§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. David Davis.]10.17 pm
§ Sir Peter Emery (Honiton)
Computers and their use are not a normal subject for debate in the House. The subject of the computerisation of our family doctors' practices has almost never been raised, and has never been raised as an individual subject for debate. Basically, I come to praise the positive steps taken by Health Ministers over the past five years, although in a minor way I will ask for reconsideration of a wrong done to a medical practice in my constituency.
Taking major steps further to encourage medical practices to use computers and various software packages in dealing with medical records has brought, and I hope will continue to bring, benefits to the patient, and it is the patient who matters. The accurate presentation to any doctor seeing a patient of that patient's record, the full and easy referral to past treatment and the ease of transfer of records are obvious benefits. The screening of procedures, the control of prescriptions and the identification of patient groups are further benefits for doctors and for patients.
The Government have set aside £44 million for the period 1989–92 to aid and to stimulate the installation of computers in doctors' practices and that must be welcomed by all of us. I am worried that, certainly in the beginning, all those funds were not used. Therefore, the Government's record in general terms has been good. I urge them to continue to meet the necessary level of funding to maintain and update where necessary what has been achieved.
However, there is one specific item in respect of which I believe—nay, I know—the Government have fallen down. What are the facts? A large and excellent doctors' practice in Axminster, which is within my constituency, with Drs. Church, Sutton, Vann, Evans, Hodges and Taylor as partners, decided to computerise the practice. The doctors examined carefully the hardware necessary to provide access for each doctor and also for the pharmaceutical dispensery. They spent time arriving at a decision on the correct software. They were not opting for a particularly expensive scheme. It was not a Rolls-Royce, but a practical working and adaptable system. Following my automobile analogy, it was a Rover system. They based their decision on a clear statement in a Department of Health approved document, entitled "Funding General Practice 1990". According to that document, no nfundholding practices such as the one to which I am referring were entitled to reimbursement of computer costs from April 1990. They were entitled to 50 per cent. of maintenance costs, 50 per cent. of purchasing, leasing or upgrading costs, and 50 per cent. of the first year of staff costs. That document—I now quote from it so that I can make certain that I am not misleading the House—states:Special software packages are being developed commerci-ally and will be available before April 1991. They will:Enable practices to run budgets on a day-to-day basisAccount for expenditure incurredProduce monthly and annual reports and statements for the FPCKeep track of hospital referralsFurther guidance on software will be issued in the Spring of 1990.505 There was no mention of a restriction on the cost or repayment that a practice could obtain. The Under-Secretary of State for Health acknowledged that fact in a letter to me of 31 January 1991. In the second paragraph he said:During our discussions I accepted that there had possibly been some scope for misunderstanding. Even though Dr. Vann's practice has not applied to become a fund-holding practice you mentioned the GP fundholder brochure which, while mentioning the 50 per cent. maximum contribution, did not specifically mention the additional list size criteria on the same page.What are the facts? A large, excellent doctors' practice proceeded—how many doctors did the same?—and made a claim for the reimbursement that they expected. Having spent £25,775 on computerisation, the doctors might reasonably have expected a 50 per cent.—£12,800—reimbursement. They were amazed and "aghast" when they received only £4,830 from the family health services authority. In this instance, the Department of Health is diddling general practitioners.
I have pressed the Minister on this matter both in correspondence and in a visit to the Department when he and his officials told me that they would reconsider it. Our correspondence culminated in a letter on 14 August, stating:From 22 July 1991, family health service authorities (FHSAs) have been given management discretion to target funds in order to maximise value for money and service to patients. The limits that previously existed within the Statement of Fees and Allowances (SFA) which related reimbursements to list size have been removed.Hooray. I have won. However, the letter continued by referring to non-fundholding practices, which do not affect this case.
The letter then continued:With regard to Dr. Vann's request for retrospective payments"—"retrospective" is the Minister's word not mine because the payments were not retrospective. They were demanded when the doctors installed the system. The letter reads:With regard to Dr. Vann's request for retrospective payments to be made to GPs who have been reimbursed under the previous arrangements, the object of the scheme, as has been explained in the past, is to ensure the widest possible spread of computing within a cash-limited budget.I emphasise the words,within a cash-limited budget.The letter continued:In the light of this, there is no provision to make further payments to those doctors who, like Dr. Vann, feel that the scheme which operated when their claim was made was less generous than the present. If Dr. Vann wishes to upgrade his system, then the reimbursement for his upgrade costs will be assessed under the revised arrangements. I am sorry that, despite the delay, I cannot be more helpful.The Minister's argument seems to be, "It is impossible to act because the costs have increased above the Treasury total for computerisation." Therefore, on 13 February 1991, I tabled a written question:To ask the Secretary of State for Health how many general practitioners in previous years, in complying with his wishes to move to use computers, applied for a grant for the installation of a computer system that was above the figure of payment sct out in the published computer cost reimbursement schedule.That was accepting that the scheme, to which I did not think that reference had been made, might have been applied.
The Minister's reply to me stated: 506No figures are held centrally either in respect of individual claims made by GPs or individual amounts reimbursed by family health services authorities".—[Official Report, 13 February 1991; Vol. 185, c. 512.]I found that interesting because it appears that the Minister does not know how many doctors made a claim that was above the amount of the reimbursement schedule or, if he did know, he was unwilling to tell me, so I must presume that he did not know.
One can imagine my indignation when I finally received a copy of a letter that had been signed by Mr. Ian Fleming, one of the Minister's officials, clearly stating in annex A:The scheme was introduced in April 1990 (but took into account in its first year any systems obtained by GPs since April 1989). £24 million was made available in 1990–91 (to cover the two years) but was significantly underspent".It was not a case of there not being any money, but simply that the Minister would not darn well apply it. I believe that that money has been carried forward, which means that funds are available today if the Minister should decide to pay the Axminster practice.
I have been a Minister and I know that there is a difference between Ministers being in charge and Ministers who are run by their civil servants. If the practice had not done the efficient thing and had installed only part of the structure, to a value of £8,000, it would have received 50 per cent. of that £8,000. Last year and this year they could have upgraded it at a cost much greater than the initial expenditure and much less efficiently. In that case they would have obtained 50 per cent. of their total extra computerisation costs under the new scheme. The doctors are being held to account for being efficient. They are not being fairly treated by the Department.
Therefore, I say to the Minister, "Gird your loins. Tell the office that a way must be found to pay the balance of slightly less than £10,000. Do not allow the civil service to say that there are ways in which it cannot be done. Any civil servant will find ways of not doing something." I am confident that if my hon. Friend the Minister wants to do this, he can. I expect him so to do.
§ The Parliamentary Under-Secretary of State for Health (Mr. Stephen Dorrell)
I am grateful for the confidence of my hon. Friend the Member for Honiton (Sir P. Emery) in my competence. I do not dispute that if I chose to instruct that the payment be made, it could be made. On that proposition I have to agree with my hon. Friend. But before I talk about whether I should use that discretion, I should like to say that, as my hon. Friend said, I have known about his concern about the Axminster practice virtually since I arrived in the Department of Health 18 months ago.
My hon. Friend has been an effective and persuasive advocate in private and now in the House of the interests of his constituents. The arguments, as he -has presented them to me both on earlier occasions and tonight, are, indeed, seductive. However, I will seek to set them in the wider context of the Government's commitment and programme for the computerisation of general practice. I shall show why I do not think—it is not what my officials think, but what I think—that I would be right to use the discretion which he correctly said lies with me.
I agree with my hon. Friend about the substantial benefits which computers can bring to a modern general practice. They can perform simple administrative tasks which were previously both dull and expensive. Indeed, 507 they can do so more accurately than traditional methods. Registration and administrative and financial returns are all functions which computers can carry out in a modern general practice.
In addition, and more important, computers can keep clinical records and, therefore, be of direct clinical value to the general practitioner. They can keep records of the attendances of a patient at the surgery, the clinical condition of the patient and the prescriptions written for the patient. They can produce repeat prescriptions when the doctor so authorises. So computers are a valuable tool for a clinician in general practice, as well as being a valuable administrative tool to a partner in a practice.
Therefore, the Government see the extension of computerisation in general practice as an important part of our commitment to the growth, modernisation, expansion and development of primary care in the NHS. That has been a consistent record of the Government since 1979. Our commitment is much wider than computers. We have shifted substantial sums of money into the extension and development of primary and community care in the NHS.
The primary and community health care sectors of the national health service have increased their share of the health service budget from 28 per cent. in 1979 to 33 per cent. today. That represents a growth of expenditure in those sectors of roughly 80 per cent. in real terms. That money has been used to increase the number of lay staff, practice nurses and other professionals available in general practice and to improve the physical facilities in which general practice is offered. It is a substantial record of investment in the expansion of primary and community health care. Computers have an important part to play in that wider programme.
As recently as five years ago only 10 per cent. of general practices had access to computers. On 31 March 1987 there were 942 practices in the national health service which used a computer. Four years later, on 31 March 1991, that figure had risen to 6,130, which represents 63 per cent. of all general practices within the health service. The practice that my hon. Friend mentioned is typical. Computers tend to be concentrated in larger practices. On 31 March this year 76 per cent. of all general practitioners in the NHS had access to a computer.
That is a substantial record of success in support of a much wider strategy of developing primary care as an essential part of modern health care delivery. How was that expansion of computerisation brought about? Substantial encouragement for the computerisation process in the primary care sector was developed by the scheme which my hon. Friend the Member for Honiton criticised.
Until I changed it earlier this year, the scheme had four essential elements: it met 50 per cent. of the system costs and 70 per cent. of the initial staff costs. However, both those were subject to a ceiling, determined by the practice list size.
§ Mr. Dorrell
I shall come to that in a moment.
The fourth key point was that for the first two years of the programme, between April 1989 and March 1991, we committed a budget of £24 million to the programme.
My hon. Friend had two criticisms of the way in which the programme was put into effect. First, he is concerned 508 about the application of the list size criterion. He is concerned about its merits, but, perhaps more important in the context of his constituents' practice, he is concerned about whether they knew that the limitation on the payments due existed within the scheme that we were operating.
I have told my hon. Friend in private and I am happy to tell him in public that if the doctors concerned say that when they installed the computer they did not know that the list size criterion existed, I am happy to accept that as a statement of fact. I am happy to accept that they did not know that the payment that they stood entitled to receive was limited by the list size criterion.
However, even if Dr. Church and his partners did not know of the operation of that rule, many others in primary health care knew. The correspondence files of my hon. Friend the Member for Kettering (Mr. Freeman), my predecessor, stand witness to the fact that the existence of the list size limit was known and was the subject of substantial criticism from representative organisations within the profession.
I answered my hon. Friend's question about how many payments were made to practices—where list size criterion limited payment—saying that I did not know the answer. That was a statement of fact because the totals were not available to me. However, I know that substantial numbers of doctors invested in computers, while complaining about the operation of that rule.
I am absolutely confident that Dr. Church and his partners are not unique and that many other doctors are in the same position, in the sense that they made financial investments during 1989–91 and the payments that they received from the fund were limited by the operation of the list size criterion.
§ Mr. Dorrell
Indeed, my hon. Friend is fighting a wider battle than purely that of Dr. Church and his partners.
My hon. Friend's second criticism of the way in which the scheme has worked is that the £24 million budget which was set aside for the two financial years—and I emphasise two years–1989–91 was underspent. The actual amount disbursed under the scheme in the two years for which it ran was £17 million, not £24 million. My hon. Friend says that cash is available which could be used at least to make some payment to doctors who had their payments limited by the list size criterion.
I considered that point during the summer, when we were considering the rules of the scheme which should operate for the current financial year. I decided on a different approach, and I will explain that approach and why I adopted it. My hon. Friend, and the medical profession more widely, seemed to me to have made a powerful case against the rigid operation of the list size criterion. That is why, for the current financial year, it has been abolished. I recognise that that provision has limited payments to my hon. Friend's constituents, but it is no longer limiting payments to doctors because, as of April of this year, it no longer applies.
The next facet of my approach was that I wanted to see more flexibility in the hands of local family health services authorities over the application of funds and the use of the substantial sums of money that are available to them for the development of primary health care. So for this year I made the computerisation funds part of the wider fund 509 available to FHSAs to support not merely computerisation but the extension of ancillary staff in general practice and the development of new accommodation facilities for primary health care.
Those three elements now all come out of the same fund, with discretion in the hands of the FHSA to use the fund for any one of those three purposes, but with a clear steer that the amount for the current year should be roughly £20 million, which my hon. Friend mentioned.
I believe that the spending levels that we are now seeing, through the new scheme that I announced in the summer, vindicate the judgment I made because the £17 million that was spent in the two years of the initial scheme represents an average spend of £8.5 million. The initial budget for the current year was £13 million, which was increased to £20 million to take account of the £7 million underspent in the first two years. So the budget fixed for the current year was £20 million and the £7 million underspent in the first two years of the scheme did not go back to the Treasury—it was not lost to computerisation—but was committed to the further development of GP computerisation.
I inquired of my officials—those officials who are supposed to have such total control over everything I do—what the experience would be of the new scheme during the current financial year. I am pleased to tell my hon. Friend that the latest estimate we can make for the spend on computerisation this year will not be £20 million but £25 million. So there will be a £25 million spend in a single year, in the current financial year, against an average of £8.5 million in the two previous financial years.
That will be possible because I made the scheme more flexible, so the FHSAs are allowed to use the funds that would previously have been limited to practice premises and ancillary staff to support the continued development and expansion of computerisation of primary health care.
§ Mr. Dorrell
Not at all. It is a constant of any Minister's experience—my hon. Friend referred to his experience as a Minister—that when a new scheme is introduced, there will always be somebody who did the same thing on his own initiative in the previous year and who feels that those who benefit from the newly introduced scheme are receiving an unfair advantage over the individual who took the real risk and did it himself.
§ Sir Peter Emery
My hon. Friend has been most fair, and I understand the argument that he propounds. However, will he give one undertaking? If, at the end of this year, the total funds—I reckon those to be £44 million, but that figure may not be quite accurate—are underspent, will my hon. Friend advertise for people who, from 1989 to 1991, did not receive their full allocation and allow anyone, including my constituents, to apply to help them use up any unused balance? That would be very fair.
§ Mr. Dorrell
I said that my hon. Friend's arguments were always powerful, persuasive and seductive and he has just demonstrated that fact once again. Unfortunately, he double counts in quoting a figure of £44 million—
§ Mr. Dorrell
For three financial years. The budgets that we announced were £24 million and £20 million, which my hon. Friend has added to make £44 million. But he forgets that the £20 million included a £7 million carry-over from last year's underspend, so the amount is not £44 million but £37 million.
As the spend over the three years will be more than that —last year's spend was £17 million and I expect this year's to be £25 million, making a total of £42 million—I suppose that I could give my hon. Friend the assurance that he seeks, but even if our figures were so way out that I could be caught on that commitment, when I consider the matter next May—assuming that the burden still falls to me to do so—I would have to make the same calculation as I made this year. I would have to ask whether it is right to use the measure to reward people who did something two years ago, or whether it would be better to use the money to encourage people to continue the process in the future. This summer, I concluded that the latter was better than the former and I can give my hon. Friend no assurance that I would not reach the same conclusion again.
§ Sir Peter Emery
I do not accept absolutely my hon. Friend's final factor. If a balance were left over, it would be reasonable for him to try to use it to repay those who have set the trend. Those are the people from whom the doctors are seeking advice and asking, "How has this worked with you?" Therefore, I believe that the Minister should give me the assurance that I seek.
§ Mr. Dorrell
As I said, the assurance would cost me nothing, because I am confident that it would not be activated.
§ Mr. Dorrell
Politics are partly about applying principles, as well as stitching up deals. The principle must be whether it is right to use public money to reward something that has happened anyway or to encourage something that might not happen if we do not use that public money. When faced with that choice this summer, I chose to encourage people to continue to develop computerisation in primary health care rather than simply to reward directly those who did something very valuable —there is no doubt about that, or about the fact that they did it at their own risk—some years ago.
§ Question put and agreed to.
§ Adjourned accordingly at thirteen minutes to Eleven o'clock.