HC Deb 26 May 1989 vol 153 cc1235-44

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

9.34 am
Mr. A. J. Beith (Berwick-upon-Tweed)

I am very glad to have this opportunity to raise in the House and to draw to the attention of the Minister some of the implications of the Government's health proposals for the county of Northumberland and in particular for my constituency. Many arguments are raging about the proposals, and there is a great deal of concern among doctors, nurses, the various health professionals, community health councils and, above all, patients. Some of the arguments are at a high political level, questioning the Government's commitment to the National Health Service. Today I want to focus on the applicability of the proposals to a county with Northumberland's problems and on some of the aspects of the proposals which I believe will cause severe difficulty there.

In doing that, I am bound to refer to the report of the Select Committee on Social Services which was published yesterday. The report's concluding paragraph states: If the Government's proposed timetable for introducing the vastly greater changes to the health service proposed in the White Paper is adhered to, we have serious fears that the stability of services and continuity of patients care may suffer during the years of transition to a new, untested system. As we said in our Report last year: 'the strengths of the NHS should not be cast aside in a short-term effort to remedy some of its weaknesses'. That remains our considered view. That is certainly the view of many health professionals in Northumberland. It precisely echoes their concern that there is a case for reform and change, but many of the proposed changes are untried, untested, and uncosted, and, if implemented wholesale, they could prove quite disastrous, especially if they are implemented hastily. Many people would share the view expressed by the Select Committee.

Far more decisive and strong views have been expressed in other ways. A ballot was conducted by consultants and junior hospital doctors in the Newcastle hospitals, which are the main hospitals used by patients from the Northumberland area. More than 400 hospital doctors voted on the proposition: We believe that the White Paper is flawed in its fundamental principles. It puts financial considerations before patient care and will eventually destroy the NHS. We oppose the White Paper. Three hundred and fifty-five of the hospital doctors in those Newcastle hospitals voted for the proposition, 31 voted against and 29 abstained.

On another proposition— The creation of self governing hospitals will lead to a fragmented Health Service, create a two tier system of health care and destroy the comprehensive nature of the NHS"— 361 of the hospital doctors voted in favour, 28 voted against, and 26 abstained. Those are very strong views from those who are most directly concerned at the hospital end of patient care in my area. The Minister must consider those views seriously.

The community health councils expressed themselves very strongly in carefully argued representations from the local community health council in my area and from the community health councils' national organisation. They concluded in their report: Although there are a number of proposals which will undoubtedly he beneficial to the users of the NHS, the main themes of the White Paper do nothing to strengthen the position of patients or to improve patient choice. Indeed, the overall effect of the White Paper will be to promote cost containment at the expense of a high quality service that is responsive to the needs of those who use the service. … Despite the rhetoric of the White Paper, the NHS of the 1990s will be dominated by managers, cash limits and marketing. There can be no guarantee that the interests of patients really will come first and, indeed, their interests are likely to be ignored totally unless the user's voice is heard clearly at every level of the NHS. The Select Committee on Social Services stated that the Government would be wise to take account of their critics. Instead, the Government's initial reaction was to insult their critics by suggesting that family doctors were reaching for their wallets, motivated only by personal interest when they had deep and genuine fears about the effect of the proposals on their patients.

Family doctors know infinitely more about the reality of caring for the sick than do the handful of advisers and officials who concocted the White Paper in the seclusion of Whitehall. That view is shared by the public. The general public have a great deal more confidence in their doctors than they have in Ministers or Members of Parliament. The Government must show more respect for those whose practical knowledge of the working of the Health Service is so much greater than that of the people who are advising them.

In talking about Northumberland, I shall take family practitioners as my starting point. Northumberland has an outstandingly good family practitioner service and very good family doctors. There are reasons for that. It is an attractive area in which to live and work. Furthermore, in recent years general practice has become attractive and popular among the postgraduates of the medical schools—if anything, slightly to the detriment of hospital consultancy, partly because of the difficulties of developing a career as a hospital doctor and the initial hardships that are involved. We all remember the recent row about the long hours worked by junior hospital doctors.

Another major attraction is the element of self-management and personal responsibility that is involved in general practice. Whatever the reasons may be, it is fairly obvious that, particularly in areas such as the one I represent, we have benefited from the tendency of some of the best graduates to go into general practice where they try to raise the standards of general practice as high as possible. These young doctors are firmly committed to providing the best possible standard of service. They are well aware of the deficiencies in the general practice service, some of the worst of which are to be found in the inner-city areas. They are in no way blind to the possibility of reform, change and new ideas, but their worry is that the Government have got it wrong in a number of key respects which will adversely affect the work that they are trying to do to raise the standard of general practice.

One of the most powerful attractions of an area such as Northumberland is the prospect of working in GP-run hospitals. In the hospitals at Berwick, Alnwick and Rothbury the medical services are provided by and are under the leadership of local general practitioners. That is a positive recruiting attraction. Many medical graduates want a combination of direct patient services and family care and the ability to exercise their skills within a hospital. Keeping that balance and enabling that pattern to continue, thus ensuring that hospitals continue to exist in that form, is crucial to the continued success of general practice in areas such as mine. They have had enormous backing from the local community. We are fighting a permanent battle to keep our hospital services.

There was a vivid example of that recently when the health authority decided to withdraw the maternity services provided by the Hillcrest maternity unit in Alnwick. It told my constitiuents that in future they would have to go to Ashington for maternity services. The community rose in revolt—but positive and constructive revolt. They devised alternative plans that would save the Health Service money in running costs, and they went on to raise the difference in capital cost that was necessary to create a new maternity unit. Over £100,000 was raised in a very short time. Money is still coming in from voluntary efforts by the local community. They have saved the district health authority a lot of money and have ensured the continuance of GP-run maternity services in Alnwick. That shows how much the doctors have the backing of the local community.

We are also having constant battles to retain the surgery facilities that are provided at our hospitals in Alnwick and Berwick. Surgery is carried out there by visiting consultants. The district health authority has hinted several times that it does not want this arrangement to continue; it wants to concentrate its facilities at the new district general hospital in Ashington. However, it is a team effort. The GP services, the hospital, and surgery at the hospital come together to provide a good standard of health care for a scattered area that does not fit the pattern for which the district general hospital model was devised.

General practitioners in my area feel strongly that the Government have got their proposals wrong in a number of key respects. They felt that way about the contracts; they still feel that way about many aspects of it. On the face-to-face time aspect for the contract, for example, the Government still seem to be ignoring the hospital work side of it. The contract arrangements do not seem to take account of the fact that our general practitioners spend many hours in the casualty service of the local hospital and on the geriatric ward of the local hospital. They serve hospital patients in many other ways. Unless that is properly calculated, it makes nonsense of the face-to-face time provisions in the contract.

Similarly, the minor surgery payment arrangements in the contract seem to expect doctors to carry out in their consulting rooms minor surgery that they now carry out in a hospital, which is a far better place to do it and a far more satisfactory arrangement.

I am glad that the rural practice aspect of the contract is to receive further consideration. If there is to be proper provision for scattered rural areas, that is essential. In an area such as mine, going out to visit a patient can involve a 50-minute or one-hour journey in each direction. I am talking not about practices that have extended far beyond their natural boundaries but about practices whose natural radius extends over 10 or 15 miles into extremely hilly country.

Perhaps the most infuriating feature of the Government's contract for general practitioners is the ever-increasing emphasis on list sizes—on relating capitation allowances and list sizes in such a way that the pressure is on to increase the number of patients on a doctor's list. It is impossible to increase the number of patients on a doctor's list in a rural area without amalgamating practices and putting them on to a scale that is quite inappropriate to the provision of an effective service in a large scattered area.

There are many other disadvantages of the list size and capitation arrangements. There is likely to be an adverse effect on the employment of part-time women doctors. That is a particularly valuable feature of general practice. It is much appreciated by women who like to be attended by a woman doctor, and it is very helpful in the development of family planning services, well woman clinics and other activities in which the help of a woman doctor is particularly important.

The Government have caused a great deal of anxiety among doctors in my constituency about many aspects of the contract, but that is as nothing compared with the anxiety that has been created by some of the proposals in the White Paper. The one which has caused the greatest anxiety is that the family doctor's ability to refer a patient to the hospital that he or she considers to be most appropriate to the needs of that patient will disappear.

To give the Minister the background to how the Health Service operates in my area, Northumberland is a large county with many scattered communities. Many referrals are to hospitals in Newcastle or Edinburgh. Many of my constituents and those of other hon. Members are much closer geographically to the Newcastle or Edinburgh hospitals than they are to the district general hospital that the district health authority is developing in Ashington. The new district general hospital there will be of great benefit to patients in the south-east of Northumberland, but it is a very mixed blessing for patients in Berwick and Haltwhistle and even in some of the western areas in my constituency. For geographical and very strong medical reasons, doctors have for a long time referred their patients to hospitals in Newcastle and Edinburgh. There are many services that the district has not previously sought to provide, such as paediatrics. We look to Newcastle hospitals to provide such services.

The Government's proposals would take away the ability of doctors to refer their patients where they choose, on medical or geographical grounds, unless they are budget-holding practices. Only six practices in the whole of Northumberland would qualify as budget-holding practices. Some of them may choose not to do so. They may find the arrangements unattractive because they may not think that it will be in the interests of their patients. However, the Government's working paper 2 states: G.P.s should be encouraged to refer patients within the terms of the contract and to those hospitals or departments which, in the District's view offer the best value for money care … but an open-ended commitment on the part of the D.H.A.s to meet all non-contractual referrals would be incompatible with both the disciplines which the new system is intended to inject and with control of budgets. One of the doctors in my constituency, Dr. Colin Brown, comments in a letter to the press that The White Paper thus restricts rather than enhances patient's choice. I can see what will happen. The district health authority, having committed its resources so heavily to building the Ashington district general hospital, will tell doctors, "That is where you will have to send your patients." That will be the emphasis of its policy. Removal of the right of referral will destroy my constituents' ability to get medical care where it can best be provided and where it is most geographically convenient. There will be outrage in Northumberland if the Government proceed along those lines.

The proposal for self-governing hospitals could work severely to the detriment of the Ashington district general hospital. If some of the Newcastle hospitals turn themselves into self-governing hospitals, in spite of the opposition of their medical staff, GPs in my constituency will be unable to refer their patients there unless they are in budget-holding practices. The self-governing hospital might attract the best staff with higher rates of pay and by somehow improving conditions and concentrating on facilities that attract money rather than those which are most needed. That would prevent the Ashington district general hospital from getting off the ground and attracting the staff it needs to achieve the quality which the district health authority wants it to achieve.

The third proposal which is much resented by GPs is that concerning the prescribing of drugs. We have supported the Government in their attempt to move steadily towards more generic prescribing, but the proposed budget system has created suspicion among doctors. They believe that the system will create many suspicions among patients that it could be a serious handicap. Doctors think that patients will lose confidence in them if they believe that, because of the indicative drug budget and other cost-related features of the system, doctors are giving not the best advice that they can give but the advice which the budget requires them to give. Irrespective of whether that fear is justified, if it becomes reality it will harm the doctors' relationship with patients on which general practice is based.

There is enormous worry about the cost of the Government's proposals. The Minister was unable to provide the Social Services Select Committee with any estimate of the costs which will arise from these proposals. Many of the proposals are very costly in terms of administration and accounting. All this charging for patient services from one authority to another, one hospital to another and general practice to district health authority will involve a mammoth amount of accounting, detailed record keeping, detailed submission of accounts and checking from one body to another. It will cost a great deal of money. There has been no commitment of resources to ensure that those costs are not met at the expense of patient care.

There is no resource allocation working party formula to help historically underprovided regions such as the north of England. Abandonment of the principle that areas which have historically been underprovided with medical services is a serious disadvantage to the regions such as the north of England, and it will make it impossible to deal with the long-standing and deep-seated problems that have shown up in all of the major reports, such as the Black report, on the health problems of the region.

The cost problems are made worse by the fact that we have a high proportion of elderly patients in my constituency. I am sure that the air makes people live longer, or perhaps the attractions of the place draw more retired people to come to live among us. There is no doubt, however, that the proportion of elderly people in the area is very high. That has serious implications for GPs' drug budgets and for other medical budgets, such as community care. The Government have made no commitment about the costs of community care.

I said earlier that the standard of general practice in Northumberland is outstandingly high. We confront severe difficulties, however, with community care because the people involved simply do not have the resources necessary to provide anything like the service which is now accepted in many urban areas. Community care in rural areas is more costly because of the distances involved and the small number of people involved in each facility. That is especially true for specialised facilities for the mentally handicapped, the long-term mentally ill and people with infirmities or diseases which can be dealt with in the community but only by the provision of specialised facilities. Such facilities are costly, but we have no commitment to meet them. To many people, this is a more urgent health priority than many other things which the Government discuss in the White Paper.

There is an unrealistic expectation that vast savings can be made as a result of the Government's proposals and that patient care will not be damaged in the process. I listened to an exchange in which the Minister of State suggested to a Back Bench colleague that enormous savings have been achieved in a hospital in the north-west. I happen to know it well because two of my close relations died while in care there. Both were cared for by skilled nursing staff to the best of their ability. I know from personal experience, therefore, that what the Minister regarded as a great benefit—the fact that the hospital is getting more patients through more rapidly—put enormous strain on the hospital and the staff who work in it. The statistics on patient throughput which the Minister found so attractive hid real hardship and desperately difficult conditions on the wards. The idea that huge savings are there to be made by speeding up the process and making it all more efficient is quite worrying.

Efficiency improvements can always be made, but I question the idea that there is a huge pool of resources that can be extracted from the Health Service to pay for proposals such as these by pushing patients through more quickly and reducing the level of care. Services such as general practice and community care will be cash limited, as the Government make clear in the White Paper, but tax relief for private health insurance is not. However many people decide to take it up, that much money will be spent. It is not limited to £40 million. It can go up to any level. There seems to be a big difference between the Government's attitude to the provision of money for private medicine and their attitude to the essential needs of the Health Service.

The Government's concept in the White Paper is to introduce a chain of management command running from Districts through regions to the Chief Executive and from there to the Secretary of State". That is a worrying feature of the proposals. The ambition of a centrally controlled National Health Service is particularly worrying to an area such as Northumberland. Some 300 miles from London, one does not have much confidence in the ability of those who sit in the Department's headquarters to make sensible decisions about an area which is so different from anything they are used to.

We fear that so centralised a management system will have no regard for local differences and needs. Local community representation is being squeezed out at every level. Elected councillors are to be removed from health authorities. It makes no sense to have a centralised system when the needs of various areas are so different. I hope that I have convinced the Minister that there are significant differences in the way in which any system can be operated which argue against such centralisation.

There is another theme which has run through many of the most cautious and responsible criticisms of the Government's proposals. It is that they do not contain any element of pilot study or experimentation. That criticism has been made by doctors in my constituency, by community health councils and by the Social Services Select Committee. So many of the proposals are so untried that they deserve to be tested systematically. They should be tried out in a certain area perhaps with some guarantee that, if they go wrong, quick action will be taken to ensure that patients do not suffer. Instead, the whole thing is being thrust on the Health Service without any experimentation or pilot study.

I fear that the Government have got themselves into a corner with their NHS proposals and that they have become frightened of losing face. They have jumped to the conclusion that every critic is motivated by personal interest and remuneration or by such fundamental political hostility that they would never believe that the Government had any good intentions. I ask the Government to put those paranoid thoughts from their mind and start to take seriously the well-directed criticism from people with enormous practical and professional experience in the Health Service, which is echoed by many patients with recent experience of the NHS. I hope that they will look again at the damaging features of the proposals.

I have sought to illustrate, in the case of Northumberland, that in some respects the Government's objectives are negated by the White Paper rather than carried forward by it. Patient choice will not exist if the doctor's right to refer patients to the most appropriate hospital is taken away. The price of not listening to advice such as this will be high for patients in areas such as Northumberland.

10 am

The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman)

I congratulate the hon. Member for Berwick-upon-Tweed (Mr. Beith) on selecting this subject. It is an important one, and he has described fully and carefully his interpretation of the effects of the White Paper upon his county and constituency. In September I hope to visit the ambulance station in Berwick and the infirmaries in Berwick and Alnwick. I will write to the hon. Gentleman before a date is set. It is the most beautiful part of the country, with the exception of my constituency, and I am looking forward to my visit.

This has been a wide-ranging debate and, although the hon. Gentleman has geared his remarks to the effects of the White Paper, as he sees them, upon his constituency, it is with some anticipation that the House awaits his further remarks and those of his colleagues in the SLD. We await with great interest their positive and constructive proposals for reform of the NHS. There has been a deafening silence in the past few months. Only recently the Labour party has set forth its proposals, many of which march in step with the Government's, particularly in terms of the quality of service.

I am at one with the hon. Gentleman and the representatives of the medical professions in his constituency in saying that we are looking for reform in the NHS. It is a great British institution but it should not be immune from change. After 40 years, it is appropriate to review its functioning. That does not mean that it should not receive further resources, it has, is, and will continue to receive an increase in Government resources. At the same time, it is appropriate to consider change. We approach change on the basis of improving the quality of care—we are at one on that—rewarding general practitioners for the effort they put into their practices in looking after their patients and improving the quality of care and providing patients with more information so that they can make a more informed choice about who should look after them.

The hon. Gentleman began by quoting the report of the Select Committee on Social Services. I think that the House will share the disappointment felt by my right hon. and learned Friend the Secretary of State and myself at the fact that the Committee clearly wrote its report before listening to my right hon. and learned Friend's evidence. That is rather strange. The report complains that, to use the hon. Gentleman's words, the reforms are uncosted, untried and untested and that the proposals are being rushed through—a short-term dash for change. I reject that charge entirely.

Self-governing hospitals and group practice budgets are experiments. There will be many examples in some parts of the country and none in others. The medical professions will watch carefully the success of the introduction of greater delegation of authority and decision-making in hospitals and primary care and will consider any problems or drawbacks that may arise. Therefore, that is a staged implementation of the White Paper, which will be monitored carefully.

We have a two-year period for discussing, debating and consulting on our reforms before most of them are introduced in April 1991. The hon. Gentleman suggested that reforming the funding of the system, which is the kernel of the reforms, should be piloted. That cannot be done. A system of funding cannot be changed for just one part of the country or one hospital. One either changes the system or not. It is possible to introduce delegation of authority on a more experimental basis and that is what we propose to do.

The hon. Gentleman cited the Newcastle doctors and I understand that about half of them voted on a motion. I have not seen the precise text of that motion. As I understand it, those who support it are alleging that financial considerations are being put before patient care. That is wrong. Financial considerations should march alongside considerations of patient care—it was ever thus. The late Richard Crossman, as Secretary of State for Social Services, pointed out that demand for health care is unlimited. It is important that hospital doctors and general practitioners share the responsibility of managing the resources, which are not infinite, with the administrators. Therefore, financial considerations are always present in examination of patient care, but they do not come before patient care.

The reforms that we are introducing into the management of hospitals—the resources management initiative which I support and which has received widespread support in the hospital service—are based upon the assumption that doctors, nurses and administrators share responsibility for the management of resources.

The hon. Gentleman's main point referred to the right of general practitioners to refer patients. He was right to say that in theory, general practitioners can refer patients anywhere within the NHS. That is an unlimited, theoretical right. The problem is that with our present system of funding, that right is more theoretical than practical in certain parts of the country. That is because a doctor wishing to refer a patient from the home counties to a London teaching hospital may be told that it cannot take his patient because its budget is limited and it will run out of funds. We shall change the basis of funding. If a general practitioner who holds his own budget or a general practitioner operating within the contract system laid down by the district health authority—I shall come to that because it is the kernel of the hon. Gentleman's concern—wants a patient to go to a particular hospital, money will follow the patient and the receiving hospital will be able to expand its activities.

The hon. Gentleman's fear was that the district health authority would force a large proportion of his constituents to go to Ashington for acute care and away from Newcastle and Edinburgh. There is no prospect of any change in the status of Alnwick or Berwick infirmaries. Their work is respected and I am talking about acute care. I note that the new hospital at Ashington is expensive, costing about £30 million. We are replacing an unlimited, theoretical right of referral with a system in which money will back up the referral patterns of general practitioners.

The district health authority will have the responsibility for placing contracts for the care of those in its district with its district general hospital and with other hospitals outside the district. I expect contracts with hospitals outside districts to reflect the sensible referral patterns that currently exist. I assure the hon. Gentleman that I expect district health authorities to work closely with family practitioner committees, group practices and doctors in establishing such contracts, which are simple and clearly written to facilitate that flow.

Doctors may wish to refer some patients who are outside the contract system to distant hospitals, perhaps because a doctor was at medical college with a consultant or because the patient is suffering from a unique disease that has to be treated, for example, in a London hospital. We are asking health authorities to set up contingency funds to pay for specific contract referrals. It would be madness if the Government were to distort the sensible clinical referral pattern of doctors, thereby jeopardising the clinical care of patients and profoundly disturbing the medical profession. Under our facilitating measure, we are trying to solve the problem of doctors who say "I want my patient to be cared for in a hospital 20 or 30 miles outside the district. The receiving hospital cannot finance treatment because it is on a limited budget." The proposed system will be much more flexible, and in certain cases—it may not apply in the hon. Gentleman's constituency—patients will receive care quicker.

The hon. Member for Berwick-upon-Tweed fairly referred to the problems affecting rural GPs. He expressed his support for our decision, which has been agreed by the general medical service committee, to refer the issue of rural practice payments and the income of GPs in rural areas for further consideration. We have agreed to remove the remuneration scheme for rural practitioners from the present negotiations, and it will be considered by the central advisory committee on rural practice payments. Pending the committee's decision, the retention of the rural practice payments scheme will be welcomed by rural practitioners.

The hon. Member for Berwick-upon-Tweed referred to self-governing hospitals and speculated that there may be one in Newcastle. He is concerned that the self-governing hospital in Newcastle might bid away staff from Ashington and the infirmaries in Alnwick and Berwick to the detriment of local patient care. However, a self-governing hospital begins the year with no money. It is not funded directly by the district health authority. It must win contracts through private sector referrals and patient referrals, not only from its proximate health authority but from distant ones. It will not have the unlimited ability to bid up pay rates and poach staff from surrounding hospitals. It will be subject, as are all hospitals currently, to financial stringency, with the discipline of budgets and ensuring that its books balance.

The hon. Gentleman referred to indicative drug prescribing and expressed his fear that doctors will not give the best advice because they will be constantly thinking about money. He implied, although he did not say so, that some patients will not be given the drugs that they need. I refute the allegation that has been made by some people, but not by the hon. Gentleman, that patients will be denied the drugs that they need. General practitioners are not being cash-limited individually or collectively. Drug budgets are indicative and are designed to put downward pressure on drug budgets, not cut them. If GPs' drug prescription budgets are in excess of their indicative or target budget for the year, we are asking them to explain why to their family practitioner committee. There may be good reasons for their having exceeded their budget, such as an epidemic, because the original budget was incorrectly calculated or because the cost of drugs has risen. For whatever reason, they are being asked to talk sensibly and maturely to their family practitioner committee, and I believe that many GPs welcome that.

The proposals in the White Paper are regarded by hon. Members and many in the medical profession as being designd to improve the quality of patient care, to improve choice and flexibility and I commend them to the House.

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