HC Deb 29 March 1990 vol 170 cc785-92

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

11.3 pm

Miss Emma Nicholson (Torridge and Devon, West)

My previous Adjournment debate might have been the shortest on record. I cannot claim that I shall break that record tonight, but I shall be as brief as possible as the Minister for Health has already dealt by letter with one of my two requests from that earlier Adjournment debate, which was reflected in its title.

Following my attempt to speak during my previous Adjournment debate and the Opposition's determined and successful efforts to ensure that women's health care issues were discounted at their pleasure, the Minister kindly wrote to me to state that she was altering the method of scrutinising hysterectomy data so that the women concerned could not be identified. I express not just my gratitude for her action, but that of the Royal College of General Practitioners, whose president, Dr Pereira Grey, practises in Exeter at the university.

Tonight I ask the Minister only to consider a particular aspect of the new contract for general practitioners. The contract contains many excellent features, but, as it is not yet in place, it naturally has some sharp edges. The Parliamentary Under-Secretary of State for Health always listens and I am grateful to him for his thoughtful help on several issues during more than five years, war widows to name but one, and I know that he will listen to and think about what I say.

The cause of my concern is the new system of target payments for cervical smears. We have moved from stepped sessional payments to a steep incline. If a doctor reaches up to 50 per cent. of his target list—in England and Wales the target list is women between 25 and 65; in Scotland between 20 and 60—he will receive nothing. When he hits 50 per cent. and reaches up to 79 per cent. he will receive £760. For reaching 80 per cent. plus of his target he will receive the handsome sum of £2,260. Is that too steep an incline? I believe that it may have unexpected and possibly unwelcome results.

I do not question the importance of preventive medicine. During my time with the Save the Children Fund I launched the "Stop Polio" campaign. Several years ago I found to my abhorrence that, in Lambeth, children had a 37 per cent. uptake of immunisation against polio, but once the fund had established the campaign in Malawi, we managed to achieve a 95 per cent. success rate there. It is galling that in a developed country such as our own we should have such a low uptake of immunisation. The same is true of cervical smears.

Cervical smears represent intrusive preventive medicine and, although the GP has a crucial role to play, the final right to respond lies with the patient. The effectiveness of cervical smear has also been questioned—a subject into which I do not intend to delve. An article in The Lancet of 22 June 1989 questioned: Do cervical smears reduce mortality and morbidity? It asked whether there are some harmful effects from such smears. The case for smears is not quite as clear cut as that for immunisation against childhood diseases such as polio. I shall not explore that interesting matter, but I commend the article to the Minister. I am sure that he has seen it. I believe that it contains some analysis, which, on reflection and once the cervical smear programme has continued, may prove to be more important than we now realise.

Tonight I want to draw attention to the steepness of the targeting. I want the Minister to consider the data that I offer in terms of lists from GPs, which demonstrate their difficulties in reaching their targets in an acceptable manner. The Minister should reconsider the way in which we can assure women that their preventive health care in this matter will be best looked after.

I believe that there should be a case for informed dissenters—women who are educated of the need to have a smear, are well informed, but who take the conscious decision not to have it. I should like such a woman not to be dominated by the knowledge that she may be disadvantaging her GP financially by a large sum of money. Consider the woman who might represent the 79 per cent. target rather than the 80 per cent. attainment, who believes that she is withholding that large sum of money from her doctor. I should like to find a way of allowing her to opt out without affecting the doctor's income.

The test is not thought to be relevant to certain categories of women—for instance, those who have never been sexually active, those who are severely mentally or physically handicapped, nuns, ethnic minorities, women who have had hysterectomies, the terminally ill and those undergoing treatment for long-term conditions. Let us take the example of ethnic minorities: given the clustering of different groups in the United Kingdom today, many women on the target list might well belong to a religion which would cause them to feel unhappy about being treated by a male practitioner in any event. I know that the Minister shares my concern about the shortage of women GPs. Younger women, in particular, will feel very distressed if the test is pressed on them as a matter of urgency and priority, but women in their early 60s,—whether or not they belong to ethnic minorities—will also feel unhappy if they are continually pressed to take the test, perhaps many years after they have ceased to be sexually active.

This is not an attempt to pretend that some GPs are unscrupulous and will be unpleasant. In the very best practices there may be an over-zealous receptionist. I received a letter from a widow of 64 who was deeply distressed. She had visited her GP and found that he was away; she saw a stand-in doctor, who, although delightful, "targeted" her fiercely, saying that if she did not have the test his income—or that of her own GP—would be at risk. She went home. Since then, the receptionist has telephoned her a number of times.

My constituency contains a higher-than-normal proportion of mentally handicapped people. I hasten to add that that is not caused by any inborn genetic error, but is due to exceptionally good provision of medical care and social welfare. Parents bring their children to live there, because they know that they will receive the best possible treatment. That has skewed the lists of some GPs—as has the fact that the constituency contains more than one convent: nuns and virgins are at almost incalculably low risk. A male doctor will be admitted to an enclosed convent only in extremis, and it would be extremely distressing if the sisters were subjected to such pressure.

At the other end of the spectrum, I was talking this morning to a GP in Glasgow who has an unusually high turnover of young women because of the local student population. She has an annual "handover" of 12 per cent., but manages to target only 46 per cent. She is a very determined woman, and is keenly aware of the necessity involved. There is a good deal of social deprivation in her area, and she finds the pattern interesting. She writes letters to all the previous smear patients, and to all eligible women. I know that the Minister will be very interested to hear that the response rate from those eligible women, who are not normally seeing her, is as low as 5 per cent. I must admit that I am puzzled as to how a keen and eager woman GP with a large socially deprived population in the east end of Glasgow, who through her best efforts is reaching only 46 per cent. of the target, can do any better.

I have a batch of material from different areas, which I shall show the Minister after the debate, if I may. It contains letters from general practitioners telling me of their particular difficulties and why they find this a daunting target. One GP from Middlesex has an over-large number of special patient groups on his list, including a convent, two homes and five community hostels for the mentally handicapped. Another practice in the north-east reached 75.6 per cent. of its cervical cytology target in 1987–88. However, the GP does not believe that the practice can reach the 80 per cent. requirement for the higher target payment because of the resistance to smear tests encountered in women in the 60-64 age group. That is a prevalent feature in areas such as mine, where there is an unduly high age profile.

I have several other examples of where difficulties arise, including inner cities. A GP practising in Manchester states: I am working in an inner city area where it's difficult enough to motivate people to come along anyway. If you do your patients' smears or vaccinations and then they move on he also has an area where the mobility rate is high— you find that you are doing work and not being paid for it. The mobility of the British population causes great problems for GPs. The latest survey shows that we each move, on average, once every five years. The slowness with which medical records follow the patient makes it difficult for the GP to have an up-to-date and accurate register to obtain the payment. It is probable that only 45 per cent. of GPs have an accurate age, sex register.

If doctors have this steep target payment, it is difficult not to believe that at least a few of them will be intrusive and invasive, which may upset many women. I should be unhappy if that happened. While nearly all the doctors to whom I spoke were totally in favour of cervical screening for all sexually active females, they were also in favour of a woman's right to say no, without being afraid of upsetting her GP or even, in extreme cases, being asked to leave his or her list. Will the Minister consider those points?

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

I congratulate my hon. Friend the Member for Torridge and Devon, West (Miss Nicholson) and convey to her the apologies of my hon. Friend the Minister for Health who cannot be with us tonight. My hon. Friend the Minister was hoping to have replied to an earlier attempt at this Adjournment debate, and I am a poor substitute to deal with this subject.

I welcome my hon. Friend's support for the screening programme. She describes it as invasive, which I can understand. It is an important programme for women between the ages of 25 and 64, who should be screened at least once every five years. We should not forget women over the age of 64, who should also benefit from regular screening, although they are not part of the more formal programme to which I referred. I am also grateful for my hon. Friend's comments about the measures on anonymity of information which we have introduced, in terms of statistics passing from general practitioners to the family practitioner committee. That was an important step to protect information about individual hysterectomy becoming, at least in patients' minds, too widely known.

Some 2,000 deaths a year can still be attributed to cancer of the cervix, which is 2,000 too many. Screening can undoubtedly reduce that number. Experts in the Department of Health estimate that an effective screening programme could reduce that number by 80 per cent.

To illustrate our belief that we can do better, my hon. Friend might be interested in two recent reports, one from the Association of Community Health Councils of England and Wales, and the other from the department of epidemiology and social oncology in Manchester. They have published data based on their respective surveys of community health councils and district health authorities. Among community health councils, take-up has varied between 16 per cent. and 75 per cent. Of the 99 out of 185 community health councils which responded to the questionnaire, 34 gave an indication of take-up. The majority, 24, reported take-up ranging from 46 per cent. to 75 per cent.

Of the 178 out of 190 district health authorities which responded to the surveys, only 66 provided information on take-up; 22—33 per cent.—reported take-up of between 51 per cent. and 75 per cent., and 28–42 per cent.—reported take-up of between 26 per cent. and 50 per cent. My hon. Friend will agree that we can and should do better to save the lives of as large a proportion as possible of the 2,000 or so women who die each year. Those statistics suggest that we can do better.

The present position is as my hon. Friend described it. It might be helpful to put it on the record that for the lower base payment to be made there must be a 50 per cent. take-up. If that is achieved, on each quarter day after 1 April one quarter of £760—the amount payable per annum for the average practice—will be paid. The average practice will have 430 women. If the practice is larger, the payment will be commensurately larger, and vice versa. The figures that my hon. Friend quoted were for average practices.

If at the end of the quarter in question more than 50 per cent. of the available patients who fall to be screened have been screened, the payment will be made, and the same applies to successive quarters. If the percentage arising on the quarter day is 80 per cent. or more, the sum will be three times higher. My hon. Friend referred to £2,280, and a quarter of that will be paid on the quarter days.

Health authority clinics can do the screening. If they do, they contribute to achieving the target, but the doctor does not receive the proportionate payment for what the clinic achieves. The same is true for immunisation and vaccination.

It is important to note that we have increased the capitation payments which apply whether or not the doctor achieves either the lower or the higher targets. As my hon. Friend will recall, that has been increased from £8.95 to £12.40 per head per annum.

It might be helpful if I try to set down four basic aims of the screening programme. First, we want to try to reach all categories at risk. I have to part company with my hon. Friend at this point because the Department has received medical advice that all women, except those who have had hysterectomies, whatever their status or professional calling in society and whatever their history of sexual activity, are in theory liable to catch cancer of the cervix. We want to reach all categories.

Secondly, we believe that reaching the 50 per cent. target should be achievable for all doctors. It is interesting to note that the Doctors and Dentists Remuneration Review Body, in its calculation of the average award for next year of an 11.5 per cent. increase in remuneration, assumed that all doctors would achieve at least the basic 50 per cent.

Thirdly, the higher target—the 80 per cent. target—should be seen as a real bonus and challenge. The nub of the problem that my hon. Friend described is the pressure that may arise through seeking to achieve a higher bonus. However, we have so structured it that it presents an additional 0.8 per cent. in doctors' remuneration, so that if a doctor achieves the higher target, his remuneration is increased by 12.3 per cent. for the year 1990–91.

My hon. Friend cited certain categories for potential exclusion. I am not suggesting that we should act on her proposals, but if we did, logically we should aim for 100 per cent. target payment. If we excluded all those categories, including those who refused screening as a matter of conscience and those who failed to respond to two or more letters, instead of the 80 per cent. target which is an attempt to recognise that some women may not wish to enter the screening programme, we should increase the target figure.

Our fourth aim is to reach all geographic areas of the country. My hon. Friend referred to inner city problems. She must have been thinking of the Asian community where social or religious pressures might be involved in any consideration of taking up the screening programme. She might be interested to know that we have recently funded four cancer screening development workers at Kirklees, Camberwell, Liverpool and north-west Thames. I have seen the link workers working with the Asian community in Leicester—particularly the women—to explain the benefits of screening. It is vital to make sure that women doctors are available to provide the screening.

We also provide an extra incentive for those working in the inner cities who may have difficulty reaching the higher target figures by providing a special inner city supplement of £8.80 per head. That is the maximum, so with an average patient list of 2,000 patients in a practice in an inner city deprived area, the doctor could earn £17,000 over and above the remuneration that would be payable in my hon. Friend's constituency or mine which do not suffer from inner city deprivation.

I am not suggesting that that is a substitute for achieving the higher target figure, but it must be remembered that it is a relatively generous programme that will affect 10 per cent. of the population.

Mr. Ivan Lawrence (Burton)

There is a serious question of interference with civil liberties and individual freedom. Nobody would challenge the well-meaning nature of what the Government are doing and the desirability of it, but I hope that my hon. Friend will keep in mind that in some areas, such as my constituency, substantial numbers of Muslim ladies do not want to subject themselves to the screening programme; nor do the doctors wish to impose it on them. I have heard of a doctor who has 600 nuns on his list of patients. In those circumstances there are considerable problems. I know that my hon. Friend is concerned about these matters, and I ask him to bear in mind the strength of feeling. There comes a time when the nanny state should not go too far and invade people's freedom.

Mr. Freeman

The hon. and learned Gentleman re-emphasised the main and final point that my hon. Friend raised—

Mr. Lawrence

I am the Minister's hon. and learned Friend.

Mr. Freeman

The hour is late and this is the third Adjournment debate that I have dealt with in the past 48 hours.

Members of the Muslim community are as liable to cancer of the cervix as are those in any other section of the community and it is our responsibility to make sure that there are proper incentives, and no more, for the general practitioners involved to educate and encourage members of the Muslim community, as well as nuns and virgins, to have screening. The medical advice that we have received is that all except people who have had hysterectomies could be susceptible to cancer of the cervix and it could be beneficial for them to have regular screening.

I look forward to studying the cases presented by my hon. Friend the Member for Torridge and Devon, West. It is most unprofessional for a doctor to place pressure on a patient over and above explaining the benefits of screening. Such pressure is unnecessary and reprehensible, and where it occurs the Department will ensure that family practitioner committees pursue it.

It is not our aim that pressure should be placed on women. If they decide, for whatever reason, not to take the screening test, that is their right and no further pressure should be brought to bear. That should not entail a penalty for doctors. I have already said that achievement of the higher target will bring a bonus—an increase in average remuneration of 11.5 per cent. We do not want doctors to give up once they have reached the 50 per cent. base target and to say, "I shall never reach the target of 80 per cent., so I will make no further effort." They should remember that a capitation payment is offered, and that it is their duty to draw to patients' attention the benefits of the screening programme.

May I give my hon. Friend the Member for Torridge and Devon, West five assurances? First, I shall report directly what has been said tonight to my right hon. and learned Friend the Secretary of State, who is concerned about the matter. Secondly, the Department will carefully monitor the outcome of the new doctors' contract and whether pressure is brought to bear on patients. Thirdly, we shall give careful thought to the national campaigns and to the campaigns aimed at explaining to the ethnic minority communities the benefits of screening in a sensible and balanced way. Fourthly, the Doctors and Dentists Remuneration Review Body will monitor carefully the remuneration of doctors to ensure that they suffer no financial penalties if, after hard endeavours, they are unable to reach the higher target. Fifthly, I look forward to reading the dozen cases that my hon. Friend mentioned. I shall pursue them and write in detail to her.

Question put and agreed to.

Adjourned accordingly at twenty-eight minutes to Twelve o'clock.