Primary Health Care Services

HC Deb 25 June 1987 vol 118 cc146-54

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Boscawen.]

10 pm

Mr. David Atkinson (Bournemouth, East)

I am grateful to you, Mr. Speaker, for selecting my subject for debate tonight, especially as this is the first Adjournment debate in the new Parliament. The only other first that I have achieved in this House was to be the first Back Bencher to be called after the then Leader of the Opposition, the right hon. Member for Blaenau Gwent (Mr. Foot), when he sat down following his spontaneous reaction to the Budget statement a few years ago. I am a little better prepared for this occasion, because I have been seeking this debate since the new year.

A year ago, my right hon. Friend the Member for Sutton Coldfield (Mr. Fowler), then the Secretary of State for Social Services, announced to the House the first comprehensive review of our primary health care services since the NHS was established in 1946—over 40 years ago. Those are the services that people contact first for health treatment and advice. They represent more than 90 per cent. of the contact that people have with the NHS. They include family doctors, dentists, pharmacists, opticians, health visiting and other community health services, and they are used by more than 1 million people on an average working day.

It is accurate to say that by and large people remain satisfied with the services. They may object to matters that are outside the control of the practitioners, such as prescription charges and hospital waiting lists, but those matters are outside the scope of this review. Certainly, during the nearly 10 years that I have been a Member of the House, I have received few complaints from constituents about local primary health care services. I represent a constituency with one of the highest proportions of elderly people in the country, and the demand for such services is therefore high. It is also true to say that one of the characteristics of the British people is to put up with inadequacies and inefficiences without making a fuss or complaining. I suspect that that applies especially to elderly people, particularly if it concerns those upon whom they rely when they are ill.

By any standards, a review of our primary health care services was long overdue. The past 40 years have seen a revolution in medical technologies and treatment, as well as in social developments and changes in patients' expectations. The great advances in information technologies should, in themselves, offer new opportunities for a more effective and economic service. However, none of those advances can or should substitute for that personal touch, a private period of communication between practitioner and patient, which is such a valuable source or comfort and cure in itself. If there is one consistent complaint against family doctors, it is that that personal relationship is no longer always to be found. People complain that early appointments are hard to obtain and that the conditions and procedures in some waiting rooms leave much to be desired.

I cannot judge how much that dissatisfaction about the lack of communication is contributing to the growing interest in alternative medicines. A recent British Medical Association report on alternative medicines noted that such practitioners devote on average eight times longer to a consultation than the average general practitioner and that there can be little doubt of the appreciation and gratitude of most patients for a long, detailed and sympathetic examination by a physician. I am impressed by the considerable feedback I have received from my constituents which suggests that they are finding relief and cures from alternative medicines when conventional treatment appears to have failed. I have campaigned for several years of this issue and the time is long overdue for alternative and complementary medicines to be impartially investigated and properly recognised by the NHS with the long-term aim of being included within it.

I regret the negative and professionally prejudiced attitude of the BMA's report last year, especially towards chiropractic, the professionalism and competence of which I have come to respect through having the Anglo-European College of Chiropractic in my constituency. The BMA report's conclusions challenge the experience of many of my constituents as well as contradicting what a growing number of GPs are recommending and, indeed, practising. I look forward to learning from my hon. Friend tonight of a more positive attitude by the Government towards alternative medicines.

As the House knows, as part of his review of primary health care services my right hon. Friend the Secretary of State published a discussion document as a basis for extensive consultation. It contained several ways of achieving his twin objectives of raising standards of care and making services more responsive to the needs of the public. The consultation period ended on 31 December 1986. One reason why I sought the debate was to provide an opportunity for the House to learn of the progress of that review. It also provides an opportunity for me to record the results of my consultation with those who practise in my constituency.

The House may be interested to learn that in response to my right hon. Friend's call for a wide debate I invited most of the NHS doctors, dentists and pharmacists in my constituency to attend several meetings to discuss the proposals affecting them. I gave each of them a questionnaire to complete and return, which most of them did.

To encourage what it calls "better practice", the Green Paper suggests that the system of payment to doctors should better reflect the services they provide and the number of patients on their lists. First, I asked my doctors whether they accepted the principle of introducing a good practice allowance into the system of payment to general practitioners. I found them evenly divided. Many felt that it was more appropriate to penalise bad practices, while some wanted a genuine effort to help poor performers to improve their facilities rather than to be fined for practising in areas of particular difficulty.

The vast majority of my doctors agreed that better information about practices should be made available to the public, although to allow them to advertise was not generally thought applicable in areas such as Bournemouth because lists of local GPs in post offices and citizens' advice bureaux were thought to be sufficient.

On the question of choice of doctor my doctors were marginally in favour of simpler ways for patients to change their GP; most felt that the present system was simple enough although the patients were unaware of it. It was felt that improvements to existing complaints procedures could undoubtedly be made. Patients, especially those with language difficulties, were often unaware of their rights, which should be widely publicised — for example, in waiting rooms and on medical cards. Complaints should be discussed with a local arbiter as soon as they were received, and a suggested extension of the eight-week limit was not welcomed.

On the Green Paper suggestions for retirement, unlike the BMA, the majority accepted the compulsory retirement of doctors at 70 as well as requiring approval to stay in practice from the age of 65. They were evenly divided as to whether the present 24-hour retirement system, under which doctors can retire and rejoin the NHS at once and draw both pay and pension, should end.

On relations with local hospitals, most of my doctors wanted to be given more information on their referral rates and how these compare with other doctors, but they stressed that such statistics were not particularly relevant and it would be dangerous to draw conclusions or make comparisons.

There was not great support for the Green Paper's proposal to increase the number of GPs involved in the regular checking of children under school age in place of community medical officers. If GPs were to take this on, they should be paid to do so.

Finally, my doctors submitted a large number of suggestions to promote prevention in primary health care. Several were predictable, such as a swingeing tax on cigarettes — advice clearly ignored this year in the Budget in the interests of low inflation—if not banning them altogether with all advertising and sports sponsorship. There was a desire for more funding for the Health Education Authority, more health education in school and a call for every individual to have a health card. Another suggestion was that individuals should he called in for an annual screen health check.

Many of the doctors I questioned simply wanted fewer patients on their lists to enable them to spend more time on appointments and preventive counselling. One practical suggestion was for tertiary health prevention; that is, for GPs to be informed of those patients receiving mobility allowances or invalidity care and attendance allowances. Thus, doctors would be able to take whatever action would be appropriate to prevent the deterioration in health of those already disabled.

The dentists I questioned did not regard access to practices as a problem within my constituency. Preventive care was tending to lead to a shortage of patients and greater competition among dentists. Therefore, any change in contracts to encourage availability of services was regarded as unnecessary. Most of the dentists were against any further relaxation in the restrictions on advertising. They believed that matters had already gone too far and that advertising was not only unethical, but was also ineffective, if not counter-productive. The cost of advertising would have to be passed on to patients and it could lead to a price war, fast dentistry or misleading claims. Reputation and recommendation were generally accepted as the best form of advertising.

The vast majority did not want the law altered to enable unqualified people to run or own dental practices. They could see no benefits to patients from such an alteration and a wide scope for abuse. With regard to prevention I found unanimous support for the right of access for all children to be treated on a capitation fee basis and broad support for the requirement to give proper advice on maintaining oral health to be fully defined in contracts.

It was felt that the present fee structure based on piece work does not give sufficient encouragement for preventive work and encourages over-prescribing. As with doctors, dentists wanted more time to spend with their patients, especially the young, to explain the need for proper health care. However, the present system of remuneration is regarded as encouraging quantity at the expense of quality, and there was almost universal demand for its reform.

Unlike the doctors, I did not find the same support from the dentists for the Green Paper's proposals for compulsory retirement at 70. They were nearly all opposed to that proposal, believing that it was for patient demand to decide whether dentists should remain professionally active. Dentists are looking for more flexible arrangements from my right hon. Friend regarding retirement.

Finally, on the suggestions to discourage unnecessary treatment, including the recommendations of the committee of inquiry, if was felt that the Green Paper was over-reacting to what was, despite the present system of remuneration, not a widespread problem. It was felt that unnecessary treatment could not otherwise be controlled, except by a stricter monitoring by the dentist reference service and a wider use of officers.

Needless to say, I found wholehearted support for the fluoridation of water supplies. I support that policy and I am aware that my hon. Friend the Minister also shares that support. I should be grateful to learn what progress is being made to implement the Water (Fluoridation) Act 1986 throughout the country. To eliminate dental decay, the loss of teeth, and all the time wasting and costly treatment by the fluoridation of water supplies, without any proven risk, must be sensible.

With regard to the proposals in the Green Paper concerning pharmacists I found broad support for their extended role within the context of the recommendations of the Nuffield Foundation report. It was emphasised that pharmacists were the only health practitioners always available, without appointment, six days a week. On Sundays a pharmacist is available somewhere in the locality. For pharmacists to take on a wider advisory role would be time consuming and it is reasonable to suggest that pharmacists should receive better remuneration. That applies especially to pharmacists who have greater involvement in domiciliary and home delivery services. Such a role is especially important in constituencies such as mine in which there are a large number of rest homes and nursing homes.

Pharmacists should also be actively participating in the education of others involved in community health. The wider use of pharmacies to display health education and health promotion materials was widely accepted. Indeed, such work is already being undertaken with regard to the anti-drug and anti-smoking campaign and advice on family planning. They were not so sure about the practicality of maintaining records of prescriptions issued, which could apply only to regular customers, nor did they regard themselves as the right people to advise GPs on the administration and handling of particularly complex substances, which would certainly require specialist training. They agreed that there did exist further scope for the relaxation of the restrictions on the sale of medicines, but stressed the need to restrict drugs to their generic names. They welcomed the limited list of drugs, because it reduced the scope for the NHS to be exploited by the drug companies and because too many drugs are produced that are effectively the same, bar the packaging. They could not support non-qualified people doing dispensing without a qualified person being present.

I hope that my hon. Friend the Minister and her Department will find the results of this consultation in my constituency helpful and not too late to be taken into account in drawing conclusions on the Green Paper consultation. I promised my local practitioners that their views would be drawn to the attention of the Secretary of State. I am grateful to them for meeting me and for this opportunity to report to Parliament.

I conclude by making three important recommendations about the health services generally. First, my experience with this consultation exercise on primary health care together with that as a constituency Member of Parliament who takes a particular interest in mental health—I am the honorary parliamentary consultant to the National Schizophrenia Fellowship—has confirmed that we have a long way to go in providing adequate care in the community. I hope that the current Griffiths review into community care will come to the same conclusion as that of the Audit Commission in that respect.

With regard to schizophrenia sufferers and others who are mentally ill, I am convinced that we are making a grave mistake in closing down our old mental hospitals without adequate accommodation, care and social support being available in the community. Seedy bedsits by night and aimless wandering by day is not a reality that can be tolerated by any civilised society such as ours. I look forward to a further opportunity to enlarge on that to the House in the near future.

Secondly, again my experience concludes that we must now question whether our general practitioners can any longer remain independent of all other NHS services and stay outside the control of agreed targets and costs. Thus, I share the Select Committee's recommendation that the Government should review the likely benefits of the amalgamation between the family practitioner committees and the district health authorities.

Finally, one of the experiences of the recent election campaign was that, despite the Government's magnificent record, compared with that of the previous Labour Government, of making available more resources than ever before for the National Health Service, the public and the patients remain unconvinced. The facts do not match their expectations or experience, and, given even greater demands on our health services, that situation is unlikely to change.

Therefore, to promote a more effective National Health Service and to encourage our people to appreciate better the price that they are paying for it, I hope that the Government will now give the most serious consideration to the establishment of a Department of Health completely separate from that of social security, with the appointment of a Secretary of State for Health, who should have at his disposal all the resources arising from a health tax separately levied from general taxation and shown as such on all pay slips and tax demands. Only in that way do I believe that the public will appreciate that our National Health Service is neither free nor unlimited, and only then will our people be more prepared to accept the personal responsibility of ensuring the future health needs of themselves and their families in the private sector, which, in my view, is what the Government should ultimately aim for.

10.18 pm

The Parliamentary Under-Secretary of State for Health and Social Security (Mrs. Edwina Currie)

I congratulate my hon. Friend the Member for Bournemouth, East (Mr. Atkinson) on winning his election in Bournemouth, East and, indeed, all my hon. Friends whose faces I see shining so happily on the Back Benches. It is so nice to welcome such a large crowd to our first Adjournment debate in the new Session. I hope that we shall find many of them sitting on those Benches listening to Adjournment debates in the many long months and long hours of the nights to come, as well as you yourself, Mr. Speaker. It is a great honour to have you chairing our proceedings today.

I am particularly glad that primary care is the subject of the first Adjournment debate of the new Session. I hope that that augurs well for all the work that we want to do on primary care and prevention in the years that face us. There are major changes to come which I believe will be of great benefit in many of the ways that my hon. Friend has described, for our patients and for all those who work in the National Health Service. I think that my hon. Friend's constituents in Bournemouth, East know that they are most fortunate to have him as their Member of Parliament.

My hon. Friend memtioned one important point: many of his constituents are elderly. I understand that more than 40 per cent. of the patients in some of the practices are over 65 years old. Therefore, it is particularly valuable to them to have a young, energetic and caring Member of Parliament who so sensibly takes responsibility for their welfare, and I hope that they recognise the immense effort that he has put into his survey of opinion among his constituents on the primary health care discussion document. I am grateful to him for that.

My hon. Friend may know that we have introduced a new review system for family practitioner committees. The area that he representates is covered by the family practitioner committee for Dorset. I undertook the review of that committee on 19 March 1987. I had the pleasure of meeting the chairman and senior officers of the FPC and I was most impressed by their efforts towards steady improvement of the services—I want to put that on record.

The family practitioner committees are no longer only contractors' committees as they used to be. They are no longer solely responsible for ensuring that doctors, dentists and pharmacists are paid. They are there to promote good health, to identify gaps and to help fill them. For that reason, if for no other, we are not keen to pursue the suggestion that has been made in the Cumberlege report on community nursing, and the social services committee report on primary health care—that the district health authorities and family practitioner committees should be amalgamated. We have already stated that that Cumberlege proposal is not be be pursued.

One of the major reasons for establishing the FPCs as independent authorities in April 1985 was to give a stronger voice to family practitioner services as part of a wider primary health care within the health service as a whole. They must be given time to fit into their new roles. The evidence that I have seen in Dorset is that they are settling down well. It is too soon to contemplate further major changes, and we have no plans to change that part of the Health Service in the way that has been suggested for the time being.

I turn now to the survey of opinion among his constituents about our discussion document that my hon. Friend conducted and described. We appreciate his enterprise greatly. I hope that he will not mind if I do not comment in detail on all his proposals and suggestions, partly because the consultation period, although over, has not yet resulted in our plans being determined. We shall take his views into account along with all the other comments that we have received and I hope that he will find that acceptable.

The whole idea of the primary care review was to establish and pursue four main objectives. The first was prevention, a subject upon which my hon. Friend touched several times. Secondly, the review was to raise standards of care. Thirdly, it was to make services more responsive to the needs of the public, which he has rightly identified as being a matter of concern to many people. Another well-thumbed document that my hon. Friend has in his own office — the election manifesto — contains that as one of the principles for the Health Service. Fourthly, it was to obtain the best value for money. All the things that we want, and many of those that his constituents would like, do not come free or cheap.

During the consultation period, which was from April to December 1986, 2,500 organisations in England were directly consulted, and we received more than 2,000 comments. My hon. Friend will realise that it takes some time to co-ordinate all that. We have a commitment to respond to the social services committee report on primary health care and we hope to discharge that shortly.

As regards spending on primary health care, the Government have an astonishing record, and I am proud of it. Real spending on family practitioner services between 1978–79 and the year ending in April 1987 increased by 37 per cent. in real terms. That compares with the growth of the other side of the Health Service—the hospital and community health services—of 21 per cent. So, the proportion of total NHS spending that goes on primary care has jumped. Spending on it is now at record levels.

Within the family practitioner services spending on general medical services has gone up by nearly £400 million or 53 per cent. in real terms since we took power. Spending on the general dental services has gone up by nearly £230 million or 42 per cent. in real terms. As a result, since 1979 in England we have 15 per cent. more doctors in the general medical services, 46 per cent. more ancillary staff such as nurses employed by general practitioners, and those numbers are growing very fast, 19 per cent. more nursing and midwifery staff working in primary care, 20 per cent. more dentists in the general dental services and 11 per cent. more retail pharmacies in England and Wales. That was in a period during which we were all worried that the number of retail pharmacies was falling. Finally, there are 38 per cent. more ophthalmic opticians in England and Wales. If I might just pick up obliquely my hon. Friend's last remarks, the growth in the number of ophthalmic opticians shows that when one changes something, one often improves it. This change has resulted in, a great improvement in services to the public.

My hon. Friend asked about fluoridation. He was a supporter with me when we passed the Water (Fluoridation) Act 1985. Very good progress has been made since then. In the areas of the country that have the worst dental decay, which I think he and I would agree are the areas where we would like to see improvements in fluoridation — north-western, Yorkshire and Oxford health regions — fluoridation groups have now been formed and are actively engaged in planning the introduction of fluoridation. From early next year, in the west midlands region about 1 million people will benefit from fluoridation. In Trent, which is the region covering my own constituency, fluoridation is now built into the region's strategy and the water in my own village is now fluoridated. Many parts of Trent have natural fluoride in the water which gives some protection. In the Wessex region, which covers my hon. Friend's constituency, the water systems are surprisingly complex and we would like to see progress with fluoridation move a little faster than it is. On the other hand, for a variety of reasons it is not one of the regions with the highest levels of dental decay. However, we would like to see some progress in those neighbourhoods.

My hon. Friend raised the question of alternative medicine. He probably knows at least some of the answer. Medical treatment under the Health Service must be given or prescribed by a practitioner registered with the General Medical Council. Such practitioners can offer any form of therapy. We are very interested in the current debate on altervative medicine. I noted his reference to the British Medical Association report. As he rightly said, some of it was favourable and some of it was rather critical. We have not yet formed any plans to restrict or enhance the role of alternative therapists but we shall be considering an application from the Research Council for Complementary Medicine for grant aid under section 64 of the Health Services and Public Health Act 1968 to support work and to identify in scientific terms the benefits of alternative therapists. The Medical Research Council is already supporting a comparative trial of chiropratic and conventional care for back pain. The results of both these trials may well be of the greatest interest.

I note my hon. Friend's comments on mental health.

Mr. Matthew Taylor (Truro)

Will the hon. Lady give way?

Mrs. Currie

I am sorry, I cannot, as I have to finish at 10.30. I note my hon. Friend's comments on mental health and I would like to put on record our appreciation of the representations he has made with such distinction in this important and often ignored area. I hope he will accept that I have noted what he has said and that it will be taken into account. He also suggested a separate department of health and the way in which that department might be funded. These are matters for the Prime Minister and for the Chancellor of the Exchequer, as indeed are his remarks about cigarettes and one or two other matters in which we share an interest. It is most important that these interests get put on record and that views are taken. As far as I know, there are no immediate plans to make changes in the ways he suggested.

I thank my hon. Friend warmly for raising these issues. He has provided us in detail with all the information that he gathered from his constituents and I assure him that it is very much taken into account. His constituents are fortunate to have him and I am fortunate to have been able to respond to the first debate this session on primary care, which is a most important subject to us all.

Question put and agreed to.

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