General Practitioners (Night Service)

HC Deb 11 July 1995 vol 263 cc806-45 7.16 pm

Mr. Alex Carlile (Montgomery)

I beg to move, That this House shares general practitioners' concerns as to the continuing provision of a high quality service by night as well as day, given increasing demands; seeks to facilitate improved methods of work so that general practitioners can provide a more flexible, clinically appropriate and more modern way of providing emergency care outside normal hours which is right for patients, fair on the taxpayer and manageable by family doctors; believes there should be a right for general practitioners to transfer responsibility for out of hours care to another general practitioner without unnecessary interference by the Family Health Service Authority; supports the need for substantial, ongoing patient education campaigns on the appropriate use of the out of hours emergency service; and calls on the Government to take all reasonable steps to avoid industrial action by general practitioners. It is a matter for regret that I have neither the attention—[Interruption.]

Mr. Deputy Speaker (Sir Geoffrey Lofthouse)

Order. Can we have some quiet on the Front Bench, please?

Mr. Carlile

Thank you, Mr. Deputy Speaker.

It is a matter for regret that we do not have the benefit of the presence of the new Secretary of State for Health on the Government Front Bench. The right hon. Gentleman would not be coming fresh to the situation, because he was once a junior Minister in the Department of Health, and should have a ready understanding of the issues that we shall discuss.

If the Secretary of State had come here, we might have been reassured that he had reviewed the stubborn attitude of the Minister of State, who as usual is grinning from his position on the Front Bench. Had he been born in Cheshire, he would not have needed transmogrification. Of course, it is still open to the Secretary of State to wind up the debate, but I think that we shall find that he does not like working out of hours, and so has decided to send his junior partner out on this call.

It is worrying that we should have a dispute of the kind that now exists on out-of-hours provision between Ministers, representing the Government, and general practitioners. It is extraordinary how the Government have managed to make fervent opponents out of a traditionally moderate profession. It is perhaps a pity that the Minister of State, who is present tonight, did not follow the slogans of his own patient education campaign in relation to this issue. One of those slogans, which one sees on surgery walls, reads, pithily, "Be nice, think twice." I realise that, for this Minister, that would have presented a formidable triple challenge.

Perhaps the Minister might take advantage of another of the slogans of the Government's rather weak patient education campaign: "Help us to help you." That is a bit bland but, if he repeated it when he got up each morning, he might find it easier to review this desperate issue between general practitioners and the Government. The leaders of GP professional groups could not be considered, even in the wildest of imaginations, to be revolutionaries set in a political cause against a Conservative Government.

I doubt whether Dr. Sandy Macara has a poster of Che Guevara on his wall; or that Dr. Ian Bogle has a poster of Danny Cohn-Bendit—or that they did even in their student days. Knowing those two gentlemen, I suspect that they were more likely to have been inspired by the likes of Winston Churchill and R. A. Butler, yet we find them challenging the Government because of their attitude towards the most basic part of the national health service—primary medical care.

For more than two years, the Government, led by the right hon. Member for Surrey, South-West (Mrs. Bottomley), the Minister of State and their colleagues in the Department of Health, have managed to reduce morale among GPs to a new low, to the very brink of industrial action. I and my Liberal Democrat colleagues want to avoid that, as do the majority of GPs, but there is a real danger that, unless the Government change their attitude now, the dispute will escalate. If it escalates, it will be to the disadvantage of patients. If it is to the disadvantage of patients, let it be known that, although the Government might try to blame the doctors, the Government will be to blame, not the medical profession; for it is plain that it is within the Government's capability to end this dispute successfully, if reluctantly.

If the Minister of State goes contrary to form and displays a change of mind tonight, we will hail that change. One always hails a good premiere. What one is rather bored by is a tedious repetition of past poor form.

Let us consider the problem, for there is a problem, that faces GPs. I have to confess—if it is a confession—to being a GP's son. I remember when we lived in Burnley in Lancashire, in the old house that contained the surgery, that, occasionally, the telephone used to ring at night and my father would go out to make a call. He had a big practice, but night calls were a rare occurrence in those days. Times have changed and demands have increased. By the time my father retired, the number of night calls had increased significantly, and the partners who succeeded him in his practice have been subjected to a burgeoning demand for night services.

By 1989–90, some 936,148 night visits were made by GPs. By 1993–94—albeit the statistics cover a two-hour longer period than in the year I have just mentioned—some 1.832 million night visits were made by GPs. The latest estimate that we have been able to obtain from the British Medical Association is that, in the past year, 2.3 million night visits were made. These are visits demanded of doctors by patients. A doctor turns down a night visit at his peril—if he does not attend and something goes wrong, he is in trouble. Doctors—or at least the health service—have to be able to meet that demand. The number of night visits has increased more than six times in 25 years, and it has doubled since the introduction of the new GP contract.

I should say that I am delighted to see that the new Secretary of State has joined the debate for a short time. I congratulate him on his appointment. As I said earlier, he comes to the Department of Health for a second time, I believe, and therefore with some experience. I shall repeat the hope that he might decide to wind up the debate himself rather than leave the out-of-hours provision to his junior partner, the Minister of State. It would certainly be helpful—I repeat this in his presence—to hear that the Secretary of State has immediately reviewed this very worrying dispute, which must have been taking up significant space on his desk when he arrived in his new office.

I shall now return to the problems faced by doctors. An average of six night visits a month are made by doctors, and an average of 36 patient consultations per month are made out of hours. Many of those consultations, of course, are not night visits. There is much anecdotal evidence of greater weekend demand than many people think exists. It is clear that weekend demand has risen as quickly as night visits. Patient expectation, but not always patient responsibility, has risen. It is right in a debate such as this—I hope that hon. Members on both Front Benches share this view—to be quite robust about the attitude of patients and to ask them to be far more considerate than they sometimes are towards their GPs and out-of-hours provision.

In our consumerist society, legitimised by the patients charter, patients are expecting more at all hours from their doctors. For what should be an emergency service, the anecdotal evidence of misuse is striking. One doctor tells of a call for a home visit only to find when he got there that the family he was called to had gone out for a walk. Another tells of a man who complained that his hands had gone blue and that he feared a serious circulatory problem, only to be told, when the doctor arrived on the emergency call, that he had received some blue dye from the overalls that he had washed earlier that evening. One woman even woke a doctor in the middle of the night to ask him to deliver sleeping tablets because she could not sleep.

Doctors are at times victims of the inconsiderateness of their patients, but they also find themselves picking up the pieces of a society broken by Government policy. They constantly have to deal with misplaced, often seriously psychiatrically ill, community care patients. They are often the only people to whom chronic schizophrenic patients, who have been dumped in loneliness in society, can go. They often have to deal with the drug and violence problems of inner cities and are at physical risk when they go out on night calls. In rural areas, doctors have to provide almost all the emergency medical cover. Indeed, they are often called out to do what turns out to be emergency dentistry, which they are not able to complete.

The situation is fraught with problems for GPs. In May of last year, after many months of negotiation, the BMA and the Government agreed on changes to GPs' terms of service. It had taken months to clarify whether GPs could use their own judgment to decide whether a patient required a home visit, which seems an extraordinary issue for the Government to argue about for so long, and it took many more months to decide how to implement a very small amount of flexibility in how out-of-hours care was provided.

Now, negotiations on the payment scheme have run into the sand, but it is not principally an issue about money. Doctors are not simply holding out for more money. The real issue that concerns the BMA is the form of the out-of-hours system. Doctors want to move away from a scheme that positively encouraged—perversely encouraged—GPs to undertake out-of-hours provision themselves, whatever the effect on their work, rather than use other people to do it for them, because they were paid more for doing it themselves, which seems irrational.

An offer of £2,000, plus £9 for each visit, was rejected as, for many doctors, it would be a direct pay cut. It is extraordinary how the Government believed that they could offer doctors a pay cut as an incentive to accept a new contract. The offer was increased to a lump sum of £2,000 and a £20 fee for each night visit. That offer was also rejected, not on money grounds, but as a crude approach to the far more complex problems of the structure of and demand for out-of-hours care.

The Minister groans audibly when I say that the dispute is not mainly about money, which shows that he has not begun to understand the issues that the British Medical Association is trying to put to him. I suggest that he or, preferably, the Secretary of State, should meet Dr. Bogle and Dr. Macara shortly—I believe that the Secretary of State might well be intending to do so—so that a new view can be taken of what the dispute is really about.

The Minister for Health (Mr. Gerald Malone)

It is not the British Medical Association that I have some difficulty understanding, but the hon. and learned Gentleman. In one voice he says that he is against what he says are the perverse incentives in the scheme. If I paraphrase him correctly, they are perverse incentives that mean that doctors are encouraged to do their own visits. What has happened is that, in the new fee structure, a different incentive reduces the perverse incentive that he criticised, yet he is criticising what we have proposed as well. Which does he prefer?

Mr. Carlile

I am afraid that I find that intervention totally incomprehensible. I suggest that the Secretary of State reads the submissions—if he will listen for a moment—presented to him by the BMA, start with a clean sheet and ignore the prejudices of his Minister of State, which have become the major obstruction to resolving the dispute. Sometimes it helps to take a new look. Perhaps the Secretary of State will do that.

Of course, money is part of the question. Indeed, Dr. Brian Hope of Salford suggested that not many Conservative Members would leave their lovers' beds for that sort of money unless it was to ask a parliamentary question. That was a rather unfair gloss on the real issue. It is not simply a pay dispute between a profession and its paymasters, but a dispute about realistic provision of high-quality patient care. The Minister can put his finger in the dyke, but the hole will grow unless the Government are prepared to study the structure of out-of-hours provision and produce a resolution for the future.

There is a way forward on six issues. The Government are right to support the development of GP co-operatives. They offer a good solution to out-of-hours care. Such co-operatives, however, cover only 17 per cent. of patients, and the National Association of GP Co-operatives would, I think, recognise that it will take a considerable time for them to be suitable for all types of area, particularly some inner-city practices and rural areas.

The whole profession, including the co-operatives, is united in the belief that the Government's £45 million offer has been made in a way that provides no equity between practices and areas of different types. My first suggestion to Ministers, therefore, is that they consider the way in which the £45 million has been offered and find out whether they can re-tailor it into a more equitable offer for general practices throughout the country.

In due course, I should like to hear from the Minister that the Government's door is open on the issue of distribution at least. It would be interesting to hear from him where that £45 million is to come from, however. Is it new money? That is a simple question and the Minister can answer yes or no. Is it new money? Perhaps the Minister would like a couple of hours to think about that question before winding up—so that he can give the sort of obfuscatory answer to which we are accustomed to hearing from him.

It is my suspicion, and that of many connected with the medical profession, that the £45 million is about to be lopped off other health service budgets, which will suffer as a consequence. That cannot be tolerated. If it is to be lopped off other budgets, the Minister should tell us where it is being taken from. We look forward to hearing an answer to those questions at the end of the debate.

My second suggestion for Ministers is that payment for out-of-hours calls should be available to all doctors who are qualified to practise as general practitioners. The present system is ludicrous. Only general practice principals can receive the £20 fee for a consultation, which means that, if a principal arranges for an on-call service to do his out-of-hours calls, the £20 fee is not payable. That seems manifestly unjust and militates against the provision of efficient out-of-hours care that does not put too much pressure on doctors.

Despite the amusement with which the Minister evidently regards this debate, my third suggestion is that the Government should set about redefining the contract. It is unclear to GPs how much of their contract covers in-hours work and how much covers out-of-hours work other than night calls. There is separate provision for night calls, but doctors deserve, and are entitled, to be told what proportion of the payment that they receive is intended to cover working during the evening, on Saturdays after lunchtime and on Sundays, all of which are out of hours.

How much of the capitation fee and the other allowances notionally covers evenings, Saturday afternoons and Sundays? The importance of having that information separately is that there is absolutely no reason why doctors should not be given the flexibility to arrange their practices and their activities by taking into account the answer to that question. It would enable some of them to manage their practices differently. It would enable some to hive off all their out-of-hours work and it might lead to the burgeoning development and rapid acceleration of GP co-operatives to cover more than merely the night calls that they cover at the moment.

Just as doctors are told what part of their earnings comes from night calls, so they should be able to negotiate their working arrangements to take into account other out-of-hours provision. That would also enable doctors who are inclined and able to do sessions in hospital to broaden their experience and provide more specialist services, to do so in a more manageable way.

My fourth suggestion for the Minister is that technology could be improved. Obviously one cannot use distance technology to deal with night calls. Computer facilities are not yet in every home. Technology can help the management of practices, however, and many general practitioners' practices now have significantly improved computer systems. The use of telecommunications technology, and its being made available to doctors in a cost-effective way through the national health service and the family health services authorities and their successors, would mean that they could work more efficiently, especially in rural areas and heavily populated inner cities.

My fifth suggestion relates to rural areas. I represent a rural area in which the population is widely spread, the largest town has about 11,000 inhabitants and there are many small settlements. In such areas, the provision of out-of-hours services is very different from that in a suburban environment. I invite Ministers to take the view that a special settlement is needed to ensure that facilities can be provided properly in rural areas.

My sixth suggestion concerns the efforts that have been made in patient education. They are commendable so far as they have gone, but they have footled around the edges of the matter. There is prime time advertising for all sorts of Government-sponsored campaigns. In my view, patient education should be such a campaign. The message is a simple one: caring doctors need caring patients. Getting that message across requires a fairly hard sell. We have yet to see that hard sell from the Government.

Mr. Robert G. Hughes (Harrow, West)

The hon. Gentleman suggests that there should be television advertising and a big campaign to support the Government's plans for GPs. He may or may not be right, but is not that rather at odds with what has been said by his colleagues in the Liberal party who have criticised every advertising campaign the Government have carried out, whether successful or not, and used bogus figures to say that money is being wasted? He cannot have it both ways. Perhaps he can; he is a Liberal.

Mr. Carlile

The hon. Gentleman is factually wrong. The Liberal Democrats have always been happy to support campaigns that have not trailed the Government's party politics. Of course, we now know how the Government behave. We have a Cabinet of 24 in which two Ministers are there to serve not the country but the Conservative party. That is the political world in which we live.

We are prepared to give the Government the credit of our support if they are prepared to go in for non-partisan campaigns of patient education. The sort of campaign that has been run on drink-driving might well be effective in educating patients to be considerate towards their doctors.

I make a further suggestion to the Government. It would be worth looking, on a pilot project basis, at some different models for certain aspects of primary care provision. For example, provision of health care for the elderly chronically sick can make great demands both on GPs and on hospitals. Many hospitals have experience of, and excellent departments that specialise in, care for and diseases of the elderly. In some of the more populous areas, it might be worth considering modelling primary care so that it is provided using the hospital as a base rather than via GPs or in the hospital. I have received representations, not from the BMA but from individual doctors, suggesting that such an approach might help to take some of the strain from them.

The danger is that doctors will take the view that there is no point in co-operating with the Government and that the Government will have to solve the problem themselves. We could get a system in which some doctors just shut up shop at 5 pm and do not want the payment because it is not worth the effort. As a result, as in some continental countries, we might make patients reluctant to approach their doctors even when they need them. We have to try to find a balance. I believe that what the Government have offered falls far short of a balanced system. Indeed, the demoralisation of the medical profession is surely evidence enough that the Government have failed to find that balance.

There is a shortage of new doctors. One in eight places on general practice training courses is vacant. The shortage of new doctors is especially evident in practices that do their own out-of-hours cover. The recent vote by the BMA surely demonstrated the extent of demoralisation. There was a turnout of 77 per cent. of doctors—which would do many constituencies credit in a general election—and 82.6 per cent. of those who voted said no to the Government's offer; only 17.4 per cent. said yes.

The Government's response has been extremely poor. Thus far, they seem to have chosen to challenge the GPs. It might have been better for the profession and for the public if the Minister of State, who seems to have made the running on this issue, had joined the right hon. Member for Surrey, South-West, now the Secretary of State for National Heritage, in that attack of fugue, in the psychiatric sense, that sent her off deluded to another job which has put her in charge of fugue in the musical sense. I am not sure how the Minister of State would have done as a Minister of Music, but at least we might have had other new Ministers at the Department of Health singing in harmony rather than in the discord with which the Government are approaching doctors.

If we are to avoid a disaster for out-of-hours provision, the Minister must become a fugitive from his usual intransigence. It is perhaps a vain hope, but nevertheless it is a hope, that we might at last, at the end of tonight's debate, hear something positive from the Government.

7.45 pm

The Minister for Health (Mr. Gerald Malone)

I beg to move, to leave out from "House" to the end of the Question and to add instead thereof: notes that the Government has continued to meet the recommendations of the independent pay review body for general practitioners' pay, which is for a 24 hour commitment to their patients; welcomes the Government's constructive approach to addressing the profession's concerns, which includes an extra £45 million to support general practitioners' out of hours services, makes it possible for general practitioners to transfer responsibility for providing out of hours cover to another doctor and restructures payments so that the average general practitioner will receive an extra £800 per year for night visits; supports the approach of the Patient's Charter, which stresses to patients that with rights come responsibilities; and believes there is absolutely no case for general practitioners to take industrial action which would inevitably harm patient care. If that is the sort of the stuff that the hon. and learned Member for Montgomery (Mr. Carlile) comes out with on behalf of his clients in court, I hope that he does not have the nerve to charge them anything for it. It was a mixture of relatively pompous and personal points, which I did not mind.

I think it is good that a Minister should sit on the Front Bench happy with his lot and that he should grin occasionally—with his supporters firmly behind him, backing the Government's cause—moving onwards to destroy the hon. and learned Gentleman's arguments. Of course I am happy with my lot; the hon. and learned Gentleman will have to put up with that. He will see that I smile from time to time as he makes the odd bon mot, with which I intend to deal in my remarks.

The hon. and learned Gentleman offered a poor agenda for change and failed to acknowledge the substantial way in which the Government have moved on the issue and have listened to GPs and to the arguments advanced by the British Medical Association over a considerable period, not least since I joined the Department last July. In my own defence, I must say that it is entirely wrong to say that we have not listened; we have. We have responded a great deal and in detail to the concerns, many of which were set out by the hon. and learned Gentleman and some of which I will be able to respond to fairly positively this evening.

Perhaps it would be helpful to the House if I put firmly on record the Government's current offer. Our offer is designed to meet the concerns about work load and about pay for out-of-hours work. The two go together. I notice that the hon. and learned Gentleman fell into the trap of saying that, of course, it was not about money and then in the next breath that it was something to do with money. The truth of the matter is that it has to do with both. That is why the Government's offer has been constructed carefully to meet both the work load argument and the out-of-hours pay argument.

Let me go through the essentials of the offer currently on the table. An extra £45 million has been provided for GPs within the overall health budget. Its purpose is to support alternative out-of-hours arrangements and to give GPs more flexibility and choice in managing their work load. As I said, that money comes from the total national health service budget, which in England is more than £30 billion per annum. It is not from—and this must be the concern of GPs—funds that would otherwise have been devoted to general practice. As far as GPs are concerned, it is new money that was intended to be brought to bear on a specific problem. The hon. and learned Gentleman is quite wrong to suggest that the Government have not been specific about that. We have been specific from the outset and I endorse what we have said on that point before.

The hon. and learned Gentleman asked how the arrangements will work. The offer was put on the table not in a prescriptive sense but in the hope that we could reach an agreement in principle with GPs and talk through the detail.

The hon. and learned Gentleman mentioned a number of schemes, including 24-hour primary care centres. Such schemes will be in our mind when spending the £45 million on the arrangements that we want to put in place to guarantee and underpin quality out-of-hours cover.

Since I was appointed, I have made a point of spending a great deal of time in general practices to see what the problems are and how out-of-hours care is provided. In particular, I have made a point of talking to GP co-operatives and to those who represent them in their national association. Anyone who takes an interest in such matters will understand that a number of basic arrangements are in place, such as GP co-ops. Some have been established in Kent, and I visited one in Reading. Interestingly, the one that I visited in Reading also dealt with rural areas.

It is important to dispel the myth that co-operative arrangements cannot by their very nature deal with the problems of rural areas; in certain circumstances, they can. The hon. and learned Gentleman mentioned rural areas specifically. I recognise that they can have special difficulties, which is why we said that we would consider special arrangements whereby some of the £45 million can be devoted to locum arrangements for GPs in rural areas if it is not possible to form a co-operative. The Government's mind is open on that point, and the Secretary of State's door is open not only on that point but on others too.

I take this opportunity to make it clear to the House and to the hon. and learned Gentleman that my right hon. Friend the Secretary of State will be meeting GP representatives about that very issue: the date is set for Thursday this week. Of course, he will be extremely keen to listen to all that they have to say, and it is right that he should do. As I have said before, I hope that the meeting will provide an opportunity to take matters further.

The hon. and learned Gentleman referred to a fundamental issue but did not examine it in detail. Where the Government part company from those who are arguing about this issue is the separation of the 24-hour contract. It is vital for the quality of primary patient care that someone must have custody of that care. The way in which the system developed in the health service—before the 1990 contract and after the 1990 contract, which reinforced it—is that the GP principal closest to the patient must have custody of that patient's care. Of course, that GP cannot be expected to provide care 24 hours a day, seven days a week and 365 days a year. That is why there are other arrangements for cover, such as sharing within a practice, joining a GP co-operative, using deputising services or making more permanent arrangements to transfer the responsibility from one GP to another.

I reiterate the Government's determination not to undermine that element of patient care but to examine reasonable mechanisms under which doctors' work loads can be shared as long as there are permanent quality arrangements in place. We have made it clear in the negotiations that we are happy to examine the regulations, and have offered to do so, so that doctors who want to move more permanently out of out-of-hours work will be able to do so.

The original offer for night visit payments was a flat rate of £2,000, which would enable a number of doctors to employ deputising services up to that amount. In addition, there was a £9 fee if the visit was to be undertaken by a GP principal. We have moved a long way on that issue, and the fee now being offered is £20—more than double the original offer. The average general practitioner will receive an extra £800 a year for night visits compared with the arrangements currently in place. It is therefore entirely wrong for the hon. and learned Gentleman to say that, even with that specific mechanism delivering a part of the payment due to them, doctors will be worse off under the Government's proposals.

I must set out the Government's record on pay in general. The hon. and learned Gentleman told the House that morale was at an all-time low. The implication of his remarks was that the Government have behaved badly towards the profession for a long time. Since 1979–80, pay for general practitioners has increased in real terms by 40 per cent. That is a record of which the Government can be proud. It underpins the importance that we attach to general practice, and I hope that it is a record that the medical profession recognises.

Mr. Alex Carlile

Will the Minister say why increasing numbers of GPs are now retiring in their early fifties to avoid the burden that they believe is involved in working in the national health service?

Mr. Malone

If the hon. and learned Gentleman scratches the surface, he may discover that quite a few retirals are followed by a return to a temporary practice or a move to another sector of health care. It is ludicrous for the hon. and learned Gentleman to suggest that, by paying doctors an average of 40 per cent. more, we are encouraging them to leave the profession. In overall terms, doctors have been extremely well treated by the Government and well served by the independent review body system. The implication of the hon. and learned Gentleman's comments is that the work load is too great. The work load has changed, and the very structure of the way in which GPs provide services is very different from what it was even a few years ago.

One hears the stories that go around, but I must set them in their proper context. I wish to put the facts firmly on the record. There is an average of 70 night visits a year per general practitioner. That means six a month. The work load survey is the best available overall evidence about work loads and it is far more reliable than the odd individual and sometimes unsupported anecdote that we sometimes hear. The British Medical Association participated in the survey that was submitted to the independent review body.

The 1992–93 survey revealed that doctors work an average of 31.9 normal hours a week, 6.9 out of hours—including two hours on night visits—and 19.2 hours on call. The problem is that the anecdotes on which much of the general debate on out-of-hours care is based are not supported by the work load study. The study also revealed that, between 1989–90 and 1992–93, working hours increased by 2 per cent. but remuneration increased by 8 per cent. in real terms. By any national indicator and across the system as a whole, which is what the independent national review body must consider, doctors have been well supported in cash terms. They have also been well supported in terms of their work load.

Listening to the hon. and learned Gentleman and other Opposition Members, one would think that the changes in the role of the general practitioner had occurred unsupported. Let us run through the figures relating to GP support. The number of all-staff support in general practice is up from 37,000 in 1989 to 51,000—a 38 per cent. increase. The number of nursing staff has risen from 4,600 to 9,099, a virtual doubling of their number. The number of non-nursing staff is up from 32,000 to 42,000, a 30 per cent. increase, and the direct cost of providing those increases in staff has risen from £242 million to £510 million. That is not an unsupported system, which is how the hon. and learned Gentleman chose to portray it.

It is clear that there have been changes and developments in what GPs do. More care is rightly provided in the primary sector. Indeed, it is the purpose of a primary care-led national health service, but the hon. and learned Gentleman's suggestion that all this has happened with GPs picking up the burden unsupported, either in terms of those who work within practices or in terms of the Government's cash commitment to ensure that they are properly paid, is quite wrong. It is an argument that I refute absolutely.

The Government have responded to the concerns that have been expressed over some time in a variety of meetings between the British Medical Association and me and between it and my right hon. Friend the former Secretary of State. Part of the difficulty has been that, as we have made progress in a number of areas, the goalposts have occasionally been shifted and new arguments put. That is what has happened now, and the hon. and learned Gentleman will be well aware of a call, on the record, to look at the total separation of the 24-hour contract into two parts.

Before that proposal is considered, we must consider its implications. It would mean, for example, that a patient would have to look to two GPs for their services through a 24-hour period. What would out of hours mean? Would it still be an option for a GP to do some out-of-hours service and merely to relinquish the responsibility for night calls? Would the split operate from 6 o'clock in the evening, or at 10 o'clock? To whom would the patient look?

That separation is a dangerous road to travel and would be against the history of the way in which primary care has developed since the NHS came into being. It would be bad for the quality of patient care and it would be a retrograde step. When the hon. and learned Gentleman starts to embark on that path, I wonder whether he has really considered all the implications.

I understand what GPs' leaders are telling us: family doctors are finding it increasingly difficult to balance the demands of their out-of-hours work and their home life. We do not underestimate that strength of feeling. We recognise that GPs work extremely hard, and we are determined to address those concerns not just for the benefit of GPs but to safeguard the quality of patient care.

The importance of underpinning that quality of care was brought home to me recently in an Adjournment debate. A difficulty had arisen in a case of out-of-hours cover. The important thing was that at least the patient knew to whom she could turn. It is important to continue to encourage the high patient satisfaction that is delivered through primary health care, which is one of its greatest assets. We must be extremely careful not to build into that system the potential for demarcation disputes and uncertainty about to whom the burden should be passed. They would cause great difficulties and would not do the profession any good in the long term.

I reiterate that, within the context of the present system, we wish to make progress and explore what has been said recently by the profession to see whether we can build further on our initiatives. The hon. and learned Gentleman mentioned one extremely important initiative: how patients address and use their GP service. I must say to him that it was slightly fanciful—I do not know whether he thought it through—to suggest that we should launch a multi-million campaign, with me, as the Minister, on television instructing patients on how they should behave. It appears that that would be compelling and would result in patients changing their practice. My hon. Friends might be rather interested to see such a demonstration, but I am not sure that it is one that I would support.

If patient practice needs to be changed, the people to lead that must be medical practitioners, because it is important for them and their professional futures that they do nothing to undermine their relationship with their patients. In many cases that lead has already been taken. I recently visited a practice in Essex where a patient education campaign was vigorously under way. Details of how it operated were contained in the patient practice brochure, which had been issued to all patients. Out-of-hours calls had reduced significantly as a result. The Government are prepared to help and build upon that sort of initiative, and I hope that we can move forward on the issue.

Mr. Alex Carlile

I am glad that a practice has been able to achieve something with a patient education campaign. Does not the Minister agree, however, that there is a serious problem with the view that some patients have of the NHS, exemplified by the 11 million-plus hospital appointments which were not kept in the last year for which statistics were available? Does he also agree that many GPs are not as skilful in managing their practices or patient relations as the example that he gave, particularly those hard-pressed, single-handed GPs who are attempting to function in some inner-city practices? Does not he think that the Government should bear the responsibility for patient education for the great mass of patients?

Mr. Malone

I have already said that we are prepared to help and support schemes, but I would wish to talk through with the profession how one could do that in detail. We are engaged in that process. The hon. and learned Gentleman should know that evidence exists of best practice and good practice around the country. I have told the medical profession that, if we can reach common ground on the out-of-hours issue, we can then proceed with patient education. The thought that such a programme could proceed against the background of the proposed industrial action of the medical profession is somewhat fanciful. That would undermine the process from the start. To embark on such a programme now would not represent a sensible use of public funds, nor would it achieve the result that everyone is seeking.

We have heard from the hon. and learned Gentleman many of the arguments that have surrounded the issue over time, but not much that illuminates the initiatives that he and his party would take and that would go much beyond what the Government are doing.

Mr. Alex Carlile

I offered six new ideas.

Mr. Malone

I listened to those six ideas, and quite a few of them happen to be precisely what the Government are already doing. The hon. and learned Gentleman mentioned rural areas, and I have set out precisely what we are doing in that respect. He mentioned patient education, and I said that the Government are prepared to respond to that proposal. He mentioned a range of novel ideas about providing out-of-hours care. I have explained that we prepared to look at such care and innovate and have set aside £45 million for that purpose. Much to my regret, as long as the problem with out-of-hours work continues, that £45 million lies unused either for the benefit of GPs or their patients. It could be used to improve the services from which patients would benefit.

The hon. and learned Gentleman spoke about increased use of technology. I do not know what he meant by remote technology in the home. I suppose that even the Liberal party has caught up with the introduction of the telephone around the country. In extremely good practices, especially in 24-hour primary care centres, a lot of consultation can be carried out by telephone to reduce the burden on GPs. I am on all fours with the hon. and learned Gentleman on that practice.

The only point on which I disagreed with the hon. and learned Gentleman related to the separation of the contract. Were he to follow a route towards a double structure of primary care, he would be wrong.

We have moved some distance in the past few months in response to what doctors have said to us about two key areas. First, we must not compromise the quality of patient care in reaching a new arrangement for out-of-hours work and, secondly, we must strive to reduce the worst of the work load burden, and I am happy to consider whatever arrangements could be introduced by GPs to assist.

Substantial progress on the new arrangements has been made, which must be recognised by the House, not just on its own merits but especially in the context of the way in which the Government have underpinned their commitment to general practice in words of encouragement and in deeds, cash and commitment over a lengthy period.

I hope that we can put the current problems behind us soon. I hope that, when my right hon. Friend meets the profession later this week he will be able to make further progress, because it is in the interests of patients that we resolve that matter quickly.

8.9 pm

Mr. Nicholas Brown (Newcastle upon Tyne, East)

This is the first parliamentary occasion that I have had to congratulate the right hon. Member for Loughborough (Mr. Dorrell) on his appointment as Secretary of State for Health, and I congratulate him on my own behalf and on behalf of my right hon. Friend the Member for Derby, South (Mrs. Beckett), unreservedly. I welcome him to his appointment and congratulate him on his merited promotion.

I also take careful note of the fact that the Minister of State is still with us. He said that he was happy with his lot, and if he is happy with his lot we are all happy for him.

The hon. and learned Member for Montgomery (Mr. Carlile)—rather churlishly, I thought—regretted the absence of the Secretary of State for the opening minute and a half of the debate. That was rather to overlook the much more welcome, and I hope permanent, absence of the previous Secretary of State.

The Liberal Democrats in their motion tell us, among other things, that we should aspire to a pattern of out of hours services which is right for patients, fair on the taxpayer and manageable by family doctors and appropriate for 21st century health care. Opposition Members would certainly aspire to that, and I congratulate the Liberal Democrats on phrasing their motion in that way.

The words were not original; I guess that that will not come as a surprise to the House. They were lifted from something that the right hon. Member for Peterborough (Dr. Mawhinney) said in 1993 when he was Minister for Health. So that is a part of the Liberal motion that can unite both sides of the House.

The case for debating the increased demand for out-of-hours service is well made. Demands have increased by five times in the past 25 years and doubled in the past three years. The hours worked by general practitioners during the out-of-hours period—as was at least implicitly conceded by the Minister of State—have increased. They have increased by 49 per cent. since 1985–86, the middle of the last decade.

GPs undertake twice as many night visits now as they did before the new contract was introduced. The number now is 2.3 million visits per year, and that compares with 1.1 million in 1989–90. Twenty-three per cent. of doctors spend 80 hours or more a week providing services to patients and being on call, and the cost of out-of-hours service to the national health service has quadrupled in recent years to £82 million a year. That follows the renegotiation of the general practitioner's contract in 1990.

The Chancellor of the Exchequer can hardly fairly complain about that quadrupling of the cost, because the present Chancellor of the Exchequer was the Secretary of State for Health who renegotiated the contract.

It is right for the House to pause and ask itself why demand for out-of-hours services from general practitioners is growing, and appears to be growing disproportionately. There are several possible reasons.

The research on that subject is quite thin, so, although the Minister of State rightly deplored relying on anecdotes, to some extent we have to, because his Department either has not done the research or is not sharing the research with the rest of the House. I suspect that the latter, rather than the former, is more likely.

There is a growing consumer culture—a culture that is encouraged by the patients charter, which has brought the language of consumerism into the health service. People are told of their entitlement or right to be seen by a GP at any hour of the day or night, and I notice that, in the Government's amendment to the Liberal Democrat motion, they refer to supporting the approach of the Patient's Charter, which stresses to patients that with rights come responsibilities". You would expect, Mr. Deputy Speaker, that the rights and responsibilities would be expressed even-handedly in the patients charter, so I thought I should check that that was so, because that was not the impression that I received on first reading the document. I decided to thumb through my copy, looking, not for the rights—the document is full of what it describes as "rights" and "expectations"—but for the word "responsibilities", to note where responsibilities were mentioned.

A paragraph on page 10, right at the bottom, says: You can help the NHS by only calling out your GP at night if it cannot wait until the next day", which is a perfectly fair thing to say. Later in the document, at page 24, there is another duty as opposed to entitlement, where the document says: Warning—don't keep old medicines around the house. Please return them to your pharmacist for safe disposal. The rest of the document is full of, "you can expect this, you can expect that; you are entitled to this, you are entitled to that". I read on, in search of the section that mentioned responsibilities, which the amendment to the motion suggests that I might find. It is not until one reaches page 28 that the word "responsibility" appears at all. It does say that if you must use the services, you can help the NHS by using its services responsibly and it suggests that patients return equipment such as wheelchairs and crutches … when you no longer need them and become a blood donor and always carry an organ donor card and so on.

Right at the bottom of page 28, the last page of the document, it says: remember that you benefit if your GP has a good night's sleep, so please only call your doctor out at night if it cannot wait until the next day. I believe that the Government are pushing it somewhat to describe the construction of the document as stressing that with rights come responsibilities". The patients charter does no such thing.

Mr. Michael Fabricant (Mid-Staffordshire)

I too have a copy of "The Patient's Charter and You", and I have been looking through it. In fact, the mentions of out-of-hours treatment are all on page 10, and there are two statements. One is: when it is and is not appropriate to call on your GP for out-of-hours treatment and the other is the line that the hon. Gentleman read: You can help the NHS by only calling out your GP at night if it cannot wait until the next day. That seems to me to be an especially balanced approach to out-of-hours visiting. It is all very well for the hon. Gentleman to play games with his computer or count through manually when responsibility is and is not mentioned, but it is not fair to say that that is a reflection of what the charter is all about.

Mr. Brown

The hon. Gentleman suggests that I exercised enormous skill and spent an enormous amount of time checking how many times the word "responsibility" is used in the patients charter. As the word occurs only once, it did not take me long.

Mr. Fabricant

You had to read it.

Mr. Brown

As the hon. Gentleman fairly says from a sedentary position, it put me to the obligation of reading the patients charter, but, as I am the shadow Minister of State and therefore required to take an interest in such things, that is perhaps no bad thing.

As I have diligently done my bit to prove my point, I hope that the hon. Gentleman will do me the courtesy of now going through the document and telling me how many times the word "expect" occurs. He will no doubt have completed his research before 10 o'clock, and can perhaps intervene on another speaker to tell me what he has discovered.

Mr. Matthew Banks (Southport)

So this is what you use Short money for, is it?

Mr. Brown

The hon. Gentleman, as he intervened from a sedentary position, appears to suppose that I am using his hon. Friend as an unofficial deputising service. I am sure that he can serve in that capacity as long as he starts counting now.

It is obviously also the case that, in a society in which people are used to consuming services late at night—taxis, chemists, late night shopping, fast food delivery—it will occur to them to try to consume medical services late at night. Indeed, the universal availability of the telephone, which the Minister mentioned, has meant that people are now used to telephoning for things that they certainly were not used to telephoning for when the original terms and conditions of the general practitioner's contract were set, because people did not have telephones when the service was first structured as it now is. There is an expectation that general practitioner services will be available at night, that they can be summoned up as of right and that an entitlement exists. The Government's patients charter has done much to underpin that way of viewing the service. I also believe, although it is difficult to find hard evidence to make the point precisely, that, to some extent, emergency services—there is a parallel with the ambulance service—are used as a substitute for the more conventional provision of primary care.

Having said all that, it would be wrong for the House to overlook the fact that much of the out-of-hours work performed by general practitioners is genuinely needed. It would also be wrong of us to overlook the fact that most of our fellow citizens consume the national health service in a responsible way. There can be no doubt—there is no quarrel over the issue between myself and the Minister—that pressure on the service has increased. I am certain that it has an effect on general practitioners' work load and morale.

There has been a drop in the number of people coming forward to train as GPs—a 15 per cent. drop since 1990. There has been a similar drop in the number of more senior doctors coming to general practice having been hospital doctors, having worked abroad or even having left the service temporarily for family reasons. There is also an increasing trend towards early retirement, as we discussed earlier. That is facilitated by the early retirement package for GPs, which allows general practitioners to quit at 50 with a lower pension. General practitioners still find that attractive and avail themselves of the package. The issue will not go away, and it clearly has to be addressed.

I am certain that the solution is not to be found in ending negotiations. I am equally certain that the solution will not be found in industrial action in the national health service, which I oppose. The issue is not primarily about money, although money is involved. It is a little rich for the Government amendment to refer to payments so that the average general practitioner will receive an extra £800 per year". The figure is arrived at through the complexities of the GP contract and the complexities of the way in which general practitioners are paid.

I believe—I stand to be corrected if I am wrong—that within the figure of £800 the Government include money that would be carried forward from last year's underspend. The money would be paid to general practitioners in any event and is not new money specifically to be paid to general practitioners for the out-of-hours service. If I have misunderstood that or have misrepresented the Government's position, I shall happily give way to the Minister. I think that I am broadly right in saying that the figure of £800 is as high as it could be and includes money that would fall to GPs anyway.

Mr. Malone

The hon. Gentleman will understand that the mechanisms in place do not always deliver the money to GPs. The point about the change in the fee structure mechanism now proposed is that it will deliver money. When compared with the present structure, GPs will be, on average, £800 better off.

Mr. Brown

I rather thought that I had got it right. If I ever get into terrible trouble and if the Minister of State is in private practice I shall almost certainly employ him to represent me in the courts—I certainly would not employ him as a doctor. The Government are clearly inflating their £800 figure to get it as high as they can. It does not represent new money given to general practitioners that they would not otherwise receive. That is what the Government seem to be trying to imply, but it is not true.

Mr. Malone

I am grateful to the hon. Gentleman for giving way again, because it is a fairly abstruse point.

It is of course the case that the global pool of money that the independent review body recommends is delivered in a number of different ways through different fee mechanisms. What the hon. Gentleman says is right: the money is part of that funding. But it is funding that may not have been drawn down, and will now be delivered. What the review body will recommend in succeeding years will depend upon what is paid this year. It is important to draw the money down at an earlier stage rather than leave it there untouched. The hon. Gentleman's suggestion that it does not matter because the GPs would have got the money anyway is wrong. It is a figure that they will receive, on average, in addition to what they would otherwise have received this year.

Mr. Brown

If the Minister is now saying that there was some prospect that the element that stood to be carried over would not have been carried over, he should say that to the GPs rather than to me. He would be announcing a new concept. I do not think that it is for the Minister to withhold the money—the Minister shakes his head and confirms that the position is as I understand it.

If the solutions are not to be found in industrial action, which the Minister and I oppose, it logically follows that negotiations must continue. That is clearly the right way to proceed. The solutions will not be found in simplistic statements. I was slightly surprised to hear a leading Conservative intellectual, the hon. Member for Harlow (Mr. Hayes), say on the "Today" programme in early June, when stating the position on behalf of the Government: If someone rings up a GP and says I've got a sore throat come and see me, you tell them to get lost, don't you. Such simplistic solutions will not help, and I do not think that the solution lies in that approach.

There is merit in a public education campaign. Although the Minister clearly disqualified himself from playing a leading role in it, I do not think it would do any harm if the Minister went on television and explained what the out-of-hours service was for and what it was not for. Those are not points about which the major political parties are quarrelling, so why not spell out how the service should be used responsibly and, perhaps, give some examples of irresponsible or inappropriate use of the service? I do not believe that a public education programme will solve the problem, but it has a part to play.

The solutions lie in a co-operative way of working in general practice. The internal market exacerbates the problems. The Labour party's policies, with the emphasis on public service rather than the internal market, go a long way to resolving the problems. In our new policy document, we advocate closer co-operation between GP practices and local health authorities, both in the commissioning of hospital services and in the planning and development of primary care.

A successful solution to the problems faced by general practitioners providing out-of-hours service has been the formation of local GP out-of-hours co-operatives. One such example is the out-of-hours co-operative in the Kensington, Chelsea and Westminster health authority. Under that scheme, local GPs can sign up with the co-operative and divert all out-of-hours calls to the co-operative switchboard. In return, the GP agrees to participate in a duty rota for taking calls and making home visits organised by the co-operative.

As well as that excellent example of co-operation, the co-operative goes further and employs drivers to take the general practitioners to the patients' homes. That relieves the GP of the stress of navigating and driving alone to different parts of London. The scheme fosters a welcome team spirit among GPs on night duty and reduces the likelihood of GPs being attacked while making home visits—the more so as they have the driver with them. It is a more efficient way of dealing with out-of-hours calls and it significantly reduces the burden on individual GPs.

Another example—again, wholly in line with the health policies recently launched by the Labour party—is the one-stop shop such as the one in Norwich, which provides advice and information to local people. The scheme is intended to change the pattern of primary care delivery to meet the needs of today's population. Out-of-hours services are certainly among the range of services that the Labour party is keen to see improved in order to benefit patients and to relieve the pressure on GPs which, it seems, will remorselessly increase as they have to carry out their out-of-hours services.

Our proposals for co-operative working between GPs in the commissioning and planning process lend themselves to the possibility of locality groups of general practitioners setting up out-of-hours co-operatives and one-stop health shops. That is in complete contrast to the Government's approaches, which are underpinned by the national health service reforms. In many instances, fundholding has forced GPs into competitive relationships with their professional colleagues.

We want to replace competition in the health service with co-operation. We believe that all health care professionals will want to co-operate with each other, with the aim of delivering ever-higher standards of patient care. The competitive requirements of the internal market work against co-operation and hinder the development of innovation which brings with it efficiency in the health service and, dare I say it, greater benefits to the patients.

8.30 pm

Mr. Bob Dunn (Dartford)

I had intended to welcome the Secretary of State to his new post and to wish him well within his new terms of reference. However, as he is not in the Chamber, I shall not do so.

When the Liberals hold their weekly meeting and examine the success of the two half-day debates, I think that they will conclude that they have been an utter waste of time. In the last debate, the Minister for Transport in London successfully duffed up the Liberal party on its proposals for the railways, and I think that we are about to see a repeat performance in this debate, as I have heard nothing so far to convince me that the Government have got it wrong with regard to out-of-hours patient care. In fact, my support for the Government is reinforced by what I have heard from the Liberal Benches today.

I am sorry that the Liberal Democrat spokesman, the hon. and learned Member for Montgomery (Mr. Carlile), and his parliamentary minder the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) are the only Liberals present, as it would have been of benefit to all their colleagues to listen to the debate and understand why the basis on which they applied for it is wholly misguided.

Mr. Matthew Banks

If the parliamentary minder, the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood), had not been present, the hon. and learned Member for Montgomery (Mr. Carlile) would not have realised that the words of the motion that we are debating this evening were those of our parliamentary colleague, the right hon. Member for Peterborough (Dr. Mawhinney). That was clear from the exchange that took place when the matter was referred to earlier. [Interruption.]

Mr. Dunn

I will try to speak above the outbreak of frustration from the Liberal Benches. I am happy to respond to my hon. Friend's point. He is entirely correct: it is a very strange debate on a very strange day.

When I was much younger, I remember reading the history of the Liberal party—it is always wise to read about the history of one's opponents. The Liberal Democrats were once a great party. In our constituencies we probably have—as you do, Mr. Deputy Speaker—a Grenville street, a Gladstone road and a Rosebery gardens, but will we find an Ashdown street on the new housing developments in our constituencies?

Mr. Alex Carlile

Will the hon. Gentleman give way?

Mr. Dunn

No, but I shall give way shortly. I want to finish this important point.

I suspect that we shall not see an Ashdown street, a Carlile road or a Beith gardens in the new housing developments in our communities. It is more likely that we shall find an Ashdown tip or an Ashdown recycling plant, because that would be appropriate to the once great party that is now reduced to a parliamentary sect.

The Liberal Democrats are no longer a party because, according to my definition, a political party has to be based on a philosophy; it must have principles. The one thing that the Liberal party has shown itself to be to date is a wholly unprincipled party without a philosophy. It is no longer motivated by philosophy, but by opportunism—as we can see at all levels of government, from parish to Parliament.

I wish to make an important announcement to the House, if I may, Mr. Deputy Speaker. Earlier this week, we heard that a Mr. Steven Stenton, who was until the weekend a Liberal Democrat member of Kent county council, decided that his future no longer lay with the Liberal Democrats, and on Monday he applied to become a member of the Conservative party.

Mr. Carlile

Will the hon. Gentleman give way?

Mr. Dunn

I am in full flow. I will give way in a moment. That now increases—

Mr. Deputy Speaker (Mr. Michael Morris)

Order. I am not sure whether the gentleman referred to is a patient or whether he attended out of hours. Either way, perhaps the hon. Gentleman will assist the Chair by returning to the motion.

Mr. Dunn

I mentioned the incident because the defection took place out of hours, Mr. Deputy Speaker. It took place at the weekend.

Mr. Carlile

Does the hon. Gentleman accept that his "full flow" simply confirms what a dry summer it has been? Does he accept that all political parties, including the Conservative party, have their loonies and that we are happy to see the odd loony go to the Conservative party rather than somewhere more sensible? Will the hon. Gentleman explain why he is prepared to vote today against the very deliberately chosen words of the right hon. Member for Peterborough (Dr. Mawhinney)?

Mr. Dunn

I will certainly pass on the hon. and learned Gentleman's comments to Mr. Stenton. I am sure that Mr. Stenton's decision will be reinforced by what has been said today.

I shall vote for the Government amendment because the Government are doing exactly what I want them to do. I am here to support the Government and to advise, caution and warn them on those occasions when they get things wrong. So far, I have heard nothing from hon. Members on either side to cause me to change my mind. I came to the debate with an open mind; I wanted to listen and to learn from the debate. I am a genuine parliamentarian of the old school.

I welcome the Minister's announcement that talks will continue between the British Medical Association and the Government. That is right and proper. No one in the House wants to see general practitioners take industrial action. There was a perceived loss of professionalism on the part of teachers when they went on strike. I hope that the doctors have learnt from that incident and I am sure that they do not want to go down the same route. There has been a diminution of the perceived professionalism of the Royal College of Nursing since it decided recently to abandon its 80-year-old strike ban. Clearly, the Royal College of Nursing no longer deserves the description "royal"—and it is no longer a college, but a nursing trade union.

Mr. Carlile

Disgraceful.

Mr. Dunn

It may be disgraceful, but it also happens to be true—it is amazing how I can throw my voice and speak twice. The hon. Gentleman must enter the real world. If he spent more time in the House, he would understand the genuine concerns of our constituents. The Royal College of Nursing is no longer royal and it is no longer a college; it is simply a trade union. The BMA, to which hon Members opposite have referred, is probably the same thing.

Dr. Macara may not have posters on his wall of Daniel Cohn-Bendit—I am probably one of the few people present who remembers Danny the Red—or Che Guevara, another hero of the pot-smoking left, but Dr. Macara is no Conservative.

Mr. Carlile

He was.

Mr. Dunn

Well, he is not now.

Mr. Carlile

You have driven him away.

Mr. Dunn

Am I to be protected from such outbursts, Mr. Deputy Speaker? Dr. Macara is not a Conservative; he might have been a Conservative once for the wrong reasons, but he is not a Conservative now—and that is all that matters.

I have received only one letter about the subject of out-of-hours patient care, and that worries me. Some 80 per cent. of my constituents in Dartford are covered by fundholding general practices. It may well be that the people I represent are satisfied with that arrangement and with the provision and dispatch of services to them and to their families. If there were a tremendous groundswell of concern, as reported by the hon. and learned Member for Montgomery, I suspect that I might have heard more about it from my local GPs, who often write to me about their concerns. However, they have no concerns about this issue.

I wonder, therefore, why the Liberal party chose to debate the subject today. I read the Liberal motion with great interest. The motion about out-of-hours patient care in the name of the leader of the Liberal party refers to the need for a method of work that is manageable by family doctors. The proposals by the Minister of State on 20 April confirm that that is also the Government's view. They want a manageable system and they hope that the public who use GPs' services will differentiate between genuine and non-genuine calls. The hon. and learned Member for Montgomery mentioned some examples earlier.

Anyone who has been a parent knows the anxiety and stress that parents face when a small child is ill. Sometimes it a balance of judgment between being concerned and frightened about the health of one's child and ringing the doctor, or waiting until the next day, hoping that it will not matter too much. There will always be a balance between wasting the doctor's time and asking the doctor to come round because one is frightened out of one's wits because one's child is so ill.

The motion believes there should be a right for general practitioners to transfer responsibility for out of hours care to another general practitioner". That was also proposed in the offer on 20 April 1995, so what is the problem? The motion also supports the need for substantial, ongoing patient education campaigns on the appropriate use of the out of hours emergency service". No one in the Chamber has disagreed with that so far. The hon. Member for Newcastle upon Tyne, East (Mr. Brown) said as much a few moments ago, but that was also in the offer.

There is a need to make patients aware of the stress that they can put on doctors and, more importantly, doctors' families. The hon. and learned Member for Montgomery gave an account of his own family, with a father who was a GP in my native Lancashire.

Inevitably, there will be occasions when the implications will not get through to those who waste time. We have heard nothing about what should be done about irritant patients who continue to waste time because there is something wrong with a little finger, the plasters have run out or they cannot get headache tablets. We must also be aware that the stress on GPs is huge and when they become tired because of out-of-hours work, their judgment may be affected. As society is increasingly litigious, it is necessary to protect doctors from what may be called the American syndrome, and that concerns every Member of Parliament.

I firmly believe that everything that the Government have done to date is right. I have no doubt that the Minister will listen to what has been said by hon. Members in all parts of the House before replying to the debate. I am sure that the BMA will also listen carefully to the words of hon. Members. One can wave the wand of disruption only once or twice before it becomes devalued and the BMA must be concerned about its long-term image in the community.

We all know that society makes many more demands on public servants, whether they be Members of Parliament, local councillors, therapists, social workers, doctors or anyone in the public eye. There must be a balance and GPs must be protected. That is why I am wholly in favour of the Government amendment.

8.42 pm

Mr. Michael Fabricant (Mid-Staffordshire)

It is indeed an honour to follow my hon. Friend the Member for Dartford (Mr. Dunn) who is a parliamentarian of the old school, as he said and I am now happy to endorse. He said that he had received just one letter from a constituent. I, too, have received only one letter regarding this matter and that was from my own general practitioner. He is my personal general practitioner, Dr. Barry Jones, a fundholder at the Minster practice in Lichfield. Not only did we discuss the matter in his surgery, but we also discussed it in the Eastern Eye Indian restaurant in Lichfield, where from time to time I hold my surgeries.

My hon. Friend the Member for Dartford spoke about plasters running out. My general practitioner was telling me that one patient phoned him up saying that his cotton wool had run out and he needed another prescription. He had cotton wool on prescription for a number of years following a prostate operation. When my doctor asked why he still needed cotton wool, the patient said that he required it because of the prostate operation. My doctor asked why he still needed it after four years. It transpired that he was using the cotton wool to stuff soft toys and he was doing it on the national health service. That gives some idea of people's expectations when dealing with the national health service.

I listened to the advocacy from the hon. and learned Member for Montgomery (Mr. Carlile). He was certainly no advocate in respect of general practitioners. When he began his speech, seven Liberal Democrat Members were in the Chamber. He made some puns about fugues and one Member left halfway through. He then proceeded to contradict himself as to whether or not it was an issue of money and I noted that another Liberal Democrat Member had walked out. He then made a joke as to whether the Secretary of State was present. His supporters went down to three and at one point there was only one. I see that now there is only himself and the ever-present Liberal Chief Whip, the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood), sitting silently and noting the lack of support from his own side.

Mr. Dunn

The minder.

Mr. Fabricant

As my hon. Friend says, he is the minder, the silent and ominous one noting what has been said.

The hon. and learned Member for Montgomery said that out-of-hours care should not be an issue of money. He went on to talk about the redistribution of wealth, but he made absolutely no practical suggestions, except for the one about advertising, to which I will return later. At that point there was absolutely no one else from the Liberal Democrat party in the Chamber.

He said that there should be remote control diagnosis and I wondered what he envisaged. Perhaps the hon. and learned Gentleman will intervene and tell me whether there should be remote control diagnosis by means of the latest technology. Is he suggesting that the Government should provide everybody in the country with remote-control ECG and EEG machines or other paramedic technology that we should all have in our homes so that we could hook up should a diagnosis be required? That is an example of Liberal Democrat muddled thinking.

My hon. Friend the Minister of State rightly pointed out that some £45 million in additional funds will be made available for out-of-hours patient care. He spoke about 24-hour primary care centres and GP co-operatives. Incidentally, it was interesting that the hon. Member for Newcastle upon Tyne, East (Mr. Brown) said that the Labour party supported co-operatives and one-stop shops. In his typically amiable way, he advocated everything that already exists and has been introduced by the Conservative Government, but he chose not to mention what the Labour party would do to fundholders or trusts because there is no clear Labour policy on that.

Mr. Nicholas Brown

The hon. Gentleman is being uncharacteristically unfair. I said that I felt that the Government fundholding structures set neighbouring general practices against one another and that such a competitive way of working was not the best way to solve the out-of-hours problems. I said that our co-operative model was a better way to proceed, so I dealt with the points to which the hon. Gentleman has just referred.

Mr. Fabricant

The hon. Gentleman is reiterating the points that he made in his speech, but he did not say whether he would abolish fundholding overnight if Labour came to power.

Mr. Brown

Yes, it is our intention to phase out individual practice fundholding as currently structured over a period which may be as long as three years, but hopefully will be shorter and certainly in the first period of a Labour Government.

Mr. Fabricant

The hon. Gentleman is being untypically mealy-mouthed. He spoke about phasing out, he then said it would be abolished over three years and then he said that abolition would happen in any event, possibly within the five years of a Labour Government, should one come to power.

Mr. Malone

I would not like my hon. Friend to be under any misapprehension that Labour would do other than offer a fatal threat to GP fundholding. It is not mealy-mouthed—Labour is planning to abolish fundholding and to do away with all the benefits that it brings patients.

Mr. Fabricant

If that is the case—although one would not think so listening to the hon. Member for Newcastle upon Tyne, East, who presents a confused picture about the amount of time that phasing would last—there would be a problem. Every general practitioner in Lichfield is a fundholder, including many who told me that they always vote Labour. Hearing the hon. Gentleman, I wonder whether they would ever vote Labour again.

Mr. Brown

I must correct the hon. Gentleman. I did not say that fundholding would probably go but that it would go. The Minister and I disagree on whether or not that policy is right but there is no disagreement between us, for once, as to Labour party policy. GP fundholding will go.

Mr. Fabricant

That is sad news. I wonder whether the hon. Gentleman has any policy on trusts. He shrugs. It appears that members of Labour's Front Bench are now conferring and making policy on the hoof. I await a further intervention, to learn what would happen to trusts. There seems to be some confusion. In fact, there seems to be an argument between Labour Front-Bench members.

Ms Estelle Morris (Birmingham, Yardley)

indicated dissent.

Mr. Fabricant

Nevertheless, we await Labour's suggestions with interest.

The offer is clear—an extra £45 million within the overall health budget to support alternative out-of-hours arrangements. As my hon. Friend the Minister said, that extra funding would not otherwise be available to general practitioners. There would also be additional help for rural doctors within that £45 million.

Mention has been made of studies of GPs' work load, and it is worth reiterating the hours that they work. I take my hon. Friend the Minister slightly to task, in the sense that there is no such thing as an average practitioner. Nevertheless, the average GP works a normal 31.9 hours per week and 6.9 hours per out-of-hours, making a total of 38.8 hours—plus 19.2 hours on call.

There is a requirement for a re-education programme. The hon. Member for Newcastle upon Tyne, East talked about the patients charter, which is an excellent publication. The hon. Gentleman, or perhaps one of his assistants, has spent the last few days counting the number times that "expect" and "right" appear in the charter. That is rather amusing, because one can well imagine that if the charter included no expectations or rights, the hon. Gentleman would be the first to complain. The existence of the patients charter provides patients with a clear guide to what is expected of them and of practices, which cannot be a bad thing.

Difficulties have, however, arisen—primarily because of patients' expectations. It is not just the relationship between patients and doctors that demands re-education. I well recall my first surgery after I entered Parliament. One gentleman talked to me for five or six minutes, leaving me wondering what point he was trying to make. It eventually transpired that he was concerned that his wife was, to use his words, playing around. I wondered whether he expected me to raise that matter in a parliamentary question. Clearly, he had come to see me simply to express his worries and to talk them over with someone. That sort of thing is becoming increasingly common in the relationship that the public have with Members of Parliament and general practitioners. Perhaps the accessibility of politicians and of general practitioners on television creates an image that is not always helpful.

My discussions with my own GP included one this afternoon, after I decided to take part in this debate. He told me about some of the problems that have confronted him out of hours. This evidence may be anecdotal and, as I said, there is no such thing as the average GP.

A few weeks ago, Dr. Barry Jones was telephoned at 3 in the morning by someone who had toothache, wanting to know whether it would be all right to take aspirin or paracetamol. On another occasion, he was telephoned at I in the morning by a very drunk lady who asked whether he could provide a morning-after pill because she had committed an indiscretion some hours earlier—whether drunk or sober, we do not know. In another incident, Dr. Jones was telephoned at 3 in the morning by the parents of a child with a runny nose, who were concerned that their child might have meningitis.

Mr. Hugh Bayley (York)

The hon. Gentleman has described some of the frivolous reasons for which GPs are telephoned in the middle of the night, but how will the Government's proposal to throw money at the problem reduce the number of such calls? Should not the Government consider instead ways of reducing pressures on general practitioners, possibly by involving people other than GPs in the provision of out-of-hours medical services?

Mr. Fabricant

The hon. Gentleman is not necessarily right in suggesting that people other than GPs should be brought in. That would not solve the problem. I am flabbergasted—and I am rarely flabbergasted in the Chamber—to hear a Labour Member say that the Government are throwing money at the health service. If throw money at the health service we must, then we must—because the Government have a commitment to the NHS. I am grateful to the hon. Gentleman for reminding the House of that commitment. He asked whether something else could be done. Earlier, I mentioned re-education, and I will develop that point shortly.

I will cite a few more examples of calls to my doctor because they are not just frivolous problems; they are educational, too. If anyone is listening to this debate, such examples might even strike a chord and hold them back from telephoning their doctor unnecessarily.

Another patient who telephoned my doctor was suffering from diarrhoea and vomiting—apparently such calls occur frequently—following a two-week holiday. The illness had lasted for a whole week; yet nothing was done about it while on holiday. Instead, the patient rang at 2 am for the doctor's advice. That is not only frivolous but an especially selfish use of the national health service. On another occasion, my GP was telephoned at 4 am and asked whether he could produce a sick note to say that an individual, who had been arrested earlier that evening for breach of the peace, was not fit to attend court. The list of such calls goes on and on.

My general practitioner—who is clearly not average judging from the figures quoted by my hon. Friend the Minister—says that in the past five years his out-of-hours work has quadrupled and he reckons that at weekends the work out of hours has increased some tenfold.

I do not think that there is an easy answer to the problem. If there are answers, they will vary depending on whether they apply to rural, urban or inner-city practices. Of course primary care centres can help and the Government are already supporting them. The situation is particularly difficult in rural areas, but again my hon. Friend the Minister is throwing money—to quote the hon. Member for York (Mr. Bayley)—at the problem. Throwing money at it might be appropriate occasionally.

My doctor reckons that he generally works a 47.5 hour week and, on average, he is on call for nine hours each working week—not including disturbed sleep. As he said rather wryly, since Members of Parliament work long hours but have begun to introduce Jopling reforms, perhaps there needs to be a similar reform of the hours of GPs. Without weakening the services and, indeed, the Hippocratic oath taken by general practitioners, implementing such reforms would not be easy.

There is no question but that the patients charter benefits patients. However, it has also increased patients' expectations and we should address that problem. I mentioned the pastoral role of Members of Parliament when I described someone coming to my surgery to talk about his wife playing around. Too many GPs are also expected to play such a role. One wonders whether the church could play a greater pastoral role rather than its being expected of GPs.

There is a clear role for re-educating patients in what they should expect of GPs—and what should be expected of Members of Parliament. In Staffordshire, we have a very good commercial radio station called Signal Radio. The local family health services authority put out a commercial which, to me, stated the obvious. Clearly, however, it needed to be done. It explained that every time someone does not turn up for an appointment at a hospital, it costs the NHS money and it could mean a longer waiting list for an appointment next time. I would have thought that people would realise that if they could not attend an appointment they should telephone beforehand to allow others to fill the slot. It is a sad indictment that a commercial needs to be put out asking people to think of someone else and to "love thy neighbour as thyself".

The Government have introduced the excellent "Help Us To Help You" campaign, yet it could go a little further and need not involve great expense. Television advertising is expensive and I agree with my hon. Friend the Minister that the money could be better spent. However, I think that a radio campaign, which is on average about a tenth of the price of a television campaign, could be very effective, especially compared with other forms of advertising and promotion.

My hon. Friend the Minister is absolutely right when he says that GPs have a role to play too. I quoted from the patients charter, as did the hon. Member for Newcastle upon Tyne, East. The line on page 10 referring to when it is and is not appropriate to call on your GP for out-of-hours treatment should be included in the practice's own charter. So far, well over 50 per cent. of GPs and their practices have produced such charters, but the roles of both doctor and patient in out-of-hours treatment need to be more clearly stated in them.

We must provide better patient care. One of the great aspects of medical provision in Lichfield, and in mid-Staffordshire in general, is the ability of fundholders such as Dr. Barry Jones to send their patients to hospitals: the money follows the patient rather than the patient following the money. That is one of the most important changes that we have made over the past few years.

The hon. Member for Newcastle upon Tyne, East laughs, because he thinks that I am merely quoting a slogan. For the first time, however, the Victoria hospital in Lichfield has a dermatology centre, a new paediatric centre, physiotherapy, an ophthalmic centre and a new surgical wing. That is all due to money following the patient: fundholders such as Dr. Barry Jones can direct their patients to the Lichfield hospital and consultants from Wolverhampton, Birmingham and Sutton Coldfield must now come to Lichfield. Previously, patients from Lichfield had to go to those cities.

What would the hon. Member for Newcastle upon Tyne, East do? He said that perhaps in a year—or three years, or five years; he was not sure of the time involved—Labour would phase out fundholders. My only criticism of fundholding is that we have not introduced it universally; although it is universal in Lichfield, and virtually no GP in mid-Staffordshire is not a fundholder, unfortunately not every GP has become a fundholder nationally. It is through fundholding, however, that GPs are empowered to provide funds for patients as and when they are needed.

The NHS is safe in Conservative hands. It would clearly be in a very rocky state if it were in the hands of the Labour party—I would mention the Liberals, but as they are an irrelevance it hardly seems worth while. There should be more fundholders. GPs are a family practice, and they too will be safe in our hands. I have no doubt that, with a Minister of State like ours—caring, sharing, listening and co-operative; GP co-operatives were introduced by a Conservative Government, not by the Liberals and certainly not by the Labour party, which advocates them—the NHS will survive and continue to go from strength to strength.

9.8 pm

Mr. Roger Sims (Chislehurst)

Some GPs complain that they work long hours, that they are on call at all hours and that their social life is often in danger of being disrupted. As my hon. Friend the Member for Mid-Staffordshire (Mr. Fabricant) said, they will find no more sympathetic audience than those of us who are present now. Being a doctor is rather like being a Member of Parliament: it is not simply a job, but a way of life, subject to the vicissitudes that I have just described.

Whether some of us are at our best after a late-night sitting is an open question. Some of us occasionally are, but I suspect that some are not. Certainly, if I were unwell, I would not wish to be attended by a GP who had had only two or three hours of interrupted sleep. Accident, illness and disease are no respecters of the clock. Patients expect and need the 24-hour availability of GP services, and the Government should ensure that such services are available. The question is, of course, how that can be done.

The British Medical Association has stated that the issues are not about pay but about restructuring. The structure suggested by the Government, of a lump sum for each GP, payment for calls and substantial development funds for out-of-hours arrangements, seems to be entirely reasonable. My hon. Friend the Minister has deployed the Government's case, while the BMA has deployed its case. The differences are not great, and it should be possible for men and women of good will to sit around a table and agree.

The BMA states that it believes that, With willingness on the Government side, the differences between them could be settled. That may well be right, but only if there is also willingness on the BMA side. I am bound to say that threats of industrial action such as the BMA is making do not help the atmosphere for such discussions, and the BMA does itself and a respected profession no credit by waving that particular stick.

The BMA has listed various requirements which would need to be met for the differences to be resolved. Having listened to my hon. Friend the Minister earlier in the debate, I think that very nearly all the requirements are being met, although one or two seem a little unreasonable. The BMA says: The Government's recent offer tied up the so-called right to transfer responsibility in so much red tape—by requiring FHSA approval—as to render the proposal impractical. It should be sufficient for GPs to make proper arrangements for the transfer and simply inform the FHSA. The FHSA is responsible locally for ensuring proper provision of GP services. It would not be good enough for GPs just to make arrangements that they thought were in order and then tell the FHSA. It is entirely proper that the Minister should require the FHSA to approve any arrangements for the responsibility of the right to transfer.

The BMA also pleads that the Government should commit themselves to a public education campaign, a point that was made by the hon. Member for Newcastle upon Tyne, East (Mr. Brown) and reiterated strongly by my hon. Friend the Member for Mid-Staffordshire (Mr. Fabricant). I must say that it is a plea with which I have considerable sympathy.

I am very much in favour of the patients charter, but I can also understand why some doctors have asked "What about a doctors charter?" The hon. and learned Member for Montgomery (Mr. Carlile) referred to specific incidents in which doctors had been called upon unreasonably, and my hon. Friend the Member for Mid-Staffordshire has just quoted similar examples. That is a real dilemma, and every GP could cite similar cases, because I am afraid that some people make unreasonable demands on their doctors.

Such treatment is not confined to doctors. As a member of the Health Select Committee, I was involved in the inquiry and report on the London ambulance service. One feature that emerged from the evidence before us was the fact that people will telephone for an ambulance for the most trivial complaints. That means that an ambulance is often out on the street dealing with such calls when a genuine emergency call comes through.

Doctors are faced with similar calls. It is one thing to take a telephone call in which somebody asks about something rather trivial that can be dealt with by telephone, but it is a good deal worse if a doctor receives a somewhat garbled message, a few comments and a plea for him to go out and answer the call, only to find when he gets there that the problem is something that could easily have waited until the morning—if, indeed, his services were required at all.

Like the hon. and learned Member for Montgomery, I am a member of the General Medical Council, so I see what sometimes happens if doctors do not respond to calls which prove to be genuine. The consequences of a failure to respond can be serious, so one understands the dilemma of doctors who find themselves obliged to respond to almost every call, just in case. There is a real case for some sort of public education campaign to help people to realise in what circumstances it is right and proper to send for a doctor, but also to know what other steps they could take when the case is not so urgent.

As I have said, the differences between the Government and the BMA are capable of resolution around the table—but surely not across the Floor of the Chamber. The Liberal Democrats have not put their valuable parliamentary time to the best use tonight.

9.17 pm

Mr. Robert G. Hughes (Harrow, West)

It is a bit much if the Liberal Democrat spokesman who opened the debate, the hon. and learned Member for Montgomery (Mr. Carlile), cannot be bothered to stay for three hours to listen to his own debate—but I guess that the Liberal party never had much staying power.

I could describe the reaction in the Chamber to his speech as "general satisfaction" with what he said. That may surprise some hon. Members, but I say it because he had so much self-satisfaction that that made enough satisfaction to go round for everybody. We were treated to the stuff that he no doubt dishes out by the yard in the courts, and for which he is well paid. Frankly, it did not cut much ice here.

Once again, the hon. and learned Member for Montgomery showed us that there is nothing that the Liberals think too important to play party politics with. His was a trivial approach to the issue, trying to pretend that the complex issues did not exist or that we could wish them away. That was in stark contrast to the serious speeches from the Minister and from the Labour Front-Bench spokesman. Naturally, I agreed much more with the Minister than with the Labour spokesman, but they both made serious speeches about a serious subject that should not be trivialised.

I noticed several other features of the speech by the hon. and learned Member for Montgomery, the first of which was his patent dishonesty about money. The cry went up, "Is it new money?" Lots of new money has gone into the health service, we all know that. But of course it sounds good to ask the question, and that is all the Liberals care about. It sounds good to ask, "Is this new money?" and then to say that it is not, because it is not new since the beginning of the year. "Will it be taken from other services?" It sounds good, makes people attracted to what the Liberals say, but does not add up to anything substantial.

Once again, when the Liberals say that they want more money to be spent on something, they will tell us, "Well, this was in our proposals at the last election. We were the only people honest enough to say that there should be an increase in income tax." They did say that there should be an increase in income tax—of one penny. But they seemed to have forgotten how much one penny in income tax raises. It is less than £2 billion. When one adds up the sort of things that they say would be paid for from that one penny of income tax, one will see that it comes to about £8 billion or £9 billion. It is a patently dishonest approach.

The Liberals have the absolute cheek to say that there should be a large-scale advertising campaign about the responsibility that patients have in using GPs. Of course more responsibility should be shown. I shall come to that in a minute. My hon. Friend the Member for Mid-Staffordshire (Mr. Fabricant) pointed out some of the examples of abuse of the system. It was my experience last summer of having to answer attacks from the Liberals about the advertising campaigns that the Government are carrying out. The Liberals tell us, "It is only the Government trying to use them to their own advantage."

One area that the Liberals attacked was the newspaper campaign for people to carry the form—I believe it is the E1011—that one takes to European Community countries to claim medical services. The Liberal spokesman at the time told us that it was a complete waste of money, because of the number of clippings that were sent back from the newspapers. That was a deliberate misrepresentation of what that campaign was about. I have taken my family abroad, and it was seeing the Government's advertising campaign that made me think that I must go and get the form and ensure that I had it with me.

The Liberals have the cheek to suggest that they want more advertising, because they could then attack us in next year's fanciful parade. I shall make one prediction: this year, another Minister will have to answer more attacks from the Liberals on Government advertising. They did last year and the year before. Liberals are creatures of habit. Doubtless they will try it again.

Mr. Fabricant

Ironically, is it not the case that the Liberals enjoy an almost enviable position? They can make commitments to spending. They can attack Government policy one moment and then advocate it the next, simply because they know—not even deep in their heart of hearts, but quite openly—that there is no chance of them ever becoming a party of government, so they can take that irresponsible stance.

Mr. Hughes

Indeed. I shall come to some of the inadequacies of the Liberals in government—as we see in local authorities—in a minute.

Those of us who use the NHS, who are customers of the NHS, know how important this part of the health service is. I ask doctors to reflect on what they are threatening. They are not low-paid workers. They are paid 50 per cent. more than Members of Parliament. I am not complaining in any way about what GPs are paid—of course it is right that they are paid well—but they have to clarify in their own minds whether they are talking about money.

There have even been suggestions that the BMA has taken the stance it has because of the BMA elections that are going on at the moment. I hope that that is not true. We are dealing with people's lives. We are talking about people who use the out-of-hours service because they are frightened. Anyone who has had a child screaming and being sick in the middle of the night—as a parent, one is worried about what will happen, and one cannot take the child to a casualty department, and that is not the right use of a casualty department, anyway—knows how important that service is.

I cannot believe that the very good GPs it has been my experience to come across—our own family GP, GPs in my constituency, and those mentioned by my hon. Friends—those responsible and caring people, would have any truck with industrial action that would inevitably hurt patients. However it was dressed up and however people pretended that it was merely an administrative matter, it would hurt patients, and they have to understand that.

I must comment on a couple of the things that the Liberal Democrat spokesman, the hon. and learned Member for Montgomery said on the subject. He made two statements that I would regard as a threat. First, he suggested that we should charge for out-of-hours service calls that turn out to be hoaxes. I do not understand how that is supposed to work, but, as my hon. Friend the Member for Mid-Staffordshire pointed out, Liberal Democrat suggestions are not supposed to work, but merely to sound good.

How would one collect the money? What is it supposed to mean? He is suggesting that the Liberal Democrats are not in favour of a service that is free at the point of use.

Mr. Alex Carlile

Nonsense.

Mr. Hughes

It is all very well for the hon. and learned Gentleman, who has just wandered back into the Chamber, to say that that is nonsense, but I am reading what he said. He has suggested a charge, and it is no good him sitting there with a puzzled frown on his face. He must face up to what he has said. He suggested that there should be a charge, and perhaps he will now tell us what he meant by that.

Mr. Carlile

Does the hon. Gentleman agree that the fact that 11 million appointments are broken in national health service hospitals is a problem? Does he agree that, to ensure a national health service that is free at the point of delivery to the patients who use it properly, we must consider ways in which we can ensure that patients attend meetings? It may not be feasible to charge patients 50p for a broken appointment, but if that is not feasible, would he like to suggest how he would ensure that patients do not miss 11 million hospital appointments? Has he anything constructive to say?

Mr. Hughes

I am glad that the hon. and learned Gentleman now has the figure right, because he mentioned 5.5 million appointments in The Independent of 6 July. At least he has got it right this time.

Mr. Carlile

Now answer the question.

Mr. Hughes

The hon. and learned Gentleman made a point, and suggested that there should be a charge, but in his intervention he recognised that that was nonsense. I expect him to speak nonsense—he has been doing it all evening.

Mr. Carlile

What is your answer?

Mr. Hughes

This is a serious problem, but hectoring from a sedentary position does not provide an answer. I accept that I do not have an answer, but I do not make the sort of stupid suggestions that we hear from the hon. and learned Gentleman.

I will continue with the cutting from which I was quoting. The hon. and learned Member for Montgomery also suggested that he would take away the right of elderly people to have their GP as their first point of call. Again he is looking pained, but that is what he said, and it is more proof that the Liberal Democrats simply do not have a proper policy. They say one thing, but when one questions them, they say, "Oh, no. Goodness me. That's not what I meant. Are you talking about that policy document? We are talking about now."

He said: Perhaps also, the elderly could be treated primarily in hospitals and not by GPs. He would be prepared to deny the elderly the right to use their GP in the first instance. If that is not what he meant, he should apologise to the House.

Mr. Carlile

Will the hon. Gentleman give way?

Mr. Hughes

If the hon. and learned Gentleman is going to apologise, I will. If it is going to be the same rubbish that we heard earlier, I will not. But I do not think that I will take time from his hon. Friend the Member for Roxburgh and Berwickshire (Mr. Kirkwood).

I have one final point about fundholding GPs and the ability of those GPs in particular to run new services. I want to praise the Elliott Hall medical centre in my constituency, and in particular its patients' association. This is a wonderful GP service, providing a range of new services, which have not been thought of by others—so much so that people want to leave other GPs to join their books.

The hon. Member for Newcastle upon Tyne, East was wrong to say that he wants to take away that ability to experiment, run new services, compete and enable others to do see they are doing. To do so would take away many of the improvements in the health service, and that is not a move that my constituents would welcome.

9.29 pm

Mr. Matthew Banks (Southport)

I am grateful to you, Mr. Deputy Speaker, for allowing me to catch your eye briefly in this debate, which has, at times, bordered on the bizarre. However, I think that my hon. Friend the Member for Harrow, West (Mr. Hughes) made an excellent and powerful speech. So did my hon. Friend the Member for Chislehurst (Mr. Sims), who has momentarily had to leave the Chamber. I particularly enjoyed the remarks of that great parliamentarian, my hon. Friend the Member for Dartford (Mr. Dunn), who I know will be returning in a few moments.

The hon. Member for Newcastle upon Tyne, East (Mr. Brown) referred, rather more flexibly than the right hon. Member for Derby, South (Mrs. Beckett), if I may say so, to the possibility of GP fundholding ending under any future Labour Government. I detected something of a discrepancy between what he said and what his right hon. Friend said, when she made it clear not long ago that GP fundholding as it currently stands is unacceptable, to use her word, and that she would put a stop to it in the first year of a Labour Government. [Interruption.] I notice that the hon. Gentleman seems to be saying something else. In my characteristic fashion, I give way to him.

Mr. Nicholas Brown

The Minister and I uncharacteristically agreed that I was not saying something else. For once there is no disagreement between my right hon. Friend the Member for Derby, South (Mrs. Beckett) and the Minister of State.

Mr. Banks

I hear what the hon. Gentleman says. No doubt we will be able to compare what the hon. Gentleman said with what his right hon. Friend said on 29 June on the BBC's "Newsnight" programme, because there is a discrepancy. No doubt we will return to it on a future occasion.

Of course, this is a Liberal Democrat debate and I should point out to some of my hon. Friends that they are Liberal Democrats, not Liberals. There is a Liberal party in this country, which did not throw in its lot with the Social Democratic party. Its national headquarters is in Southport, and long may it remain so. They are a splendid lot. They did not renege on everything they believe and on their principles to join the SDP in a sort of mark 2 Labour party. At least with the Labour party, we know where we are—

Mr. Brown

A minute before, the hon. Gentleman said the opposite.

Mr. Banks

The hon. Gentleman suggests that we do not know where we are with the Labour party. I was drawing a fast veil over the hon. Gentleman's discrepancy with the right hon. Member for Derby, South.

Due to the shortage of time, I would like to make only a couple of quick points in relation to this Liberal Democrat-inspired—if that is the right word—debate. I am aware that Liberal Democrats say one thing at one end of a constituency and another thing at the other end. On the one hand, they propose retention of a modified GP fundholding scheme—having, of course, changed their minds twice—and on the other hand they support a system in which GPs could choose to manage funds themselves, or as part of a locally-based consortium, or could ask the local authority to manage funds on their behalf. That would create the sort of politicised system within a local authority which the British Medical Association totally opposes.

I do not know whether the hon. and learned Member for Montgomery (Mr. Carlile) appreciates that but we should bear in mind that he did not seem to know that some of the words of his party's motion were the words of my right hon. Friend the Minister without Portfolio. It is clear that the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) had to tell him that. The hon. and learned Member for Montgomery has had little support from his side in this debate.

Mr. Paul Tyler (North Cornwall)

The hon. Gentleman has not had any.

Mr. Banks

The hon. Member for Cornwall, North (Mr. Tyler) helpfully makes a sedentary intervention. Nowhere among the Opposition is there a better example of someone who says one thing at one end of his constituency and another thing at the other—one thing to one person and another thing to another. He has been absent for most of the debate, but the least said about that the better.

This has been a poor debate. My colleagues have drawn attention time and time again—and had longer than I in which to do so—to the shortcomings of the policies advocated by the hon. and learned Member for Montgomery. The debate has been a waste of good parliamentary time. It is a great pity that the hon. and learned Gentleman was not supported by a few more of his colleagues, but I have no hesitation in supporting the Government amendment.

9.35 pm

Mr. Archy Kirkwood (Roxburgh and Berwickshire)

I am grateful for the opportunity to reply to the debate, which I want to bring back to reality. In the time available, I want to make a number of points to which it is important that the Minister has the opportunity to reply.

I want to refocus the House's attention on the words of the motion that occasioned this debate. The motion states that the House "shares general practitioners' concerns" and refers to the need to facilitate improved methods of work so that general practitioners can provide a more flexible, clinically appropriate and more modern way of providing emergency care". Those words were carefully chosen, and we knew exactly where they came from—they are the words of the right hon. Member for Peterborough (Dr. Mawhinney), but I suggest that they are none the worse for that.

The motion goes on to talk about a right for general practitioners to transfer responsibility for out of hours care". I carefully took note of the fact that the Minister gave some support to that notion. The motion then talks about the need for "ongoing patient education campaigns" and ends with an exhortation to the Government to take all reasonable steps to avoid industrial action by general practitioners. It is a very measured motion. If Conservatives vote against it, they will be voting against not only the sentiments expressed some years ago by the right hon. Member for Peterborough when he was responsible for health matters in a previous incarnation, but almost everything else that every Tory Member who has contributed to this evening's debate said about the need for education and for changes such as the transfer of responsibility for out-of-hours care. Far from being wild or irresponsible, the motion is very measured.

We are in a serious position. It is very unusual for the Government of the day, after two years of negotiation, to be confronted with potential industrial action by doctors. In fact, it is quite unprecedented—a point ably made by my hon. and learned Friend the Member for Montgomery (Mr. Carlile). Something is seriously wrong.

It is no use Conservative Members saying that the British Medical Association is out of control or that it comprises a bunch of radical or irresponsible people; it is the BMA's members who are driving forward its policy on this issue. They are frustrated and dismayed, and wholly out of sympathy with the way in which the Government have handled the matter. That is certainly the message they have put to me loud and clear.

I shall refer to some of the contributions to today's debate and then—I hereby give notice to the Minister—deal specifically with rural problems. It will come as no surprise to the House to learn that my colleagues and I were very mindful of the particular problems confronting rural areas when we chose this important subject for debate.

Will the Minister answer the question asked by my hon. and learned Friend about the £45 million? Can it be better targeted? Where has it come from, and what services in the NHS will suffer as a result of its being redeployed? Will the Minister also deal specifically with the matter that arises in relation to one of the six constructive points made by my hon. and learned Friend about the transfer of responsibility and education? Those issues in particular are important ones, where there is a real prospect of progress.

The Government claim to have listened, and that was the main thrust of the Minister's argument, but he offered no succour to practitioners in rural areas. He talked about the £45 million provision. I understand that capital investment is needed for certain new services and facilities when developing co-operative or depute doctor services.

The Minister went on to argue, however, that some of the £45 million could be deployed in the payment of locum services. If one spread the £45 million throughout the GP population, it would be equivalent to £1,500 a head. It costs £175 a head for one night's locum cover in my constituency, so that £1,500 would provide 10 nights' locum cover in a year. If the Minister has founded his argument on that possibility, he has forgotten that there have been many losers under the new flat rate scheme, which provides £2,000 plus a £20 payment.

GPs in my area are currently paid £48.45 per night visit, but of course they have other out-of-hours responsibilities as well. People generally do not understand that there is a difference between night visits and the other burdensome responsibilities that GPs must face during the rest of the early evening and at weekends from, Saturday morning through to Monday.

Throughout the debate, I have had the sense that the Government do not understand the strength of feeling among individual doctors and their organisations about the problems from which they are suffering. The BMA has suggested to me that the average GP's working week is 62 hours, despite talk in the debate about a week of 47.5 hours. The BMA has also calculated that 23 per cent. of GPs spend 80 hours or more a week on call and providing services to patients, while just 8 per cent. work less than 40 hours a week—many of whom are part-time doctors.

Doctors face many problems, not just because of out-of-hours work but as a result of the 1990 contract. They have seen their independent contractor status eroded. They have had to bear the extra duties placed upon them because of screening and health care checks, as well the additional bureaucracy that the Government have loaded on their backs, which they greatly resent. Evidence suggests that those changes have led to much disillusion, to which my hon. and learned Friend the Member for Montgomery adverted.

On education, I noted that the Minister said that he did not think that there was much between us. That may be true. Leaving aside the rather trite remarks of the hon. Member for Harrow, West (Mr. Hughes) about our previous attacks on the Government, I want to make it clear that we would support a nationally sponsored organised education campaign. It would not need to cost an absolute fortune, but it could provide a framework within which local practitioners could conduct their own campaigns.

That campaign could get across to folk that it is in no one's interest to have a tired GP, who has had no sleep the night before, attending to people's needs and diagnosing their illnesses. The hon. Member for Chislehurst (Mr. Sims) made a good speech about that. I am sure that the House could agree on that. Were we to get some assistance at the right level from the Government towards such an education campaign, it would send an important signal to doctors and suggest to them that the Government were taking their concerns seriously.

Mr. Fabricant

Will the hon. Gentleman give way?

Mr. Kirkwood

I am sorry, but I do not have time.

It is important to underscore the pressure that doctors feel they are under. An article in The Independent last month reported that an independent survey carried out by Alcohol Concern between 1979 and 1990 ranked doctors with sailors and publicans as the people most likely to develop alcohol-related liver disease. That is a measure of the desperation to which doctors are being driven.

Secondly, there is evidence, which was adverted to by my hon. and learned Friend the Member for Montgomery, that early retirement is increasing. In 1987, early retirement accounted for 16.6 per cent. of the total retired doctor population; it now accounts for 22.8 per cent. Forty per cent. of women doctors and 10 per cent. of newly qualified male doctors leave the service within five years of qualifying. Those are all signs of the increasing bureaucracy, the increasing expectation of patients and the increasing work load. The Government ignore that at their peril.

When I checked with a practice in Hawick, in my constituency, I was told that a vacancy in the Hawick practice had recently been advertised, and that, five years ago when a vacancy in the same practice was advertised, there were 75 applicants; this year, there were 11. That is a measure of the difficulty of encouraging people to work in rural areas against the background of the out-of-hours commitment.

Ministers simply have not recognised that times have changed, and that it is now impossible to provide the proper level of service that GPs need to provide to meet the requirements of the moment.

I am surprised that there was not a greater input by Labour Members. The hon. Member for Newcastle upon Tyne, East (Mr. Brown) made a sensible speech—sensible because of the emphasis he placed on the need for education. It was interesting that he supported that idea, although I notice that his new document did not come up with any great solution.

Mr. Brown

Will the hon. Gentleman give way?

Mr. Kirkwood

I honestly do not have time.

Mr. Brown

rose—

Mr. Kirkwood

I do not have time. [Interruption.] I was trying to be nice to the hon. Gentleman.

All the Conservative Members who spoke were from relatively built-up areas. We heard from the hon. Members for Winchester (Mr. Malone), for Newcastle upon Tyne, East, for Dartford (Mr. Dunn) and for Mid-Staffordshire (Mr. Fabricant). The latter is a bit of a rural area, but the vast majority of the speeches came from people who had no appreciation of the problems that confront practitioners in rural areas.

We must acknowledge that the demands have increased by five times in the past 25 years, and doubled in the past three years, as has been said. In 1993–94, a GP was paid on average 2.8p per patient per week to provide that service. The service is an emergency service, and the Government have not succeeded in communicating that message to the general public. Increasingly, patients expect to be able to call on GPs to provide non-urgent care at any time of the evening, night or weekend. That forces local GPs to work night and day in a way that might impair their professional judgment. That position is not healthy, as I have said, or in anyone's interests.

Rural practitioners are at a much greater disadvantage than their colleagues who live in communities with deputising services or co-operative practices. There are no options available to them, nor will there be after the Government's package is introduced. They are determined, in rural areas, to try to provide a high-quality service over a wide and sparsely populated area, and I urge the Government to try to ensure that special consideration is given to those problems in rural areas in their current negotiations with the BMA.

The Government must be more flexible. Much is at stake in those negotiations. Something must be sorted out in the next nine days. I hope that the new ministerial team at the Department of Health will take advantage of that new opportunity to have a completely fresh look at the position, so that we can have more flexible, clinically appropriate, modern ways of delivering care outside normal hours that, as the motion says, are right for patients, fair on the taxpayer and manageable for GPs.

9.48 pm

Mr. Malone

With the leave of the House, Mr. Deputy Speaker.

I am sad to tell the House that I believe that the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) has about as much knowledge of the subject as he revealed he had about my constituency, when he described a large tract of rural Hampshire as a built-up area. My constituents will be astonished, as will those of several of my hon. Friends.

I do not know where the hon. Gentleman was when I followed his hon. and learned Friend the Member for Montgomery (Mr. Carlile) at the beginning of the debate. I specifically went through each of the six points, and I do not intend to use the short time available to me to do so again.

Yes, of course we are prepared to look flexibly on arrangements which we have said we shall be happy to put in place, especially for rural practices. It is obtuse of the hon. Gentleman to say that one simply divides the sum of money and spends it entirely on locums. I was making the point that we can make it available as a support system in rural areas—I would not expect to see it used exclusively.

I shall now address a number of important points raised in the debate. The hon. Member for Newcastle upon Tyne, East (Mr. Brown) asked an important question about research. Research is important, and there has probably not been enough into the subject. I am pleased to be able to tell the House that the National Primary Care Research Centre in Manchester—which is sponsored by the Government to the tune of £15 million over 10 years and which I had the great pleasure of opening a few weeks ago—will be studying the issue, and will be holding a conference in the autumn on the subject of 24-hour primary care.

The subject will include considering innovative ways of providing out-of-hours care through GPs and others. It will inform us and help to formulate the future research programme.

The hon. Members for Roxburgh and Berwickshire and for Newcastle upon Tyne, East mentioned the problems of recruitment for general practitioners. I do not think that it is a sign of a shortage if, in Hawick, there are 11 applications for one practice place. The hon. Gentleman has a way of turning the arguments to suit his party. If there were 75 applications, he would say that there were not enough places, and that there was an unemployment problem among doctors. As usual with the Liberals, they want it both ways.

Although recruitment is often raised as a current difficulty, there is no firm evidence that it is a substantial problem. The average number of applications for advertised vacancies in GP partnerships ranges from three to 34 and, in most cases, the figure is, oddly enough, 11—the same figure as that in Hawick. Perhaps the hon. Member for Roxburgh and Berwickshire can take some consolation from the fact that, on this occasion, Hawick appears, unusually, to have the same figure as the national average.

It is also true that the number of GP principals has been increasing steadily under this Government. The number is currently increasing at the rate of 1 per cent. per annum. The last survey of GP training places showed that, overall, vocational training schemes were still being filled with good-quality candidates, notwithstanding a fall in the overall number of applicants.

We keep a careful eye on that issue. It is important for the long-term benefit of primary care that excellent people continue to come forward for recruitment, are retained in general practice and take up posts in general practice when they are advertised. There is no suggestion that the Government are complacent about that.

There are still sufficient numbers of people coming forward to apply for single-handed practices, which are often highlighted as a particular area of difficulty. The last figures I can give the House show that, for the year ending 30 September 1994, the figure was 19.

A number of points were raised by my hon. Friends, who sustained the debate. It is astonishing that, in a debate in the Liberal party's time on what they clearly consider to be an important subject, that party chose to put up two speakers. [Interruption.] The Greek chorus that has now arrived certainly was not present for the debate. The hon. Member for Orkney and Shetland (Mr. Wallace) is usually good at getting his points across from a sedentary position, even when he is not recognised by the Chair. I should have thought that he could have made a bit more effort to do so during the debate.

Mr. James Wallace (Orkney and Shetland)

Will the Minister give way?

Mr. Malone

Now that the hon. Gentleman has arrived, I shall give way so that he can make an original point.

Mr. Wallace

The Minister is descending to unusual depths. He usually knows better than to try to make cheap points. If he had ever attended debates initiated by the Liberal Democrats—it is probably stretching things too far to suppose that he has—he would have known that it was rare for more than two of us to have the chance to speak. That is something that is wrong with this place and the way it operates.

Mr. Malone

I dare not criticise the Chair, as you well know, Mr. Deputy Speaker. I am delighted that at least the hon. Gentleman has agreed to turn up for the final moments of the debate.

My hon. Friend the Member for Mid-Staffordshire (Mr. Fabricant) made a speech peppered with personal anecdotes and tales of his constituents who had consulted GPs. I advise the House that those tales would have made hon. Members' hair stand on end. There are clearly a number of problems in my hon. Friend's constituency.

However, both he and my hon. Friend the Member for Dartford (Mr. Dunn) pointed to the fact that they had had few letters about the issue in their constituency mailbags. Perhaps that is because there are thriving co-operatives in their constituencies, with excellent innovative arrangements in place. That may go some way towards explaining why my hon. Friends have heard little about the subject.

A theme of the debate was general practitioners' concern about the burdens they bear. I hope there can be a meeting of minds on the issue when the medical profession meets my right hon. Friend. I received a letter today from the local Hampshire medical committee—I must inform the hon. Member for Roxburgh and Berwickshire that it is a rural committee—which expresses dissatisfaction and makes the point: GPs want changes in their out-of-hours arrangements to provide emergency night care more effectively and efficiently, while ensuring that all patients continue to get the best quality care". I quibble with none of those words. We are talking about a method of delivering that care and making sure that firm arrangements are in place to secure the interests of patients. We share common objectives, and I hope that I can agree with the hon. Member for Roxburgh and Berwickshire—

Mr. Bayley

Will the Minister give way?

Mr. Malone

No, I will not give way. I hope to agree with the hon. Gentleman that those matters can be resolved.

There have been a number of rather spectacular suggestions about how to deal with the problems that GPs face today. I think that my hon. Friend the Member for Harrow, West (Mr. Hughes) mentioned the great plan of the hon. and learned Member for Montgomery (Mr. Carlile) for dealing with problems of patient abuse in the national health service. I had read it earlier, and it is an interesting plan.

The hon. and learned Gentleman plans to charge patients 50p each time they break an appointment. I would be interested to see the collection framework that would be put in place. I have no doubt that the threat of 50p each time would strike terror in people's hearts. I have no doubt that the collection system would not be bureaucratic. I wonder whether the hon. and learned Gentleman considered allowing the right of appeal, and whether one would receive legal aid for appealing against a 50p fine. I thought that Liberal Democrat policies were invented on the Benches opposite and not in Montgomery's local libraries, which would probably have to collect those small amounts.

There are many ways of effectively ensuring that there is no abuse of the health service. When it comes to cancelled appointments, the hon. and learned Gentleman should visit hospitals which have robust pre-admission arrangements in place, and where cancellations have been reduced to zero. I did not see many 50p pieces in those hospitals when I visited them.

It has been a typical debate from the Liberal Democrats; they change their tune all the time, don't they? On this issue, it is important to remind the House what Liberal Members have said in the past. On fundholding, in 1992 they said: There is no case for GP fundholding". In 1994 it was a case of, "Hang on a minute, it might be popular." They agreed that GP fundholding does seem to have brought benefits". On 3 July 1995, the hon. and learned Member for Montgomery gave us the simple answer when he said: We would encourage the development of joint commissioning groups. One has to be realistic, and it is not realistic to abolish all fundholding at a stroke. I do not believe that the Labour party would regard that as realistic either. The development of joint commissioning groups … would ensure that fundholding would wither on the vine. Indeed, fundholding has always been a kamikaze policy …The Liberal Democrat view on fundholding is absolutely clear."—[Official Report, 3 July 1995; Vol. 263, c. 48.] That view has changed on a number of occasions.

I do not think that what was said from the Liberal Democrat Benches today has enlightened us about how to solve the problem of out-of-hours practice. It is important that we do, and it is in the interests of the patients. While guaranteeing the quality of their care, we must also lessen the burdens on the medical profession. That is the purpose of our policy, and I believe that, with good will, it will succeed.

Question put, That the original words stand part of the Question:

The House divided: Ayes 35, Noes 229

[10.00 pm
AYES
Ashdown, Rt Hon Paddy	Kennedy, Charles (Ross, C&S)
Banks, Tony (Newham NW)	Lewis, Terry
Barnes, Harry	Loyden, Eddie
Beith, Rt Hon A J	Lynne, Ms Liz
Campbell, Mrs Anne (C'bridge)	Mackinlay, Andrew
Campbell, Menzies (Fife NE)	Maclennan, Robert
Campbell-Savours, D N	Maddock, Diana
Carlile, Alexander (Montgomery)	Mahon, Alice
Chidgey, David	Michie, Bill (Sheffield Heeley)
Clapham, Michael	Michie, Mrs Ray (Argyll & Bute)
	Rendel, David
Clwyd, Mrs Ann	Simpson, Alan
Corbyn, Jeremy	Skinner, Dennis
Cunningham, Roseanna	Steel, Rt Hon Sir David
Dafis, Cynog	Tyler, Paul
Ewing, Mrs Margaret	Wallace, James
Flynn, Paul	Wigley, Dafydd
Graham, Thomas
Harvey, Nick	Tellers for the Ayes:
Hughes, Simon (Southwark)	Mr. Archy Kirkwood and Mr. Don Foster.
Jones, Nigel (Cheltenham)

NOES
Ainsworth, Peter (East Surrey)	Brandreth, Gyles
Alexander, Richard	Brazier, Julian
Alison, Rt Hon Michael (Selby)	Brooke, Rt Hon Peter
Amess, David	Browning, Mrs Angela
Arbuthnot, James	Bruce, Ian (Dorset)
Arnold, Jacques (Gravesham)	Burt, Alistair
Arnold, Sir Thomas (Hazel Grv)	Butcher, John
Atkins, Robert	Butler, Peter
Atkinson, Peter (Hexham)	Carlisle, Sir Kenneth (Lincoln)
Baker, Nicholas (North Dorset)	Carrington, Matthew
Banks, Matthew (Southport)	Cash, William
Banks, Robert (Harrogate)	Chapman, Sydney
Bates, Michael	Clappison, James
Bellingham, Henry	Clifton-Brown, Geoffrey
Beresford, Sir Paul	Coe, Sebastian
Booth, Hartley	Colvin, Michael
Boswell, Tim	Congdon, David
Bowis, John	Coombs, Simon (Swindon)
Boyson, Rt Hon Sir Rhodes	Cope, Rt Hon Sir John

Couchman, James	Knight, Dame Jill (Bir'm E'st'n)
Cran, James	Knox, Sir David
Currie, Mrs Edwina (S D'by'ire)	Kynoch, George (Kincardine)
Day, Stephen	Lait, Mrs Jacqui
Dorrell, Rt Hon Stephen	Lawrence, Sir Ivan
Douglas-Hamilton, Lord James	Legg, Barry
Dover, Den	Leigh, Edward
Duncan, Alan	Lidington, David
Dunn, Bob	Lightbown, David
Durant, Sir Anthony	Lloyd, Rt Hon Sir Peter (Fareham)
Dykes, Hugh	Luff, Peter
Elletson, Harold	Lyell, Rt Hon Sir Nicholas
Emery, Rt Hon Sir Peter	MacGregor, Rt Hon John
Evans, Jonathan (Brecon)	MacKay, Andrew
Evans, Nigel (Ribble Valley)	Maclean, Rt Hon David
Evennett, David	McLoughlin, Patrick
Faber, David	McNair-Wilson, Sir Patrick
Fabricant, Michael	Madel, Sir David
Fenner, Dame Peggy	Maitland, Lady Olga
Field, Barry (Isle of Wight)	Malone, Gerald
Fishburn, Dudley	Mans, Keith
Forman, Nigel	Marland, Paul
Forsyth, Rt Hon Michael (Stirling)	Marshall, John (Hendon S)
Forth, Eric	Marshall, Sir Michael (Arundel)
Fowler, Fit Hon Sir Norman	Martin, David (Portsmouth S)
Fox, Dr Liam (Woodspring)	Mawhinney, Rt Hon Dr Brian
Fox, Sir Marcus (Shipley)	Merchant, Piers
Freeman, Rt Hon Roger	Mills, Iain
French, Douglas	Mitchell, Andrew (Gedling)
Gallie, Phil	Mitchell, Sir David (NW Hants)
Gardiner, Sir George	Moate, Sir Roger
Garnier, Edward	Monro, Sir Hector
Gill, Christopher	Montgomery, Sir Fergus
Gillan, Cheryl	Needham, Rt Hon Richard
Goodlad, Rt Hon Alastair	Nelson, Anthony
Goodson-Wickes, Dr Charles	Neubert, Sir Michael
Gorman, Mrs Teresa	Nicholls, Patrick
Gorst, Sir John	Nicholson, David (Taunton)
Grant, Sir A (SW Cambs)	Norris, Steve
Greenway, Harry (Ealing N)	Oppenheim, Phillip
Greenway, John (Ryedale)	Ottaway, Richard
Griffiths, Peter (Portsmouth, N)	Page, Richard
Grylls, Sir Michael	Paice, James
Gummer, Rt Hon John Selwyn	Patnick, Sir Irvine
Hague, William	Patten, Rt Hon John
Hampson, Dr Keith	Pattie, Rt Hon Sir Geoffrey
Hanley, Rt Hon Jeremy	Peacock, Mrs Elizabeth
Hargreaves, Andrew	Pickles, Eric
Harris, David	Porter, David (Waveney)
Haselhurst, Alan	Portillo, Rt Hon Michael
Hawkins, Nick	Powell, William (Corby)
Hawksley, Warren	Rathbone, Tim
Hayes, Jerry	Redwood, Rt Hon John
Heald, Oliver	Renton, Rt Hon Tim
Heathcoat-Amory, David	Richards, Rod
Hendry, Charles	Roberts, Rt Hon Sir Wyn
Heseltine, Rt Hon Michael	Robertson, Raymond (Ab'd'n S)
Hicks, Robert	Rowe, Andrew (Mid Kent)
Hill, James (Southampton Test)	Rumbold, Rt Hon Dame Angela
Hogg, Rt Hon Douglas (G'tham)	Sackville, Tom
Horam, John	Sainsbury, Rt Hon Sir Timothy
Howell, Sir Ralph (N Norfolk)	Scott, Rt Hon Sir Nicholas
Hughes, Robert G (Harrow W)	Shaw, David (Dover)
Hunt, Rt Hon David (Wirral W)	Shaw, Sir Giles (Pudsey)
Hunt, Sir John (Ravensboume)	Shepherd, Colin (Hereford)
Hunter, Andrew	Sims, Roger
Jack, Michael	Smith, Sir Dudley (Warwick)
Jackson, Robert (Wantage)	Smith, Tim (Beaconsfield)
Jessel, Toby	Soames, Nicholas
Jones, Gwilym (Cardiff N)	Speed, Sir Keith
Jones, Robert B (W Hertfdshr)	Spencer, Sir Derek
Key, Robert	Spicer, Michael (S Worcs)
Kirkhope, Timothy	Spink, Dr Robert
Knapman, Roger	Sproat, Iain
Knight, Mrs Angela (Erewash)	Squire, Robin (Hornchurch)
Knight, Greg (Derby N)	Stanley, Rt Hon Sir John

Steen, Anthony	Walker, Bill (N Tayside)
Stephen, Michael	Waller, Gary
Stern, Michael	Ward, John
Stewart, Allan	Wardle, Charles (Bexhill)
Streeter, Gary	Waterson, Nigel
Sweeney, Walter	Wells, Bowen
Taylor, Ian (Esher)	Wheeler, Rt Hon Sir John
Taylor, John M (Solihull)	Whitney, Ray
Taylor, Sir Teddy (Southend, E)	Whittingdale, John
Temple-Morris, Peter	Widdecombe, Ann
	Wiggin, Sir Jerry
Thomason, Roy	Wilkinson, John
Thompson, Sir Donald (C'er V)	Willetts, David
Thompson, Patrick (Norwich N)	Wilshire, David
Thornton, Sir Malcolm	Winterton, Mrs Ann (Congleton)
Thurnham, Peter	Winterton, Nicholas (Macc'f'ld)
Townsend, Cyril D (Bexl'yh'th)	Wood, Timothy
Trend, Michael	Young, Rt Hon Sir George
Trotter, Neville
Twinn, Dr Ian	Tellers for the Noes:
Viggers, Peter	Mr. Simon Burns and Mr. Derek Conway.
Walden, George

Question accordingly negatived.

Question, That the proposed words be there added, put forthwith pursuant to Standing Order No. 30 (Questions on amendments) and agreed to.

MADAM SPEAKER forthwith declared the main Question, as amended, to be agreed to.

Resolved, That this House notes that the Government has continued to meet the recommendations of the independent pay review body for general practitioners' pay, which is for a 24 hour commitment to their patients; welcomes the Government's constructive approach to addressing the profession's concerns, which includes an extra £45 million to support general practitioners' out of hours services, makes it possible for general practitioners to transfer responsibility for providing out of hours cover to another doctor and restructures payments so that the average general practitioner will receive an extra £800 per year for night visits; supports the approach of the Patient's Charter, which stresses to patients that with rights come responsibilities; and believes there is absolutely no case for general practitioners to take industrial action which would inevitably harm patient care.