.
§ Question put and agreed to.
§ Adjourned accordingly at twenty-seven minutes to Twelve o'clock.