HC Deb 01 November 1989 vol 159 cc326-74 3.50 pm
Mr. Robin Cook (Livingston)

I beg to move, That an humble Address be presented to Her Majesty, praying that the National Health Service (General Medical and Pharmaceutical Services) Amendment (No. 2) Regulations 1989 (S.I. 1989, No. 1897), dated 15th October 1989, a copy of which was laid before this House on 16th October, be annulled. I was much entertained to read in last week's Health Service Journal that a senior official had told the journal that the Department of Health expected Opposition Members to come out with all guns blazing in today's debate. I am much obliged to the Department for the constitutional innovation of informing the press of the tactics to be used by the Opposition.

I am being invited to come out firing to defend a profession which—as the whole House knows—voted overwhelmingly Conservative at the last election. I accept my democratic duty with a familiar resignation, as I know that, having accepted those votes, Conservative Members have no intention of defending that profession. I bring to the task a cold and clear perception that there is no prospect of support from them. I am well aware that, had the Secretary of State and I reversed roles and had I occupied his office during the past six months, there would have been no prospect of the BMA's senior negotiators rolling over and playing dead as readily as they have been doing since his announcement that he would ignore them and impose the contract regardless.

The Secretary of State and I are, however, probably in agreement on one matter. The important question is not whether the contract will inconvenience GPs, but whether it will affect patients: that is the issue on which the debate must turn. As I said in the July debate, there are areas of congruence between the Secretary of State and myself on the contract. For instance, I see every reason why GPs who arrange to make their own night visits should be paid more than those who do not; nor do I see any objection to GPs being required to provide leaflets setting out the nature of their practice. I also find it impossible to oppose the proposal that the maximum holiday to which a GP is entitled should be cut—or, as one GPs' paper put it in a headline last weekend, slashed—to six weeks a year. I am happy to support such a suggestion, even when it is made by Ministers who have achieved some notoriety on account of their own holiday arrangements.

These issues, however, are not the core of the new contract; they are the lace trimmings intended to make it more appealing to the eye. The key issue—the key clause —which has caused most GPs to decline to sign on the dotted line is the fundamental shift that it represents in the increase in the capitation element from 46 per cent. to a figure which, although undisclosed, will be at least 60 per cent.

The effect—which we must assume to be deliberate—is to provide an incentive to lengthen patients' lists. I am familiar with the riposte from Ministers that the average list cannot lengthen because, as patients are poached from one GP by another, the average must stay the same. That is merely to restate the laws of arithmetic.

Patients may choose. I do not wish to be contentious on that point. I am happy to accept that patients should have the choice. My contention is that whether patients choose or are poached, the average remains the same. That conceals the fact that the contract is clearly designed to result in a smaller number of practices with longer patient lists. That is in flat contradiction to the policy pursued for the past 20 years by successive Governments, of encouraging smaller patient lists. In fairness to the Government, it also contradicts the trend of their policy throughout the past 10 years towards smaller lists.

Mr. Michael Stern (Bristol, North-West)

Will the hon. Gentleman explain why he objects to patients choosing their GP? Is he saying that the principle of smaller lists, which he believes to be common to both the Conservative and the Labour party, gives the House the right to direct patients to stay with a doctor whom they do not like rather than go to the one of their choice?

Mr. Cook

Absolutely nothing I said suggests that I object to the concept of choice. Patients have choice now and I am in favour of making that choice easier. However, I am not in favour of giving GPs an incentive to seek a longer patient list and of penalising those who, sensibly and in their patients' interests, decide not to take on more patients than they can handle, which would result in their having less time for their existing patients. That has nothing to do with patient choice, but everything to do with the incentives to be offered to general practitioners.

As recently as 1987, consensus on this matter was restated by the Select Committee on Social Services. Commenting on the then White Paper on primary care, it said: The proposal to increase the proportion of GP's income derived from capitation was universally opposed. Patients' associations were among those opposing it. The statement continued: The case for further reductions in the GP's list size seems unanswerable. It would be unfair to suggest that the Secretary of State has answered the case. He has chosen to ignore it. It is a powerful case. More patients on a list mean less time for each patient. The case is all the more powerful as we know that patients want more time with their GP.

The magazine Which? carried out a survey last month which concluded that nine out of 10 patients expressed a preference for more time with their GP. That is entirely reasonable because seven minutes, the average consultation time in Britain, is the lowest in Europe.

Mr. Jerry Hayes (Harlow)

Will the hon. Gentleman give way?

Mr. Cook

No. I wish to finish my point.

The Secretary of State is well aware of the Which? survey. We know that, because he quoted from it at the press conference when he announced that he was to impose the contract. He quoted the following: We think the new contract is likely to expand the services available to patients. It is a pity that he did not quote the next sentence: We think the Government may have misunderstood how highly patients value the time they spend with their GPs. We do not think that you will get more time with the GP in the surgery. Less time with the GP may mean more time with the nurse.

Mr. Hayes

The hon. Gentleman has nearly shot the fox but not quite. Which? said: We think the new contract is likely to expand services to patients. Surely that is crucial, because patients will get more choice. It is all very well for the hon. Gentleman to complain about practice teams, but through family practitioner committees the Government will give the teams better opportunities to help the GP in the practice. Surely that should be welcomed.

Mr. Cook

Hon. Members will observe that I quoted the passage that the hon. Gentleman was so anxious to put on the record. On his second point, it is ironic that he should make the case that the Government will rely on primary health care teams using other professionals and employees to provide services when, from 1 April next year, for the first time in the history of the NHS, his Government will place cash limits on exactly those professionals.

Apart from the Which? survey, there is also a study by Wilkin and Metcalfe of what happens when patient lists lengthen. It discovered that, as patient lists lengthen from 2,000 to 3,000 patients, the average contact time per patient falls from 30 to 20 minutes a year. There are already 3,000 practices with more than 2,500 patients per GP. Any contract that tried to meet what we know patients want would set out to reduce the number of practices with large lists.

Mr. John Bowis (Battersea)

Is not the answer to the hon. Gentleman's point to increase the number of doctors? Is he able to explain how doctors' patient lists will be expanded along his lines if more and more doctors will be available to share the work load?

Mr. Cook

The number of general practitioners has increased during the last 20 years. However, during the last 12 months, the period during which we have been debating the contract, the number of trainees in general practice has fallen. I shall express grave anxiety later in my speech about the fact that many of those trainees are now finding it increasingly difficult to enter general practice precisely because of the contract that is now before the House.

Any contract that sought to meet patients' needs would seek to reduce the number of practices with large lists. Instead, the Secretary of State is seeking to increase their rewards. Logically, therefore, he expects the number of practices with long lists to increase. If the Secretary of State continues to deny that that is what he expects and wants, there is a simple way to convince us that that is not what he seeks.

I put to the Secretary of State the question that I put to him last July: if he does not wish patient lists to lengthen, and if he shares the consensus of the last 20 years that patient lists should be reduced, why does he not accept the BMA's proposal, which is on the negotiating table, to reduce the maximum number on patient lists from 3,500 to 2,500? Will he not accept that basic step, which would provide some protection to patients against general practitioners deciding as a result of this contract that the sensible and rational response is to hold as many patients as possible on their lists?

The Secretary of State for Health (Mr. Kenneth Clarke)

Does not the hon. Gentleman agree that that would impose an artificial constraint upon doctors? It would prevent a GP from taking on to his list a patient who wanted to go on to his list because the patient was satisfied that he or she would get good service from that GP. How does that equate with the hon. Gentleman's unconvincing assertion that patient choice is one of the issues that he is bearing in mind?

Mr. Cook

No, it would not have that effect. The artificial barrier of 3,500 patients is already there. When a GP hits the 3,500 barrier, the practice takes on another partner. Under our proposal, practices would not be obliged to turn away patients. High patient list practices would be provided with a financial incentive to take on additional partners, thus increasing the tendency to reduce patient lists by increasing the number of doctors. That would provide greater, not less, choice to patients.

Patients are not the only victims of the proposal. The growing number of women GPs is another casualty. In parenthesis, may I say that I welcome the advent to our debates of the hon. Member for Surrey, South-West (Mrs. Bottomley). I hope she will forgive me if I say that our welcome to her, warm though it is, is as nothing compared to the unfeigned welcome that we give to the departure from our debates of her predecessor. Conservative health policies certainly can do with a woman's view.

I noticed the unfortunate statement earlier this month by the Conservative Medical Society, which urged an increase in Britain's population. It says: A return to enhanced birth rate would eventually allow more women to return to their prime task of bringing up their families as their profession whilst the young as yet unmarried provide the recruits to the health care profession as in the past. I suspect that that passage was not drafted by the Secretary of State. He will be aware that, as a strategy for filling GP vacancies, it is deeply flawed. It requires six years at medical school, followed by a year in a hospital, followed by a year as a GP trainee to qualify as a GP. By the time that a woman has completed that, she will be in her late 20s, most likely be married and probably starting a family. Therefore, on the whole, women GPs seek more moderate list sizes. The average list size of women GPs is 35 per cent. below the national norm.

The fear is that, under the new entrepreneurial age being ushered in by the Secretary of State's contract, practices will want to take on not a woman partner but a partner who will play his full part—it will be "his" full part.—in the competitive struggle to maintain income by pushing up patient lists.

I acknowledge that the contract contains new arrangements for part-time GPs, but that overlooks the fact that in the new war to attract and retain patients practices will not want part-timers. Since the first draft of the contract was published in the spring, there has not been a single part-time partnership advertised in Scotland. Curiously, much of the stress in the rest of the contract is to provide services for women and children, such as screening, immunisation, well-woman clinics and child health surveillance. All the evidence shows that women find it easier to accept those services from women doctors. If the Secretary of State is to meet his targets, the hon. Member for Surrey South-West had best take him aside and explain to him that he should make it easier, not more difficult, for women to enter general practice.

The issue whether GPs should be rewarded by numbers goes much deeper than whether there will be enough time for each patient or whether patients will have the right of access to a woman partner. At the heart of the debate is how we motivate the medical profession. The current edition of "Pulse" contains a profile of a GP practice in Bristol. It is located on a council estate called Hartcliffe, which scores high on the deprivation scale. It has an unemployment rate of 30 per cent., and 48 per cent. of families are single-parent households. The practice does not believe that it will qualify for the new deprivation allowance because it is allocated on a ward basis and, because of affluence elsewhere, their wards score below the Jarman scale.

There are intense demands on the medical practice; 70 per cent. of the children registered with it come from families in which one parent is under 21 and require considerable support. The practice has therefore adopted the conscious policy of reducing the patient-doctor ratio. It has succeeded in reducing it by 25 per cent., with the objective of increasing the amount of time spent on each patient. Far from rewarding it for that ethical decision, the contract will penalise it for not getting stuck into the competition to maximise list size. Here we glimpse the long-term damage of the contract.

The Secretary of State has based his contract on the explicit premise that the only motivation he can recognise is a financial incentive. The majority of GPs spend most of their day not on activities that they have calculated will maximise the revenue of their practice but on activities that in their view best meet their ethical duty to their patients. It is clear from the many conversations that I have had over the past two weeks that many GPs feel deeply the insult that they saw in his comment that he is asking them to do only 26 hours a week. The majority of GPs do well over 26 hours a week, and many work easily twice those hours.

Yes, there may be a few passengers, and, yes, it may be that the only thing that will prod those passengers into greater productivity is the sharp stick of hard cash, but the tragedy is that the Secretary of State has drafted his contract to address the motivation of the minority. The danger is that he will therefore undermine the much finer performance of the majority of GPs, who are motivated by a sense of ethical duty and the public service ethos. If all that matters is meeting the minimum for financial reward, that minimum may become the maximum that anyone does.

Mr. John Maples (Lewisham, West)

If the contract is as misconceived as the hon. Gentleman has said, why did the BMA negotiators agree it?

Mr. Cook

I am sorry to have to advise the hon. Gentleman that the BMA negotiators did not agree to the contract. They recommended it to their members because there was an explicit understanding that if their members, did not vote for the contract the Secretary of State would withdraw the concessions that they had negotiated. That was the precise basis on which they agreed to recommend it in the ballot.

The hon. Gentleman's intervention brings me to my next point, which concerns, not the contents of the contract, but the style in which it has been negotiated. As the hon. Gentleman has reminded us, the contract was put to a postal ballot of BMA members. We have been repeatedly led to believe by Conservative Members that postal ballots are the model of modern trade unionism. In the postal ballot on the contract, the membership, in an 82 per cent. poll, rejected the contract by 76 per cent. to 24 per cent. As the hon. Gentleman has reminded the House, that was in a ballot where the Secretary of State had the BMA negotiators on his side, recommending a yes vote.

A word other than "contract" is needed to describe this document. A word that captures more honestly the authoritarian, centralising nature of the Government who are imposing it would be "edict" or "decree". Those words more accurately capture the flavour of the document that the House is debating.

Perhaps it is a matter of indifference to patients whether the contract is negotiated or imposed. Contracts that are imposed have to be written in a bunker because they cannot go through a process of full consultation which involves taking the people on whom it will be imposed into one's confidence.

We are debating a detailed manual of how doctors should practise medicine daily in their surgeries, which has been written by civil servants in an office in Whitehall. When I read comments in the medical press about the contract, I was struck by the fact that, often, doctors who agreed with parts of the contract were appalled, nevertheless, at how amateurish the contract was in setting them out. For example, on child health surveillance, Dr. Curtis, of the British Paediatric Association, said: the proposals have been ill-thought out, not properly worked through and I am appalled at the rate at which they are instituted". Dr. Wilson, a pioneer in developing annual reports for practices, who voluntarily produced an annual report on his practice for five years, said: The information which the regulations demand is of little use. It seems to have missed the mark and instead of being for the field workers it is for the administrators back at head office. Dr. Brian Wiggins, who has specialised in minor surgery at his practice and has his own specially constructed surgery unit, says that be believes that the list of minor surgery has been drawn up by a bureaucrat with little surgical experience.

Fortunately, the bureaucrat in question broke cover last week. Mr. John Shaw, the under-secretary in charge of family practitioner services, addressed the family practioner committees' annual conference last week and explained why he had not felt able to indulge in face-to-face discussions with GP leaders on the new contract. He said: I took the view that in dealing with such detailed fine print the most effective way was to do it in writing. So there we have it.

Mr. Kenneth Clarke

The hon. Gentleman has entered unusual ground by attacking one of my civil servants by name and by quoting him out of context. The two areas that he refers to—child surveillance and minor surgery —were put into the contract at the request of the BMA. Mr. Shaw engaged in about 100 hours of negotiations with doctors on those services and on the details of how they would be described in the contract. The quotation he has just used describes what was happening at the later stages when we were drafting—crossing the t's and dotting the i's. Criticism should be aimed at the doctors who were closely involved, on the BMA side and on mine, in drawing up the details. The hon. Gentleman should not make cheap attacks on the civil servants involved when he is trying to find a reason to negate this patient-friendly contract.

Mr. Cook

I am sorry that the Secretary of State believes that to quote his civil servants is to attack them. I was quoting the observations of those doctors who practise medicine, who have carried through exactly the kind of innovations that the right hon. and learned Gentleman is now making mandatory and who clearly from their comments do not believe that the regulations which are now being imposed upon them reflect medical expertise or advice.

The House is invited to pass this edict, which is being imposed despite the rejection of the profession and which was drafted on the explicit basis that it had best be done in writing. When they come to put up a museum to the Government, there should be a special place for this statutory instrument as a document which is one of the finest demonstrations of the Government's style, based on the conviction that the Government know what is good for the rest of us and on the belief that the more one ignores advice, the more one demonstrates the strength of those convictions. Fortunately, the day when the Government can be consigned to that museum is approaching.

There is a sad irony in today's debate, which I am sure has not escaped the Secretary of State and which must privately trouble him. He has chosen to copy the Prime Minister's style of management at the very moment that his colleagues are queueing up to beg her to change it. We are told that the Conservatives want more consultation, listening and sensitivity. They are about to hear a speech from the Secretary of State which all experience warns us will show that he revels in the fact that he is ignoring the doctors' ballot and relishes the idea that he knows better than the GPs in their constituencies what is good for their patients.

The Secretary of State will then invite Conservative Members for the first time in the 40 years of the NHS to impose a contract against the will of GPs. That vote provides an interesting footnote to the turmoil of the past week. It is the opportunity for Conservative Members to show whether they really meant all those fine words about more consultation and listening, or whether the Prime Minister got it right, in that it will be "business as usual". Business as usual means that the Secretary of State knows best—better than the 75 per cent. of GPs who rejected his contract and the 70 per cent. of the public who consistently rejected his White Paper. If the right hon. and learned Gentleman's colleagues fall for that, those GPs and that public majority may well conclude that the Government do not know how to change their style. If people do not like the style, they had better change the Government.

4.17 pm
The Secretary of State for Health (Mr. Kenneth Clarke)

There should be a wide measure of agreement between myself and the hon. Member for Livingston (Mr. Cook) on large parts of this contract. I suspect that there is a much wider measure of agreement between us than the weasel words that the hon. Gentleman has chosen to use would show to the outside world. I am sure that he agrees with me that we are dealing with one of the most important parts of our National Health Service—the family doctor service. I have said many times and am happy to say again that the British family doctor system is the particular feature of the British health care system that in large part accounts for the particularly high quality of health care which we achieve in this country.

I begin gladly by paying tribute to the contribution that family doctors make to the Health Service. We have spent the past 10 years increasing the numbers of those family doctors. We have increased the number of people in their support teams and expanded the service that they provide. When we return in later debates to the details of the White Paper on the wider NHS reforms which I am putting forward, I shall repeatedly emphasise the key role that we will expect GPs to play in the new National Health Service in influencing decisions on implementing provisions for the development of services and the distribution of resources in their locality as never before. Where money follows their patients, the hospitals and community services will respond to GPs and their pattern of referrals even more than they have in the past. They will be the patients' advocates and guides within the NHS even more than they have been before.

We begin, I am sure, by agreeing that the majority of general practitioners work extremely hard. Many of them are workaholics and they are certainly completely dedicated to their patients and to the NHS. In putting forward a new GP contract, my aim, which should be shared by all hon. Members, is to raise the standards of our family doctor service still higher by getting rid of the unevennesses that we all know exist from place to place. My other aim is to reward more fairly those who work most effectively in the family doctor service and to give incentives to best practice, new services and higher levels of performance wherever they are achieved.

We ought to remind ourselves throughout the debate —although we have not forgotten so far—that we are not deciding how much family doctors should be paid. That will be determined by the Government—as it always is —on the advice of the Doctors and Dentists Remuneration Review Body. Family doctors can be very well paid and deserve to be when they nake the full contribution that the best undoubtedly do to the National Health Service.

These regulations and the debate look at the subject from the patient's point of view. The House is deciding whether the Government are right to specify more carefully what family doctors should be paid for in future. The effect of our decision will influence the income of individual family practitioners, because it will determine to a large extent which of them are paid more than the average net remuneration recommended by the Doctors and Dentists Remuneration Review Body and which are paid less. That will be a fair reflection of the contribution that each doctor is making and the services that he or she is providing.

Mr. Andrew Rowe (Mid-Kent)

Is my right hon. and learned Friend aware that one of the practices in my constituency has set its face against increasing the patient list size? However, it has already worked out that, under the terms of the new contract, by providing the level of service it already provides, every partner in that practice will be about £4,000 better off.

Mr. Clarke

In assessing the impact on their incomes, doctors will look not only at the number of patients they have, unless they have an exceptionally low number of patients that could be expanded, but at the type of services they are providing, the targets they can hit and the new services they can add which will be encouraged by the contract because they will be better rewarded.

Why are we introducing a new contract? There has been a difficult and protracted process of consultation and negotiation. The present contract is 25 years old and its weakness is that it does not reflect the huge changes that have taken place over that quarter of a century.

We are looking back to a contract that was drawn up by a Labour Minister who eventually introduced regulations that he had been induced to draw up in the face of the threat of industrial action with which general practitioners were confronting him. It does not specify clearly what services doctors should provide. There have been many changes in the past 25 years. I will remind the House of the key changes that have taken place during the years for which we have been responsible. They underline our motives which have been challenged by the hon. Member for Livingston.

Since 1979, the number of GPs in the National Health Service has increased by 20 per cent., from 25,614 to 30,789. Those numbers are likely to continue to increase. The average list size has fallen from 2,229 in 1979 to 1,928 now and that decrease in average list size is plainly going to continue. The number of practice staff—nurses, receptionists and other support staff—that make up the primary care health team has increased by 70 per cent. since 1977. We are introducing cash limits to target that help better, and the Government have made it clear that they intend to expand those primary health care teams and increase the help available to doctors to help them expand their teams by removing some of the limits that specify the type of staff who can be employed on primary health care teams.

Dame Elaine Kellett-Bowman (Lancaster)

Some of my doctors are worried that in future they may have to justify the employment of one of those members of staff. They feel that in those circumstances it would be difficult for them to plan ahead, because they would not know what they would be planning for.

Mr. Clarke

The Government will honour the commitment into which we have always entered, to reimburse 70 per cent. of the cost of all the staff employed by GPs from the relevant date, which is next April. Thereafter, when a post falls vacant, GPs will have to notify the family practitioner committee and the committee will have to endorse the continuing need for that post. The reason for that is that 70 per cent. of the cost of those jobs is paid out of public funds, so it is only fair that when the post is renewed, somebody should be given the opportunity to confirm that it is a justified use of public expenditure. I do not envisage that the average family practitioner committee will go around cancelling nurses' posts and rejecting receptionists or practice managers. However, we cannot simply say to the GPs that they can carry on hiring whoever they want and that the family practitioner committees will write off the cost. The post should be checked as it comes up for renewal when the existing contract holder withdraws.

There have been substantial increases in the number of doctors and their support staff, and there has been a dramatic decline in average list size. The last survey also showed the effects that had had on the work load of family doctors. The last survey was carried out in 1985–86 and showed that the average family doctor worked 38 hours a week on general practice. That 38 hours included calls made by the doctor when on call. That average will strike all of us as low. I agree with the hon. Member for Livingston that it is easy to find general practitioners who are working many more hours than 38 a week on their practices. The reason that the figure is low is that there is a huge variation in time from one doctor to another. When one finds a doctor who says that he genuinely works double those hours, it has to be borne in mind that almost one in four of general practitioners were found to work fewer than 30 hours each week on general practice, and the remuneration system should reflect that.

Mr. Michael J. Martin (Glasgow, Springburn)

On the question of the GPs' work load, does the Secretary of State care to comment on the fact that a Doctor Kermani at a health centre in Essex has stated that the Government will give GPs more work? He is being told by the Government to give information which is normally confidential between patient and doctor on the patient's housing, employment and family problems. Is that true?

Mr. Clarke

It is not, unless the doctor has the patient's consent to do so. The doctor's comment no doubt refers to the surveying of elderly patients when they are visited. That is an extraordinary description of the service, to which I shall return in a moment. The work we are specifying is work that is being carried out in every particular by practices somewhere in the country already.

There is a great variation in the hours worked, and the remuneration should reflect that more accurately. Overall, remuneration has risen dramatically under this Government. We now have 20 per cent. more GPs.

Ms. Harriet Harman (Peckham)


Mr. Clarke

No, I will not give way or I shall be giving way after every other sentence.

Doctors' remuneration has increased as well. We have 20 per cent. more doctors than when we took office and the average total remuneration is up by 37.2 per cent. ahead of inflation, to £67,066. The net remuneration—I am not entering into the argument about the value to doctors of many of the indirectly and directly reimbursed expenses which, as self-employed men and women, they are also given—is up by 22.3 per cent. ahead of inflation to £31,105.

Our policy in government has been to increase the number of GPs dramatically, to increase the number of their staff, to bring down patient list sizes and to extend the range of services available by taking on nurses and support staff. We are paying doctors very much better than did the previous Government who, in their last years in office, allowed doctors' pay to drop. The numbers are continuing to rise and all those trends will continue.

Against that background, it is wholly reasonable to stipulate the patient services that we expect should be provided and to lay down some tighter stipulations about the availability to patients of individual doctors. That brings us on to consider the requirements of the contract. I described the hon. Member for Livingston as having used weasel words because he hardly addressed himself to any aspect of the contract. I suspect that, when we examine the items that we are specifying, almost all of which have been challenged by some of the GPs whose cause the hon. Gentleman is advocating, we will see that he actually agrees with them. Every time he mentioned en passant night visits or something of that kind, he accepted that. The Opposition dare not oppose the great bulk of the real content of this contract. They accept that it is in the patients' interest, and they know that they should support it.

I shall deal briefly with some of the things that even the hon. Gentleman would not have the nerve to challenge. One is the minimum 26-hour availability for patient services at times convenient to the patient. That is a minimum. Of course many doctors will be more available than that, particularly if they have large lists. A 26-hour minimum stipulation is not unreasonable for someone in full-time practice. Higher fees for night visits were agreed. Plainly, patients prefer that if they must have a night visit it should be made by a doctor whom they know or one of his partners or close colleagues. When the doctor carries out that work, it is right that he should be paid more than someone using a deputising service.

I am sure that payments for minor surgery are agreed. The new arrangements for payment of child surveillance should certainly be agreed. As I said, that provision was inserted at the request of the British Medical Association. The details were worked out with the BMA over an enormous period to reach their present stage.

We are giving a higher capitation payment to GPs for their patients over 75. When we pay that higher capitation, it is right that the GP or a member of his team, such as a practice nurse, should try annually to check the home circumstances of the elderly person. It is not enough to say, "We will pay you more for having somebody over 75 on your list whom you might know little about and see rarely." It is a reasonable stipulation to have an overall picture of how that person is coping. Somebody should visit the home and make sure that the home conditions are all right, that the patient is coping with the shopping and cooking and that, generally, nobody else's attention needs to be drawn to that elderly patient.

All those services cannot seriously be challenged. At some of the meetings I have attended, some GPs have queried the need for me to specify that they might do some of those things.

Mr. Derek Conway (Shrewsbury and Atcham)

My right hon. and learned Friend is defending his case very valiantly. Will the 26-hour availability that he mentioned for general practitioners, particularly those in large rural areas, include travelling time and not just availability in surgeries?

Mr. Nicholas Winterton (Macclesfield)

He has made that concession.

Mr. Clarke

Yes, that is correct. I am grateful for the support of my hon. Friend the Member for Macclesfield (Mr. Winterton). It is a concession which I made in negotiations with the GMSC. I made it largely at the behest of Conservative Back-Bench Members from rural areas who challenged me about the 20-hour requirement without travelling time for home visits—a proposition I originally made.

Mr. Michael Morris (Northampton, South)

On availability to patients, my right hon. and learned Friend referred to 42 weeks, which is accepted, and 26 hours. Is he aware that, if five days occur alongside the 26 hours, a general practitioner on call over a weekend will work for 12 days without a break?

Mr. Clarke

I am grateful to my hon. Friend for pointing out that they are required to work for 42 weeks of the year. The hon. Member for Livingston shares the problem of several of my critics—he has not read the contract. He thinks that we are slashing holidays to six weeks. Ten weeks are available, not only for holidays but for study leave and other things. Nevertheless, the six weeks have nothing to do with the contract.

On my hon. Friend's second point, yes, that can happen, but it is when the doctor chooses to be on call because he or she wants to give that service and wants to be paid more and not use a deputising service. We are not saying that they cannot use deputising services sometimes, but, when they are on call themselves because they choose to be, they should be remunerated more for those calls than for using the deputising service. That will be in the hands of the doctor.

Dr. Lewis Moonie (Kirkcaldy)

How does the Secretary of State propose to enforce the contract?

Mr. Clarke

The role of FPCs will be greatly enhanced. For example, on the 26 hours—[interruption] The hon. Member for Kirkcaldy (Dr. Moonie) laughs at the idea that any of this might be enforced. At least he is not claiming that it is onerous—yet that was the argument, by implication, of his hon. Friend the Member for Livingston. I am greatly strengthening the family practitioner committees because they have a duty to manage and develop primary health care services in their areas. The committees will be notified by GPs of their ordinary availability to patients. That will mean that, if someone is not making himself available for the minimum 26 hours at times that are convenient to patients, he can be challenged by the family practitioner committee.

The Opposition will not have the nerve to attack the new requirements to strengthen the activities of GPs on health promotion and disease prevention, which is an important part of our contract. Some doctors are against that, but I do not think that many members of the public oppose it. Plainly, the family doctor service is an important arm of the NHS in health promotion. As a result of the contract, when patients first register with their GP they will be offered a check-up and three-yearly check-ups thereafter. The check-ups will be fairly minimal, but will provide an opportunity to give advice on developing problems and to detect problems early.

We have also set targets for proper levels of child vaccination and for screening for cervical cancer. The targets that we have set for vaccination are those recommended by the World Health Organisation. I do not see why we, with our National Health Service, should not set ourselves the objective of attaining World Health Organisation recommendations. Targets for cervical cancer are also important and make allowance for the fact that some women may refuse such tests and some may not require them. The 50 per cent. lower and the 80 per cent. higher targets reinforce all that we have done in recent years to improve screening for cervical cancer which, I remind the House, still causes about 2,000 deaths a year, most of which are wholly avoidable.

Mr. Nicholas Winterton

My right hon. and learned Friend makes an extremely good point and is developing his argument carefully and constructively. What happens if a doctor does his utmost to reach the target but does not do so, through no fault of his own? Is it right that, after all the effort and time the doctor has put in, he should not receive the full remuneration?

Mr. Clarke

All doctors are paid for vaccination and for cervical cancer screening. Those things are now an ordinary part of a doctor's duties. We are talking about a kind of bonus payment for hitting particular targets. We are trying to encourage a positive effort by all doctors, which many of them now make, to advise and encourage patients to vaccinate their children or to undertake screening tests at the required intervals. There are still some doctors who challenge the requirement to drive ahead with cervical cancer screening in the way that we have suggested. I had such a challenge from a doctor yesterday. However, most doctors do not object to that.

The only argument was about how the doctors are paid. There is a big difference between paying people for each item, according to the number that they do in a year, and the system that we propose, which sets a target level at which a bonus will be paid because all the efforts of the practice have succeeded in encouraging people to take steps that are in their interests and the interests of then. families.

Mr. Nicholas Winterton

I must press my right hon. and learned Friend on this matter. I understand that the maximum bonus could be about £1,500. That is quite an amount of money to anyone, and certainly worth earning. If a doctor contacts every patient about cervical cytology or the immunisation of children but, because of religious or other grounds, does not achieve his target, is there any reason why that doctor should not be awarded the top bonus? He has done everything possible to reach the target.

Mr. Clarke

We shall measure the effort, and someone who is making such an effort has little to fear from our targets. We do not say 100 per cent. because we anticipate that some people who have religious or personal objections, which they are entitled to have, will not wish to undergo screening tests. That is why we have gone for 90 per cent. in one case and 80 per cent. in the other. Those are reasonable targets, which should certainly be reached by the most active practices.

Mr. Keith Bradley (Manchester, Withington)

Will the right hon. and learned Gentleman give way?

Mr. Clarke

No. I should like to get on. I am sure that this matter will be raised later, and I shall deal with it then.

When I set out the contents of the contract, I do not believe that many speeches will be made in the House—whatever letters hon. Members may have received from a few GPs—to challenge much of it. The hon. Member for Livingston, in an attempt to achieve topicality, suggested that the way in which we set about achieving that contract somehow reflects an unfortunate style on the part of the Government. Over the years, I have been engaged in the process of negotiation and consultation many times, but I have never been engaged in one that has been so tortuous and protracted as our consultations on the contract. I have not been engaged in many negotiations where I have made more concessions than I have in this respect.

The distant origins of this process lie in the time when I was Minister for Health—I am glad to say that my hon. Friend the Member for Surrey, South-West (Mrs. Bottomley) now holds that post—and I tried to raise the question of improving the contract with the royal college. The process got going with the 1986 Green Paper on primary health care. The Government then held 10 public meetings in consultation on those proposals and we received more than 2,000 representations. The overwhelming tenor of those representations was that the contract should be addressed to improving health promotion and disease prevention. There was a great deal of public response and that response was channelled into the White Paper. We then had more than 100 hours of negotiation with the BMA negotiators to discuss all the points.

On 4 May, I had a long meeting with the negotiators, who are extremely tough. The hon. Member for Livingston claimed that those negotiators "rolled over". That is a surprising description given my experience of the general demeanour of the GMSC negotiators. In their opinion and in mine, however, we reached a settlement on 4 May. On behalf of the Government, I made some substantial concessions to reach that position.

I wanted to get rid of seniority allowances—I have Labour predecessors who tried to do the same—as I do not believe that they are performance-related, All they show is that one is growing older. I conceded on that, however, and so long as doctors keep their full seniority allowance, we required that people should go in for the postgraduate training allowances that we are now introducing. I conceded on the basic practice allowance figures, partly in response to arguments, which I did not altogether accept, about the impact of that allowance on women doctors. I was also pressed on the rural practice payments scheme, as I was by a number of my hon. Friends. I agreed to abandon my proposals on that, although I believe that they were advantageous to doctors living in sparsely populated areas. We have agreed to refer that matter to the central advisory committee and it will come back to us on it in due course.

Target payments are an important part of the debate, and I conceded on the lower levels of target payment. That is an important concession as, especially with vaccinations, a high proportion of practices will hit the lower target payment.

On 4 May, I proceeded on the basis of the concessions made. The negotiators then recommended the resulting agreement to their members, but, because of the internal politics of the BMA, unfortunately, all that went wrong and there was subsequent controversy about the contract. [Interruption.] According to the medical press, the vote was conducted in extraordinary circumstances. Long after the vote had been taken, I had meetings that were full of reasonably friendly rural doctors. They all told me that they had voted against the contract because they should be able to keep their rural practice allowance. They were astonished when I told them that we were not withdrawing that allowance. The level of knowledge, among all the campaigning, was slight.

Many of the people who forced the vote were attacking the negotiators as much as me. Given that I have had my difficult times with the negotiators I sometimes feel sympathy for them when I see the attacks upon them. Only yesterday I read The Journal of the Dispensing Doctors Association, which contained an editorial and an amazing article entitled "Willigo Wilson", both by Mr. Roberts and both of which attacked the chief negotiator of the GMSC, Dr. Michael Wilson. He is a pleasant and friendly man, but an extremely tough negotiator. I shall give a flavour of the type of attacks that he has faced.

The Journal suggested that "Willigo Wilson" should go because he had surrendered so miserably to the Government over the contract, and stated: A further contribution to the ensuing disaster for general practitioners was that Dr. Wilson accepted that the emphasis in the fight should be almost solely on the effects of the Contract on patients". The article set out what the themes and aims of the GMSC should be and asserted: The interests of doctors and patients do not always coincide! Having agreed that the interests of patients should be put first, the author of the article advises Dr. Wilson: I would remind him, as he splutters over his morning cornflakes, that military leaders have shot themselves for less! for conceding to the position reached on the contract. The editorial addresses me by saying: Yes, Mr. Clarke, the 1990 Contract will hit our wallets and I am not ashamed to admit it I have good news for the rather unpleasant Mr. Roberts —he is wrong. As I have already said, the new contract will not hit his wallet. The rubbish in The Journal, which is sent to all members of the association, no doubt inspired those members to cast an unreasonable vote against the contract and to mount unreasonable attacks upon Dr. Michael Wilson. He is an honourable man who defends doctors' interests, but, to be fair to him, he also remembers the interests of patients.

To be fair to the profession, I should note that doctors have re-elected Dr. Michael Wilson, who recommended the contract to them, as their leader. We all know that feelings about the contract are fading away rapidly as individual doctors find out more about it. With stuff such as that which appeared in The Journal still being written I wonder who advises the Opposition. Which section of the medical profession does the Labour party listen to when it trots out all its opinions? It is obvious that that medical opinion is not speaking on behalf of patients, but on behalf of the more hot-headed members of the BMA. Such people give the Opposition an inadequate briefing so that they can make selective attacks on parts of the contract.

Mr. Robin Cook

Since the Secretary of State has been so kind as to ask who advises us, will he state just which organisation, whether medical, the BMA, one representing patients or any other organisation concerned with health policies and medical politics, supports his proposal to increase the payments by capitation fees and increase the incentive for longer patient lists? I just want the name of one organisation.

Mr. Clarke

I do not believe that what we have done increases the incentive for longer patient lists. The Labour party's approach to the Health Service debate is to talk in terms of organisations. All it needs is for a couple of trade unions and associations to give their views and the public interest, public advantage and patient interest are instantly forgotten. The hon. Gentleman cannot challenge the patient advantages of the contents of my contract. All it needs is for a trade union to oppose it and he will vote against it. He cannot argue against the public interest involved.

The hon. Gentleman claims that capitation will encourage less time to be given to each patient. The main effect of increasing the capitation element is that it will give added reward to doctors who attract and retain their patients. The idea that we should turn away patients from a particular doctor when those patients want that doctor is extraordinary. I also find it extraordinary that patients will be attracted to a list of doctors who give less and less time to each patient. That is the argument that the hon. Gentleman has tried to put together.

If a doctor has a large list, it is unlikely that he will want to increase it—a constituent of my hon. Friend the Member for Mid-Kent (Mr. Rowe) has already decided not to. If a doctor wants to increase his list size, however, he must attract the patients on to his list. He is more likely to attract them if he offers them more time rather than less. If a doctor already has a large list, he is unlikely to want to increase it; instead, he will consider the services offered.

At the moment, nearly a quarter of our practitioners work more than 30 hours a week. If a doctor is induced to try to expand his list, I do not believe that he will say that at least seven minutes for each patient is not available when that patient comes in for a consultation. Doctors must decide whether they will be able to put in the increased work to justify the increased list. The judgment of the attractiveness of a particular practice will be made by the patients.

I agree with Which? and everyone else that most patients want more time with their doctor. Therefore, the ones that offer more time are the ones most likely to attract patients. The hon. Member for Livingston has already conceded that the idea that most lists will go up is a mathematical impossibility. I advise him to talk to some of the medical lobbyists about that, because I have been unable to persuade some of them that the lists of all doctors will not rise as a result of my proposals.

The female doctors point is an important one. I am glad that the hon. Member for Livingston anticipated that I had never heard of the extraordinary sentence which he read from a publication of the Conservative Medical Society. To be fair to the society, it may have been written by an individual member; I cannot believe for one moment that it represents the policy of the CMS.

We are seeing an every-increasing number of women GPs and wish to do so. Without doubt, we shall see an increasing proportion of women GPs because, at the moment, about 40 per cent. of the trainees up and down the country are women. There are changes in the contract which make it easier to employ women. Part-time contracts are to be allowed for the first time. The valuable concept of job sharing, which professional women of this sort are perfectly capable of organising, is introduced for the first time into the family doctor service. It has been made easier to employ a locum when a women doctor is absent on maternity leave.

I have never been able to understand the argument that the contract is hostile to female doctors, unless it is argued that the contract must be so constructed that male doctors will be given a financial bonus for taking on a woman doctor. I have faced arguments in which that seems to be the proposition. The contract is so based on consumerism and patient choice that rising patient demand for more women doctors and patients' preference to go to practices with women partners will have a key effect and make career possibilities in the family doctor services ever more attractive to women.

Mr. Tim Devlin (Stockton, South)


Mr. Clarke

I am near the end of my speech and shall not give way as I have taken longer than I intended in this short debate.

This contract is much more attractive than the previous one and for the Opposition to vote against it is perverse if they really mean it when they say that they are in favour of a patient-oriented service.

What if some of the details are wrong? There is not much wrong in the drafting. There should not be, because, after we had reached the 4 May agreement, the consultation at the final stage of the drafting took months. The GMC was helpful and made helpful contributions to the drafting before we reached the present stage. Parts of the contract may be wrong and it may not be exactly as planned, although I believe that the impact on consumer patient services will be beneficial.

Sooner or later, the contract may be revised when new developments in practice come along. We shall take a look at the targets and consider which other services we should be encouraging. We should not wait another 25 years before doing that. If, in a few years' time, a successor of mine decides to take another look at the GP contract and start negotiating amendments to it, I hope that he will have less of a pantomime and a farce and can make more sensible progress than I or my predecessors at the Department have been allowed to make during the past two or three years. I also hope that he faces an Opposition who at last realise that all parties should be substantially on the patient's side in the disputes about the family practitioner service.

The patient must take advantage of the contract. We have taken the opportunity to make it easier for the patient to judge practices and choose a family doctor who exactly suits his or her family. The regulations will make it easier to change doctor, and this part of the contract will come into effect earliest. From 7 November in England and Wales and 22 November in Scotland, patients will be able to change doctors simply by registering with a new one. That removes the existing need for the patient to obtain the permission of his or her present doctor or family practitioner committee. That change was opposed by the negotiators during our discussions, but we have put it in place.

Under the regulations, GPs will have to provide practice leaflets. The last letter that I received on the subject was from the constituency of my hon. Friend the Member for Loughborough (Mr. Dorrell). One of his constituents wrote to me enclosing a copy of a practice leaflet that he had received. He said that this was the first time he had had any contact with his doctor for many years and thought that this was a highly desirable outcome of the discussions in which we have been engaged.

All over the country, GPs are producing leaflets and, from the information which the GPs will have to provide, family practitioner committees will produce local directories setting out the services available throughout their area. I hope that the Monopolies and Mergers Commission proposals to the profession are soon accepted, so that the information can be made available to the public, and doctors, if necessary, can promote their services, as long as they do so in a responsible and professional fashion. That will ensure that, once we have created a more consumer-oriented family doctor service, patients will be in the best possible position to take advantage of it.

Therefore, I recommend the regulations to the House and ask for their endorsement. What we have done is wholly consistent with the Government's overriding objective of strengthening this vital public service and making our great National Health Service a better Health Service in relation to the family doctor service.

4.55 pm
Mr. Charles Kennedy (Ross, Cromarty and Skye)

The Secretary of State for Health is to be congratulated on his characteristically skilful advocacy of his case. However, in these affairs, he represents a somewhat Jekyll and Hyde character. This afternoon we have heard a different Secretary of State from the one whom we have seen and heard talking about doctors over the past few months on national television screens, on national airwaves and in the press.

When the original agreement was concluded, I sat and watched the Secretary of State on Channel 4 news. The language he used was blunt and straightforward. He said that he had won his case against the BMA. That was not the tenor of his remarks this afternoon, because he has had some time to reflect. I dare say that passions have cooled on both sides of the negotiating table, but that was his frame of mind when he first approached the matter.

The Secretary of State this afternoon was not the man who enraged medical opinion—not just professional BMA opinion, but the very patient opinion the importance of which he was at such pains to stress in the later stages of his speech today. He was not the man who, on that infamous occasion, spoke of GPs being more interested in their wallets and incomes than in patient care and patients' standard of service. He presented a different face to us this afternoon. The negotiations are complete and the Secretary of State was right to say in his concluding remarks that there are significant passages of this contract which all of those who want to see an improved National Health Service, improved accountability, choice and sensitivity towards the patient as the consumer—in the non-profit sense—would wish to embrace.

There is more than a suggestion in the behaviour and oscillations of the Secretary of State in recent months to suggest that this is one example where the Government, who have benefited so much from high-profile media advertising have, for once, found themselves at the sharp end of that type of advertising. The Government—perhaps all parties, given that we debate health issues year in and year out—have learnt an important lesson. The lesson is certainly relevant to the Government, who have been at pains to stress how much they are doing for the National Health Service, although, apparently, they are not persuading the public of that—they cannot turn around the political opinion polls on that issue.

Some of us criticise the Government year in, year out, about the damage done to the Health Service. Perhaps that has some effect in persuading public opinion. Once doctors began to tell patients of the damage and potential damage being done to the Health Service, they carried more credibility than any elected Member, and certainly any member of the Health Department, whether official or ministerial.

The rash, intemperate and thoroughly provocative approach adopted by the Secretary of State over the past few months made what would always have been a difficult, convoluted and intricate negotiation—there is no debate about that—a far worse task. In part, that was due to the deliberately provocative style adopted by the Secretary of State. To a certain extent, the Secretary of State has got his comeuppance.

Mr. Devlin

Will my right hon. and learned Friend the Secretary of State comment on the fact that the House is substantially empty this afternoon? From what has been said, it seems that this matter should be one of great concern to hon. Members from both sides of the House. Perhaps, with the increased interest in the economy and the counter-productive propaganda put out by the doctors, particularly the BMA, which has turned hon. Members and people outside the House against the BMA, the contract which we are debating today—in which all of us are so interested—has ceased to be a controversial issue and my right hon. and learned Friend the Secretary of State has won the argument.

Mr. Kennedy

I shall be generous to both sides of the House and assume that, as hon. Members can now stand in the Lobbies and watch live broadcasts of these proceedings, hundreds of hon. Members on both sides of the House are gathered round the television screens hanging on to every word of those contributing.

I saw for the first time today an example of "doughnutting", whereby the few Opposition Members present congregated around their Front-Bench spokesman. We also had a little bit of that around the Secretary of State, but there was a bigger hole in the middle. [Interruption.] I see that my hon. Friend the Member for Ceredigion and Pembroke, North (Mr. Howells) has just joined me. I am sure that hon. Members will agree that he makes a convincing doughnut. Let us put down the somewhat meagre attendance to the televising of our proceedings.

If the hon. Gentleman thinks that the heat has gone out of the issue, he is somewhat misguided. When the new Session begins later this month and the new Health Service legislation is introduced, he will find that, although the contract issue will be over from a legislative point of view, the rumblings and knock-on effects will be with us for some time.

Mr. Kenneth Hind (Lancashire, West)

Will the hon. Gentleman give way?

Mr. Kennedy

If the hon. Gentleman will forgive me, I will not give way, as many hon. Members wish to speak.

As one would expect, the Secretary of State referred to capitation fees and to the effect of likely increases in list sizes, which he dismissed. It is important to mention that both salary and allowances are included in the capitation element of a GP's income. The Secretary of State has been tempted to reflect the tendency on the part of the press to total all the available allowances plus the salary of Members of Parliament and say that that is our effective gross income. The Secretary of State has been slightly guilty of that at times, but it is not fair.

The capitation element will increase from 46 per cent. to 60 per cent. Much as the Secretary of State may try to reject or counter the argument, the near-certain effect of that will be to increase list sizes. Surely it is not desirable for GPs, who should be spending more time with their present patients, to end up spending rather less time with more patients.

The Secretary of State tried to counter that, particularly in response to the hon. Member for Livingston (Mr. Cook), by talking about the extension of the range of services and how that would make general practice more attractive. I welcome further information for patients and the greater ease with which patients will now be able to change from one surgery to another, although that is much overdue. But the logic of the funding arrangements that the Secretary of State is modifying under the new contract is that the greater the demand for the range of services being provided by a given practice, the greater will be the increase in the list size and the less time there will be available for each patient. I do not see how the Secretary of State can make the kind of case that he attempted to make in a rather mollifying way this afternoon and at the same time be consistent on the arguments that he is otherwise praying in aid for the new contract.

The Secretary of State referred to immunisation and the system of bonuses in the new contract, with lower bonuses for 70 per cent. vaccinations and 50 per cent. smears, and higher bonuses for 90 per cent. vaccinations and 80 per cent. smears. A key consideration here is how one defines a target population, as the Government have been at pains to do. That is particularly true in areas of rapid population change, not least in the inner cities.

The clear evidence of the Black report's in-depth analysis of take-up levels and health deprivation shows how difficult it is to get through to the very target groups that one is trying to reach on matters such as immunisation, preventive medicine and recall facilities. All too often it is likely to be the more socially confident, the better educated, those with slightly better incomes and so on, who take advantage of any additional facilities that are offered. Despite the best efforts of GPs, health authorities and the Department of Health, the people who are considered to be the most vulnerable, and so the most valuable to reach, are missed as a result of the demographic and practical difficulties that the Government are trying to address.

A great deal needs to be done to overcome problems created by lack of knowledge and fear about, for example, immunisation. It is clear that the Government have a major role to play in health education. The rather worrying suggestion that has emanated from the Secretary of State, not so much this afternoon as on previous occasions, is that almost all the responsibility for that can be landed in the front line at the feet of the general practitioners.

In deprived areas, or among the more deprived categories of the population, the direct patient-doctor contact may come only at the point of acute illness. In the build-up period, where preventive measures could be taken rather than waiting for the crisis, intervention and cure, all too often related social conditions, such as housing or the environment generally, play a stronger part than the general practitioners in the front line. The Secretary of State has given insufficient attention to that fact.

Mr. Devlin

I am grateful to the hon. Gentleman for giving way again. Representing, as I do, part of inner-city Teesside, I am, like him, concerned about this matter. A point that he has omitted to mention, which he might like to consider, is the additional funding that will go to GPs under the Jarman index of social deprivation, which is one of the new features of the contract. Will he also comment on the new system of visiting and inspection for the over-75s, a particular target group which is often overlooked in inner-city areas?

Mr. Kennedy

The Secretary of State said that the measures taken for the over-75s meet with general approval, and they have not been a source of any serious or significant contention. They are to be welcomed. I have no criticism of that. That section of the population will grow as people live longer, more active and healthier lives, and that is a welcome trend. Therefore, those measures do not go to the heart of today's debate.

With regard to social deprivation and the indices that can be used to show it, we have still not overcome the fundamental difficulty that Black discovered, to which I referred earlier. The problem will not necessarily be conquered by a simple statistical change. An increase in the range of services, material on those services and increased patient choice in the GP's surgery cannot be expected to overcome fundamental social problems which prevent people from going to the GP's surgery until illness strikes, as a result of ignorance, lack of education and counselling from an early age, when most of the interface can and should take place with the family doctor service. That fundamental difficulty cannot be overcome without going much further than the measure we are discussing this afternoon.

I do not wish to detain the House, so I shall conclude with one issue which the Secretary of State mentioned towards the end of his speech—the position of female general practitioners. He was quite right to mention the increase in the number of women GPs, which has almost doubled in the past 10 years. They now represent 22 per cent. of all general practitioners in Britain and 25 per cent. of general practitioners under the age of 40. The demographic shift is most apparent and is to be welcomed.

The Government claim to welcome that development and say that they want to encourage that trend. The primary care White Paper referred to special arrangements to attract women to General practice and to encourage their appointment to the vacancies which occur". That is a noble sentiment indeed, and I do not think that there is much disagreement on that until we look at the contract. The likely effect of the new contract will be exactly the opposite of encouraging more women GPs into the Health Service, particularly because of the inbuilt disincentives it offers to part-time and flexible working arrangements.

I shall cite just one example. At present, on average., a part-time female GP brings about £15,000-worth of allowances by joining a general practice. If the practice pays her £18,000 which, on average figures, is about one third of a senior partner's annual salary, the practice is getting about 20 hours a week for an annual net outlay of £3,000 per year. Under the new arrangements, that female GP is likely to bring £6,000 or less in basic practice allowances, so there will be a major and significant shortfall, which represents an equally major and significant disincentive. The cost of employing her will therefore be much greater and the likely result is that, instead of additional part-time, flexible working arrangements being available as the Government claim and wish to enhance, the opportunities for female general practitioners will contract as GPs do exactly as the Secretary of State says that they will not do, and build up their lists to make up for the financial shortfall which will occur. The contract is a discriminatory measure in that cardinal respect.

As I said earlier, many aspects of the contract are to be welcomed and carry all-party support. But there are also major aspects which have been thoroughly divisive and have not been helped by the belligerence with which the Secretary of State has pursued his case. In his previous post at the Department of Health, he was the only Minister I have ever come across who thought that BMA was a four-letter word. As soon as he came into any contact with that organisation, he seemed to adopt a most intransigent attitude and decide that it must be gloves off. On this occasion, when the BMA took the gloves off, he began to bleat and complain in a rather plaintive fashion. One does not normally associate bleating with the Secretary of State, but we shall give him the benefit of the doubt.

Generally, the motives behind the contract cannot be divorced from the motives involved in the broader issues arising from the White Paper and the legislation which will follow. Despite those areas in which significant progress has been made and which are not the subject of partisan disagreement this afternoon, it is clear that the basic motivation is the reduction of medical costs within a political context to suit the whims of the Prime Minister much more than to suit the priorities of the patients.

Mr. Kenneth Clarke

Would the hon. Gentleman care to point out one respect in which the contract will reduce costs?

Mr. Kennedy

Reduction in costs will occur in the very last example which I cited, relating to female GPs. That is a cost reduction in terms of the employment of those general practitioners and in terms of the availability of employment for female GPs. That is an obvious example.

The motto should be "people first" in health care. Sadly, it is proving increasingly to be "cash first, people last", and on this occasion the profession, in a rather muted sense, is somewhere in between as a result of the contract.

5.15 pm
Dame Jill Knight (Birmingham, Edgbaston)

I do not know whether the speech of the hon. Member for Ross, Cromarty and Skye (Mr. Kennedy) meant that his minuscule party will be voting for the motion. If that is his intention, he will be voting against a large number of excellent provisions for patients and doctors.

My right hon. and learned Friend the Secretary of State is not only a much-maligned man, but a most unfairly maligned one. His opponents use every trick in the book to twist his words and muddy his intentions. I thought that he was being exceptionally mild and magnanimous when he told the Conservative party conference: I do not think the BMA have been trying to be entirely helpful.

Mr. Devlin

Will my hon. Friend give way?

Dame Jill Knight

No, I wish to get into my speech first.

I thought that the description by the hon. Member for Ross, Cromarty and Skye of my right hon. and learned Friend's attitude towards the BMA was not accurate. I thought that, when my right hon. and learned Friend most recently expressed his views on the BMA, he was being rather sweet. If that was an accurate comment on the recent activities of the BMA, I tremble to contemplate how members of the BMA would behave if they were trying to be unhelpful.

I do not think that my right hon. and learned Friend's comment was accurate. The BMA has not only been obstructive, but has been intentionally misleading, putting the fear of God into elderly, sick and nervous people in the consulting rooms of its members. I find that very difficult to forgive. Members of the BMA have distributed leaflets which they must have known, not to put too fine a point on it, contained blatant lies. They misled people over the Health Service review and they are doing it now over a contract which is good for doctors and excellent for patients.

It will be excellent that the over-75s will have an improved service. Elderly people are well aware that many of their aches and pains are due to age, but I have heard of frequent cases where doctors hurriedly dismissed those aches and pains without checking. A great deal can be done to improve the hearing, sight and general comfort even of the elderly, and an annual check-up is exactly what they need.

I like the plans to improve health promotion clinics, immunisation and screening for cancer. I am interested in the women's national cancer control campaign. Now, due to the new contract, it is coming on stream with more energy than ever. I approve of regular assessments of the development of children. That used to be done far more than it is today by the ordinary school medical service; there have been gaps in that and I am pleased that it is clearly stated that children are to have regular assessments.

I am glad that there will be additional staff in the surgeries, especially chiropodists and physiotherapists. That is a new and good idea——

Ms. Harman

It is not new.

Dame Jill Knight

It is certainly a new idea to encourage all doctors to have such people in their surgeries. I will not answer any more sedentary interventions from hon. Members who do not know the whole position. These additional people are to be the rule rather than the exception.

It is sensible that doctors should be available to patients on an eyeball-to-eyeball basis for at least 26 hours a week. We appreciate that they work more hours than that because of travelling time, filling in forms and so on, but it is excellent that this improved service for patients is to be introduced.

So much for the way that the contract helps patients, but there is also a great deal that it will do to help doctors. The hon. Member for Ross, Cromarty and Skye claimed that my right hon. and learned Friend said that general practitioners received an average of £65,000 per year—

Mr. Kennedy

I did not.

Dame Jill Knight

The hon. Gentleman said that the sum quoted did not include expenses.

Mr. Kennedy

I said that when the Secretary of State referred to the total gross income of general practitioners, he was adding together salaries and allowances. I drew a comparison with the way in which members of the press talk about Members' salaries. They add up office allowances, living allowances and salaries and make people think that we are millionaires. Some Conservative Members are millionaires, but some of us most definitely are not.

Dame Jill Knight

That is exactly the point that I am trying to make. As usual, the hon. Gentleman is wrong. My right hon. and learned Friend has always said that the sum of about £67,000 per annum includes expenses—

Mr. Kennedy

Sotto voce.

Dame Jill Knight

That is not true. I have my right hon. and learned Friend's press release, which clearly states that the sum includes all expenses. A press release cannot be sotto voce. Indeed, my right hon. and learned Friend has been fair in his remarks about average expenses.

For the first time, doctors will receive specific payments for carrying out certain duties such as minor surgery in their surgeries. It is a good and useful service because it alleviates the work load on hospitals, but previously doctors have not received a specific payment for that work. They will also receive payments for health surveillance and health promotion.

It is worth uttering a word or two on the subject of postgraduate education allowances. Although some doctors go to great lengths to keep abreast of all medical developments, others do not. There is to be an allowance to encourage doctors to keep up to date. There will also be increased payments for night visits—I hope that the Opposition favour that. Necessary improvements to doctors' premises will also attract specific payments, and there will be an increase in capitation fees.

One matter that worries me is the proposed supplement for every patient living in an area of deprivation. Not all needy people live in such areas. Perhaps my right hon. and learned Friend would say a few words about what "area of deprivation" will actually mean. Does it mean that doctors will receive additional payments for looking after people who live at certain addresses in rundown inner-city areas? Part of my constituency is an outer-city area, and people ignore the fact that, for example, there are more one-parent families in that part of Birmingham than there is in the inner city. I hope that my right hon. and learned Friend will bear that in mind and think not only of where the patient lives, but the extent of his need. I appreciate that that is not always easy to delineate.

Under the contract, it will be easier for patients to change doctors. There will be much less bureacracy and patients can just turn up at a surgery and ask to be put on a doctor's list. I am sure that all hon. Members know of vexatious patients. Some doctors will have to have those patients on their lists. If a doctor says that he does not want them on his list any longer, they are passed around like a parcel. Under the contract, will a doctor have the right to say that he does not want a particular patient on his list? That needs to be clarified.

I ask my right hon. and learned Friend to repeat, in every speech, the following points—even though he and I know that they should be superfluous: first, that he has an unwavering and inflexible commitment to the principles of the NHS; secondly, that he believes in an NHS funded largely out of taxation giving free medical treatment to everyone regardless of means; and thirdly, that not for one moment will he contemplate privatising the NHS.

Repetition may be boring, but some people have such thick heads that only by repetition can we get the right ideas into them. We must continue to repeat the truth. I am sick and tired of listening to accusations against the Government and Ministers that they want to privatise the NHS. Anyone who listened to the words that are used would know perfectly well that the allegations are untrue. All the attacks, all the aggro, all the unfairness will not, I hope, deter my right hon. and learned Friend from continuing to improve the NHS. Of one thing I am certain: he will go down in history as having been a great, reforming and improving Secretary of State.

5.29 pm
Mr. Michael J. Martin (Glasgow, Springburn)

I should like to ask the Secretary of State a number of questions. Let me say first, however, that all the general practitioners in my constituency to whom I have spoken—and most have approached me—have said that they want the Secretary of State to know that his contract stinks. It is absurd for any hon. Member to say that the BMA executive supported the right hon. and learned Gentleman; anyone who knows anything about negotiation will be aware that there is a difference between expressing support and telling the membership, "This is the best that we can offer."

The question of changing doctors worries me. It is easy for the Secretary of State to say that if a patient turns up at a doctor's surgery he must take that patient on. In London, chronic traffic congestion means that it can take hours to cross from south to north; if a GP whose surgery is in the north-east takes on a patient who lives in the south-west, emergency call-outs are bound to be a problem. As the hon. Member for Birmingham, Edbaston (Dame J. Knight) pointed out, patients can be vexatious, and, unfortunately, some are even deranged. Such a patient might deliberately pick a GP whose surgery is on the other side of the map, just to be awkward.

I did not oppose parental choice in regard to schools, but it has nevertheless thrown up numerous problems. Excellent school buildings are half empty, and the Government are taking no steps to find out why. It is all very well for them to say that parents are still making up their minds; we have expensive buildings to keep up.

While Springburn was being redeveloped, it took us about 10 years to establish a health centre that is now second to none. We managed to persuade doctors to leave their converted shops in the high street and to provide the community with chiropody—notwithstanding what the hon. Member for Edgbaston said about that—as well as eye tests, dental checks, nursing sisters and a chemist, all under one roof.

A large health centre may contain six or seven practices. Let us say that some of those doctors are not attracting patients, and that their existing patient lists are dwindling. The Secretary of State may say that the patients are switching to other practices within the centre, but let us assume that they are going elsewhere. In such circumstances, a conscientious doctor will have to pay higher overheads because of the new contract.

I know that the patient is all-important, and that he has the right to decide. If I did not like my doctor I should want to leave his practice. If, however, overheads must be spread among fewer doctors, what help will the Government give? What help will they provide when patients who quite enjoyed visiting a health centre are cut off from it by a new road, and the doctors' list suddenly becomes smaller? Conservative Members shake their heads, but patients in my constituency have decided to stop visiting their health centre because the road is too dangerous to negotiate, and doctors are losing patients through no fault of their own.

The Secretary of State mentioned preventive care. In a middle-class community where people are relatively well off, a woman who becomes pregnant is more than likely to want first of all to find out about pre-natal care. In parts of my constituency, however, conscientious doctors know that, unless they go out and knock on the doors of women who have been housed under a "difficult to let" scheme, such women will not obtain the care they need.

We have been told that deprived areas are to receive an allowance. Bureaucrats, however, are terrific at drawing a line around an area on the map and designating it an area of deprivation in which a supplement is payable. An afluent area may contain one or two deprived streets, and the local doctor will know that he must visit the neighbourhood himself if he wants to obtain patients. I hope that we shall be told tonight that that will not happen.

The Secretary of State must be aware that, in areas of high unemployment, the problems for practitioners are getting worse and worse. Most people are visiting their surgeries suffering from depression because they are out of work; wives, too, arrive complaining about the pressures put on family life. I worry about the way in which the Government seem to think that practices should be run like nice, efficient businesses. A GP's work is not like a job churning out alarm clocks, for instance, in which payment is made for results. The Government's proposals will mean that the more sympathetic the doctor, and the more prepared he is to listen to patients, the fewer patients he will have.

A year ago, my wife had a serious operation. Two members of the local practice had said, "I will give you a prescription; you will be all right then." The third listened. He made an appointment with a consultant, and my wife obtained the necessary operation—from which, thankfully, she has now recovered. But what would have happened if all three doctors had been under pressure, and had not listened? A doctor who sits signing a prescription while the patient is still talking does not inspire confidence. [Interruption.] I did not hear what the hon. Member for Staffordshire, South-East (Mr. Lightbown) just said, and I do not approve of the practice of speaking from a sedentary position.

When the Secretary of State glibly talks about choice and says that patients can move, he forgets that, even if they are dissatisfied, elderly patients may not be able to get around as well as they did when they were 30 or 40 years old so they may have to content themselves with the local practice. He must know that in many inner-city areas, our communities are getting older. That puts a burden on GPs. In areas where the community is young and upwardly mobile, a GP may have only a few elderly patients while in other areas where the community is becoming ever more elderly, he may have many. Comparisons must be made and allowances built into the system.

I heard what the Minister said about the emergency doctor service. I do not knock that service, even though it is privatised. I would rather have a doctor in the surgery who is fresh then a doctor who had answered four or five calls the night before. We should examine the deputising service and in some cases encourage it, provided that the doctor does not lose contact with his patients or simply take the easy option. Doctors in the deputising service go out with a driver. Doctors may be afraid to go to areas with a high level of crime and drug problems. There have already been reports of assaults on doctors. Doctors have been called out by a bogus caller and assaulted for their drugs when they arrived in the street where they were expected. At least if doctors go on emergency calls with a driver, they will have some back-up.

I hope that the Minster for Health will examine thoroughly all the matters to which I referred, particularly the problems in inner-city areas, and that she and her colleagues will see that there are vast differences even within tightly knit communities.

5.42 pm
Mr. Michael Morris (Northampton, South)

I deeply regret having to speak and vote against the regulations. I do not vote against my party lightly, particularly on an issue that involves my family, whom I try to keep out of politics. However, occasionally one must do what one believes is right.

I declare an interest immediately and it proves that I know something about general practice. My wife has been a general practitioner for over 25 years, initially in the inner-city area of Hackney in London and for the past 16 years in Bedfordshire. At the Conservative party conference in Blackpool in 1973 she received a phone call asking her to stand in on an emergency basis in Biggleswade because there was a shortage of GPs. Blackpool conferences were different then. In those days people were allowed to speak against the motion and the debates were not fixed as they were this year. In those days speakers knew and worked in the National Health Service. This year we listened to a doctor who did not work in the National Health Service telling us how marvellous the proposed reforms were. I found that cheeky. Moreover, I understand that he is not particularly successful in private practice.

I have several other interests to declare. I have been a member of the Public Accounts Committee for the past 10 years and the member of that Committee who has asked the most questions about the National Health Service. The health side of what was the Department of Health and Social Security hardly covered itself in glory in the past 10 years. I expect that my colleagues on the Committee will agree that it is not an exaggeration to say that it was probably the most badly organised Department in the Civil Service. Perhaps now that we have an independent Department of Health, that will change. It certainly needs to do so. I also serve on the Council of Europe's health committee and I advise two pharmaceutical companies. I think that I can claim to know at least as much as the Secretary of State about the National Health Service.

The negotiations for the new contract have followed a familiar pattern. First, the Department issued a set of proposals. The Secretary of State has often been at pains to tell us how long the negotiations have lasted. After all this time and with so many civil servants and officials who are doctors in the Department, one would think that the initial cockshy would be somewhere near a contract that would be acceptable to all parties. But what did we have in February? We had far-reaching proposals for changing both the terms of service and the remunerative system of general practice. My hon. Friends seem to forget the juxtaposition of those factors.

The changes in the terms of service—one of the key platforms—were to include no opting out of the 24-hours-a-day cover, which is right, and direct consultation in the surgery for at least 20 hours per week spread over five days. The Department seemed to forget about home visits. Doctors were to be required to live within a reasonable but undefined distance of the surgery. Several other conditions, which are well known to my colleagues, included regular medical assessments, practice leaflets, and production of annual reports. I listened to my colleagues with some incredulity. I wonder how many of them have read the statutory instrument issued by the Department of Health which sets down the required content of annual reports. They are to be long. Perhaps some of us should write a similar annual report for our constituents. [HON. MEMBERS: "We do, every four years."] Some of us do it more often than annually. Changes in the percentage of the square footage of a surgery devoted to the reception, surgery or nurses' surgery cannot be of the least relevance. Other questions have to be answered in the annual report, the purpose of which is questionable. Family practitioner committees will have to be informed of other professional commitments. That is perfectly fair.

The changes to the remuneration system altered 50 per cent. of the revenue of an average GP's practice. The Department was not simply tinkering at the fringes of the regulations; it introduced a wholesale change in remuneration. Out went seniority, group practice allowance, vocational training allowance, postgraduate training allowance, supplementary basic practice allowance, supplementary capitation, cervical cytology fees and child immunisation fees. On top of that, the basic practice allowance, night visit fees and rural practice payments were changed. That is a long list. In came capitation fees of 60 per cent. We have all heard a great deal about advisers in recent weeks. Advisers have suggested that 60 per cent. will be only the start. Will it be 70 per cent. in a few years' time and 80 per cent. a few years later? My hon. Friend the Minister must state that 60 per cent. will be the maximum and that it will not be changed.

The proposals state that in order to receive full remuneration a doctor must have 1,500 patients, reach cervical cytology and immunisation targets, provide annual check-ups for the over-75s, medicals for newly registered patients and medical assessments every three years for patients aged 16 to 74, undertake minor surgery, organise health promotion clinics, establish staff training, produce a practice leaflet, provide an annual report, accept child surveillance responsibilities, attend specified postgraduate training sessions and carry out night visits on a practice roster.

It does not end there. Last year, I was happy to support the changes to fees and allowances that were incorporated in the Health and Medicines Act 1988. I have long believed that that element of GP work should be cash-limited. However, this afternoon my right hon. and learned Friend said that there will be a review not just of new ancillary staff but of existing staff. When a nurse leaves a practice, the family practitioner committee will have the right to say to the doctor, "You may not have another nurse." I very much hope that that dimension, which has not been highlighted, will be dropped.

The Health and Medicines Act also contains provisions relating to isolated general practices and computerisation. The Bill that will come before the House in a few months' time will impinge on general practice. The main items for discussion are practice budgets for those with over 11,000 patients, particularly drug budgets, the medical audit and the recomposition and reorganisation of the FPCs. Each will lead to a new list of proposals before their introduction.

Throughout the summer months there was negotiation under duress. I met the Secretary of State several times. By August, there was a second edition of the contract. Seniority payments were mixed up with postgraduate allowances and seniority payments. The new two-tier system relating to cervical cytology and child immunisation is to be welcomed, but it is compulsory and will create problems in towns and cities that have large ethnic populations. That issue must be addressed.

Promises were made about rural practice payments, adjustments to the basic practice allowance and transitional payments to help small practices. That is greatly to be welcomed. The point that I made in an intervention about the 26 hours and five days need to be examined. The majority of general practices do not have access to a standby deputising service. It is all very well for hon. Members with inner-city seats to assume that all general practices have a deputising service. In many areas of the country they do not. It cannot be right, as the hon. Member for Glasgow, Springburn (Mr. Martin) said, that any general practitioner should be on call for 12 days before he gets a break.

All this starts on 1 April 1990. The White Paper proposals to which I referred start a year later. That, by any yardstick, is a pretty tight timetable. It would have been better to roll it out as we went along, but my right hon. and learned Friend has decided otherwise. All these changes to the terms of service will have to be brought about in each surgery in fewer than six months. What other business would be expected to face a 50 per cent. change in its revenue within six months?

Family doctors are already busy people, as are their ancillary staff, but they will have to modernise and introduce computers. What, however, are the facts? Only 25 per cent. of general practices are fully computerised, and only a tiny percentage of FPCs have packages available to control everything from the other end. Those of us who are involved in health matters have received a mailing shot about an argument between the Department of Health and the private companies that are producing the software for the 25 per cent. of general practices that use computers. If something is to be up and running by next April, there should be no argument about who owns the software, with the GPs perhaps having to buy it off the particular company involved. I hope that when she winds up, the Minister for Health will deal with that point. It is absolutely central to getting everything moving by 1 April 1990.

All these changes are supposed to produce value for money, but can one find the figures? The only figure that I have found in either the first or second edition of the contract is the 50 per cent. reduction in the benefit that is to be paid to general practitioners. That is on record. As soon as the terms of service are in writing—I shall be grateful to know whether they are yet in writing and whether the red book has been updated—they will have to be priced by the review body. I hope that the statement of fees and allowances will be available by 1 January 1990. Every practice is making its plans which will come into effect on 1 April, so I hope that the Minister will confirm that the statement of fees and allowances will be published by 1 January 1990.

There have been many changes to the administrative and clinical system. GPs can do without the additional problem of having to speculate about revenue. No one should be expected to negotiate for half the final package just on faith. Is the Minister able to say what the cost of the changes will be? I know that the Public Accounts Committee, of which I am a member, will investigate that question with interest. It is only right that we should have the Government's forecast of the cost of the changes.

Very welcome though the new Minister for Health is at the Department, she will have to tighten things up a bit. Following the imposition of the agreement, we know that the directives on the national priorities for family practitioner committees arrived weeks late. I am glad to see that my right hon. and learned Friend the Secretary of State has returned to the Treasury Bench. He promised to give general practitioners six months' notice of any changes. We are five months away from implementation of the scheme, so we have already lost a month.

I deplore the abuse that has been showered on hard-working general practitioners—in my constituency and by my friends. Equally, I deplore the British Medical Association's advertising campaign. I spent 20 years in advertising. The BMA should fire its agents.

I also deplore the assertion that GPs earn about £65,000 a year. That figure includes staff salaries, medical supplies and their share of medical premises expenses. They are not minor items. The taxable figure is £31,105. No Member of Parliament would expect his or her salary to be judged on a basis that included the secretarial allowance. Commentators such as Dr. Vernon Coleman in The Sun are being mischievous when they suggest a higher figure.

I deplore the lack of time, the bureaucracy that has been imposed on general practitioners, the unreality of the annual report and the intrusion into certain patients' lives, just to meet an arbitrary target. It will undermine the long-standing doctor-patient relationship which has never hitherto been based on financial considerations. That relationship is in danger of being changed. The new contract that is being imposed on GPs will not aid or improve general practice.

The passing of the regulations will be sad for general practitioners. General practice is the one part of the National Health Service that is admired the world over. The pressure that the new bureaucratic contract forces on GPs must mean that they will have less time for patients, and hence patient care. All the surveys show that every patient wants more time, not less, with his doctor. I fear that doctors who traditionally have counselled and consoled the bereaved will be forced to reduce some of that work.

This is not the freer, caring society for which I thought the Conservative party stood. I regard this as a bureaucratic system imposed from above, and I think that it should be rejected.

6 pm

Dr. Lewis Moonie (Kirkcaldy)

I should like to begin by quoting from a letter sent to me by Dr. Michael Wilson, who is chairman of the general medical services committee of the BMA. It puts a rather different perspective on his views from that rather misleadingly given by the Secretary of State. It says: For the first time in the history of the health service, a Secretary of State has decided to impose his own contractual terms. There are some desirable components, but there are also important elements which are misguided and ill-conceived, for example, the target payments for immunisation and cervical cytology, and the shift towards a more capitation based payments system. Attached to this letter are more details of our views on these elements. There have been misleading reports in the media that general practitioners would be taking industrial action as a result of this imposition. I deplore the fact that the public may have been disturbed in any way by these reports, and have written to the Secretary of State to make it clear that the BMA was not responsible for this press speculation. At a recent meeting, the Committee decided firmly against any form of action which would be damaging to patients. In order to protect patients' interests, which remain paramount, and to sustain general practice in the NHS for the future, we will subject key aspects of the contract to a careful audit to provide us with information on the contract's defects and the problems arising from its imposition. That paints a different picture from the one that the Secretary of State attempted to paint this afternoon.

I support most of the principles and motives underlying the contract, although I disagree profoundly with some of the changes proposed, which have not been properly thought out and will almost certainly damage rather than enhance the primary care service. The Secretary of State was good enough to acknowledge that we probably have the best primary care service in the world. We must remember that it is run very cost-effectively and that it takes only 7 per cent. of total resources devoted to health care.

There are two underlying objectives for the new contract, both of which are laudable. The first is to improve the health experience of the population, and the second is to provide a better and more uniform service. It is essential to consider the new contract in the context of the Health and Medicines Act 1988 and the Government's proposals in "Working for Patients", which contain a third objective, again with which I do not disagree, of cost containment to exert downward pressure on the inexorable increase in health care costs year on year. It does the Secretary of State no credit to suggest that that is not the case. He should defend honestly that laudable objective.

We are trying to make the service more cost-effective, and there is no doubt that the health of the British people needs to be improved. The Government have targeted immunisation in childhood and cervical screening of adult women. We now immunise against polio and diphtheria —fortunately, mainly diseases of the past—whooping cough, measles and mumps, which sadly are still subject to regular epidemics, and rubella, which is a mild disease in itself but which has horrendous consequences for the next generation if a pregnant woman has the misfortune to have an attack. Massive improvements have been made over the past decade or two. Better vaccines are available, so therefore much of the fear and prejudice associated with vaccines, particularly whooping cough vaccine, has been overcome, and there have been tremendous improvements in the methods by which we ensure that the service is delivered to its target population. The same applies to cervical screening, which is responsible for thousands of preventable deaths every year. The failure of the present system to prevent those deaths is a national disgrace.

There is no doubt that, nationally, there is wide variation in the quality and standard of primary care and, regrettably in its accessibility. It is over a decade since Knox and others in the Dundee department of geography commented on this mismatch between the siting of GP practices in the centre of towns and the siting of the population on the periphery. Sadly, much of that problem has not yet been corrected. Housing schemes are ill-provided with basic services and do not have regular transport links to surgeries, and many people who live in them are on low incomes. I accept that inner London has particular problems that are the equal of those in smaller cities. That raises the first anomaly, because without a major effort to tackle the twin problems of multiple deprivation and poverty, all the Secretary of State's efforts in the contract are doomed to failure.

I do not propose to repeat the comments made by the hon. Member for Northampton, South (Mr. Morris) on the detailed proposals of the contract. I have the greatest sympathy for the hon. Gentleman's predicament tonight, and I welcome his rational opposition to the proposals. I see several critical deficiencies in the Secretary of State's proposals, which negate the good intentions of his objectives. He grossly understates the importance of collective, rather than individual, action in health care. That has been a major failing of the Government's philosophical approach to society since they took office, so we should not expect them to change their approach on health care.

There are long-standing deficiencies in the present service that the Secretary of State has failed to tackle, such as the fragmentation of responsibility for the community's health between district health authorities and family practitioner committees. The Minister should learn from the far superior administrative system in Scotland, where one health board is responsible for each area and provides a single coherent purpose to health care, which is sadly lacking south of the border. I shall give some examples from my county of Fife, which is a mixed agricultural and industrial region and which in many areas has massive problems associated with the recent loss of the mining industry. We have immunisation rates of well over 90 per cent. and a target of immunising 100 per cent. of children who are able to take the vaccine over the next few years.

The successful introduction of the new measles, mumps and rubella immunisation, which was piloted in the county over the past three years, is being followed in other counties and again has achieved high target success. There are lower, but still rising, figures for whooping cough. Over 75 per cent. of children are immunised against it, which compares favourably with other areas. We are proud of that success story, but it is the product of an enormous collective effort by GPs, health visitors, the community health service, health education and effective and enthusiastic leadership from the health board. The service is underpinned by an equally effective computerised call-up system, without which we would not have a hope of reaching the target population.

On cervical screening, there is a collective commitment to improving the take-up of the service, backed up by research into why women fail to attend for screening, despite being sent an appointment and despite it having been followed up. Those facilities are starting to pay off in higher take-up rates.

Our GPs need no further incentive to improve their rates. They do not need bonus payments, which they will attract anyway because of the level of service that they are providing. They have been given the tools, support and leadership of the health board; they require no further incentive than their professional pride to ensure that standards are maintained.

Why has the Minister failed to benefit from our experience in Fife? Why is he introducing an untried alternative when there is such a patently successful system north of the border? There is no guarantee that the system that he has introduced will succeed, and he has produced no evidence to suggest that he has any expectation other than his own prejudice to support it. Are the Minister and his Department blind? Are they unable to see it? Can they not afford the eye tests which they brought in last year? Without an efficient system, the best GPs will be unable to meet their targets. The Minister's proposal is doomed before it is introduced, and he fails to realise that.

The second factor that obstructs the Minister's good intentions is the nature of the primary care system. GPs are self-employed, and that is one reason for the vast variation in standards which they apply. They can choose what level of service to give.

I thought it was a bit rich of the Minister, in reply to my earlier intervention, saying that GPs signing a contract was all that was required for family practitioner committees to ensure the proper level of service was provided.

I assure the Minister that GPs, as with any other body of people, vary in the quality of service that they give. I cannot see the FPCs following them around to see how long they spend in the car as a proportion of their 26 hours of patient commitment per week, or to see whether they finish surgery early because they are going to the golf course or somewhere else. Without a proper monitoring system, how can one say that the contract will be properly enforced?

Many GPs have a captive population of patients who are prevented, for geographical reasons, from moving to another doctor. There are few teeth in the contract to improve that.

Why does not the Minister look at the option of a salaried service in areas which have difficulty in providing a service under the present system? Why is there such a deafening silence about medical audit? I know why—it is so difficult to bring in.

Although I am a member of the medical profession, I have been a stern critic of it for the past 20 years and I have a stronger track record than the "Johnny-come-latelies" on the Conservative Benches who criticise only when they see that their own political futures could be damaged.

The Secretary of State professes to recognise the problem of working in deprived inner-city areas. Has he recognised that inner-city GPs earn well below his much-touted average earnings, let alone the combined salary that the popular press has quoted so frequently or even the average target taxable earning. We know of GPs whose take-home pay is less than £1,000 a month. Averages blur the difference between them and GPs who earn fat salaries, mostly in the home counties and in other areas where there are plenty of extra perks and extra fees to be earned. There are not many fat salaries to be earned in Tower Hamlets or in the centre of London. I can tell the Minister that for a start. GPs there cannot afford nice premises, even if the buildings are available and if one takes into consideration the percentage of the cost which the Government so generously provide—70 per cent. I can assure the Minister that 30 per cent. of £1,000 will not provide much in the way of premises in the centre of London.

Any allowances that the Secretary of State proposes for deprived city areas will go no way towards solving those problems. GPs in those areas cannot find suitable staff to work for them. It is not a question of not being able to pay them. One of the reasons why they use deputising services so frequently, as other right hon. and hon. Members have said, is that it is unsafe for them to visit many parts of the area after dark. They cannot afford to employ a driver as a bodyguard and the police are no help as they refuse to accompany them. At least with a deputising service there is a nice large driver sitting in the car downstairs to provide some form of back-up. This is another problem in the delivery of health care which is not being tackled.

It is easy for us to say that we have noble intentions with the contract, and that as long as GPs all work hard it will be all right. It will not. We have to change the system within which GPs are trying to operate; otherwise, we will not be able to change the result of what they do.

The Department of Health seems to be incapable of conducting the most elementary investigation in the real world in which GPs have to operate. The Department is bloated—although not quite so bloated as it was earlier this afternoon—by a large increase in the number of people that it employs directly in central services.

The saddest failure of these proposals is the change in the balance of remuneration between basic practice allowance and capitation fees. That will penalise the better GP who knows, because he or she faces the fact every working day, that a better, more comprehensive service is possible only with fewer patients. It is not so much that there will be a tendency for a bad GP, who gives a poor service, to attract as many patients as possible on to his or her list, as that a good GP, who wishes to reduce the number of patients on the list, will be unfairly penalised by the reduction in basic practice allowance and the move towards a larger capitation fee—unless the capitation fee is much larger than the Minister anticipates.

If GPs wish to engage another partner to provide a better service, they will suffer a catastrophic fall in income. Why has the Department of Health failed to set proper targets for list sizes? There is adequate information available to make it clear that the ideal size of a practice is between 1,200 and 1,500 patients per GP—well below the current level. I do not expect the Minister to achieve such a target overnight, but he should certainly set that target now. If the Minister's objective is to reduce list sizes to a level at which all the good things he has talked about can be achieved, he should structure the payment system in a way that will make it desirable to do so—by penalising GPs who have too many patients on their lists. I assure the Minister that GPs with a list size of more than 2,000 patients do not provide the service that he imagines they are providing.

It is not possible to do so. Is this vaunted commitment to greater care only a facade to hide his real objective of a cheaper, nastier service?

The Secretary of State has had a glorious chance to improve primary care with this contract. His failure to do so is due as much to the incompetence of his Department as to his own arrogance. I hope that it is not too late for him to think again.

6.16 pm
Mr. Jerry Hayes (Harlow)

I was disappointed with the speech of the hon. Member for Kirkcaldy (Dr. Moonie). He started well, as he seemed to support just about everything that the Government are doing, but he lapsed into momentary incoherence when he talked about the catastrophic decrease in GP incomes. He overlooked the fact that the Government have said that there will be a transitional period of two years when bringing in the regulations to stop that happening. It would be helpful if right hon. and hon. Members read the regulations.

Dr. Moonie


Mr. Hayes

I shall not give way.

Dr. Moonie

The hon. Gentleman is misrepresenting what I said.

Mr. Hayes

I have become accustomed to the fact that the BMA has done for sensible political argument what myxomatosis has done for rabbits. I found it rich that the hon. Member for Livingston (Mr. Cook), who, to give him credit, has occasional moments of lucidity, criticised my right hon. and learned Friend's handling of the GP contract. Good heavens, in 1975, 7,800 GPs sent in their resignation letters. In 1975 there was industrial action by consultants and threatened industrial action by junior doctors.

I have always assumed that the House of Commons went barking mad only towards the end of July. It appears that there is also barking madness during the spillover period.

The House should analyse carefully, precisely what the Opposition and some of the other parties are voting against. They are voting against "Promoting Better Health," against the White Paper that received much professional acclaim, and against a higher capitation fee for rundown areas. They are voting against giving women doctors the opportunity of part-time work—not just half the hours but a quarter, which has never been in any contract before.

The Opposition are voting against screening and preventive medicine. They are voting against giving every person over 75 on a doctor's list the opportunity of getting a visit from either a GP or a member of the practice team. That is remarkable. They are voting against immunisation targets—for example, rubella immunisations, about which the hon. Member for Kircaldy talked. Our immunisation figures are appalling compared with World Health Organisation statistics. Surely setting targets is the way forward to protect our young people.

The Opposition are voting against payments to GPs for minor surgery and against the postgraduate training allowance. That does not seem to make any sense.

Mr. Martin Flannery (Sheffield, Hillsborough)


Mr. Hayes

It is interesting that the hon. Gentleman, who has just wandered in from the streets, should come into the Chamber and say, "Rubbish." It is nice that there are now four Opposition Members here during this debate on an Opposition prayer. However, I should not be too critical and try to score too many party political points.

These sensible measures were recommended by the BMA's negotiating committee. If only the BMA had not played such a foolish political game by winding up its members to such a degree that they believed that any contract from the Department of Health came from the jaws of Hades, there would not be such a mess and misunderstanding.

Mr. Flannery

The hon. Gentleman is in a mess.

Mr. Deputy Speaker (Mr. Harold Walker)

Order. There is too much sedentary noise from so few people.

Mr. Hayes

What quality sedentary noise it is from the hon. Member for Sheffield, Hillsborough (Mr. Flannery)! They say that empty vessels make the most noise.

Dr. Moonie

The hon. Gentleman is an empty vessel.

Mr. Hayes

The hon. Member for Kircaldy accuses me of being an empty vessel. His vessel is very full indeed, by the sound of it.

Dr. Moonie

On a point of order, Mr. Deputy Speaker. If hon. Members refer to my constituency, is it not in order for them to pronounce it correctly?

Mr. Deputy Speaker

I hope that the hon. Member will correct the hon. Member for Harlow (Mr. Hayes).

Mr. Hayes

I hope that I will pronounce the name correctly, especially as my parents have just moved to Scotland. The Conservative party has a great interest in Scotland.

The only difficulty of which my right hon. and learned Friend the Secretary of State should be aware is targeting. Many general practitioners throughout the country to whom I and many of my colleagues have had the opportunity of speaking are worried about targeting because they feel that they are meeting their targets now. They are worried that when they go to the family practitioner committees they will find that the family practitioner computer has gone horribly wrong. I ask for an initiative from the Department to ensure that FPCs get their act together to help GPs to look after their patients in the best way.

The Opposition are voting against some very sensible preventive health measures. I regret that. I am sure that my hon. Friends will join me and my right hon. and learned Friend the Secretary of State in supporting these health measures, which will help patients in our constituencies.

6.23 pm
Mr. John Battle (Leeds, West)

We should take the contract in the full context of the Government's health policy. Last weekend, the Government announced that 11 health districts would be chosen to carry out some comparisons of practice, as a prelude to introducing the White Paper proposals on the NHS. We had hoped that the Government could agree that it was crucial to have a comprehensive evaluation before any of their health proposals were implemented. Like others, we have regularly suggested that such an evaluation should include fuller assessments of health needs, especially assessments that are locally and regionally sensitive. I say that as one who represents Leeds, West, which includes a section of the inner city.

In August, in response to the publication of the monitoring report by the Office of Population Censuses and Surveys on infant and perinatal mortality, the former Minister for Health rejected further research on the wider social causes of ill health. He contemptuously dismissed regional and social factors. The principles in the contract, in terms of the index of social deprivation proposals, will be undermined because that research has not been carried out.

We all accept that any serious and major reform always involves risks, but it also imposes costs. It is difficult to carry out a genuine reform on the basis of a reduction in service. Unless an evaluation is carried out at an earlier stage, major mistakes, which later need correcting, may be made. The impression is that the reviews, and the contract as the vanguard for them, will set cash limits in concrete.

I remember the early days when the Departments of Health and Social Security were one Department. There are echoes now of what happened then. We were promised the great social security reviews—with the tag, of course, that they would be at nil cost, which in practice meant that they were reviews with a reduction. We all know of the great suspicion that this measure will end up as a cost-cutting exercise. To see this, we need simply to glance at the Government's practice, at the experience of cash limits which were imposed on, for example, the social fund. Budgets initially set at the centre included built-in factors based upon a declining take-up. Such approaches end in a reduction in service to the people and undermine sensitivity to local needs and demands. The people in need are left out. At the heart of the Government's approach is the issue of cost-benefit analysis. It may satisfy accountants, but it does not serve human needs. Emphasis on quantity can undermine the quality of provision. It may be forgotten that the purpose of the exercise is to serve people.

I am reminded of the inner-city initiative during the late 1970s and early 1980s. A former Secretary of State for the Environment introduced the urban programme monitoring initiative. That showed an obsession with monitoring on a quantitative basis, annual reports and micro-levels of accountancy, which resulted in officers being instructed to count the number of trees in environment improvement schemes and to send the information back in a report to the Department of the Environment. Pensioners in mini-buses provided to take them to luncheon clubs had to fill in journey measurement and time sheets. That was not the practical purpose of the programme, but is that the kind of contract monitoring which is envisaged in these proposals?

We are moving in a direction where "Yes, Minister" becomes real life, but it is a little too close to reality. I remember one of the "Yes, Minister" programmes about a totally efficient hospital which had a brilliant input and output ratio. In average accountancy terms, it ran perfectly—because it had no patients, as it had not yet opened. Unfortunately, patients would have messed up the ledger entries. Perhaps it is therefore better not to include patients at all. Human beings with whom we are dealing are not totally efficient animals.

Turning to the specifics of the doctors' contract, the Secretary of State might tell us what the assessment of the family doctors' future role in health care is. The emphasis is emerging in the community care proposals, with which we have yet to deal. The change will surely shift the work in the direction of local GPs because there will be fewer people in hospitals and institutions. We are told that there will be a welcome emphasis on prevention, health

How much space will there be in the contract for home visits? Will the system simply be based on a bonus payments approach, or will there be a genuine increase in service provision, as is needed? Several questions will arise. Will the need for GPs to pay attention to costs, budgets and annual reports distract them from the quality of care that they offer? Will the paperwork and accounting reduce patient contact time? Will the good intentions of dealing with primary preventive care be undermined by budget considerations and bureaucratic proposals?

There seems to be further contradiction when we take the contract in the context of the Government's proposals. What is proposed for the doctors is to challenge their autonomy and unaccountability in the contract. However, under the proposal for hospitals there is a real possibility that self-governing hospital trusts will become privatised and independent, as is being proposed at the Leeds general infirmary. In other words, there will be a fragmenting of local provision, which contradicts the Government's approach to doctors' practices. On the one hand, they say standardise and on the other they say opt-out. When their proposals are put together, collective and co-ordinated provision in the Health Service will be undermined.

We welcome the introduction of child health surveillance services. Let us hope that that will not be dealt with simply in terms of remuneration. It will increase the work load, but more importantly, it should recognise that there are unequal starting points in the country's health provision. If we study birth weights, it becomes more than obvious that good health is not evenly distributed throughout the nation. The strains on some health authorities are greater than on others. The recent OPCS report on baby deaths published in August highlighted that the health divide between Britain's more prosperous regions and the poorer regions is growing wider. Although the perinatal mortality rate for England and Wales in 1988 was 8.7 per thousand and the infant mortality rate was nine per thousand, the regional breakdown shows big variations throughout the country within that improving trend.

The Select Committee on Social Services said last December that Britain's infant mortality record is not improving as fast as it should. The Committee called for further research into the links between baby deaths and social deprivation. That research has yet to be initiated by the Secretary of State. That sensitivity to an area analysis demands a much more comprehensive approach before the contract can be introduced.

There is also the question of interpreting and enforcing the contract. If a GP wants to increase his list size, he would do best by attracting fit and healthy patients whom he sees rarely and who make few demands on his time. The long-term sick will be more time-consuming and he will do better if he refers them to another GP down the road. That is a perversion of the provision of health care to those who need it.

Not every person in Britain has an address as some are homeless and others live in hostels and accommodation for the homeless. What is the provision in the contract for them? It is, incredibly difficult to arrange doctor provision for hostels in order to provide care for the homeless or mentally ill.

On enforcement, we have a stark reminder of what happened to the nurses. This morning I received a letter from a nurse in my constituency. She asked what will happen to community staff and especially preventive medicine. She said that she had been a health visitor and that she does two district jobs—she is both a specialist in diabetes and a mothers and babies health visitor. However, she is still waiting for her grade to be settled. She sees others doing less and with fewer qualifications moving to the H grade. We have a long way to go before the contract can be settled. If the experience of the nurses is anything to go by, we will have to wait years for implementation to be sorted out if the proposal is not first solidly thought through.

In their eagerness to transfer social costs into market prices, the Government manage to demonstrate gross insensitivity to the detailed effects of their proposals. Our challenge is to a Government who seem to be entranced by the business man's ethic of profit. The euphemism is now the "discipline of the market". In the current edition of The Salisbury Review I was interested to read an article by Ian Crowther entitled: "Thatcherism and the Good Life. "He said: A modern business enterprise, by its very nature, has as its highest goal the maximisation of profit; what it provides in the way of goods or services is secondary. But to force this commercial model on every other species of corporate life—for example, on public service broadcasting, the health service, the legal profession and the universities—is to betray either an indifference to non-economic motives or an ignorance of how in reality they are sustained. If it is obvious—as surely it must be, that the highest loyalty of a soldier or a policeman or a fireman can never be to material gain, it should be hardly less obvious that there are others in the community—among them dons, doctors, nurses, teachers and lawyers—whose character would be altered irrevocably and for the worst if the pursuit of profit, instead of being incidental to their professions, were to be made central to them. Britain would be the poorer, literally, if millions of its citizens did not still think of service as the primary and profit as the secondary motivation in their working lives. That they do so is testimony to the truth that man is not just an economic being but a moral, social and political being as well. I would have hoped that those were the motives driving the Government but we know that that is not the case. However, perhaps the Government will bear in mind the parallel with the poll tax. We reminded the Government that if it was not thought out it would be brought back time and again with alterations.

Mr. Conway

On a point of order Mr. Deputy Speaker. The hon. Gentleman is a solitary figure on the Opposition Back Benches and he is trying to spin out the debate for the Opposition. However, even his colleagues are not listening. I would be grateful if you would bring the hon. Gentleman back to the subject of the NHS contract.

Mr. Deputy Speaker (Sir Paul Dean)

I remind the hon. Member for Leeds, West (Mr. Battle) that the time available for the debate is very short.

Mr. Battle

Perhaps Conservative Members do not like to hear what I have said. However, they might learn that when points are put to them in advance of the legislation it may save the country from the turmoil it is experiencing with the poll tax. I hope that they will withdraw the contract. If they do not, the British people will pass judgment at the appropriate time and elect a Government who adopt a different approach from the market-driven one of the present Government.

6.37 pm
Mr. Nicholas Winterton (Macclesfield)

I have only a few seconds in which to participate in this important debate. I congratulate my right hon. and learned Friend the Secretary of State on his positive and rather more agreeable presentation of the Government's case on the GP contract. I only wish that what he said had carried a majority of not only general practitioners but the people of the country.

As yet, my right hon. and learned Friend does not carry a majority of either doctors or the people in what he is seeking to do in the contract—[Interruption.] My hon. Friend the Member for Shrewsbury and Atcham (Mr. Conway) points out that he may obtain that majority in the future but he does not have it now. There is considerable evidence to suggest that the contract is somewhat misguided.

I have grave reservations about the increased percentage of doctors' remuneration that will come from capitation. It will go up from 46 per cent. to 60 per cent. I have performed considerable service on the Select Committee for Social Services and I can say from experience that one of the greatest services a doctor can provide is not minor operations, immunisation or screening but the counselling and advice that he gives either on a visit or in his surgery. The contract will lead to a position in which doctors have less time to spend with individual patients rather than more.

My remarks have been much supported by the Select Committee. If my right hon. and learned Friend reads our latest report—the eighth report—he will see that we say on page 38: A number of observers indicated their concern that increasing the proportion of GP income from capitation payments and the introduction of indicative drugs budgets could mean GPs will pay greater attention to the workload and financial implications of having some groups of patients on their lists. I have said that to my right hon. and learned Friend before. The report continues: They indicated that this could mean refusals to accept elderly or chronic sick patients who apply to join the practice. My right hon. and learned Friend assured the Committee: the Government intend to minimise this likelihood and that the number of chronically sick could be taken into account in determining actual or indicative GP budgets However, I must point out to my right hon. and learned Friend that the working paper on GP budgets does not explain how such patients will be defined and identified. Our views were strongly supported by the Health Visitors Association and by others such as the Faculty of Community Medicine, so we are not speaking in isolation.

Indicative drug budgets are another relevant issue. Clearly, there is downward pressure from Government on the cost of drugs, but surely effective prescribing should not be judged in terms of medicine costs only. Medicines provide excellent value for money compared with many other forms of treatment. Keeping patients out of hospitals or out of community care by appropriate medical treatment is both socially and economically advantageous. I hope that the emphasis on capitation and the Government's clear move to cost-limiting and cost-fencing the family doctor services will not lead to a less good service than we have at present. For the reasons I have expressed and for others that I have not time to express, I cannot support the Government in the Lobby tonight.

6.41 pm
Ms. Harriet Harman (Peckham)

I warmly congratulate the new Minister for Health on her appointment and on her involvement in the debate.

The debate has been useful in sounding a cautionary note for the future of the family doctor service and I hope that the Government will take heed. We are debating today the effects that we think the new GP contract may have. It could mean that patients have less time with their doctors, when we all know that they want more time and should have more time. It could mean elderly and chronically ill patients being culled from their GPs' lists. It could mean a widening gap between the service that one receives if one lives in a well-heeled suburb and the service provided in a deprived, inner-city area. It could also mean that patients have less chance to choose a woman GP, and there is much to justify those concerns.

Mr. Conway

Will the hon. Lady give way?

Ms. Harman

I will not give way because I want to justify our concerns.

The Secretary of State flatly denies those concerns and simply asserts that patients will receive better care. However, if he is confident of his case and certain that his predictions about the beneficial effects of the contract will be justified, let him give the House the following assurances. He must monitor what happens to list sizes and not talk merely about average list sizes. He must monitor the length of consultations and what is happening to immunisation and screening. He must monitor the number of women GPs, the ability of the elderly and the chronically ill to have the GP of their choice and the gap between the inner cities and the suburbs. He must give the House and members of the public a commitment that, if his contract has the effect that we fear, and which he denies, he will come back to the House and amend the regulations.

The main concern expressed this afternoon has been that the effect of the new contract will be that patients have less time with their doctor. Once again, the Secretary of State has asserted that that will not be the case, but there is a widespread belief that an increase in the capitation element of a GP's income will lead to an increase in list sizes, and that an increase in list sizes will lead to less tame for each patient. That view is shared by Which? magazine, the magazine of the Consumers' Association, by the Select Committee on Social Services, about which the hon. Member for Macclesfield (Mr. Winterton) spoke, and by the Patients Association.

The Secretary of State responds by saying that none of that will happen because we shall have the same number of GPs and patients, so average list sizes and consultation time will remain the same. The Secretary of State is content to say in defence of his contract merely that average list sizes will stay the same. Previously, the Government had supported a reduction in list sizes—a trend which had been supported by successive Governments—yet that aim appears to have vanished today. We are talking only about whether we can prevent list sizes from increasing as a result of the contract.

We need to continue to reduce list sizes because it is only with smaller list sizes that doctors will be able to expand their preventive work and health promotion work. It is only with smaller list sizes that they will be able to play a real part in providing care in the community and to respond to the demands of patients which have rightly increased. In the past 10 years, the average number of visits made by patients to their doctors has increased by 35 per cent. That is one statistic that we never hear from the Government.

Above all, the Government should be presenting measures to reduce list sizes and to increase the time each patient has with his GP because that is what patients want, as all surveys show. Most notably, the Which? survey discovered that more than 90 per cent. in its survey listed time with their GP as their priority. However, it is clear that the proposals will not increase patient time and that is disappointing.

Worse still, there are good grounds for believing that patients will have less time with their GP. Increasing the fee per patient—which is what the capitation element is—as a percentage of doctors' incomes provides doctors with a direct incentive to take on more patients. The Government have been muddled about that. In July, the Secretary of State said: It is totally illogical to suggest that the new contract will increase average list sizes. However, in October he said: We fully recognise that the high capitation element in the new remuneration system does not favour small list practices. That is the case, because if one gives a financial incentive for doctors to increase their list size, they will do so, as GPs themselves believe. The widely held view is that increased list sizes will result not in doctors working longer, but in patient consultation time becoming shorter.

The Department of Health report on GP weekly work loads in 1987 showed that they spent about 38 hours seeing patients, plus 31 hours on call and six hours on other medically related work. If GPs work more hours, the quality of patient care will not improve. I do not want to see GPs dropping asleep in their surgeries in the same way that we see junior hospital doctors dropping asleep in the wards. General practitioners already have a full working week, yet under the contract they will be expected to take on more patients, to perform minor surgery, to carry out regular checks on the elderly, to carry out more immunisation and more childhood screening, to run anti-smoking clinics, alcohol control clinics and well person clinics, and to advise on diet, exercise and stress. As the hon. Member for Northampton, South (Mr. Morris) pointed out, they will be expected to do all that in addition to taking on extra patients to increase their income.

If the best doctors attract larger lists, it will turn good doctors into bad doctors, as my hon. Friend the Member for Kirkcaldy (Dr. Moonie) said. The number of GPs is not fixed, as the Secretary of State would like to make out. Therefore, his argument about the average does not hold. GP numbers could quickly drop if demoralisation sets in again. Once again, general practice could become an unattractive option. Women could get squeezed out, and earlier retirement could certainly mean a reduction in the number of GPs.

Only one in four GPs are women. That means that many women patients do not have the chance to choose a woman doctor and, therefore, must have a male GP. We need to continue the trend of an increasing number of women becoming GPs, but the contract threatens to reduce the number of women GPs. We must examine the figures. Women and men GPs have different working patterns. There is no such thing as the average GP. There is the woman GP's working patterns, hours and list sizes and then there is the male GP's profoundly different working pattern, hours, and list sizes. An effect of the contract—no doubt in an effort to squeeze out lazy and uncommitted GPs—is that the Government will squeeze out those women GPs who have fewer patients on their lists and work fewer hours. The reason why they work fewer hours is that women GPs, like most working women, must combine their work with their family responsibilities, whereas male GPs, like most men, leave family responsibilities to their wives.

If we are concerned to increase the number of women GPs, we must not discriminate against people for having smaller list sizes and working fewer hours. My hon. Friend the Member for Glasgow, Springburn (Mr. Martin) mentioned differences in care in inner cities and suburbs.

I now refer to the hidden agenda. My hon. Friend the Member for Leeds, West (Mr. Battle) was absolutely right. The Government think that the family doctor service is costing too much. Cash limiting——

Mr. Ian Gow (Eastbourne)

On a point of order, Mr. Deputy Speaker. Is it not a disgrace that the hon. Member for Peckham (Ms. Harman) should afford so little time to my hon. Friend the Minister, whom all hon. Members are waiting to hear with the greatest impatience?

Mr. Deputy Speaker (Sir Paul Dean)

I am sure that the hon. Lady is watching the clock, as are all hon. Members. This debate must end at 7 o'clock.

Ms. Harman

It would be right to divide the time between myself and the Minister.

The problem is the hidden agenda. The hidden agenda is about public spending. The Government think that the family doctor service is costing too much. They are cash-limiting support staff and drug budgets, and they are encouraging GP budget holders to opt for cash limited budgets. Their ultimate aim, of which the contract is part, is to increase list sizes and to reduce the number of GPs and, as a result, reduce public spending on the family doctor service.

6.52 pm
The Minister for Health (Mrs. Virginia Bottomley)

I thank hon. Members for their kind and undeserved comments. I am delighted to take on this role. I pay a warm tribute to my predecessor, now the Minister of State, Home Office, my hon. and learned Friend the Member for Putney (Mr. Mellor), who magnificently piloted the Children Bill through the House. It is a Bill in which I had a special and particular interest.

I cannot fail to be aghast at the remarks of the hon. Member for Peckham (Ms. Harman). She had her eye on the wrong target. She represents a constituency in which I worked for many years. I know directly the difference between the best of the good general practice, which demonstrates the excellent service provided by a family practitioner, and the general practitioner who is not available, who uses an answering service and who does not provide all that the hon. Lady and I want for those in the inner cities. Many hon. Members have referred to the particular problems of the inner cities, and that is why a special premium is to be available in those areas. The key must he how we can ensure that our family practitioners, who are one of the most important elements in our National Health Service, can play a fundamental part in primary health care and can achieve the standards which all of us want.

Before discussing the regulations, I must pay a tribute to the other members of the practice and primary health care team. I was not particularly sympathetic when the hon. Member for Livingston (Mr. Cook) dismissively referred to other members of the team. Frankly, a chiropodist, a clinic nurse, a counsellor and many community nurses can play a crucial part in improving patients' well-being.

Were the hon. Lady to have castigated the Government for failing to have refined the regulations and the contract for the past 25 years, she would have been nearer the mark. But to become agitated about the fact that now, at last, the Government are facing the responsibility of specifying precisely what we want general practitioners to do can only be a virtue and a force for good in the welfare of our people. Can it be wrong for any mother to know that children are to be more vigorously assessed, that their development is to be checked, and that immunisation is to be robustly pursued? Too many people are fearful of medical practices generally, and anything that we can do to encourage general practitioners to pursue the World Health Organisation targets and to look to the welfare of their patients must be good.

Can there be any objection to women having cervical cytology robustly pursued and ensuring that targets are met? I spent many years as the vice-president of the Women's National Cancer Control Campaign. In years gone by, had we thought that general practitioners would have reached targets like these, we would have welcomed them. Can there be anything objectionable in knowing that elderly relations will be visited? How many people over 75 are fearful of contacting their general practitioners and feel that they do not want to trouble them with their ailments? Often those over 75 can have their lives significantly improved and their medical conditions addressed by a visit and by assessment. That is welcome indeed. Time and again, the Foundation for Age Research has said that relatively simple medical treatments can often improve and enhance the quality of life for our elderly.

Can anybody object to payments for training and education? Anybody who examines the British National Formulary will see the speed with which medication and technical science have moved forward. Having served on the Medical Research Council, I know the speed of change and the importance of making sure that our general practitioners are promoting and encouraging the most up-to-date and best practice.

As patients, all of us have rising expectations about what we want from our medical practitioners. The contract is about promoting patients' choice, providing information, and letting patients choose who they go to. That is the answer to those who fear the capitation allowances. The crucial point is that people should know what is available and how much patients welcome the move towards greater health promotion and disease prevention. My hon. Friend the Member for Derbyshire, South (Mrs. Currie) has done a great deal to promote and encourage awareness of the importance of health promotion. How many people welcome the possibility of regular lifestyle checks and scrutiny when they go to their general practitioner?

I have not delayed the House in speaking about the role of women doctors. They have a crucial part to play. I welcome the fact that 50 per cent. of medical students and 40 per cent. of trainees are women. Many of the steps that we are taking are good news for women. Above all, the patient—the consumer who, too often, is not regarded—will be able to say, "I want to see a woman doctor." That will work as fast as any of our other objectives at ensuring that women doctors are available and have a crucial part to play.

My hon. Friend the Member for Northampton, South (Mr. Morris) spoke about the information that was forthcoming. I can tell him that the statement of fees and allowances, the red book, will be available later this month—well ahead of the schedule that he anticipated. My hon. Friend the Under-Secretary of State is shortly to make a statement about information technology in general practice.

We want to ensure the well-being and safety of our Health Service. General practitioners have a crucial and vital part to play in primary health care. My right hon. and learned Friend the Secretary of State for Health has spent many hours in discussion. The regulations and the new contract provide the basis for an effective service that takes care of patients. I urge hon. Members to vote agains—

It being Seven o'clock, MR. DEPUTY SPEAKER put the Question, pursuant to order [27 October]:

The House divided: Ayes 214, Noes 319.

Division No. 365] [7.00 pm
Abbott, Ms Diane Callaghan, Jim
Adams, Allen (Paisley N) Campbell, Menzies (Fife NE)
Allen, Graham Campbell, Ron (Blyth Valley)
Alton, David Campbell-Savours, D. N.
Archer, Rt Hon Peter Canavan, Dennis
Armstrong, Hilary Carlile, Alex (Mont'g)
Ashdown, Rt Hon Paddy Cartwright, John
Ashton, Joe Clark, Dr David (S Shields)
Banks, Tony (Newham NW) Clay, Bob
Barnes, Harry (Derbyshire NE) Clelland, David
Barnes, Mrs Rosie (Greenwich) Clwyd, Mrs Ann
Barron, Kevin Cohen, Harry
Battle, John Coleman, Donald
Beckett, Margaret Cook, Robin (Livingston)
Beggs, Roy Corbett, Robin
Beith, A. J. Cousins, Jim
Bell, Stuart Cox, Tom
Benn, Rt Hon Tony Crowther, Stan
Bennett, A. F. (D'nt'n & R'dish) Cryer, Bob
Bermingham, Gerald Cummings, John
Bidwell, Sydney Cunliffe, Lawrence
Blair, Tony Cunningham, Dr John
Blunkett, David Dalyell, Tam
Boyes, Roland Darling, Alistair
Bradley, Keith Davies, Rt Hon Denzil (Llanelli)
Bray, Dr Jeremy Davies, Ron (Caerphilly)
Brown, Gordon (D'mline E) Davis, Terry (B'ham Hodge H'l)
Brown, Nicholas (Newcastle E) Dewar, Donald
Brown, Ron (Edinburgh Leith) Dixon, Don
Bruce, Malcolm (Gordon) Dobson, Frank
Buchan, Norman Doran, Frank
Buckley, George J. Dunnachie, Jimmy
Caborn, Richard Dunwoody, Hon Mrs Gwyneth
Eadie, Alexander Michie, Bill (Sheffield Heeley)
Evans, John (St Helens N) Michie, Mrs Ray (Arg'l & Bute)
Ewing, Harry (Falkirk E) Mitchell, Austin (G't Grimsby)
Ewing, Mrs Margaret (Moray) Moonie, Dr Lewis
Faulds, Andrew Morgan, Rhodri
Fearn, Ronald Morley, Elliot
Fields, Terry (L'pool B G'n) Morris, Rt Hon J. (Aberavon)
Fisher, Mark Morris, M (N'hampton S)
Flannery, Martin Mowlam, Marjorie
Flynn, Paul Murphy, Paul
Forsythe, Clifford (Antrim S) Oakes, Rt Hon Gordon
Foster, Derek O'Brien, William
Foulkes, George O'Neill, Martin
Fraser, John Orme, Rt Hon Stanley
Fyfe, Maria Owen, Rt Hon Dr David
Galloway, George Parry, Robert
Garrett, John (Norwich South) Patchett, Terry
Godman, Dr Norman A. Pike, Peter L.
Golding, Mrs Llin Powell, Ray (Ogmore)
Gordon, Mildred Primarolo, Dawn
Gould, Bryan Quin, Ms Joyce
Griffiths, Nigel (Edinburgh S) Radice, Giles
Griffiths, Win (Bridgend) Randall, Stuart
Grocott, Bruce Redmond, Martin
Hardy, Peter Rees, Rt Hon Merlyn
Harman, Ms Harriet Reid, Dr John
Hattersley, Rt Hon Roy Richardson, Jo
Haynes, Frank Roberts, Allan (Bootle)
Healey, Rt Hon Denis Robertson, George
Heffer, Eric S. Rogers, Allan
Henderson, Doug Rooker, Jeff
Hogg, N. (C'nauld & Kilsyth) Rowlands, Ted
Hood, Jimmy Ruddock, Joan
Howarth, George (Knowsley N) Salmond, Alex
Howells, Geraint Sedgemore, Brian
Hoyle, Doug Sheerman, Barry
Hughes, John (Coventry NE) Sheldon, Rt Hon Robert
Hughes, Robert (Aberdeen N) Shore, Rt Hon Peter
Hughes, Simon (Southwark) Short, Clare
Illsley, Eric Sillars, Jim
Ingram, Adam Skinner, Dennis
Jones, Barry (Alyn & Deeside) Smith, C. (Isl'ton & F'bury)
Jones, Ieuan (Ynys Môn) Smith, Rt Hon J. (Monk'ds E)
Jones, Martyn (Clwyd S W) Smith, J. P. (Vale of Glam)
Kaufman, Rt Hon Gerald Soley, Clive
Kennedy, Charles Steinberg, Gerry
Kinnock, Rt Hon Neil Stott, Roger
Kirkwood, Archy Strang, Gavin
Lambie, David Straw, Jack
Lamond, James Taylor, Mrs Ann (Dewsbury)
Leadbitter, Ted Taylor, Matthew (Truro)
Lestor, Joan (Eccles) Thompson, Jack (Wansbeck)
Litherland, Robert Turner, Dennis
Livingstone, Ken Vaz, Keith
Livsey, Richard Walker, A. Cecil (Belfast N)
Lloyd, Tony (Stretford) Wall, Pat
Lofthouse, Geoffrey Wallace, James
Loyden, Eddie Walley, Joan
McAllion, John Wardell, Gareth (Gower)
McCartney, Ian Wareing, Robert N.
Macdonald, Calum A. Watson, Mike (Glasgow, C)
McFall, John Welsh, Andrew (Angus E)
McKay, Allen (Barnsley West) Welsh, Michael (Doncaster N)
McKelvey, William Wigley, Dafydd
McLeish, Henry Williams, Rt Hon Alan
McWilliam, John Williams, Alan W. (Carm'then)
Madden, Max Wilson, Brian
Mahon, Mrs Alice Winnick, David
Marek, Dr John Wise, Mrs Audrey
Marshall, David (Shettleston) Worthington, Tony
Martin, Michael J. (Springburn) Wray, Jimmy
Martlew, Eric Young, David (Bolton SE)
Maxton, John
Meacher, Michael Tellers for the Ayes:
Meale, Alan Mr. Frank Cook and Mr. Ken Eastham.
Michael, Alun
Aitken, Jonathan Alison, Rt Hon Michael
Alexander, Richard Allason, Rupert
Amery, Rt Hon Julian Fallon, Michael
Amess, David Fenner, Dame Peggy
Amos, Alan Field, Barry (Isle of Wight)
Arbuthnot, James Finsberg, Sir Geoffrey
Arnold, Jacques (Gravesham) Fishburn, John Dudley
Arnold, Tom (Hazel Grove) Fookes, Dame Janet
Ashby, David Forman, Nigel
Aspinwall, Jack Forsyth, Michael (Stirling)
Atkins, Robert Fowler, Rt Hon Norman
Baker, Rt Hon K. (Mole Valley) Fox, Sir Marcus
Baker, Nicholas (Dorset N) Franks, Cecil
Baldry, Tony Freeman, Roger
Banks, Robert (Harrogate) French, Douglas
Batiste, Spencer Gale, Roger
Beaumont-Dark, Anthony Garel-Jones, Tristan
Bellingham, Henry Gill, Christopher
Bendall, Vivian Gilmour, Rt Hon Sir Ian
Bennett, Nicholas (Pembroke) Glyn, Dr Alan
Benyon, W. Goodson-Wickes, Dr Charles
Bevan, David Gilroy Gorman, Mrs Teresa
Biffen, Rt Hon John Gorst, John
Blackburn, Dr John G. Gow, Ian
Blaker, Rt Hon Sir Peter Greenway, Harry (Ealing N)
Bonsor, Sir Nicholas Greenway, John (Ryedale)
Boscawen, Hon Robert Gregory, Conal
Bottomley, Mrs Virginia Griffiths, Peter (Portsmouth N)
Bowden, A (Brighton K'pto'n) Grist, Ian
Bowden, Gerald (Dulwich) Ground, Patrick
Bowis, John Grylls, Michael
Boyson, Rt Hon Dr Sir Rhodes Gummer, Rt Hon John Selwyn
Braine, Rt Hon Sir Bernard Hague, William
Brandon-Bravo, Martin Hamilton, Neil (Tatton)
Brazier, Julian Hampson, Dr Keith
Bright, Graham Hannam, John
Brooke, Rt Hon Peter Hargreaves, Ken (Hyndburn)
Brown, Michael (Brigg & Cl't's) Harris, David
Browne, John (Winchester) Haselhurst, Alan
Bruce, Ian (Dorset South) Hawkins, Christopher
Buck, Sir Antony Hayes, Jerry
Burns, Simon Hayhoe, Rt Hon Sir Barney
Burt, Alistair Hayward, Robert
Butcher, John Heathcoat-Amory, David
Butler, Chris Heddle, John
Butterfill, John Heseltine, Rt Hon Michael
Carlisle, John, (Luton N) Hicks, Mrs Maureen (Wolv' NE)
Carlisle, Kenneth (Lincoln) Higgins, Rt Hon Terence L.
Carrington, Matthew Hill, James
Carttiss, Michael Hind, Kenneth
Cash, William Hogg, Hon Douglas (Gr'th'm)
Channon, Rt Hon Paul Holt, Richard
Chapman, Sydney Hordern, Sir Peter
Chope, Christopher Howard, Michael
Churchill, Mr Howarth, Alan (Strat'd-on-A)
Clark, Hon Alan (Plym'th S'n) Howarth, G. (Cannock & B'wd)
Clark, Dr Michael (Rochford) Howe, Rt Hon Sir Geoffrey
Clark, Sir W. (Croydon S) Howell, Rt Hon David (G'dford)
Clarke, Rt Hon K. (Rushcliffe) Howell, Ralph (North Norfolk)
Colvin, Michael Hughes, Robert G. (Harrow W)
Conway, Derek Hunt, David (Wirral W)
Coombs, Anthony (Wyre F'rest) Hunt, Sir John (Ravensbourne)
Cope, Rt Hon John Hunter, Andrew
Cormack, Patrick Hurd, Rt Hon Douglas
Couchman, James Irvine, Michael
Cran, James Irving, Charles
Critchley, Julian Jack, Michael
Curry, David Jackson, Robert
Davies, Q. (Stamf'd & Spald'g) Jessel, Toby
Davis, David (Boothferry) Johnson Smith, Sir Geoffrey
Day, Stephen Jones, Gwilym (Cardiff N)
Devlin, Tim Jones, Robert B (Herts W)
Dicks, Terry Jopling, Rt Hon Michael
Dorrell, Stephen Kellett-Bowman, Dame Elaine
Douglas-Hamilton, Lord James Key, Robert
Dover, Den Kilfedder, James
Dunn, Bob King, Roger (B'ham N'thfield)
Eggar, Tim Kirkhope, Timothy
Emery, Sir Peter Knapman, Roger
Evans, David (Welwyn Hatf'd) Knight, Greg (Derby North)
Evennett, David Knight, Dame Jill (Edgbaston)
Fairbairn, Sir Nicholas Knox, David
Lamont, Rt Hon Norman Monro, Sir Hector
Lang, Ian Montgomery, Sir Fergus
Latham, Michael Morrison, Sir Charles
Lawrence, Ivan Moss, Malcolm
Lee, John (Pendle) Moynihan, Hon Colin
Leigh, Edward (Gainsbor'gh) Mudd, David
Lennox-Boyd, Hon Mark Neale, Gerrard
Lester, Jim (Broxtowe) Nelson, Anthony
Lightbown, David Neubert, Michael
Lilley, Peter Nicholls, Patrick
Lloyd, Sir Ian (Havant) Nicholson, David (Taunton)
Lloyd, Peter (Fareham) Nicholson, Emma (Devon West)
Lord, Michael Norris, Steve
Lyell, Sir Nicholas Onslow, Rt Hon Cranley
Macfarlane, Sir Neil Oppenheim, Phillip
MacGregor, Rt Hon John Page, Richard
MacKay, Andrew (E Berkshire) Parkinson, Rt Hon Cecil
Maclean, David Patnick, Irvine
McNair-Wilson, Sir Michael Patten, Rt Hon Chris (Bath)
McNair-Wilson, Sir Patrick Patten, John (Oxford W)
Madel, David Pattie, Rt Hon Sir Geoffrey
Malins, Humfrey Pawsey, James
Mans, Keith Peacock, Mrs Elizabeth
Maples, John Porter, Barry (Wirral S)
Marland, Paul Porter, David (Waveney)
Marlow, Tony Portillo, Michael
Marshall, John (Hendon S) Powell, William (Corby)
Marshall, Michael (Arundel) Price, Sir David
Martin, David (Portsmouth S) Raison, Rt Hon Timothy
Mates, Michael Redwood, John
Maude, Hon Francis Rhodes James, Robert
Mawhinney, Dr Brian Riddick, Graham
Mayhew, Rt Hon Sir Patrick Ridley, Rt Hon Nicholas
Mellor, David Ridsdale, Sir Julian
Meyer, Sir Anthony Rifkind, Rt Hon Malcolm
Miller, Sir Hal Roberts, Wyn (Conwy)
Mills, Iain Roe, Mrs Marion
Miscampbell, Norman Rossi, Sir Hugh
Mitchell, Andrew (Gedling) Rost, Peter
Mitchell, Sir David Rowe, Andrew
Moate, Roger Rumbold, Mrs Angela
Ryder, Richard Thompson, D. (Calder Valley)
Sackville, Hon Tom Thompson, Patrick (Norwich N)
Sayeed, Jonathan Thorne, Neil
Scott, Rt Hon Nicholas Thornton, Malcolm
Shaw, David (Dover) Thurnham, Peter
Shaw, Sir Giles (Pudsey) Townend, John (Bridlington)
Shaw, Sir Michael (Scarb') Townsend, Cyril D. (B'heath)
Shelton, Sir William Tracey, Richard
Shephard, Mrs G. (Norfolk SW) Tredinnick, David
Shepherd, Colin (Hereford) Trippier, David
Shepherd, Richard (Aldridge) Trotter, Neville
Shersby, Michael Twinn, Dr Ian
Sims, Roger Vaughan, Sir Gerard
Skeet, Sir Trevor Viggers, Peter
Smith, Tim (Beaconsfleld) Waddington, Rt Hon David
Soames, Hon Nicholas Wakeham, Rt Hon John
Speed, Keith Waldegrave, Hon William
Speller, Tony Walker, Bill (T'side North)
Spicer, Sir Jim (Dorset W) Waller, Gary
Spicer, Michael (S Worcs) Walters, Sir Dennis
Squire, Robin Ward, John
Stanbrook, Ivor Wardle, Charles (Bexhill)
Stanley, Rt Hon Sir John Warren, Kenneth
Steen, Anthony Watts, John
Stern, Michael Wheeler, John
Stevens, Lewis Whitney, Ray
Stewart, Allan (Eastwood) Widdecombe, Ann
Stewart, Andy (Sherwood) Wiggin, Jerry
Stewart, Rt Hon Ian (Herts N) Wilkinson, John
Stokes, Sir John Winterton, Mrs Ann
Stradling Thomas, Sir John Wolfson, Mark
Sumberg, David Wood, Timothy
Summerson, Hugo Yeo, Tim
Tapsell, Sir Peter Young, Sir George (Acton)
Taylor, Ian (Esher) Younger, Rt Hon George
Taylor, John M (Solihull)
Taylor, Teddy (S'end E) Tellers for the Noes:
Tebbit, Rt Hon Norman Mr. Alastair Goodlad and Mr. Tony Durant.
Temple-Morris, Peter

Question accordingly negatived.