§ The Under-Secretary of State for Health and Social Security (Sir George Young)
I beg to move,That the draft General Practice Finance Corporation (Increase of Borrowing Powers) Order 1981, which was laid before this House on 1 May, be approved.I present this order in conjunction with my right hon. Friend the Secretary of State for Scotland in exercise of our powers under section 6(3) of the National Health Service Act 1966. My hon. Friend the Minister for Health was to have presented it but he is unwell. He is now, I hope, obeying the injunction to physicians in the New Testament and healing himself.
The need to bring the order before the House tonight arises from the continuing high level of demand from family doctors for loans from the General Practice Finance Corporation and from the backlog of applications that built up prior to the 1980 legislation because the corporation had committed the whole of the £25 million to which its borrowing had been limited some 12 months before it became possible to increase the limit to £40 million.
The corporation advised the Government earlier this year that it might be committed up to the present borrowing ceiling of £40 million by June, and it asked us to seek the approval of the House to increasing its borrowing limit by that date in order to prevent any holdup in its expanding business. We were pleased to accede to that request and to bring the draft order before the House.
The order raises the corporation's borrowing powers from £40 million to £75 million. This gives a good margin above the expected need, and I hope that it will be adequate for the next three years. I understand that at 30 April the corporation was committed to lending nearly £38 million. It would be wrong for the corporation to commit itself beyond its borrowing limit, so an increase in its borrowing powers is now urgent.
The new ceiling will enable the valuable work of the corporation in meeting the demands from doctors for loans to continue and will also enable it to make use of the powers it received, under the Health Services Act 1980, to buy surgery premises for leasing to general practitioners. These new powers are only just coming into use, and it is too early to say yet what the demand from general practitioners for this kind of arrangement will be, but it is clear that it will add to the corporation's borrowing requirements.
I should make clear to the House that the corporation is obliged by the terms of the 1966 Act to break even, taking one year with another, and that it is entirely independent of the Government as regards its operating costs, so it makes no demands on public expenditure.
The corporation is an independent body controlled by its members. It was set up in 1966 with all-party support, and it makes loans available to family doctors working in the National Health Service to provide and to improve surgery accommodation for their patients. The members include general practitioners and persons with appropriate legal, financial and estate management experience. Appointments are made by Ministers following consultation with representatives of the medical profession.
125 The corporation is responsible for its own financial policy and raises finance by issuing stock and by temporary borrowing, both of which are guaranteed by the Treasury under the terms of the 1966 Act. The stock is then taken up by the national debt commissioners and temporary borrowing takes the form of a bank overdraft, limited to £2½ million, which gives the corporation flexibility in choosing the best time for stock issue. The issue and redemption of stock and the limit of temporary borrowing are subject to the approval of the Secretaries of State and the Treasury.
Since its establishment, the corporation has made more than 3,000 loans to individual doctors, groups and partnerships, and there is no doubt that it has played an important role in stimulating the building of new and improved premises as well as assisting doctors in purchasing existing premises or a share in them. I take this opportunity to pay tribute to the chairman of the corporation, Mr. Stebbings, and the other members and the staff of his board for the valuable public service they have given in managing and developing the corporation's business.
If the House agrees to the order, I hope very much that the corporation will be able to continue to expand its work. There has been a welcome improvement in GP premises in recent years, but there is scope for more to be done, especially in some of our inner city areas, and we should very much like to see more applications from GPs in these areas. The new powers, which Parliament agreed last year, enabled the corporation to buy and lease premises to GPs, and I hope that they will have an important part to play here as it is often in the central areas of our great cities that some GPs find that the long-term capital commitment of providing premises is more than they want to take on.
The buy-and-lease arrangements should help here, while still leaving the GPs with a deciding role in the design and subsequent management of the premises, which is what they want even if they do not own them. In my view most GPs will, however, wish to go on owning their own premises, which they see as a key part of their independent status and essential to the well-being and vigour of the profession. We in the Government strongly support the profession on that. The order will in its way help to support and strengthen that concept, and I am happy to ask the House to approve it.
§ Mrs. Gwyneth Dunwoody (Crewe)
I suppose that I am the eternal optimist. I had hoped that the Minister would be prepared to expand rather more than he has on the whole question of general practice facilities. I hope that he will not mind my saying so, but on this occasion I am rather sad to see him here. I hope that he will convey my best wishes to his colleague. I am sorry that the Minister for Health is ill. It was he who today answered a written question on the Acheson report, which specifically deals with the facilities in general practice and has whole sections dealing with the provision of general practice facilities.
The provision of money is one of the most important elements in inner city health care. If there is a primary health care team that is easily accessible to patients and is efficiently organised and properly housed, it becomes the front line in the battle against disease. When we compare those countries where a general practitioner service is not readily available with our own NHS facilities, it becomes 126 obvious that the type of general practitioner service that we have is by far the best way to combat the problems. Therefore, the provision of finance for surgery premises is of paramount importance.
The Acheson report set out in great detail some of the problems of the inner cities. There are still far too many general practitioners working single-handed and operating from substandard premises. There are still far too many practices where the patient knows that a call to the doctor after hours will almost inevitably be answered by a deputising service and a doctor unknown to him. There are still far too many practices where the GP is not part of a proper health care team but still operates as he did 20 or 30 years ago, at the beginning of the NHS.
The corporation was brought into operation precisely to deal with the problems that were arising from the independent status of the general practitioner, because there was the odd situation that those doctors who provided a high level of service for their patients were being penalised by providing those services out of their own pockets, and the man who did not provide proper surgery care was getting paid the same sort of money. The corporation was set up specifically, as an autonomous body, to deal with some of the difficulties that were arising.
We have marched on energetically, but the provision of health care in the inner cities has not kept pace with other health developments. In the recent past there has been a great deal of pressure to improve and change hospital services, but the primary health care services have not had the same kind of support.
We do not lack evidence of the difficulties. One has only to read what is said in the Acheson report, not only about the premises, but about the difficulties that arise because of the possibly inadequate stock, to appreciate the situation. The report says:Evidence submitted to us from many sources has referred time and again to the very poor quality of practice premises which may even be inadequate for the provision of general medical services … Comments have described lock-up shop front premises, poorly decorated with little or no sanitary facilities.In London, unlike Manchester, there is no adequate system of inspection and, indeed, no financial incentive to the general practitioner to extend or to improve his premises.
The Minister said that he hopes that the new buy—and—lease facilities will change all that, but it is not that simple. If he thinks that it will be easy to deal with, I refer him to the Acheson report. That spells out the problems facing the general practitioner in the inner city. It says, in effect, that property is exceedingly expensive for him to buy. If he tries to lease a shop, it is not really in his interests to improve it to make it better for his patients because those improvements might make it a bad capital investment for the doctor. If he wishes to sell or dispose of the premises later, the improvements that are demanded by the constraints of his job stop him selling property for the best market price.
The report goes on to say:The Health and Safety Executive will in the next few years be undertaking routine inspection of premises.The report hopes that it will make clear the need for improvements with regard to basic inadequacies and hazards. However, it says:We have no doubt that the evidence we have received regarding the unsatisfactory nature of many premises in inner London reflects a real problem".127 It makes various recommendations.
What is the reality of health care at primary health care level? In far too many areas, especially in the inner cities, single-handed GPs without the back-up or proper teams are not providing the levels of care that are necessary. There are far too many elderly GPs operating limited lists. The report states that one of the real improvements that could be made to encourage general practitioners to retire would be to give them a positive incentive and to provide them with better facilities. There are far too many health care centres that are not properly supplied. Even those built by the National Health Service have a considerable number of design faults which the teams have criticised.
I must declare an interest and say that we believe it is important that we should move towards health care teams at primary level. The day is gone when the doctor can provide solely for the needs of his patients. It is important that doctors should operate, if not from health centres, from units which contain many back-up services. The centres should provide nurses and midwives, with many ancillary workers embodied in the team, including pharmacists.
It is clear that unless the Government do something positive the method we are considering is inadequate. There will not be enough general practitioners to take up the moneys available through the corporation. They will be faced with problems not only of committing themselves to a considerable sum for repayment, but of having to decide whether they have large enough premises and proper clerical space for the back-up staffs and whether they will be able to agree with the local authority on such elementary things as having enough car parking space around the centre.
The Government should now be doing something positive about these matters. They should not simply be saying "Here is the money. We have upped it to an amount that is slightly more than the inflation rate, but that is all we are talking about". They should be seeking positive incentives to improve health care in our inner cities by encouraging general practitioners to set up health care units.
I do not feel that we need say automatically that GPs must work from health centres, but if the situation in the inner cities is to be changed a number of radical decisions must be taken quickly.
We must build up the primary care health services. We must demand that everyone involved, at every level, including the family practitioner committees and the people who take decisions about the numbers of doctors who are allowed to practise, the size of the lists and the numbers of deputising services that are allowed, be taken into account.
In replying to a written question today about the publication of the Acheson report, the Minister for Health said:This report not only points out the special problems in London but also shows ways to improve London's health services.When talking about cutting down on acute hospital beds, he said:the money saved can be used to build up primary care services.He said that he was very grateful and that he intends to askall the responsible authorities to consider the report.That is a totally inadequate response. We hear a great deal from the Government about their commitment to the 128 National Health Service, the way that they want to develop partnership with private health care, and the way that they are deeply concerned about the level of involvement between the community and medicine. But when it comes to the point, what do they have to say in response to a very positive report? They say:The Department will be considering those recommendations for which it is responsible.If the Department's response is about as active as some responses that we have had so far on other major reports, it will be worse than useless.
I ask the Minister to consider whether just increasing the amount of money available to the corporation is enough. Is he not prepared now to talk to the profession about the situation in the inner cities, the lack of proper provision, the number of inadequate practices, the number of elderly general practitioners, and the difficulties of getting people to provide proper health care when they themselves are not given the incentive even to improve their own practices?
I ask the Minister to address himself strongly to the evidence that has been given to him by Professor Acheson. What is asked for is very elementary. The report says that the Department shouldset minimum standards for GP premises and ensure effective inspection.That means giving them not just money to borrow from the corporation. It means giving money to provide an inspection service. It is done in other areas. It should be done in inner London.
The report says that we shouldinvolve health and local authorities in providing or assisting in the provision of premises.It spells out where the problems arise for local authorities, how local authorities fail to respond to the needs of particular areas, and how, in many instances, they have not even been asked to use the facilities that they have to improve health care in the inner cities.
The Government bear a great responsibility for the difficulties that have arisen in relation to, for example, joint financing. Since the Secretary of State for the Environment hacked the amount of money available to local authorities almost to nothing, it has been virtually impossible for the personal social services or those joint financing projects that are desperately needed by the community to be funded by local authorities. It is very important that the Government should be prepared to consider this sort of aspect.
The report asks for improved staffing levels and reduced case loads in the community nursing services. I believe that a primary multi-disciplinary health care team, working as equals, can operate effectively only if the premises in which it is working are of a very high standard. We cannot expect nursing staff to be able to see people, and, in many instances, to pass on their expertise in teaching, if they do not have room to deal with patients or to store their records, or even a place where they can easily meet the staff in the other disciplines. The recommendation in the Acheson report that we should improve the conditions of work for community nurses in terms of pay, accommodation, transport and social and recreational facilities should be an urgent priority.
One of the hazards of the independent status of the family practitioner is that if he chooses to develop his own premises by using the money that we are discussing he faces a difficulty with ancillary staff among many other difficulties. Many ancillaries are paid directly by area 129 health authorities and the calculation of their hours of work, the jobs that they are supposed to do and their job description are issues that are decided by the AHAs. There should be a positive way of encouraging co-operation at a much higher level between the general practitioner and the AHA to ensure that the team has proper back-up in terms of hours of work and the moneys that are available.
There are many other aspects of the report that I hope we shall have the opportunity fully to debate. The report was published only today, but its timing is impeccable. We do not need to ask ourselves about the problems in the inner cities. All of us who have seen the lock-up shops, who have tried to obtain general practice care and who are aware of the number of patients who are forced to dial for an ambulance to take them to an accident or emergency department to get care that should be provided by the general practitioner know that a great deal is wrong with the present system.
That will not be changed by saying to general practitioners "This money is available. If you wish you may borrow it. You may use some of our facilities in some instances to lease back premises that we have acquired." However, that is only scratching at the surface of the problem. If the Government are not prepared seriously to consider all the other implications of the provision of primary health care centres, they will be failing disastrously.
I had hoped that the Under-Secretary of State would say more than that the Government will be studying the report, that they have some money to spend and that it will be spent wisely. The Minister must know that the applications to the corporation over the past three years have been quite considerably down on some of the earlier applications, so it is not true to say that all is well with the corporation. It is doing a marvellous job. It is worthy of support. The money that the Government are giving it will cover only the backlog since the last amount was given to it some years ago.
The truth is that if we are to have proper health care in the inner cities, and if we are to retain the general practitioner services which everyone acknowledges must be the front line of our health care services, we must do a great deal more than the Government seem prepared to do. I hoped that the Minister would give us some hope that they are considering the subject seriously.
§ Sir George Young
When the hon. Member for Crewe (Mrs. Dunwoody) said that she hoped that it would be possible to have a wide-ranging debate on the future of primary health care and to consider at some length the recommendations of the Acheson and Harding reports, I found myself nodding in agreement. These are tremendously important issues. How we build on our good primary care services, how we capitalise on our GPs and whether we shift resources from other sectors of the Health Service to do so are fundamental issues that will have an effect on the future of the NHS. I hope that the hon. Lady will accept that a one-and-a-half-hour debate on an order increasing the sum that the GPFC can lend is not the right forum for such a wide-ranging debate. I hope that it will be possible at some stage to find time for it.
I think that the hon. Lady was rather impetuous in expecting the Government to come forward this evening with a response to a report that was published only this afternoon. The Acheson report, which I have read, is a 130 stimulating and radical document that has come up with new solutions to some of the old intractable problems affecting primary care services in the inner cities. I hope that we shall be able to make some progress in implementing them. I hope, however, that the hon. Lady will accept that other bodies with an interest in the matter should have the opportunity to make their views known before we take decisions.
The hon. Lady said that there were problems with the take-up of joint funding. I understand that the take-up over the country as a whole is nearly 100 per cent. If one or two local authorities find themselves unable to commit themselves to specific projects, there are provisions to switch the money to other areas in the region or, indeed, to other regions. The growth of joint funding, which is one of the real growth areas of the NHS, has been one of the success stories, and I hope very much that we can build on and develop it.
I agreed with the hon. Lady's analysis of the problems of primary care in our inner cities. These were described in some detail in the Acheson report. The report confirms that there are serious problems in primary care in London, some of them well known, and it makes many suggestions as to how they should be tackled. The report points out that the burdens on primary care services are bound to increase over the next few years as changes take place in hospital services in London. This was also recognised by LAG, the London Advisory Group, in its report on acute hospital services.
When we accepted the advisory group's report, one of our main aims was to see a shift in resources from hospital to community care. What is more, we said that a large proportion of the resources released from the acute services must be kept in London to strengthen other services, including primary care. That remains our objective and we have asked authorities to consider the Acheson report urgently to see what action they should take.
As the Acheson report points out, and as the hon. Lady said, primary care teamwork has not developed in London to the same extent as it has outside. The Harding report, which was also published today, emphasises that. That report dealt with the development of primary health care teams nationally and made a number of recommendations to encourage further development.
I think that the hon. Lady was a little unkind in implying that there had been no improvements. The number of GPs, for example, has risen from 25,614 on 1 October 1979 to 26,140 on 1 October 1980. The number of candidates for district nursing examinations shows a welcome increase from 1,875 in 1979 to 2,010 in 1980. The waiting list figures show a welcome reduction. I therefore do not accept the hon. Lady's criticism that no progress has been achieved by the Conservative Administration.
The Acheson report relates to the order before the House tonight. It identifies GPs who have been unwilling or unable to improve their premises or, indeed, to buy new premises. I think that the extra steps that we are taking today in this direction will enable some of those problems to be tackled. The corporation's financial capacity to help the GPs must be maintained and is an integral part of the improvement of primary care services.
I take it that the hon. Lady does not wish to resist the order. I ask the House to approve it.
§ Question put and agreed to.131
That the draft General Practice Finance Corporation (Increase of Borrowing Powers) Order 1981, which was laid before this House on 1 May, be approved.