§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Kenneth Carlisle.]
11.50 pm§ Mr. Gareth Wardell (Gower)I am grateful for this opportunity to draw attention to the difficulties inherent in the Government's proposals for the reform of the National Health Service. The proposals for general practice will have a crucial bearing on our primary health care. It is therefore important that they are the right policies, that they have the full backing and support of GPs and health professionals, and that they are policies which will carry the Health Service forward with enthusiasm and commitment into the next century.
From the representations that I received from GPs in west Glamorgan at a meeting on 29 March, from the Powys local medical committee and from letters that I have received from doctors, including hospital doctors, it would seem that consultation and negotiation about the White Paper "Working for Patients" and the GPs' contracts have a long way to go before they can be regarded as supportive of improvements in primary health care. The comments by the Secretary of State for Health that GPs are concerned only about their cheque books are cheap and nasty and say far more about his own values and attitudes to health care than about the average GP's concern about the best way of organising surgeries, clinics and work schedules. The projection of the right hon. Gentleman's priorities to his critics ill becomes his office and responsibilities.
Critics of the right hon. Gentleman's proposals are to be found in large numbers. Under the White Paper proposals, GPs are already concerned that their role, as it were, of an independent broker between patient and the other Health Service facilities will be undermined. At present, a patient consulting his GP can rely on the doctor to offer him a course of treatment of a referral determined only by the GP's expertise and the patient's interests. When a GP has the additional responsibility of providing treatment or referral at the cheapest option—not necessarily the most cost-effective in the long term—from the patient's viewpoint the GP is no longer independent in the same way. Public concern is already mounting and I predict that there will be many more public meetings in Wales similar to the one that Councillor Brian Ford, with the support of his local GPs, has arranged in Clydach on 21 April.
The stated aims of the proposals in the White Paper are that patients should have a new deal, more choice, higher standards of health care and better quality care. The effects of the proposed new contracts for GPs in practices outside major cities, especially in rural and semi-rural areas such as Wales, including parts of my constituency, will directly conflict with those aims. Patients will certainly have a new deal, but it will not be a better deal—they will have less choice, lower standards of health care and no better quality of care. It is ironic that a Government whose basic philosophy and lodestar is the belief that people respond only to incentives, especially financial incentives, cannot see that the new contracts comprise a series of positive disincentives to GPs to maintain and promote primary health care services.
For example, the targets that GPs must reach to be paid for immunisation programmes were set at 90 per cent. 312 Those were penal targets, penal because in England and Wales as a whole in 1987–88 the average take-up rates of immunisation for vaccines such as whooping cough and measles were 70 and 75 per cent. respectively. In Wales, take-up has traditionally been lower, at 62 and 65 per cent. respectively, and in west Glamorgan, which has been extremely resistant, take-up was an abysmal 51 per cent. for whooping cough and 57 per cent. for measles.
On 8 February 1988, from a parliamentary answer I received from the Parliamentary Under-Secretary of State for Wales about immunisation against measles, diptheria, whooping cough, tetanus and polio in each county in Wales, I note that only Powys, in relation only to diptheria, tetanus and polio, had immunisation take-up of over 90 per cent. Knowing that, and unable themselves to provide a solution, the Government expect individual GPs to meet targets that have never been reached. Even 80 per cent. has not been widely reached, even with the new triple vaccine, even in health-conscious mainly middle-class areas. If GPs respond to the financial incentive in the proposed contracts, they will not even attempt immunisation programmes but will divert their time and effort elsewhere.
Cervical cytology testing is another area of primary health care which will be seriously undermined. The target of 80 per cent. for testing women aged over 35 years at five-yearly intervals is, again, unrealistic and puts the onus on GPs to press their patients into treatment which, however clearly beneficial, too many women often do not want to contemplate. Not only is there the same financial incentive to GPs not to take on the hassle of chasing target women and the administrative workload of results and recall, but I find it petty in a particularly mean way for the Government to ignore the fact that many GPs already recognise best medical practice and test all sexually active women at three-yearly intervals, routinely and without payment. It ill becomes the Government not only to settle for targets which are less than best practice but to haggle like fishwives about targets of second-rate effectiveness which are supposed to be improving standards and quality of care.
The proposed switch of emphasis to capitation payments will do nothing to improve the choice, standard or quality of care. Linking a large proportion of GPs' pay merely with the number of patients on a list is not the progressive reform that the Secretary of State for Health claims. The policy of rewarding larger lists was abandoned as a discredited system in 1966 because it encouraged poor patient services. As lists have been reduced, GPs have improved and extended services, particularly in rural practices, and the Government cannot claim otherwise. Since 1966 there has also been an invaluable exchange of ideas between practices because GPs are not competing for patients. That is likely to be inhibited among some GPs.
Powys local medical committee has already told the Secretary of State for Health that the committee is appalled that his civil servants are completely lacking in knowledge about the way in which rural health care is organised. The practice of Dr Mark Vernon-Roberts in Scurlage in my constituency of Gower is typical of many.
As well as carrying out surgeries and branch surgery sessions and making home visits, which are extra-frequent and extra-time-consuming because of the distance, GPs also regularly and routinely visit nursing and residential homes, for which they are not paid. They hold ante-natal and baby clinics; they hold well women clinics, 313 undertaking breast examination, family planning services and blood pressure checks; and they hold well person clinics, undertaking general health examinations and influencing lifestyle risk factors. They also hold diabetic clinics and provide facilities for blood testing to save long and expensive trips to hospital, and they provide minor surgical and casualty services at the surgery and in local hospitals. In Powys, where there is no district general hospital, GPs are vital in keeping open community hospitals such as those at Newtown, Brecon and Ystradgynlais. In addition, they have prescribing and administrative functions.
It does not take a time and motion expert to appreciate that if a GP's pay is to depend on how many patients he has on his list, the standard and quality of care must deteriorate unless he discards some of his functions to take on more patients so as to keep his income up to today's levels or offers fewer services that he can afford to provide on a lower income from a lower list.
The financial incentive in the proposed contract in regard to capitation allowances is for GPs to take on more patients and reduce services so as to maximise income. The alternative is to merge practices to achieve economies of scale. The merging of practices can only reduce patient choice. When patients are ill they prefer to see a GP they know. Large practices work against that preference as they need to become highly organised and more bureaucratic. In my experience, bureaucracy and personal interaction conflict. The merging of practices is practical only in city areas. In rural and semi-rural areas it is not an option. Rural practices have traditionally been paid an extra capitation allowance to take account of the extra expenses arising from large areas and dispersed populations.
The Government propose additional capitation fees linked to a so far undisclosed population density in electoral wards. Electoral wards in rural areas are often very large and internally variable in density, so a rural doctor may find himself disqualified even though his practice area would easily meet the criteria. The question has to be asked—why abandon old and well-tested methods of distributing a fixed sum in favour of new and arbitrary ones?
Listening to the general practitioners, it is clear that in the negotiations which are still taking place the additional allowances must be seen as essential if the present level of care is to be maintained. Although there may be a redistribution of patients from one rural practice to another, it is unlikely that there will be an overall increase or decrease in the number of patients on an individual general practitioner's list. If one lives in or near a village or hamlet 10 or 20 miles from any sizeable town, with no public transport, no car or one car that the husband needs for work, and no chemist, one is glad to take the choice of general practitioners in the nearest practice and appreciate a branch surgery five miles away.
Rural practices will be particularly penalised by the capitation and rural capitation allowances proposals. They cannot obtain economies of scale. The Powys local medical committee reports that between 45 per cent. and 65 per cent. of a general practitioner's gross income is spent on staff wages, rent, rates, heating, telephones, administration and equipment for the services provided. Rural practices also operate branch surgeries for which the 314 general practitioner has to pay. If the income of practices is reduced under the terms of the proposed new contracts, it is inevitable that patient facilities at surgeries will be reduced and that more patients in rural areas will more frequently have to use or make expensive arrangements to travel to hospital for the care and treatment that could and should be available for them in their home or at the local surgery.
What is most likely to happen if rural general practitioners respond to the financial incentives in the new contract proposals as they stand is that, when a partner retires or leaves, he will not be replaced. With fewer general practitioners sharing the same number of patients, the remaining partners could maximise their income. The partners would be unlikely to take on a part-time colleague, most likely a women, because the capitation system works against part-timers almost to the point of discriminating against women. Fewer partners maintaining the same level of income into the practice to pay for extra services such as clinics, minor operations, casualty facilities and so on means a heavier work load for the remaining partners and, therefore, less time for each patient. It is a catch-22 situation.
There is another catch-22 for rural practice general practitioners—the new 20-hour rule. That is the number of hours a general practitioner must spend in the surgery each week. I have already outlined the many ways in which the role of rural general practitioners is much less centred on care in remote surgeries and, of necessity, far more geared to caring in the home and the community than the city practice with which the Secretary of State and his civil servants are more familiar. Rural general practitioners agree that the 20-hour rule would work against patients' interests in rural areas. It will do nothing to improve standards and quality of care. In fact, it will cause a deterioration in standards.
Rural general practitioners will lose out on another aspect of the new contracts. It seems possible that those who perform minor surgical operations in their surgeries will receive additional payments in recognition of that additional responsibility and the costs of providing staff and equipment for the facility. That should benefit rural general practitioners, who already undertake many such operations routinely. In comparison with their city colleagues, they save the National Health Service disproportionately more every time they perform such tasks, in terms of ambulance and hospital costs, patient care and convenience, by not referring patients to distant hospitals. However, it is just not practical and cost-efficient in the use of time for rural general practitioners to carry out at least five such procedures per session so that they can be paid for carrying out even one. The Secretary of State must look again at that aspect of the contract.
Many general practitioners are unhappy about the changes in the contract for the use of deputising services and 24-hour cover. The measure will also affect semi-rural areas where one practice covers for another, but will not affect rural practices which already cover for their partners. The exception is the single general practitioner practice. For the single practice general practitioner, the contract could be described as the death knell. All the problems inherent in the contract that I have outlined for general practitioners work against the one-practitioner practice. It seems that the Government regard such a practitioner as an anachronism, but those patients who 315 chose their general practitioner on the basis of continuing personal care from the same doctor for the whole family would not agree.
There are justified fears about the impact of the Government's proposals on the quality of patient care in primary health care. If we are really looking for policies that will enable general practitioner services to expand and develop the quality of care to patients—and not just to save money—the proposals are not only inadequate but deeply flawed. They are ill conceived and show that the Government are far removed from the real world and what is happening in general practice, especially in rural areas.
In articulating the points made to me by general practitioners, I have shown that their criticism stems from their interests in their patients' well-being. I have not found their interest and motivation in putting over their case to be purely financial. Rather they are concerned, from the real world of their practices, to ensure that what they have achieved in improving primary health care is not undermined by changes motivated only by the need to cut spending.
Since the first Black report in 1979, there has been a plethora of reports and research showing unacceptable levels of inequality in health in Britain. The Government have long paid lip service to the need to establish strong primary health care teams, led by general practitioners, to tackle endemic problems. The White Paper reforms and the proposed contracts for general practitioners provide an opportunity to implement long-needed changes. Instead, however, unless the Government are prepared to listen and negotiate on the basis of informed argument, we shall have yet another sector of fine public service sacrificed on the altar of cost cutting.
I trust that the Government will be prepared to listen and that meaningful negotiations will take place. I trust that the Under-Secretary will ensure that we do not regress to a Government preoccupation with list sizes as the criteria for good health care. I trust, on behalf of my constituents and of people throughout Wales and the rest of Britain, that rural health care will continue to be dictated by patient need, not by Government-determined, city-oriented economic efficiency.
§ 12.8 am
§ The Parliamentary Under-Secretary of State for Wales (Mr. Ian Grist)I congratulate the hon. Member for Gower (Mr. Wardell) on being successful in the selection for the Adjournment debate. He spoke with the trenchancy that we have come to expect. I welcome the opportunity to reiterate the Government's position in respect of our proposals for the new contract for GPs. In particular, I want to correct some of the misunderstandings that appear to have arisen within the profession which the hon. Gentleman has adumbrated this evening. The hon. Gentleman has made a number of points about the contract and its specific effect on rural areas and in the time allowed or left I shall do my best to answer some of the points raised.
However, I want first to underline the crucial and central role of the GP in the Health Service. He or she is the linchpin of that service and the first and main point of contact for every citizen, and will remain so under our proposals.
I remind the House that the new contract proposals now under wide ranging discussion spring from our 1987 316 White Paper "Promoting Better Health" which contained the following objectives: to improve value for money, which includes wise as well as effective prescribing; to give patients the widest range of choice in obtaining high quality primary care services; to raise standards of care; to promote health and prevent illness; and to make services more responsive to the needs of the consumer. The new contract proposals set out the methods for achieving those objectives. I shall give just three examples.
First, we propose to introduce practice leaflets and annual reports for general medical practice. These will enable patients to be better informed about the services which are available to them so that they can make more informed decisions about their choice of doctors. This is an essential change if we are to make progress in informing the patient—as a consumer—of the services provided by doctors.
Secondly, the proposed incentive payments in respect of health promotion clinics, minor surgery, services to children and the elderly will shift health promotion and disease prevention to the very centre of primary care provision. That is vital if we are to use our resources to the best possible effect for patients.
Thirdly, the switch to capitation-linked payments means that a GP will have a strong incentive to sustain and develop service standards for patients.
I believe that these and the other measures that are implicit in the new contract will make a quite fundamental contribution to securing the future of primary health care services in this country. But, of course, we recognise that change—however positive—can be and clearly is unsettling. I know that GPs in rural practice have particular concerns, which I want to deal with now.
In the first place there has been some anxiety that rural practices might lose revenue due to the change from the present rural practice payment system to the basic practice allowance rural capitation supplement. Throughout our consideration of these matters we have had the particular circumstances of general practice in rural areas very much in mind. How could it be otherwise for those of us in Wales? To begin with we have to face the fact that the present rural practice payment system is poorly targeted. Payments are made relative to rural practice areas which were defined prior to the local government reorganisation on 1 April 1974. The hon. Gentleman will accept that in the intervening period, a number of areas have undergone considerable change—to put it mildly.
By contrast the proposed rural supplement will be simple to administer and monitor, better targeted, and constructed to provide adequate remuneration for GPs serving sparsely populated rural areas. The supplement will ensure that doctors are not disadvantaged under the new remuneration system because they practise in rural areas where the population density is lower than in towns. The supplement will be banded so that GPs working in areas of greater sparsity of population will receive proportionately more per patient. It is not intended that the supplement be related to work load. It is meant to assist in sustaining broad parity of earning capacity between doctors in rural areas and those in urban areas.
The hon. Gentleman suggested that the rural supplement would work against the consumer's interests because GPs might find it more difficult to look after patients living at some distance from the surgery than those in the same ward living nearby. But that is to ignore the effect of the increased emphasis on capitation, which 317 will encourage GPs to offer and maintain attractive services for all their patients wherever they live. Each patient will attract a standard capitation fee, plus extra basic practice allowance, if the GP's list is below 1,500, plus the rural supplement which, as I have said, will be pitched at a higher level in very sparsely populated areas.
Another way in which the situation of the rural practice will be recognised is through the weighting of our proposals for basic practice allowance capitation supplement. We appreciate that there are certain basic costs in running a practice irrespective of its size. So the BPA capitation supplement, which is payable for up to 1,500 patients per GP, is to be weighted in discrete stages for each group of 500 patients so that the supplement is highest for the first 500.
As the hon. Gentleman mentioned, many rural practitioners are concerned about the requirement in the new contract that 20 hours of surgery time will be given over five days. We shall reflect on the comments made about this, but I should just like to say two things. First, I was interested to read in Pulse, a medical journal, of 18 March that in a survey that it had undertaken no less than 82 per cent. of GPs already met the proposed requirement for 20 hours spread over at least five days. I mention that only as an indicator—no more—of what is being done already.
The second point is that a number of the GPs in rural areas are already providing a wide range of services in terms of clinics and minor surgery services. A number of them seem to be unaware that the time spent in clinics also counts towards the 20 hours. In addition, under our proposals, GPs will in future be paid a sessional fee for running clinics, and we also have proposals for minor surgery fees. I hope that the hon. Gentleman will support the view that it is right to reward those GPs who put in the effort to provide those much-needed services.
Two other matters of particular concern to rural practices which the hon. Gentleman raised concern our proposals for targets for child vaccination and immunisation, cervical cytology, and minor surgery sessions. In respect of targets for vaccination and immunisation which are in line with World Health Organisation recommendations, these proposals form part of our wider efforts to increase take-up and coverage—an objective which I am sure that doctors will wish to support.
Additionally, family practitioner committees and district health authorities are being encouraged to address those issues, for example by developing effective call-recall sytems and by making best use of staff in attaining high 318 levels of coverage in their areas. Obviously, there is a place for health education in this sphere, and I am sure that the health promotion authority for Wales will have its own contributions to make here in conjunction with health education within district health authorities. I am grateful for the comments made on these two matters, and I can assure the hon. Gentleman that serious consideration is being given to the views expressed by GPs and others.
I should like to take this opportunity to correct another misconception which has been mentioned to my officials during the Helpline telephone calls, and that is in respect of part-time GPs. Again, the hon. Gentleman raised that point. If he looks at page 18 of the contract, he will know what I am talking about.
It has been suggested that, under the 20 hours proposal, GPs on a part-time basis will no longer be employable. That is a misunderstanding of the proposals concerning job-sharing, part-time working and the so-called fractional doctors. GPs wishing to work part-time will still qualify for basic practice allowance capitation supplements, but at a reduced rate. Those doctors will continue to be principals in their own right, fully responsible for the patients on their lists but the BPA capitation supplement will need to be abated for fractional GPs to take account of the fact that their standing expenses will be lower than those of a full-time GP.
However, the abatement will be pitched at a level which will act as an incentive to flexible working. That should be particularly welcome to GPs with domestic commitments who wish to return to general practice on a part-time basis. I assure the hon. Gentleman that the Government remain committed to their objective of drawing more women doctors into general practice. They will be all the more valuable to practices if they offer one of the specialties for which we are introducing new fees—for example, minor surgery or child health surveillance.
I believe that the new contract will give the most powerful stimulus to enhancing the quality of patient care. The Government are whole-heartedly committed to the objective of helping the family doctor service to maintain and advance standards of practice. We aim to encourage GPs to provide the services that their patients want, and to ensure that those who offer a range of high quality services are properly rewarded. That will inevitably lead to an improved service for patients and a level of remuneration for doctors which will more accurately reflect their performance and commitment, which is the Government's commitment, to the National Health Service.
§ Question put and agreed to.
§ Adjourned accordingly at seventeen minutes past Twelve o'clock.