§ Mr. Alfred Dubs (Battersea, South)For many years people have been paying lip service to the need for more effort to be put into primary health care services, but very little has been done about the matter. That might be because we have put too much emphasis on hospitals. Health authorities have tended to be more concerned about buildings and influenced by the weight of medical opinion that has, on the whole, tended to concentrate on hospital services.
The Acheson report stated that there was a need for urgent action. The report was published in May 1981, since when there has been not a glimmer of response from the Government. The Government have not commented on their intentions. The main purpose of the debate is to find out the Government's response to the many sensible suggestions in the report about primary health services in inner London.
The report is not radical. All it says is that it is about time that inner London caught up with the rest of the country. It makes a modest proposal and I am surprised that Ministers have not expressed their views on it.
Inner London's problems are difficult. The British Medical Journal of 30 May 1981 states:
Britain's inner cities have some of the worst social and medical problems combined with some of the poorest primary care services … Many of inner London's difficulties are ones about which the National Health Service can do nothing. Compared with the average for England and Wales inner London has more poorer people, more elderly people, more people living alone, more foreigners and immigrants, more single-parent families, more homes lacking basic amenities, generally poorer environmental conditions, and greater population mobility. All of these factors are known to be associated with greater morbidity and mortality, and it is not surprising that, as the Royal College of General Practioners' report has shown, there are more of such problems as tuberculosis, abortion, admission for mental disorder, and suicide.I agree that the problems are not of the Health Service's making, but it has to cope with some of the problems. Cuts in acute hospital services and local authority cuts have resulted in a diminution of social services for the elderly and have made matters worse. Increases in unemployment are related to an increase in the number of people suffering from depression.This is not the time to go into the Black report in detail, but it demonstrated a striking
lack of improvement and in some respects deterioration, of the health experience of the unskilled and semi-skilled manual classes (class V and IV), relative to class 1 throughout the 1960s and the early 1970s … a class gradient can be observed for most causes of death being particularly steep in cases of diseases of the respiratory system.In other words, the unskilled and manual working classes in inner London suffer particularly in health terms.General practitioners have a key role in primary health care. Most primary health care services are inter-related, but it is worth examining the pattern of primary health care in inner London. GPs in inner London are older than they are in other parts of the country. In inner London about 18 per cent. of general practitioners are aged over 65 years compared with about 6 per cent. in England and Wales. The 1979 figures tell us that there were 52 GPs in London over the age of 70, five over 85 and one over 90. It is difficult to believe that doctors of that age are able to cope with the pressures that are inevitably imposed upon general practitioners in inner London.
1355 The second feature of general practice in inner London is the unsatisfactory premises from which many GPs work. It is interesting that the King's fund, in combination with the medical architectural research union, has developed an experimental programme of adapting existing and unsatisfactory GP premises to show what can be done by using the buildings that are available rather than taking the view that the problem can be solved only by providing new buildings.
It has been suggested that general practitioners in London should play a much greater role in paediatric screening, which would be desirable in seeking to prevent the present mortality rates. However, it is obvious that many GPs, because of their inadequate premises and for other reasons, could not cope with that rather ambitious screening programme.
Another feature of general practitioner services in inner London is the balance between those who work in health centres, those who work in group practices and those who work entirely on their own. The statistics produced in the Acheson report show that in London a larger proportion of GPs do not work in group practices compared with elsewhere. In inner London, 59 per cent. of all GPs do not work in group practices compared with only 28 per cent. in England and Wales. In my constituency, which was covered by the Merton, Sutton and Wandsworth area health authority, which has been replaced by the new district health authorities, the figures show that about 56 per cent. of GPs are not in group practice. That AHA covered both inner London in Wandsworth and the outer London areas of Sutton and Merton.
There is a fairly large proportion of GPs in inner London who have rather small lists. The Acheson report reveals that 17 per cent. of all doctors in inner London had lists of under 1,500 compared with only 7 per cent. in England and Wales. That poses problems when an elderly doctor wants to retire and a younger GP is wanted to take over the practice. A small list cannot sustain an adequate livelihood unless the GP wants to spend a large proportion of his time in private practice, which many of us consider to be utterly undesirable.
It seems that the family practitioner committees should exercise a greater level of responsibility in these matters. There should be a greater degree of manpower planning exercised by the committees to ensure that when GPs retire and cease to practise they are replaced by those who can provide the basis for a satisfactory GP service. The committees should take upon themselves greater responsibility in considering the type of premises from which GPs operate. It would not be a bad thing if the committees were to set up minimum standards and use their influence to ensure adherence to them.
It is an interesting footnote, but I understand that recently the Department of Industry made available £2.5 million to enable GPs to develop computer systems, presumably for their medical records. Many GPs operate from premises and in conditions that are so backward that it is almost laughable to suggest that they might take advantage of the Department's gesture. They need the money spent on much more basic aspects of their operations than the more sophisticated area of computer systems.
It is extraordinary that, at a time of high unemployment, there is a serious shortage of both 1356 community nurses and health visitors. The reasons for it are interesting and worth developing. I suggest that too few people are trained in those skills. There are difficulties in operating in inner London. Motor cars are required and many nurses find that, with the wages that they receive, they cannot afford to run one. It would be worth one's while to consider whether they should be provided with motor cars for their work by the health authorities to which they are responsible. There is a disturbingly large turnover of community nurses and health visitors in inner London, presumably because they prefer to go to the less pressurised parts of Britain where working conditions are more congenial. If too few community nurses and health visitors are being trained, it may be worth while to consider financing their training nationally rather than leaving it to the hard-pressed area health authorities.
It is generally agreed that it would be desirable for community nurses and health visitors to have better links with GPs. One model that has been tried in some parts of Britain—indeed, even in some London practices—is that a group practice of GPs should have integrated with it a team of a community nurse, a health visitor and possibly one or two social workers seconded from the local authority. The difficulty with such an approach, although it has much to commend it, is that too many GPs in London operate single practices and they could not cope with such attachments. It would be easier if they were attached to a group practice. It also means that a GP must have an approach to his practice that would make it easy for him to co-operate fully with his support team. Many GPs would not take easily to operating in that way. That has implications for the way in which general practitioners are trained and their attitudes towards working in inner cities.
The report has an interesting table showing the rates of attachment of nurses as recorded by GPs in 1974. In inner London, 25 per cent. of all GPs had nurses attached to the practice, whereas in England and Wales the figure was 68 per cent. There is a clear need for inner London GPs to catch up with the practice in the rest of Britain. However, there are difficulties because of the number of single practices in inner London, the fact that many practices are small, that many GPs are elderly, and that perhaps their attitudes are such that they do not wish to move in that direction.
However, I suggest that the way in which those services—community nurses and health visitors—operate could benefit from a review. Such a review, which should go beyond the Acheson report, might come up with conclusions that would be beneficial to the way in which those primary care services are operated. It is not satisfactory now and the fact that there is a shortage of people may cause one to reflect that one should improve the service.
Inner London, with an increasing proportion of elderly people, is precisely the area where primary services have a major part to play. Improvements in those services would have a large impact on the elderly population in inner London. There are more isolated elderly people in inner London than anywhere else. Because of housing difficulties, their children must move away and the elderly, through their isolation, are much more dependent both on local authority social services and on primary care services so that they can continue to live in their own homes and be kept out of institutions.
Any of us who meet elderly people in our inner London constituencies will know how difficult it is for many of 1357 them. Time and again we are approached by elderly people or their children, who beg us to do something about their housing difficulties so that they can live closer together, and the elderly will not be so dependent on these services. All too often this is not possible because of the housing crisis in inner London and we are left with elderly people who are dependent on the services. Any improvement in these services would quickly pay dividends.
If we review these primary services, we find what has been called a planning vacuum in London. The difficulty lies in the structure of the regional health authorities. I have for long believed that there should be a regional health authority covering inner London because this would make it easier to plan services for areas similar to each other. The RMAs have cut London into four cake-like segments, where they are under the pressure of increasing population in the green belt and the outer London suburbs, and have to balance the pressure on their resources between those areas and the deprived inner London areas. This makes it difficult for the RHAs to allocate resources in the most useful manner.
Having a planning body, a RHA covering the whole of inner London could be of benefit only to the health service in London. I have been arguing this for years, but no one has responded to the need. However, I wonder whether there is not some way in which we can have, on a permanent basis, a way of planning services to help the disadvantaged inner London area. I appreciate the difficulties, as there would be an overlap of authorities, and the RHAs could conflict with the planning needs of inner London, but there must be some way in which the RHAs can get together and go in for more planning. Presumably this would involve a district level integration of some of these responsibilities so that some of the primary care services can be better planned. I do not know how far one can take this plan, but there is some possibility that improved services would result.
One of the conclusions that one comes to about this is that, although some of the proposals would cost money, many of them are relatively inexpensive. Therefore, the Government's view that no more money can be spent on the Health Service, and that there should be further cuts in London, does not provide a good enough excuse for not doing something about the proposals in the Acheson report.
I hope that the Minister will take this to heart. We need some will and determination. The people of inner London are disadvantaged and could do with better health care. The real need for development is in the primary health care services. We have the right to ask for a positive response from the Minister and positive action to improve the health care for the many people in inner London who need it greatly.
§ Mr. Roland Moyle (Lewisham, East)I rise to support my hon. Friend the Member for Battersea, South (Mr. Dubs), who has so ably introduced this subject. In doing so, I utter a warning to the House and to the Government. One could represent, as I have, a London constituency for about 10 years, which is referred to in the Acheson report as an inner London constituency, without realising the extent of the problems that affect general and family practice in many parts of inner London.
The problems have to be looked for, but they are there and they can be horrendous. There are two basic reasons 1358 for the failure of family practice in inner London. The first is that in the last century London had a proportionally greater concentration of population than it has even today. Therefore, it was an ideal place for the construction of large teaching hospitals. About a dozen were built because there were plenty of bodies available on which the trainee doctors could practise. They gave excellent technical service, given the conditions of the art at that time, and as a result people in inner London developed the habit of going to the teaching hospitals instead of to their family doctors. That started the rot—if I may put it that way. It has continued, to a greater or lesser extent, to the present day. It may be because Lewisham has never had a teaching hospital that we have escaped many of the problems with which the Acheson report deals. We have deficiencies and problems which there will be time enough to debate on another occasion, but I particularly want to focus on those with which the Acheson report deals.
The second reason is that a number of less than worthy general practitioners realised that the inadequacies of the family practitioner service in inner London provides an excellent structure on which to fashion a parasitic growth, which meant the minimum commitment to the National Health Service and the maximum commitment to private practice. Most of the inner London areas, of course, lie only a short distance from that lucrative field of private medical practice—the centre of London and the West End.
Those two factors have led to a continuing reliance by people in inner London on the big teaching hospitals' out-patients' department. The tradition has built up over many years that if something happens to a person, he goes to the out-patients' department. The technical assistance provided there is excellent, but there is an absence of continuing care, which is probably the single most basic principle of family practitioner service.
The general practitioners whom I have described spend the minimum amount of money on their surgeries. Some surgeries are very poor. I described one some years ago as being like a ganger's hut underneath the railway arches, and I was not exaggerating. These doctors are keen on building up their own income, and as a general rule they therefore do not wish to combine with partners in a group practice. As my hon. Friend said, there is a high concentration of general practitioners working on their own.
These general practitioners work with minimum lists. If a GP has a patient list of 1,000 patients, he qualifies for the basic allowances of NHS practice. Having done that and ensured a fall-back income for himself, he then feels free, with a minimum commitment to the NHS, to indulge in his proclivities to get income from the private sector. That has a serious effect, because the Medical Practices Committee, which has the job of recommending the number of doctors for the country generally, tries to get one GP to about 2,500 patients. On that criterion, the inner London areas are substantially over-doctored. Therefore there is a tendency to steer aspiring doctors away, thus making the problem infinitely worse.
These general practitioners not only expend their efforts on the minimum number of patients, but they devote the minimum time to that minimum number of patients. There are many examples of GPs who live nowhere near their premises, who hold surgeries for one and a half hours in the morning and one and a half hours in the evening, and disappear in between times. If one wants to contact the GP, a telephone call will probably put one in touch with 1359 the deputising services. I do not want to enter into a lengthy debate this evening on the value of deputising services. They may well be technically good, and the doctors may be good, but they cannot provide the continuous attention which is the basic hallmark of general practice.
There is the maximum disincentive to introduce a young doctor into such a set-up. If an elderly doctor with 1,000 patients dies, no young doctor is particularly anxious to take over such a list because he would have to exist in relative poverty for several years while he built it up to 2,500 in order to earn a decent National Health Service income.
The whole position leads to the vicious practice of notional retirement, whereby those general practitioners who before the age of 65 have devoted their efforts to a proper list of 2,000 to 2,500 patients, retire at 65 and, because nobody wants to take over their practice, return to work the next day, drawing their pensions with a patient list of 1,000 and the basic Health Service allowances. As has been said, there are many elderly general practitioners in inner London.
All the problems of a weak practitioner service are compounded by the fact that the stable inner London population is often deprived, with a substantial proportion of low income earners, elderly frail people, single parent families and so on. Such a population is also to a large extent mobile and rootless. Young people move in to study and then move out, without a great deal of money to live on, as the Minister might have heard had he listened to his colleague answering the previous debate. Tourists drift in and out. Commuters arrive and leave daily. A large immigrant population may, until recently, not have appreciated the standards of medical care that could be achieved in Britain. In addition, there are the homeless and rootless—not to mince words, the tramps.
The solution to all that is an early retirement scheme for such elderly general practitioners. There should not be too much discretion as to how those schemes are applied. There must be more sensitivity from the Medical Practices Committee to assess the position in a particular area. Where it finds that the number of doctors is based entirely on minimal lists, fresh general practitioners should be introduced.
There will have to be some financial enouragement for young doctors and there must be good premises. We must work towards a group practice of doctors, combined with the build-up of team work with not only doctors but other health care professions. As in other parts of the country that means the provision of good health centres. To achieve that, one would have to co-operate with local authorities. It must be made much more difficult for general practitioners to settle for short lists.
Sometimes the point is made that such problems will persist because it is not possible to encourage general practitioners to live in the somewhat dreary and deprived inner city areas to do their work. That is not a real problem for general practitioners because there is always a reasonable residential area within 15 minutes' night-time motoring which makes attending emergency cases possible. That might require a moderate level of assistance with mortgage interest rates because such residential areas might be expensive.
1360 The problem might be more serious for people such as district nurses, health visitors and, particularly, midwives, who have a large emergency element in their practice and who therefore have to live near their patients. The salaries of health visitors and district nurses are not as high as those of doctors. They do not have the same facility to live some distance from places of work and to commute. Therefore, the Government should face those serious recruitment problems.
The Acheson report is excellent. It gives evidence of very hard work on the part of those who produced it. It is clear that careful thought has been given to the problems that I have alluded to generally. It shows a willingness to propound shrewd solutions to many of the problems that my hon. Friend the Member for Battersea, South and I have mentioned. I wish that such a tool had been waiting for me to use for the problems of general practitioners in inner city areas when I moved to the Department in 1976. The report is a magnificent tool for solving the problems.
The Government have had the report for 15 months. The working party reported in May 1981. As my hon. Friend the Member for Battersea, South said, no decision has yet been reached on the report. Indeed, the Government have not even decided to reject it. In the report, there is ominous mention of the need for extra public expenditure. On the other hand, the Government have not decided to accept it in part or in whole. There has been a complete silence about it. People in London are becoming concerned. Indeed, their representatives, such as ourselves, are becoming concerned. The GLC, health authorities and the medical profession are all becoming concerned.
I hope that the Minister will tell us what the Government have been doing about the report since receiving it 15 months ago. Why has there been such indecisiveness? After all, the Department was keyed up to accept such a report at least as late as 3 May 1979. I should have thought that the Government would have improved their ability to handle such a report in the three years or more since that date. Admittedly, there has been a change of Minister this year. That must have imposed a modest delay, but that is not a proper excuse.
Between May 1981 and March 1982—the date that the hon. Member for Reading, South (Dr. Vaughan) ceased to be Minister for Health and moved on to other things—the Minister could have reached a decision. What has been going on? I hope that the Under-Secretary will enlighten us. Why has no decision been reached? I hope that he will say that the Minister has decided to accept the Acheson report and that the Government intend to proceed with it. Even if the Minister accepts the report tonight, it cannot be implemented overnight. It will probably take a tremendous amount of time to persuade the British Medical Association to accept, on behalf of its members, several of the report's proposals. They will affect not only general practitioners in the inner city area but general practitioners throughout the country. Therefore, the negotiations will be important.
Until the Government say that they accept the report in principle, the policies cannot be implemented. In the meantime, apart from odd shifts and devices and short-term expedients the situation in relation to general practice is deteriorating all the time. The problems are not becoming easier, and they tend to become worse. Will the Under-Secretary put at rest the fears of hon. Members, the 1361 Health Service, the medical profession and local authorities by saying that the Government accept the Acheson report?
§ Mr. Ronald W. Brown (Hackney, South and Shoreditch)I join the right hon. Member for Lewisham, East (Mr. Moyle) in congratulating his hon. Friend the Member for Battersea, South (Mr. Dubs) on introducing this subject. The right hon. Member is right when he says that he wished that he had a report similar to Acheson available to him. He was kind enough when Minister of State, to visit my area, and we found all the elements contained in the report.
I have complained about the problems for many years. I began in 1965 by inviting the then Minister of Health—Kenneth Robinson—to visit my area. We trod the same path that the right hon. Member for Lewisham, East trod so recently. The Minister saw the deterioration in the area and was asked what he would do about it. In 1969 the Secretary of State for Social Services—Dick Crossman—visited the area in question and we went over the same ground and heard the same stories. He went away. Then the hon. Member for Reading, South (Dr. Vaughan), the then Minister for Health, visited the area. We went to the same places, talked to the same people and saw the same things. Nothing happened. I am now waiting to introduce myself to the new Minister for Health and take him to my area. We shall see the things that Acheson has put together in one document.
I do not accept that these are new problems. I am delighted to see that everything has been put together in the report. Over the years we have raised these problems with everybody in the Department for Health and Social Services who must have been aware of them. I cannot accept that we had to wait for Acheson to draw all the facts together. My complaint is that while everybody has known about the problems little has been done.
§ Mr. BrownI know what the right hon. Gentleman is going to say. I will be paying a tribute to him, but I wanted to draw attention to the special problems of the environment in inner London as Acheson does. Those factors are not accepted in other parts of the country. People look at London and regard it as the place where the streets are paved with gold. We cannot even make our provincial colleagues accept that there are distressed areas in inner London. We had a number of rows about "RAWP-ing" with the then Secretary of State, the right hon. Member for Norwich, North (Mr. Ennals). He would not understand that when he was talking about "RAWP-ing"—taking money from London and giving it to other areas—he was causing destitution in those inner London areas. That was one of the ways in which we suffered so badly.
My area is 90 per cent. municipalised. There are a large number of high-rise flats. An elderly person who goes into hospital in any other part of the country goes home to a nice little house with a garden in which he can recuperate. He can be taken out of hospital, allowed home, and be attended by nurses. That cannot be done in my area. People cannot climb four or five storeys to recuperate with ulcerated legs. They have to stay in hospital. People say 1362 that health services in inner London are expensive, and that the acute beds have to be closed because they are not really needed.
I have never been able to get across to the various Ministers for Health that many of our hospitals are what are known as "GP hospitals". People have to remain in hospital because their living accommodation does not allow them to recuperate at home.
My constituency is covered by the statistics for the City and East London. Table 7 shows that 57 per cent. of GPs in the area are born outside the United Kingdom. Over the page the report shows that we have the largest average list size, even though we have the poorest GP service.
The right hon. Gentleman referred to surgery premises. The area has the worst possible premises. He will recall that I took him to see the ganger's hut under the bridge. A lady holding a baby was standing in the rain outside the hut which had barbed wire on top of it. I pay tribute to the right hon. Gentleman; he took action. The doctors were moved into the health centre. The facts of rain and the sick lady standing outside with her baby conspired to highlight the situation. But the right hon. Gentleman's predecessors knew of the hut and did not take action.
To some extent the report soft pedals about the condition of premises. In my area GPs operate from premises that are merely shop fronts. The right hon. Gentleman saw me advise my constituents outside one surgery to wait in the betting shop next door, where there was a carpet, warmth and music, until it opened. Sick people were leaning on the wall outside waiting for the surgery to open. The report should have made the position clearer, although it may have been trying to be friendly to the GPs. The problem has been in exposing the truth.
People also have to be sick at the permitted hours which are posted on the wall. If people are sick outside those hours they must ring the famous number, 802 6622. It is called a deputising service, but it is a moonlighting service.
The tables in the report show that 98 per cent. of the doctors in the area are permitted to moonlight. They are in their surgeries only for the permitted hours and then they are away. Few live locally. The table on page 34 shows that only 5 per cent. live on the premises of their surgeries, 27 per cent. live elsewhere in the same borough, 30 per cent. in adjoining boroughs, 24 per cent. in the next-but-one borough and 30 per cent. further afield. The people in my constituency are not getting a GP service.
They turn not to the teaching but to the ordinary cottage hospitals. The right hon. Gentleman will recall that we had a row about closing a cottage hospital. There were two other closures, so that with two more, only St. Bartholomew's would be left. It was argued that, because there was a deficit each year on the district health authority of about £1 million, one could save £1 million by closing a hospital. Every year there was a deficit of £1 million, so we closed a hospital to save money. However, the money was not saved as St. Bartholomew's hospital was causing the drain on the area. For as long as we fund that hospital from the district we will always have that deficit. I always argued that the hospitals should not be closed because once one did that, one took away from the people of the area their one chance of having proper treatment.
I appeared once before a family practitioner committee. I do not know how many hon. Members have done so on behalf of a constituent. One has to do so to understand the extraordinary procedure. One cannot speak at such a 1363 committee. One has to act as a dummy for one's client. Therefore, one hears what is going on and whispers in the client's ear. One speaks through one's client. In my committee the GP about whom the complaint was made was angry because he did not understand the procedure. He complained to the chairman that I was advising his patient. The chairman had to explain that that was the role that I had to play. I could not talk to the chairman directly. I had to advise the client. That is absurd and should be cleared up.
That problem comes about because so few people have been at a family practitioner committee and presented a case on behalf of a constituent who has complained about a GP. Therefore, I hope that that point will be considered.
Acheson comments that it is up to the FPCs to show a greater interest in the conditions of the GPs and their premises. That is not done. The committees have not inspected the premises, otherwise they would have found the gangers' hut under the bridge, with barbed wire.
As the Minister knows, I have raised the subject of community nursing many times. Every one of the strategic plans of the area health authority in my area is based on the assumption that we have adequate primary health care. Having made that assumption, other assumptions are made, such as that there are too many beds or that one does not need this or that service because the primary health care service is there. However, there is no evidence that we have ever had it.
Paragraph 6.4 of Acheson refers to health visitors. I intervened in a debate when we discussed nurses, midwives and health visitors recently. I drew attention to the fact that there were insufficient health visitors. Paragraph 6.4 refers to the average vacancy rates. The rates are high in my area. The report states:
Average vacancy rates for health visitors were higher in inner London than elsewhere".That is a stark comment. Other assumptions are based on the assumption that an area has enough health visitors. In my small district of Shoreditch, we are five short. Yet that is where the old people in my constituency are concentrated and it is the area with the highest sickness rate. They are stuck in high-rise flats and there is a greater need for health visitors. We have had five vacancies for years, but the structure plans assume that everything is all right.The Government must study the Acheson report and what they know about the situation. There is much talk about preventive work among the elderly, but no such work is done. I argue with those involved, because no one wants to admit the truth.
When we discussed the quality of GPs, we finally persuaded Bart's to set up a chair of general practice. I think that it was the first in the country and it works well. Many undergraduates study general practice in the district and we must try to emulate that work in other parts of inner London.
The Acheson report refers to the services run by the boroughs. That reference takes only two pages of the enormous report, but if the London boroughs do not carry out their social work—meals on wheels, joint financing and so—everything else comes to a halt. And in my costituency it has come to a halt.
The right hon. Member for Lewisham, East will remember that I took him to visit a lady in my constituency 1364 who was confined to a wheelchair. I fought desperately to get a ramp provided outside her flat. Unfortunately, she died before a ramp was provided. The local authority was unable to help. I do not criticise that authority, because if it does not have the money it cannot do the work. Governments are to blame. They know that local authorities do not have the resources; and the two pages of comments in the Acheson report presuppose that everything is all right.
I tell my local authority that there is no shame in an authority being unable to do the work. If it is starved of resources, it should say so and make sure that everyone knows. Governments believe that the authorities can do the work. The Hackney director of social services puts the best face on the situation that she can. She is a hard worker and does her best, but that is nowhere near good enough.
Everyone is prepared to accept the director's assurances that she can provide the home helps, but home help services are being cut. Those who had home helps for three days now have them for only two, those who had home helps for two days now have them for only one, and those who were visited one day a week now get no help at all. No new home helps are being taken on and it is a desperate situation, but because the best face is put on the difficulties, the information fails to get across and Governments go on as if everything was all right.
The Acheson report does a good job, because it brings together the information that some of us, including most Governments, have known for a long time. There is no justification in the Government having waited 15 months wihout calling a meeting with anyone to discuss the report and to decide whether it is true or false. They should have done that before coming to the House to discuss their proposed response to the report.
I hope that the Minister will say, not in broad terms, what he thinks of Acheson. We think that it is first class. What will he do? I have highlighted for him the fact that he must produce more money in Hackney, for example, if we are to get anywhere near solving our problems. The situation is desperate. I have been accused in the past of exaggerating, but when people come to my area they see that I am not exaggerating. The situation is chaotic. We must get the Government to do something about Acheson and make sure that they begin to implement it. I hope that Ministers will come to the inner London areas to see what is happening and then ensure that we receive the resources to do something about it.
§ Mrs. Gwyneth Dunwoody (Crewe)We should be very grateful to my hon. Friend the Member for Battersea, South (Mr. Dubs) for raising the whole matter of the Acheson report. He is carrying out a task that the Government should have carried out long ago. They have failed, disastrously, to live up to the expectations that they expressed originally on 20 December 1979, when the chairman of the London Health Planning Consortium wrote to Professor Acheson after setting up the primary health care study group. He explained that everyone was very clear about the problems, but they were not likely to disappear for a long time.
The Consortium therefore hopes that the Group will give particular thought to measures which could achieve change within a short timescale—say, five years. The Minister of State for Health"—then the hon. Member for Reading, South (Dr. Vaughan)— 1365fully supports this view and will await with considerable interest your report.The Consortium does not itself have any executive powers. Its role is to advise its parent bodies … Nonetheless, the commitment of Ministers and the Department to the work of the Consortium, and particularly this Study, will ensure that your report is given urgent and serious consideration.One can hardly get away from the plain English in which those views were expressed. But, in case there should have been any doubt, the introduction to the report made clear that the study group realised that the difficulties needed to be dealt with urgently. It said:There has been a continuing reduction in the number of acute hospital beds and many accident and emergency … departments in the inner city have closed in recent years. Between 1976 and 1978, 22 casualty departments closed, 5 of which were in inner London … Between 1977 and 1979 the number of acute hospital beds in inner London fell by almost 1,000 … At the same time, the effects of the recession are leading to contraction of the social services financed by local authorities … the publication of the London Advisory Group's report on acute hospital services … has reinforced the need for urgent action. The Group recommended that the number of acute beds in London should be reduced by 15%—4,000 beds—during the 1980s".So the study group was well aware of the scale of the problem and the need for immediate action, but it was also well aware that the Government's view is that if possible there should be no extra expenditure. It therefore said:where possible … the financial implications were kept to a minimum.The report is a classic indictment of the failure of inner city health care. But the real failure has been that of the present Government, because although they have here a clear blueprint for action they have done absolutely nothing. They have not discussed the report in the House, they have not made the slightest attempt to act on any of its recommendations and they have not even begun to discuss some of those recommendations that could have been implemented without any extra resources. When I asked the Minister about some of the report's recommendations, it did not matter what the subject of the initial question was; the answers were a series of "Noes".I asked the Secretary of State whether he would
issue guidance to district health authorities to establish primary health care planning teams?"—[Official Report, 30 June 1982; Vol. 26, c. 326–27.]The Minister for Health replied that it was a matter for the health authorities themselves. Will the Secretary of State issue guidance to health authorities to facilitate co-operation with local authorities in the provision for joint premises for social and health workers? No. Guidance to health authorities is contained in circular etcetera, etcetera. I asked whether there would be any decision about community nurses. I received an extremely dusty answer, although the report makes it clear that it is not simply the problem of GPs or community nursing and the associated services that make the position in inner London so disastrous.The present Government asked for the report and they made it quite clear that they intended that there should be urgent action. When they received the report, not only did they do absolutely nothing, they were not even prepared to discuss the summary that Professor Acheson and his team had made. He had spelt out what we must do.
Hon. Members have talked about the problem in inner London boroughs. Acheson said that if we were to change any of the real problems we must find positive incentives to encourage health professionals to work in better conditions. He said that the inner London boroughs had far 1366 more single-handed and far more old GPs than any other area of the country. He said that their premises were substantially inadequate and that few had simple facilities such as lavatories or areas where patients could wait in decent conditions. He said that simple and basic facilities were absent from far too many general practice areas.
Therefore, Acheson said that several things should be done. He said that the incentives for the creation of group practices should be improved and that the small lists, with their concomitant problems, should be discontinued. He said that more rapid change should be stimulated through the retirement of elderly GPs. He said that we should improve the opportunities for GPs who are trained in modern forms of practice to work in the inner city. Of the community nursing services, he said that there was a vicious circle of excessive case loads and poor recruitment. He said that several matters should be considered urgently.
Acheson also suggested that we must have minimum standards for GPs' premises and that we must try to persuade the independent contractors to improve their premises while they remain independent of the NHS. He said that there must be effective inspection, that we must no longer leave it to the old boy system of people saying, "Yes it is all right. We will see whether we can arrange some type of loan that will assist you in the long term, but we will not insist that the improvement is done urgently."
We must involve health and local authorities in assisting with the provision of premises. That could be done with considerable effect. It is in providing good health centres with several GPs working together and supporting health professionals that we can have an immediate effect on general practice, both in inner cities and in the rest of Britain.
Acheson also said that we should improve staffing levels and the conditions of work for community nurses. Hon. Members have pointed out that there is a rapid turnover in community nurses in the inner city area. One does not have to be brilliant to work out why. They work in appalling conditions, they do not receive the back up that they should and they are frequently faced with insuperable problems in keeping up a level of patient care that they regard as the minimum.
Acheson says that if we are to do anything about this we should look at the practical means of support. Recently I took a delegation of nurses to talk to the Chancellor. In this instance, they happened to be district nurses concerned about the economics of running their own cars and thus supporting the Health Service. Acheson says that if we were prepared to consider buying cars for nurses in inner cities we might get over one of the practical problems—the fact that on their rates of pay many of them cannot afford to buy their first car and find it a great hardship when they are required to do so.
Exactly what do the Government intend to do about the practical things? If nurses in the inner city are at risk and if that can be dealt with by providing them with two-way radios, why have not the Government told us that they intend to do that without delay? They have been prepared to allow the most extraordinary things to happen in relation to citizens' band radio. They should at least be prepared to find the very small capital outlay needed to give quite effective protection to nurses working in areas where they are at considerable risk.
Over and above that, Acheson spelt out in considerable detail where the services were falling down. He said that 1367 there was little co-ordination, that GPs needed to have a continuing interest in their patients, that they needed access to information and to good services within the hospital and that they needed to be positively encouraged.
We know how high the cost is to the National Health Service if GPs do not function effectively. In inner city areas, if people cannot find a good GP or if they ring one of the shop premises that have been described and are told to ring another number for the deputising service, they do no such thing—they simply go to the accident and emergency department of the nearest large teaching hospital and use its services in quite the wrong way to obtain what is in effect a GP service. That is not only expensive of resources but exactly the opposite of good primary care and it places an increasing burden on the accident and emergency services of the large general hospitals.
We know what we should be doing. We know that we should be finding resources to encourage GPs to improve the quality of their workplaces and the patient care that they provide. We know that we should be encouraging elderly GPs to retire and finding ways to help nurses in the inner city to remain in their jobs, to learn about the area and to be protected in their work.
We know nothing, however, of how the Government justify their extraordinarily casual, laissez-faire attitude to a report that they asked for and said was urgently needed. Yet they have refused to discuss the report, let alone act upon it. There is the occasional rumour, of course—that seems to be the way in which a great deal of the Government's health policy is made—to the effect that some action will be taken. For example, there was a suggestion that the Minister of State might consider inspecting a few general practice premises in the future. That is so embarrassingly superficial as to be disgraceful. It is no use setting up an inspection service if nothing is done to deal with the other major problems of primary care in inner London. It is no use saying that GPs will be encouraged to put their money into improving their practices if nothing is done about the fact that too many of them work in single-handed practices and too many of them are old and infirm themselves. Positive incentives must be given to elderly GPs to retire. There must be positive incentives for GPs to improve their practices and to go into group practices where, at long last, the patients will get the standard of health care that they need and which in the 1980s should be available to them as of right. We should not have to say to the Government that they asked for the report, they have got it, and ask them what they are going to do about it. We should be discussing how we can most usefully utilise existing resources to provide a high level of primary health care.
I am sorry that the Minister of State is not here tonight. He bears considerable responsibility for the inaction on the Acheson report. It is an indictment of the Government that they have lamentably failed to do anything about the real problems set out in the report or the obvious means of redeeming the situation that Acheson regards as urgent.
I hope that the Minister will tell his ministerial colleagues in the Department of Health and Social Security that it will be regarded as a disgrace by the House of Commons and by the population of inner London if too many general practices are allowed to continue in their existing squalor. There are too many inadequate premises 1368 and too many nurses working at personal risk and in great difficulty. Ministers must do something about it now, having failed disastrously to do so in the past.
Having told his colleagues that, I hope that the Minister will return at the beginning of the next Session with the news that the Department is acting on the report because it regards it as an extremely intelligent and helpful plan which must be put into operation.
§ The Under-Secretary of State for Health and Social Security (Mr. Tony Newton)I add to what the hon. Member for Crewe (Mrs. Dunwoody) said by expressing the Minister for Health's apologies for his not being present. He has had some trouble with his voice and, although my voice might be less satisfactory to have at the Dispatch Box, it can, I hope, be more clearly heard than would my hon. and learned Friend had he been here.
I genuinely join in the congratulations expressed by Opposition hon. Members to the hon. Member for Battersea, South (Mr. Dubs) on having raised this important subject, and to all hon. Members on the constructive, albeit at times critical, way in which they have spoken on it.
It would be possible for me to spend several minutes in saying how relatively satisfactory in some respects the national developments in primary health care have been in the past few years. We are debating the situation in inner London and in other inner city areas—although tonight's debate has concentrated on inner London—against a background of encouraging development, in broad national terms, in primary health care. I want that, at least, to be recognised. I shall not labour the point because I do not want to sound complacent.
I recognise that against that reasonable national background there is cause for concern about the position in inner London and in some other inner city areas where the pattern has conspicuously failed to follow the general pattern of improvement over the past 20 years or so. It was partly in response to that, as hon. Members are aware, that the Acheson study group was established at the end of 1979 with a remit to identify the problems of organising and delivering primary health care in inner London and to recommend what actions might be taken to overcome them.
The study group identified four main problems. The first is the disproportionate number of elderly GPs—the hon. Lady and almost every hon. Member stressed this point—often with small lists of patients, working alone under demanding conditions. The Harding report, to which there has been less reference, which was published at the same time as Acheson, argued that it was vital for primary health care services to be provided on a comprehensive and co-ordinated basis and urged that team working should be promoted wherever possible.
There was an overlap between the two reports. In endorsing that approach the Acheson report highlighted the fact that the pattern of general practice in inner London was an obstacle to effective team working. That relates to much of what the hon. Member for Hackney, South and Shoreditch (Mr. Brown) said.
Secondly, some practice premises fall badly short of the standards that one might expect from a doctor's surgery in the 1980s. Thirdly—and this has been emphasised by hon. Members—health authorities have experienced difficuties in recruiting and training sufficient community nurses to 1369 meet inner London's needs. Fourthly, there was evidence that some patients had difficulty in communicating with their doctors or in gaining access to primary health care services. Again, hon. Members have rightly focused on that problem.
The report recognises that despite the problems there is a great deal of energy, commitment and caring among primary health care professionals. In inner London as elsewhere they are providing health services and doing the best that they can for their patients. I do not want hon. Members to believe that the picture is wholly gloomy and black, but I recognise the serious problems described tonight.
Most of the criticism has been directed at the Government not making a detailed response to the Acheson report.
§ Mrs. DunwoodyThe Government have made no response.
§ Mr. NewtonI shall come to that in a minute.
The report, published in May 1981, contains 115 recommendations covering a wide range of interests, by no means all of which are directed at central Government. The Harding report contains a further 50 recommendations, many of which overlap the Acheson report. Many of the recommendations in both reports are aimed at the authorities directly responsible for the provision of services—the health authorities, the local authorities, family practitioner committees and education bodies. The then Minister for Health, my hon. Friend the Member for Reading, South (Dr. Vaughan), asked all the authorities to consider the reports as a basis for action. He sought comments from them and others. A large number of comments have been received, and the Government are considering them carefully and hope to make concrete proposals in the relatively near future.
The House should recognise that it is not easy to respond quickly to 165 recommendations, many directed at bodies other than central Government, many requiring substantial consultation with professional interests. I resist the suggestion of the right hon. Member for Lewisham, East (Mr. Moyle) that the Government have not even decided to reject the report, as if we have given no sign of our general approach. It is clear that the Government have accepted the broad thrust of the Acheson report and the need to put as many of its proposals as practical into operation, bearing in mind the need for consultation.
§ Mrs. DunwoodyWhat does the Minister base that thought on? What evidence is there that the Government accept the report?
§ Mr. NewtonIn May 1981 the Government wrote to all the authorities concerned recommending the report to them as a basis for action. We have had a series of informal discussions with the General Medical Services Committee, concentrating on many of the recommendations from the Acheson report. We have moved on to formal discussions with it on particular proposals. There have been discussions with regional nursing officers, concentrating on staffing levels for community nurses and arrangements for funding their training. That is something to which my hon. and learned Friend the Minister of State attaches especial importance and particular urgency. Earlier this year we wrote to the local authority associations on recommendations within the report falling to them and we are currently awaiting their response.
§ Mr. Ronald W. BrownIf a judgment is to be made in the not too distant future, the joker in the pack is that the Secretary of State for the Environment has already said that Hackney will lose a substantial sum next year. That means that an impoverished service will be worse off. How does the hon. Gentleman propose to get over that?
§ Mr. NewtonMy hon. and learned Friend the Minister for Health has made it clear on a number of occasions recently that it is not possible at present to draw specific deductions about the precise consequences for personal social services of expenditure decisions which have not yet been taken in relation to the PESC exercise, which will continue in the latter part of the year. To draw specific conclusions of the sort that have been drawn in some quarters in the past few weeks is to go further than the facts allow or justify.
When Labour Members ask "What have the Government been doing?", the answer is that which I have presented to the House. An extensive range of consultation, both formal and informal, has been taking place with a view to putting the Government in a position that will enable an announcement to be made in the reasonably near future that will not be virtually meaningless—for example, "We accept the report". If the Harding report is included, there are over 150 detailed recommendations. As they are not all related to central Government, a statement of general acceptance would not mean very much. We wish to announce a specific and detailed package of proposals that is based on consultation.
§ Mr. MoyleI want to try to achieve the maximum amount of agreement on this issue. Is it fair to say that the Minister is telling us that the Government have accepted the Acheson report in principle? Is he making an official announcement to that effect, and that subject to consultation the Government intend to proceed towards applying the report? That is what I am beginning to understand from what the hon. Gentleman is saying. Is that a fair summary?
§ Mr. NewtonI shall not take up and endorse the words that the right hon. Gentleman is attempting to put into my mouth. However, it is in my judgment clear from what I have said, and from what has happened over the past 15 months, that the Government accept the broad thrust of the Acheson report and the need to examine in detail its recommendations with a view to bringing about practical improvements that are directed at the problems that the hon. Lady and right hon. and hon. Members have identified.
§ Mr. Ronald W. BrownAnd provide the money as well?
§ Mr. NewtonI am not able to go further than that tonight, but I hope that I have said enough to make it clear that the Government have not rejected the report. We are endeavouring to work towards the announcement within the reasonably near future of measures directed to the problems and, as far as possible, to the solutions that are recommended in the Acheson report. It will not be possible for the Government to accept and act upon every one of the 150 or more recommendations, if we include the Harding report.
I hope that it will be possible for my hon. and learned Friend to be in a position before much longer, on the basis 1371 of the continuing consultations with professional interests—the right hon. Member for Lewisham, East recognises the need to talk at length with the BMA and other interests—to make positive and specific proposals that are based upon the Government's consideration of the Acheson report. I recognise that that is not as much as Labour Members would like me to say, but I hope that it is a clear indication of the Government's wish to make a positive response as soon as possible to what has been said tonight and to the Acheson report.