Primary Health Care

HC Deb 21 April 1986 vol 96 cc21-32 3.30 pm

The Secretary of State for Social Services (Mr. Norman Fowler)

With permission, Mr. Speaker, I should like to make a statement about primary health care services.

These are the services provided outside hospital by family doctors, dentists, pharmacists and opticians and by the community nursing and other related services. They have never been comprehensively reviewed in the 40 years since the 1946 National Health Service Act, yet they account for nearly a third of total spending on the health service and over 1 million people use the services every day.

The Government are now carrying out a comprehensive review of primary health care. With my right hon. Friends the Secretaries of State for Wales, Northern Ireland and Scotland, I am today publishing a discussion document which will form the basis for extensive consultations throughout the country. The Government's main objectives are to raise standards of care and to make services more responsive to the needs of the public. The document we are publishing discusses a number of ways of achieving those objectives.

So far as family doctors are concerned, the introduction of a good practice allowance would reward both those doctors providing the highest standards of care and provide an incentive to others. This is in line with proposals made by the Royal College of General Practitioners. An allowance on these lines might recognise such features as the range of services provided, including preventive activities; the doctor's personal availability to his patients; and the achievement of particular targets for the levels of services such as vaccination.

The Government also believe that the public are entitled to more information about the different types of services that doctors provide, to enable patients to make better choices when seeking a general practitioner. Together with arrangements that would make it easier for patients to change doctors, this would further help to raise standards and make the services more responsive to the needs of the public. This process would be assisted if—as is also discussed in the document—more emphasis was placed on capitation payments in the doctor's remuneration system, so as to increase the financial value to the doctor of the individual patient.

Among other proposed changes is a new flexible retirement system which would mean that, as now, doctors could retire at 60 but with a compulsory retirement age of 70. It is also proposed to end the 24–hour retirement rule where doctors are able to retire and rejoin the Health Service 24 hours later, collect a lump sum payment and in some cases draw both pension and pay in full.

One effect of these changes would be in inner cities, where there is a disproportionately high number of elderly doctors. Although there is some outstanding work already done there, it is particularly important to raise standards in inner cities. This will entail attracting some younger doctors, and to help achieve this the discussion document suggests the possibilites of providing financial incentives within the remuneration system; of adjusting the allowances paid to doctors for practice premises in order to compensate for the higher cost of accommodation in inner cities; and of experimenting with different forms of contract.

As regards dental services, the discussion document outlines ways in which patients could be more sure of getting the full range of National Health Service treatment. To help patients choose their dentist it suggests that the restrictions on advertising might be further relaxed and to improve value for money the Government will act upon the recommendations of the committee which they set up to consider the problem of unnecessary dental treatment. The discussion document also examines ways in which greater emphasis could be placed on preventive measures, and it outlines retirement arrangements similar to those discussed for doctors.

The Government also believe that pharmacists could and should play a larger part in the provision of comprehensive primary care services. The Nuffield Foundation recently published the report of an inquiry which shows some of the ways this can be achieved. Much has changed since the pharmacist's main function was to make up medicines himself, and he should now be enabled to make better use of his skills in advising patients and doctors on the use of medicines.

Among other matters dealt with in the document are ways of improving the procedures for dealing with complaints against family practitioners and the extension of informal conciliation arrangements for dealing with less serious complaints. The document also proposes an independent study of the quality of primary care services in England, initially in one or two areas.

I am also publishing today the report of a review of community nursing services in England carried out by a team led by Mrs. Julia Cumberlege, chairman of Brighton health authority. Among the matters about which the team has made recommendations are the establishment of neighbourhood nursing services, ways of making better use of nursing skills, and the training of community nurses.

The Government intend that there should now be wide consultation on the discussion document and the Cumberlege report, taking account also of documents published by other bodies such as the Royal College of General Practitioners and the Nuffield Foundation. We want to hear the views of all those who are interested in raising the standards of primary care whether as providers or users of the service. To carry forward the review, Ministers will be holding a series of consultation meetings not only in London but in several major cities such as Birmingham, Manchester and Newcastle. We will invite to these meetings professional bodies such as the British Medical Association, the British Dental Association and the Pharmaceutical Society. We also want to take evidence from voluntary organisations, the statutory Health Service agencies, and organisations concerned with the interests of consumers.

These proposals have been put forward for discussion and the consultations will last until the end of the year. Therefore, at this stage, final decisions have not been taken. Many of the primary health care services are already provided to a high standard, but the Government believe that further improvements are possible. It is for this reason that we have embarked on the first overall review of these services for 40 years.

Mr. Frank Dobson (Holborn and St. Pancras)

Clearly, everyone will need to consider carefully the details contained in the 150 pages of the Government's proposals, but everyone should bear in mind that the original exercise was designed to save money. In July 1982, the Government announced the Binder Hamlyn inquiry, to look into the control of expenditure and the possibility of operating cash limits. In April 1984 the Secretary of State, no doubt disturbed by the still secret recommendations of Binder Hamlyn, decided to play for time and publish a Green Paper. He certainly played for time fairly effectively, because it has taken him nearly two years to produce it. During the gestation period, all sorts of wild tales emanating from official leaks by Ministers appeared in the newspapers. Open advertising of doctors' services, the promotion of private primary care on American lines and charges by doctors for more expensive services have all been canvassed. Fortunately, none of them appear in full frontal form in the Green Paper. The Government have backed away from the consequences of their own ideology.

We welcome some of the proposals, especially those intended to provide patients with more information and greater choice. The proposals closely reflect the ones that we made in Committee on the Social Security Bill. While most people receive good service from primary care, there are parts of the country and groups and individuals which do not. The least satisfactory services are concentrated in inner-city areas, in some very rural areas and in rundown areas of heavy industry which combine the worst characteristics of both. The Green Paper pays scarcely any regard to the health problems in rural areas. They will be made worse by the Government's damaging attack on rural transport. There is little mention of rundown industrial areas.

The Green Paper refers to the problem of the inner cities, but only promises more of the same. That has not been good enough. Few of the Acheson report's 114 recommendations have been implemented. The last Government initiative has provided less than an average of £17,000 a year to the beneficiary authorities that were supposed to gain so much from the Government's initiative.

The Government are right to seek an increase in the pharmaceutical profession's involvement in day-to-day health care, but it pays no heed to the inherent conflict between objective professional advice and making money out of the sale of drugs. Government supporters of the idea of more across-the-counter sales of drugs should also remember that that proposal transfers the cost from the National Health Service to the patient. That, no doubt, is why the Treasury likes the idea.

We welcome the report of the community nursing review. Perhaps the Secretary of State could tell us why, in his blue document, he is not seeking the view of the public on its proposals for nurse practitioners and a limited degree of prescribing by nurses.

The proposals on dentistry seem unlikely to counteract the soaring cost of dental treatment and the gradual disappearance of the NHS dental service. The Labour party believes that general standards of primary care should be brought up to the standard of the best. We believe that everyone in primary care should in future play a much greater role in promoting good health by a team approach. The Labour party believes that family practitioner committees, or whoever succeeds to their functions, should take on the positive role of monitoring the health of their area and making and implementing positive plans to improve it.

Finally, we believe that, whatever changes are made in primary care and whatever response is made by the professions involved, the general health of our people will not be improved until we have a Government dedicated to eliminating poverty and unemployment, to improving safety and health at work and to providing decent housing and healthy food at prices that all people can afford. Unless the Secretary of State can tell the House that he will be able to achieve all those aims, most of his propositions will have little impact on the health of the worst off and the least healthy people in our community.

Mr. Fowler

I think that the hon. Gentleman was scratching around in his response. His reaction had a lot to do with what is not contained in the discussion document but did not have a great deal to do with what it contains. As far as I could understand the hon. Gentleman's general point, it is that he is disappointed that the proposals are so reasonable. I think that he basically welcomes our proposals. We in turn welcome the report that the Labour party now accepts the principle of the selected list and also the principle of prescription charges. It is a very sensible move on its part.

As for the specific points, such as they were, that the hon. Gentleman raised, the hon. Gentleman will be aware that resources for primary care have increased under this Government by about 24 per cent. in real terms. In other words, the cost of the family practitioner service is now about £4 billion, compared with £2 billion in 1979–80. There has been a significant increase in the number of doctors, from 26,000 to 29,000. There has also been a significant increase in the number of dentists, from 14,200 to 16,500.

I share entirely the view—so does the document—that there is a special need in the inner cities for high-quality services. We have already allocated more resources to the inner cities. I believe that our proposals for the inner cities will continue that improvement. At the same time, we want to achieve better services for rural areas.

I think the hon. Member has misunderstood what the Cumberlege committee report said about community nursing. The committee had proposed that nurses should be given better opportunities to use their knowledge and skills in the treatment of patients. We welcome that and wish to consult on that proposal.

The purpose of the document is to improve standards in the Health Service; that is the Government's intention.

Mr. Robert McCrindle (Brentwood and Ongar)

It has become unjustifiably difficult and cumbersome to transfer from one doctor to another. Does the Secretary of State agree that, if there are proposals to make that easier on the basis of adjusting the remuneration package of a doctor and the advertising of alternative services, that will be widely welcomed by the public.

Mr. Fowler

Yes, I think it will. Changing one's doctor is already reasonably straightforward, and proposals which we have set out will make it even easier. The principle we have tried to set out in the document is that the public have the right to maximum information about the general practitioner who treats them.

Mr. David Alton (Liverpool, Mossley Hill)

Has the Secretary of State resiled from earlier undertakings to publish the Binder Hamlyn report? The consultative process will not take place until 1987, does this mean that the Government have no intention of legislating in the lifetime of this Parliament? Has the Secretary of State finally buried his proposal to cash-limit the family practitioner service?

Mr. Fowler

We do not make proposals on cash-limiting the family practitioner service. The discussion document makes it clear that, currently, it is difficult to control many of the factors which determine expenditure.

The Binder Hamlyn report was received in July 1983. It seems to me that the debate has moved on from that, and the report's recommendations have been taken into account in preparing the discussion document. We do not see any point in publishing the Binder Hamlyn report in addition to the discussion document.

Following consultation and discussion, we want to have direct negotiations with the professions. There is the prospect of either legislation or a White Paper. I cannot say when that legislation will come, but I think the hon. Member would be unwise to assume that legislation could not come in the lifetime of the Government.

Mr. Roger Sims (Chiselhurst)

Is my right hon. Friend aware that, unlike the sour grapes of the Labour party, there is a warm welcome on the Conservative Benches for the discussion document—not least, for the concept of a career structure for GPs? The document also places emphasis on the importance of the patient as a consumer.

Will my right hon. Friend expand on his comments on the increased role that he sees for pharmacists? Assuming that professionals will be able to take part in the consultations, through their professional bodies, what method will be open to the ordinary patient, who may not be a member of a consumer body, to put forward his own views on the document?

Mr. Fowler

On the second point, we will be issuing a special leaflet which will set out a summary of the proposals. This is being published today with the consultation document. The leaflets will be made available to any of the public who are interested and want to take part in the consultation exercise.

We want pharmacists to have an extended role along the lines proposed in the report of the Nuffield Foundation. We want pharmacists to play a greater part in advising the public on their health care as well as doing the traditional things such as supervising the dispensing. Such dispensing could be done in a different way. We will take evidence fom the profession on this, but I believe that it is in line with what the profession wants.

Mr. Kevin Barron (Rother Valley)

I welcome parts of the Minister's statement, but in addition to talking about the need for services to meet people's needs, will he have discussions with his ministerial colleagues on what they can do to improve public access to primary health care in the form of health centres and doctors' surgeries? As a result of the abolition of South Yorkshire county council, bus fares in the county have increased this month by 250 per cent.; that limits the public's access to primary health care, because they lack the necessary funds.

Mr. Fowler

The hon. Gentleman takes me back to my last job as Secretary of State for Transport. The increased opportunities for new forms of transport provided by the Transport Act will not in any way militate against the developments that we all want to see in primary health care.

Mr. Roy Galley (Halifax)

My right hon. Friend's statement will be greatly welcomed by many in the Health Service, but do his proposals for a good practice allowance and a capitation element in remuneration amount to a root and branch reform of the present complex and haphazard system of doctors' remuneration, or is he about to miss a great opportunity? Will he be abolishing all the various additions that are now part of the remuneration calculations, which most people assume are an integral part of a GP's job, and inserting instead a basic payment with, in addition, a good practice allowance on the ground of merit and a capitation allowance for the amount of work done?

Mr. Fowler

The proposals are a development of proposals by the Royal College of General Practitioners. The good practice allowance is an entitlement that will be based on a combination of objective measures such as the GP's availability to the public, immunisation, certain rates, the range of services and a performance review. Other general practitioners will have the responsibility for that. In addition, there will be increased emphasis on capitation fees. At present, a large proportion of a GP's income comes from allowances. About one third comes from capitation fees. We want to change both those factors, and that is fundamental to the proposals.

Mr. Allan Rogers (Rhondda)

Does the Secretary of State accept that his remarks and proposals will be treated very cynically by Opposition Members, especially as, since 1981, there has been a cut of more than 20 per cent. in the number of people being trained for a nursing career in Wales? The loss of 700 people in that sector will lead to a diminution in primary health care in Wales. When will the right hon. Gentleman stop making hypocritical proposals and get down to funding the NHS instead of cutting it?

Mr. Fowler

The hon. Gentleman had better get his facts right. I do not know whether he was in the Chamber to listen to the statement—

Mr. Rogers

I was

Mr. Fowler

—but, as I said, the number employed in the NHS has increased. As I have said, under this Government the number of doctors has increased by 11 per cent. and the number of dentists has increased by 16 per cent. Those are the figures. They mean a better service for the public, and that is what the Government want.

Mr. Robin Maxwell-Hyslop (Tiverton)

When my right hon. Friend looks at average and inner-city conditions will he ensure that he does not draw any wrong conclusions about the needs of rural areas? In particular, will he bear in mind the importance of the dispensing practice in enabling people to get to work instead of wasting working time trying to reach a chemist? When doctors who are not in dispensing practices visit a patient who is ill, they have to provide the drugs free, because they have no means of recovering payment for drugs that they take with them and then leave with a patient.

Mr. Fowler

I entirely agree with my hon. Friend's general point. We are trying to concentrate on the inner cities, but I hope to have meetings in some of the rural areas in order to gain an insight into their problems. We want to develop those services in the same way. I agree about the importance of general practitioners and dispensing.

Mr. Roland Boyes (Houghton and Washington)

Will the Secretary of State amplify the part of his statement which says: The Government also believe that the public are entitled to more information about the different types of services and so on? To some of us that smells of advertising. Is that so? Many of us are worried that people may choose a doctor on the basis of the quality of advertising rather than on the quality of service delivered. In other words, some doctors may be able to spend more money on advertising than others. Will there be come controls over the information given? Will somebody monitor and control the amount of advertising that a doctor could use?

Mr. Fowler

Obviously, it will be open for ranges of organisations to put forward their views on how far the process should go and some will probably seek to have rather wider advertising than is possible at the moment. The discussion document puts forward the case for more information—a move already taking place within the profession. That is being considered by the General Medical Council, but, as I have said before, the general principle that we are trying to put forward here is that the public have a right to the maximum information about the services which different general practitioners make available. Practice leaflets and so on will make clear to the public.

Mr. Tim Rathbone (Lewes)

Will my right hon. Friend accept from the Conservative Benches contratulations on the study? May we have some elucidation of whether he is considering that the carrot of incentives and the discipline of increased choice will be matched by providing general practitioners with more comparability information so that they may assess and improve their performance in order to match that of others? Will pharmacists' numbers be guarded in my right hon. Friend's reassessment of their role, since it is worrying that their numbers are being depleted in many areas? Will the community nursing services be given greater responsibilities, particularly for preventive medicine?

Mr. Fowler

On the last point, I hope that will be one of the effects of the Cumberlege report. General practitioners who already act as trainers under the vocational training scheme inside the Health Service for general practice will carry out performance reviews of their colleagues. At least, that is one way to go about it. Legislation is already before the House on numbers of pharmacists. At the moment there is a right to NHS dispensing. Basically we are setting out a way in which pharmacists in rural areas can be protected. However, we do not want an over-provision of pharmacists, as we perhaps have at the moment, in our shopping centres and the rest.

Mr. Charles Kennedy (Ross, Cromarty and Skye)

Will the Secretary of State accept that the publication of this long-awaited and long-overdue report is welcome, not least because he has clearly rejected some of the wilder notions entertained by the former Minister for Health and has gone for some of the saner counsels of the Royal College of General Practitioners instead? In accepting the importance of primary care and the strain upon existing hospital services, which can be somewhat reduced by a greater emphasis on primary care, will the Secretary of State also concede that that will mean considerably more money and pump priming in both urban and rural areas? What attention will he give to providing the additional resources which are implicit in his statement this afternoon? Will he also accept that an expanding role for the community pharmacist is welcome and that there are those of us on this side of the House who reject completely the nonsense which was spoken by the Labour Opposition spokesman, the hon. Member for Holborn and St. Pancras (Mr. Dobson)—[Interruption.] I would not go to the hon. Members for Houghton and Washington (Mr. Boyes), for Hackney, South and Shoreditch (Mr. Sedgemore) and for Rother Valley (Mr. Brown) for health care—who appears incapable of recognising that a chemist can distinguish between profit and the health and well-being of a patient.

Mr. Fowler

I entirely agree with the hon. Gentleman's last point. Resources generally rose to £4 billion in 1984–85, which was a real increase of 24 per cent. Some of the proposals will cost money; others will mean improved value for money or will lead to savings. The overall effect will depend on the outcome of the consultations.

One impact of better primary care on hospital services, especially in inner cities, will be in accident and emergency departments that are presently operating general practices because of the inadequacies in the general practice system. If we can improve general practice, that will be a tremendous plus for the hospital service.

Sir Hector Monro (Dumfries)

I welcome this initiative, along with the great increase in resources provided by the Government. I wish to emphasise the rural aspect. Does my right hon. Friend agree that distance, small numbers and the remoteness of pharmacies and hospitals aggravate the problem of the country areas? Are not the people living there entitled to as good a service as those living in urban areas? Will he give careful thought to that?

Mr. Fowler

Yes, I certainly will. My hon. Friend's comments are absolutely right. We want the development of general practice and family practitioner services, not only in cities and towns but in country areas.

Dr. Norman A. Godman (Greenock and Port Glasgow)

Does not the right hon. Gentleman agree that far too many former patients of psychiatric and mental hospitals live out their lives in appalling circumstances? What is the likelihood of an expansion of the community psychiatric nursing services in England, Wales and Scotland in the near future?

Mr. Fowler

Those services have already expanded, but I am the last to deny that further improvements are necessary. I hope that we can put forward proposals that go a little wider than this document to help that position, which I readily recognise.

Mr. Tim Yeo (Suffolk, South)

Does my right hon. Friend agree that the ultimate success of any detailed proposals that result from the discussion document will depend, at least in part, on their acceptability to the many different people who provide the services?

Can my right hon. Friend therefore give us a detailed assurance that the consultation process will be widespread—I was glad to hear him mention voluntary organisations—and will take account even of the views of individual practitioners?

Mr. Fowler

We have given sufficient time for the consultation process and, as I have have tried to make clear, the Government intend to hold public meetings not only in London and cities such as Birmingham and Manchester, but in country areas. That will provide a genuine consultation that will add to the effect and the worth of the proposals.

Mr. Andrew Faulds (Warley, East)

Is the right hon. Gentleman aware that many of us hear of many cases where the patient suffers more from the treatment than from the original ailment? When he talks of a procedure for examining complaints against general practitioners, does he envisage the setting up of a medical ombudsman?

Mr. Fowler

We envisage simplifying the statutory procedure for complaints. The discussion document proposes to expand the time limit for complaints so that no artificial time span will be placed on the time allowed; it also proposes that oral complaints should be accepted, whereas currently the requirement is for written complaints. We are prepared to listen to any arguments or suggestions on that matter.

Mr. Roger Freeman (Kettering)

I welcome my right hon. Friend's statement and also his proposal to seek the views of those in authority at local level. Can he assure us that he will take into account specifically the comments of the community health councils, family practitioner committees and district health authorities on the way in which care in the community policies are being implemented and the areas in which they need to be strengthened?

Mr. Fowler

I can give my hon. Friend complete assurance on that point; we shall consult all those organisations.

Mrs. Ann Clwyd (Cynon Valley)

The Secretary of State said that he is concentrating on inner-city areas. Does he agree that the problem of deprivation associated with those areas are also to be found in the older industrial communities of Britain, such as the south Wales valleys? Does he acknowledge that they need the same level of increased resources as the inner-city areas, as they both suffer the same problems of unemployment, bad housing and bad environment?

May I seek some clarification of the role of the community health councils? I am glad that, at long last, the right hon. Gentleman has taken on board some of the suggestions made by the Royal Commission on the National Health Service in 1979. What does he intend to do to strengthen the role of the councils, which represent the views of the consumer to the health authority? Should they not be given more resources and more teeth? I should like to hear proposals to that effect.

Mr. Fowler

For the purposes of this exercise, the community health councils are free to give evidence—I am sure they will—to the Government on primary health care. They are in an especially good position to do so, and I would welcome their contributions.

On the hon. Lady's first point, I understand that there is nothing unique about the problems of inner cities. I have made it clear that we are seeking a policy that will bring improvements throughout the country. However, I want to recognise the position of the inner cities with their high proportion of elderly doctors, difficult working conditions and need for good premises. It is right to concentrate to some extent upon those undoubted problems.

Mr. Jerry Hayes (Harlow)

Most of my constituents will welcome the Green Paper announced this afternoon—[HON. MEMBERS: "How do you know?"] Because, over the years, many of them have written to me to complain about a small minority of doctors who, quite frankly, are too old, too rude and too incompetent to do their jobs. My constituents, together with many other constituents, hope that the Green Paper will provide proper redress.

Mr. Fowler

We should also take into account the fact that family practitioner and family health care services in Britain are probably better developed than in most other European countries. The document is intended to improve even further the standards of care provided.

Mr. Tam Dalyell (Linlithgow)

Are not the Secretary of State and the Under-Secretary of State for Scotland—to whom I have addressed questions on dental care—concerned that dentists often have to make decisions not on the basis of clinical judgment but on their assessment of what patients not covered by insurance are likely to pay, up to f115?

What on earth is all this in paragraph 5 of chapter 4 about companies having to take over certain dental responsibilities? It states: The Government would welcome discussions on the balance of advantage between these two points of view. What does the right hon. Gentleman think about that?

Mr. Fowler

Currently, there are restrictions on the setting up of dental businesses that make it impossible to have under one roof a general practitioner, a dentist, an optician and a pharmacist. It might be for the convenience of the public if that restriction were taken away, so that all those services could be provided in an integrated way under one roof. That is the purpose of the proposals, and that is why we want to hear the views of the public.

Mr. Michael Stern (Bristol, North-West)

May I congratulate my right hon. Friend on his generally welcome statement, and especially on the part that dealt with the increasing problem of the aging practitioners? He referred to them especially in relation to inner-city areas, but does he agree that the problem occurs just as frequently in aging outer-city estates? Can he confirm that, in the light of consultation, he will not restrict his view to the classic inner city?

Mr. Fowler

My hon. Friend is correct. I recognise that the problem of elderly doctors is not confined to inner cities. Our latest information is that there are 515 practising doctors in their seventies, 74 in their eighties and two in their nineties.

We think that the present arrangements are out of date. They were brought forward at a time when the idea was to enable elderly doctors to continue in practice. That is not so relevant today.

Mr. John Ryman (Blyth Valley)

What does the Minister think about the reorganisation of ambulance services? Is he aware that in Northumberland absolute chaos has been created by the relatively recent arrival of the new chief ambulance officer, who has murdered the ambulance service throughout the north-east?

Mr. Fowler

Clearly, we want the best possible ambulance service but, with great respect to the hon. Gentleman, this matter has nothing to do with the proposals announced this afternoon.

Mr. Eric Forth (Mid-Worcestershire)

All members of the Conservative party will share the emphasis my right hon. Friend is placing on improved quality of service; this is what the people want, above all else. We do not share the paranoia of Labour Members about information and advertising. Does my hon. Friend agree that all the information possible given to consumers about all kinds of medical services must be of benefit to practitioners and to patients and potential patients?

Mr. Fowler

That is clearly right. We have tried to write this document from the point of view of a member of the public. We believe that people have a right to the maximum amount of information possible, and what we have set out in the document takes us towards that goal.

Mr. Alfred Dubs (Battersea)

Does the Secretary of State agree that the health of people in the community depends on a combination of services provided by the National Health Service and by local authorities? No amount of administrative organisation, even if for the better, will make up for the continuing cuts in local authority social services, as such cuts damage the very people the right hon. Gentleman seeks to help. In addition, will he say, as he has not mentioned local authority services this afternoon, whether his discussion paper will allow proposals which might suggest a change in the balance between the services provided by local authorities and those provided by the National Health Service?

Mr. Fowler

That matter would certainly be open to argument. Social services have improved and the resources committed to personal social services have increased. The Cumberlege report on community nursing is crucial if we are to provide a better community care service that I agree with the hon. Gentleman is needed.

Mr. Peter Bruinvels (Leicester, East)

Although I welcome my right hon. Friend's statement and look forward to advertising, will he consider the problems of the inner city of Leicester, where, because of high rates and non-rate capping, many surgeries are no longer available to my constituents because doctors cannot afford to continue to run their practices and also to pay those exorbitant rates? Will he also look at the problem of doctors who cannot afford, because of the rates, to buy houses in the city of Leicester?

Mr. Fowler

I will certainly examine the need for good premises. We intend to review the payment level for premises in inner-city areas. There is a need for new premises, rather than providing, as has too often happened in inner-city areas, lock-up premises. To make that possible, we intend to increase financial help to general practitioners practising in inner cities.

Mr. Frank Dobson (Holborn and St. Pancras)

Will the Secretary of State guarantee that the proposals he is making for incentives and greater rewards for better doctors—which we support in principle—will not result in the rewards and the better doctors being concentrated in those parts of the country in which people are healthier and better of?

Mr. Fowler

The whole purpose of the paper and the good practice allowance is to improve the standards of general practice and of general practitioners throughout the country. We clearly want to improve standards in inner-city areas, but we equally want to improve them in other areas, notably country areas.