HC Deb 25 October 1995 vol 264 cc931-53

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

10.5 am

Mr. Matthew Taylor (Truro)

This is my first opportunity to initiate one of the new morning Adjournment debates, and it is quite a relief to be here in the morning rather than late at night, as has been my more common experience of Adjournment debates. The fact that we are here in the morning is relevant to the issue that I want to raise, because it has always been my view that we raise and debate issues more effectively when we are wide awake than when we are exhausted by overlong proceedings in this House.

That is all the more true for doctors, who must struggle with overly long hours and are often called out to deal with patients in the middle of the night. The Liberal Democrats in the south-west have sought this debate because we believe that all is not well down at the surgery, or—to put it another way—general practitioners in Devon and Cornwall are at breaking point.

In response to concerns raised with us by both health service professionals and patients, we recently sought the views of 1,000 GPs across the south-west, of whom 320 responded, many on behalf of their practice. That is a huge rate of return for a postal survey, where a response of 10 per cent. is regarded as very high. That in itself shows the serious concerns that many GPs have.

The survey showed that more than half of doctors work an average week of 64 hours or more, with seven in 10 often working more than 80 hours a week. Most frightening of all, however, was that some GPs reported that they were working as many as 120 hours a week. Not surprisingly, morale among GPs is falling rapidly, and that is reflected in recruitment levels. Massive work loads, increasing bureaucracy and continuing underfunding have all contributed to the present level of strain on GPs in the west country. It is a crisis that Conservative Ministers cannot afford to ignore, and which impacts directly on patient care.

GPs—any more than Members of Parliament—are not super-human, and they cannot continue to work longer and longer hours. Yet more and more work has been added relentlessly to their working day.

For instance, in recent years GPs have been required to add annual reports, medical audits, health promotion forms and early discharge schemes to their already busy patient schedules. Doctors have found themselves working more hours, but that time has been spent in the main not with patients, but at their desks completing forms. Indeed, 100 per cent. of GPs responding to the Liberal Democrats' survey said that health promotion and increased practice administration had caused an escalation in their work load.

That has not just evolved.

Mr. Sebastian Coe (Falmouth and Camborne)

The hon. Gentleman will recognise that, as a former member of the health education authority board, I have been interested in health promotion for many years. He will also appreciate that health care, education and promotion are now recognised as important parts of fundholding practices. General practitioners working within the fundholding structure are recompensed for that work, and they are recognised as providing an important service.

The hon. Gentleman paints a misleading picture of practices in my constituency. I conduct a parliamentary medical forum and I regularly meet general practitioners. The hon. Gentleman's portrayal of GP morale and the resources available to GPs is not the picture I get.

Mr. Taylor

It is the picture painted by GPs and their representatives, and I shall refer to their comments later. In view of the scale of response from general practitioners—including many in his constituency—I think that the hon. Gentleman should be aware of the pressures.

I am not opposed to health promotion: it is an important part of the health service, and should play an increasingly significant role. However, we cannot ask doctors to do more without recognising that, unless they receive additional help, they will be under pressure from increasing work loads.

As to the hon. Gentleman's comments about fundholding practices, those practices are funded on a different basis from those of other GPs. They get extra funding, and if all doctors received such funding, fewer would be under pressure. In our policy document presented at our party conference, we argue that all doctors—irrespective of whether they are fundholding, work in a co-operative group or work directly with funds managed by local health authorities—should be funded on the same basis in order to try to meet the funding shortfall.

The pressures to which I refer have not just evolved: they have resulted directly from Government policy. In my view—I appreciate that Conservative Members are unlikely to agree with it—the pressures have been caused by the Government's refusal to provide real funding for all general practices and their insistence on more bureaucracy and paperwork, much of which I believe is not required. The patients charter is one example.

The Minister for Health (Mr. Gerald Malone)

As the hon. Gentleman has mentioned general practitioners' work loads, I foreshadow that I intend to make a very important point in my speech that I am sure that he would like to address. Before the general practitioners' contract was introduced in 1989–90, my Department and the British Medical Association conducted a survey of GP work loads. Another survey was submitted to the independent pay review body last year. They showed that GPs' work loads had increased by 2 per cent. over that period, while their remuneration had increased by 6 per cent.

I understand that general practitioners are under pressure, but I do not believe that it is correct to suggest that it is as intense, or is increasing as fast, as the hon.

Gentleman claims. With respect, I suggest that there are slightly wider surveys than the one that the hon. Gentleman has carried out.

Mr. Taylor

My hon. Friend and I shall pursue those points in due course. I suspect that the problem is reflected in the comments of doctors from Devon and Cornwall because of the particular pressures they face operating in rural practices, where it is much harder to obtain the support that is available in the cities. For example, very few doctors in my area have cover for their out-of-hours work. That is the reason for highlighting the problems of Devon and Cornwall. I do not suggest that those problems are unique to that region, but I suspect that they are not reflected evenly across the whole country.

I have referred to the patients charter. Ministers boast of the benefits that the charter brings to the patient, and of the expectations that each patient is now entitled to have of his or her GP. However, while Ministers have set standards nationally, I do not believe that they have provided the necessary resources locally. In other words, the promise and the increased patient expectation that accompanies it are not matched by the necessary additional funds.

I stress that these are the views of a large number of GPs across the two counties. Some 98 per cent. of the GPs surveyed said that Government initiatives, such as the patients charter, have led to unrealistic expectations of GPs, especially given the lack of funds. GPs' frustration at the policies and their increased work load was highlighted in the recent furore over the out-of-hours settlement.

The Minister may argue that the issue has been put to bed, but that is not the case according to GPs in the south-west. Dr. Green, chair of the local medical committee in Devon, said: The current solution for out of hours is only accepted by Doctors in the South West as a first step in addressing the work load problem. While the threat of industrial action may have abated—I am glad that that is so—the deep-seated problem of doctors' hours remain.

In saying that the Government's settlement has not solved the problem, I am particularly conscious of the additional difficulties facing practices in the south-west. Rural GPs in much of Devon and Cornwall struggle with their night work, often unable to load-share. Many parts of the west country are so remote that it is difficult to see how any deputising arrangements or co-operatives could offer respite to GP night visits. In that context, our survey showed that only 38 per cent. of the GP respondents used any kind of deputising service.

I have highlighted the anger felt by many GPs in the south-west about the increased work load, imposed bureaucracy and the lack of funding from central Government. However, what is most serious are the dangers that low morale brings to patients, doctors and to the health service. I turn first to the danger to patients.

Conservative policies with regard to the health service and the hours that doctors are forced to work as a result are putting lives at risk. Some 70 per cent. of the GPs who responded to our survey said that the hours that they are expected to work could put their patients at risk. The West Briton and Royal Cornwall Gazette, a local paper in my constituency, said: Anyone driving into Cornwall on the A30 cannot fail to have noticed a roadside sign "Tiredness can kill." That it could be your worn out GP who threatens your life is chilling. Such dangers are best highlighted by local doctors. One Cornish doctor said that the strain of working long hours is leading to potentially fatal mistakes. He continued: I am sure mistakes have been made and will continue to be made by people dead on their feet; tiredness can kill. I have been on the end of a needle at 3 am and finding myself having to concentrate very hard on giving the substance intended and putting it in the right place. Similarly, a BMA spokesperson said that on one occasion when he worked "literally around the clock", he felt that he should not have been driving, let alone seeing patients. Earlier this month, a Plymouth GP said: the increasing administration and the increasing burden, especially night calls, certainly makes people less efficient, capable of mistakes and more dangerous. I do not think that we can dispute that claim when we consider the hours that doctors say that they are working.

I do not argue that the problems—particularly the issue of out-of-hours care in rural areas—are easy to solve. However, we must find solutions, because patients are being put at risk and doctors are under undue pressure.

Mr. David Harris (St. Ives)

Having spent 24 hours on an aeroplane returning from a Foreign Affairs Committee trip to Australia, I particularly appreciate the hon. Gentleman's remarks about tiredness, and I accept wholeheartedly his point that tiredness can affect performance. However, can he produce any evidence that patients in Devon and Cornwall have suffered as a result of doctors being overtired? Perhaps he could provide actual evidence rather than opinions gleaned from a survey. I am sure that the hon. Gentleman will agree that some survey results can be pretty vague.

Mr. Taylor

Many doctors responded to the survey, and a huge proportion of them conveyed their concerns. Clearly, the hon. Gentleman will be sceptical about a survey that we have conducted; I understand that. However, there is no margin of error in the figures. Some 97 per cent. of doctors have stated their concerns, and we have statistics about the hours they work. While the hon. Gentleman may not agree with my points about Government policy, I do not believe that he would argue that doctors face no pressures or difficulties. There is confidentiality about patient files and although doctors referred to cases that they had experienced, they obviously did not give names and addresses, and one would not expect them to do that. Therefore, the hon. Gentleman asks the impossible.

I shall give some facts that are available and which illustrate the danger to doctors in terms of their health and well being. The Western Morning News puts it well when it states: In the West Country GPs are too tired, stressed out and too overworked to see to their own health. For example, the chair of the Cornish medical committee says that he knows of 20 local GPs who are receiving psychiatric care because of stress caused by long hours and other work-related problems. Dr. Green, the chairman of the local medical committee in Devon, gave the example of Paignton, where there have been resignations from two practices in the past year, and a further early retirement because of stress-induced ill health.

The survey also illustrates the effects of the Government's neglect of GPs on recruitment and on the future of the family doctor service. General practice training schemes have been reporting a sharp fall in the number of applicants for places over the past four or five years, and that is now working through to general practice. GPs who are retiring, many of them early, are leaving places which cannot be filled because new doctors who are at the start of their careers are quite rightly not prepared to work under the stress and in the conditions to which older GPs have become accustomed.

Young doctors are taking part-time work, shift work or locum work in preference to making a long-term commitment to general practice. That can only be seen as a reflection of the pressures they are under. General practice is clearly not attracting doctors in the way it did in the past, and in the long run that is a serious problem because we could end up with the situation that already pertains in dental practices, where patients find it hard to get cover.

A shortage puts remaining GPs under further pressure with their patient lists. The concern was highlighted by the survey, which showed that more than half the GPs said that they would not choose to be GPs if they were starting their careers today, and 96 per cent.—virtually all of them—said that there had been a noticeable decline in the recruitment of new GPs.

Those are disturbing trends, and this concern was supported by the Royal College of General Practitioners, which responded yesterday to the survey. It said: The concern about recruitment and retention shown in your survey would be endorsed by the RCGP and is borne out by experience across the UK. The facts speak for themselves. GPs in Cornwall and Devon are suffering, patients are being put at risk, and general practices are under pressure.

It is time that the Secretary of State for Health took real action to tackle those problems by looking to cut the bureaucracy that has been added to doctors' burdens, and by addressing the problems of rural practices in particular. That needs increased funding. As we approach the Budget, I hope that the Minister will fight for NHS patients rather than agree to the tax cut election bribes that the Chancellor has said he wants.

At our party conference, and in our health policy proposal that was debated there, Liberal Democrats set out plans to cut bureaucracy and paperwork and put more money into the NHS. That money would be raised especially through increased tobacco taxation. We ought to reduce demand through wide-ranging health promotion plans, and we must provide the resources to ensure that that can be effective.

There are genuine problems in rural areas such as Devon and Cornwall. The sparsity of the population, and the fact that many GPs work more or less on their own, inevitably mean that the pressures on the health service as a whole are especially reflected in such areas. That is why we sought to debate these issues and find out more about what doctors had to say.

When we wrote to doctors we expected neither the scale of the response nor the strength of feeling. Doctors, and particularly GPs, are not traditionally regarded as campaigning left wingers, nor do I think that they are such even now. I hope that the Minister will respond positively to their concerns.

10.24 am
Mr. Nick Harvey (North Devon)

I congratulate my hon. Friend the Member for Truro (Mr. Taylor) on securing the debate and on his excellent speech, which described the worrying findings of the survey. He raised many interesting and some quite alarming points.

In particular, I was struck by the finding that 70 per cent. of GPs thought that the hours that they are expected to work could put their patients at risk. That is not a rhetorical device used by my hon. Friend, nor is it polemical: it is the opinion that was expressed by the GPs themselves. It is the considered opinion of 70 per cent. of them that the hours they are working could put their patients at risk. We should all be concerned about that, and about the long-term implications of the survey.

Mr. Harris

Percentages have been bandied about. The hon. Gentleman mentioned 70 per cent., but what does that mean in terms of numbers? How many doctors responded to the Liberal Democrat pamphlet by saying that the hours they worked could put patients at risk?

Mr. Harvey

I think that my hon. Friend the Member for Truro outlined the scale of the survey. There were 320 responses, some of which were on behalf of several GPs working together in a practice. If my mental arithmetic works quickly enough this morning, I would say that that means that more than 200 expressed the opinion that I have just described.

The survey findings seem to strike very much the same note as that struck by the findings of the study conducted by the general medical services committee of the BMA. That study was concerned, in the same way as we were concerned, about recruitment and morale in the profession. The task group dealing with that looked at the evidence from some practices that were finding difficulty in recruiting GPs.

Dr. Ian Banks, the chairman of the task group that produced the report, said: The problem of GP recruitment has now reached crisis proportions and this is bound to affect the quality of care to patients, … GPs want to see less bureaucracy in general practice. They want to ensure equity of access to the NHS for all patients and adequate resources to fund the care of patients discharged back into the community. Dr. Banks also made the point to which my hon. Friend the Member for Truro referred—that, although GPs have accepted the out-of-hours settlement, they hope that it is just a first step towards a more general recognition of the problems they are suffering and towards a more acceptable, comprehensive and long-term solution to those problems.

Not only is the health of patients being put at risk directly by tired, stressed and overworked doctors, but the recruitment crisis means that things could get considerably worse. Patient health could be jeopardised by a lack of qualified doctors who are willing to take on the GP role, and low morale in the profession is surely the decisive factor in that.

The problem is exacerbated by early retirement. Some of those who are heading towards retirement age are finding that it is all just too much for them, and there has been an increase in the trend of early retirement in the past few years. That leaves doctors, and especially those in rural practices who are struggling, with even more of a work load.

Morale is so low that some advertised jobs are attracting only two or three applicants, compared with 40 or 50 just a few years ago. Will that lead to a drop in quality? In one region, EC doctors are taking advantage of that situation by joining UK vocational training schemes. More than half the GP registrars in the East Anglian region are EC doctors. If they return to their own countries, their training will have been a costly subsidy by Britain. Although the employment of such doctors has the short-term benefit of filling training posts, it will not solve the long-term manpower problem in general practice, unless they stay on and become GPs in the national health service.

There is also the problem of part-time GPs. It is entirely good that there are more women GPs, but many of those want to work part time, and many male GPs are also seeking to switch to part-time work. As morale among general practitioners drops, fewer people want to be a GP, those who are reaching retirement age choose to retire, and others choose to work part-time, who on earth will take up the work and fill the gap that is being left behind?

Why has morale dropped? My hon. Friend the Member for Truro referred to out-of-hours work, which is a serious issue. Patients' expectations of the service that their GPs provide has increased a great deal in recent years. In some respects, that has been stoked by the Government's initiatives. It does not follow that those initiatives are wrong—far from it. It remains the case, however, that, if people expect more, more resources are needed to fulfil the expectations.

That is especially clear in relation to the out-of-hours issue. Some patients seem to expect an almost routine service to be available—not an emergency service—24 hours a day. That is something that doctors, as caring people, clearly have to struggle with, but it is extremely annoying and tiresome for them to struggle out in the early hours of the morning to answer a patient call and to find that it is a straightforward, routine matter that could have been dealt with the following morning in the surgery. Everyone recognises that that is happening on a widespread basis.

Another problem is the interaction between general practitioners and their local hospitals. Again, the position in rural areas differs from that in urban areas. Recently, I have been talking to doctors at a very rural practice in my constituency who are suffering badly in terms of their financial shortfall. They made the point that some GPs in urban areas can get around some financial deficits by going into hospitals and undertaking various programmes of work. That is not possible for doctors who operate in surgeries that are 20, 30 or more miles from the local hospitals.

In any event, the interface between the GP and the hospital causes problems. Because of underfunding in the secondary sector, GPs are spending more time trying to make the system work, liaising with patients and hospitals for appointments and treatments, and dealing with the trend to pass the prescribing costs for drugs from the secondary sector to the primary sector. GPs are often called to prescribe drug treatments for which they are not clinically responsible.

In addition, there is the problem that my hon. Friend touched on briefly, of early discharge from hospital. We all know that there is a trend towards patients being discharged earlier. That would be, and is welcome where adequate community care services exist, but sometimes that support is not there, so doctors find it difficult to care for recently discharged patients who develop post-operative complications.

My hon. Friend referred to administration. Increased paperwork shifts the emphasis of the job away from patient care. He referred to health promotion, and the hon. Member for Falmouth and Camborne (Mr. Coe) said that some recognition of that has been made in terms of fundholding GPs' financial settlement. That is true, but the fact remains that there are only 24 hours in a day, and the more hours are taken up in that sort of paperwork, the fewer are left for dealing with patient care.

Patient complaints are increasing again, partly due to some of the initiatives that have been taken. They lead to additional stress and additional paperwork, as does the patients charter. The document states that patients have various rights, but does not really give any indication that they have reciprocal responsibilities, so that has fuelled the dramatic rise in patient expectations.

When referring to the costs of the national health service, the point is often made that science advances swiftly, and medical knowledge moves fast. We need to guarantee that general practitioners, including those working however remotely out in the sticks, have time to go away and study developments in the profession; otherwise, the medical advances that are being made will be meaningless. Opportunities for study must be there, and they are impinged on by out-of-hours work.

Because of reorganisations, there has been turmoil in the NHS for five years or so. Frequent structural changes mean that doctors do not know whom they will be meeting from month to month, and the instability makes planning difficult for them. The continual denial that there is a two-tier system does not help—there is such a system. If that could be recognised and dealt with, it would assist all the planning and organisation that doctors are expected to undertake. It is obvious that, in some instances, non-clinical considerations are determining where and when patients are treated.

Why are general practitioners leaving the profession early? A survey in the west country of 515 GPs showed that not one wanted to work beyond the age of 60. The reasons cited were the increased work load and bureaucracy, increasingly unrealistic patient expectations, fear of violence, and patient complaints. Doctors have had enough, and can see no option but to get out. Basically, there is a feeling of loss of control and powerlessness in the face of seemingly open-ended demands and a belief that changes are being imposed without regard to GPs' views. Low morale is driving doctors away from the profession, and frankly, who can blame them?

What could be done? There are just a few remedies that I should like to propose. The Government must start to co-operate more fully with the profession to improve morale. They must resolve the out-of-hours issue; ensure that general practitioners have protected study time; curtail the bureaucratic burden on GPs, which is spiralling out of control; ensure equity of access to the national health service for all patients; ensure that there are adequate resources to fund the care of patients discharged back into the community; improve communication between the primary and secondary sectors; include within the patients charter a clear and realistic statement of what the NHS can be expected to deliver; and prevent prescribing costs from being improperly transferred to general practice, by ensuring that the secondary sector provides the required treatment.

The Government should also end the uncertainty caused by frequent changes to the NHS structure, give medical students more exposure to general practice during their training, and consider making general practice an element of general or higher postgraduate training in medicine.

Those are just a few suggestions that might provide some long-term solution to the problem that we can identify from this survey and from the survey conducted by the British Medical Association. None of those things can be done overnight—no one pretends that they should be—but the debate's purpose is to highlight the situation that exists, to consider what lessons can be learned from it and what remedies there might be in the longer term. I hope that we will hear positive comments from the Minister on a number of those points.

10.36 am
Mr. David Harris (St. Ives)

Perhaps my interventions during the speeches of the hon. Members for Truro (Mr. Taylor) and for North Devon (Mr. Harvey) showed a certain scepticism on my part about surveys in general, and about those by the Liberal Democrats in particular. I remember a survey they did just before the last local elections on the position of teachers in Cornwall and education funding, which seemed to give the impression that, by the end of the year, Cornwall was going to be denuded of teachers. Of course, nothing happened.

Having said that, the points raised by the hon. Members are serious ones. Not for one minute am I suggesting that our general practitioners in Cornwall, Devon and way beyond the south-west do not face tremendous pressures of the sort described in the so-called survey and by the two hon. Gentlemen: yes, of course they do.

It is a feature of modern life today that all the professions are under pressure and strain. We recognise that across the professional sector and beyond. Dare I suggest that Members of Parliament themselves are under pressure, and, in the time that I have been in the House, those pressures have mounted relentlessly and remorselessly. That is a fact of life today, and to a degree, one must accept it.

The hon. Member for North Devon was on a good point when he said that general practitioners face complaints from their patients. They probably did not face such complaints 30, 40 or 50 years ago. The whole climate has changed. People, perhaps rightly, do not think that, because a person is a doctor, an architect or a dentist, or in some other profession, he or she is beyond questioning or complaint. That is the nature of the society in which we live.

My view is that the complaint apparatus has gone a bit too far, and I hope that we will see a sensible correction of it. The inevitable result of patients' complaints is, as has already been described, additional pressure on those who, in most cases, are trying their utmost to help.

There are other pressures on doctors, and Liberal Democrat Members are right to talk about the added bureaucracy in the NHS over the years. I was delighted to note that, after his appointment, one of the first visits made by the Minister for Health was to Cornwall and the west country. I believe that he visited the constituency of the hon. Member for Truro. I am sure that my hon. Friend will say today that the checklist outlined by the hon. Member for North Devon has been addressed to varying degrees by the Government recently.

I have no complaint about the Liberal Democrats featuring the pressures under which general practitioners operate. The hon. Member for Truro made an important point about the particular pressure to maintain a night service in remote and rural areas, and that pressure undoubtedly exists.

If I have a complaint, it is that the debate might give the wrong impression to people outside. The speeches by the two hon. Members who have participated in this debate—and perhaps in others—and their concentration on the problem areas, might give the overall impression that everything is wrong with the general practitioner service. That is not the case in Cornwall.

Mr. Matthew Taylor

indicated assent.

Mr. Harris

I am glad to see that the hon. Member for Truro acknowledges that.

My hon. Friend the Member for Falmouth and Camborne talked about the impression he gains from his regular contact with GPs through the medical forum in his constituency. I am in regular contact with the GPs in my constituency, as, I am sure, are all hon. Members. When I meet GPs, I hear some grumbles, but I do not believe that it is of the scale that might be conveyed by the comments in this debate, or by the Liberal Democrat survey.

Hon. Members should visit the health centres in their own constituencies. There is a health centre run by general practitioners in Mullion in my constituency, and there is an excellent health centre in the old Stennack school in St. Ives. It is a marvellous building in the centre of town, which has been transformed and caters well for those GPs. I do not think that anybody can reasonably say that the service is in absolute crisis. I fully accept that GPs are under pressure, but overall they are providing a marvellous service to communities right across the country.

There are problems, but I believe that the Government have addressed many of them. I am delighted that a settlement has been reached with the profession over the out-of-hours difficulty, which had undoubtedly become a focus for discontent. While acknowledging all the problems and pressures faced by GPs, it would be wrong to give the impression that the service is crumbling or that it is not delivering—

Mr. Matthew Taylor

I agree with the hon. Gentleman that much of what happens within the GP service is very good, particularly in Cornwall. As with many things, the nature of communities there is that people are aware of each other's needs. That helps to generate a high level of service, but perhaps it also increases the pressures in some respects. Surely the recruitment problems illustrate the degree of urgency about this. It is becoming difficult to get doctors to do the job.

Mr. Harris

I believe that that is so, although I have yet to see the detailed figures for Cornwall. I shall want to look at that. Cornwall has always been lucky in that it has been able to attract GPs because it is an attractive part of the country. If there are difficulties in attracting GPs to such an area, it would be extremely serious. Nobody has come to me and said, "Mr. Harris, are you aware that Cornwall is facing a crisis in the recruitment of MPs?" [Laughter.] I mean GPs—there is no problem in attracting MPs.

It was interesting and revealing that the hon. Member for Truro did not provide any figures. Perhaps the hon. Member for North Cornwall (Mr. Tyler) might do that. If there are problems in filling vacancies, that needs to be addressed.

The hon. Member for North Devon mentioned the difficulties of early retirement. That is not a problem that is special to medicine. Changes in our way of life, particularly in the professions, mean that many people want to retire at 60. It may be because of the pressures, or it may be for other reasons. I do not think that the medical profession can be insulated from that.

I pay tribute to general practitioners throughout the country, but particularly in Cornwall. They perform an invaluable service. Hon. Members know the GPs in their constituencies. We are aware of their dedication, and we appreciate that the pressures on them have increased, for the reasons that I have given. If there are any ways in which we can reduce those pressures, we should do so.

I believe that the Government have been tackling the bureaucratic demands being placed upon them, and we should continue to pursue that. I have no quarrel with the Liberal Democrats for raising this important subject, but I hope that no one gains the impression that we are facing a fundamental crisis in the GP service. If there are problems, they must be tackled.

10.46 am
Mr. Rupert Allason (Torbay)

I apologise for my delay in attending the debate. One of the things I had to do this morning was speak to a GP in my constituency. I take this opportunity to pay tribute to GPs and to the GP service across south Devon. General practitioners are in the forefront of health care in this country, and in my judgment, they provide a first-rate service, particularly in south Devon.

General practitioners are sophisticated individuals and they are aware of political pressures. We can look back in the lifetime of this Administration to issues such as generic medicines, where general practitioners were articulate in presenting their case. At the time of that row, one had many patients ringing up asking why the Government intended to deprive them of the medicines they had always used, and complaining that they had been told by their doctors that the Government could no longer afford them. I do not remember receiving a call of that type in the past six years. I believe that that crisis never materialised.

There was some anxiety about the initial reforms. I remember going to see a leading GP in my constituency to hear that he was wholly opposed to fundholding practices. I sat down with him for one and a quarter hours discussing why he believed that fundholding was entirely wrong. Three weeks before the last general election, I was amused to receive a call from him saying that he had applied for fundholding status, and asking me if I could speed up his application, on the basis that it would be an asset in the general election campaign. That same doctor is now a highly articulate advocate of the benefits of fundholding practices.

I move on to the issue that has prompted the debate. The survey is interesting for several reasons. The Liberal Democrats in Cornwall and Devon produced a questionnaire that was distributed to 1,000 doctors. It seems that 680 decided not to participate.

Mr. Paul Tyler (North Cornwall)


Mr. Allason

The hon. Gentleman says no. understand that there were 320 replies.

Mr. Tyler

The hon. Gentleman may not have been in his place to hear my hon. Friend the Member for Truro (Mr. Taylor) when he introduced the debate, when he made it clear that a number of the respondents replied on behalf of their practices. Therefore, the number of doctors represented in the responses to the survey is far increased over the figure to which the hon. Gentleman has referred.

Mr. Allason

I would be interested to know precisely how many doctors are supposed to be represented. Based on the information in the survey results, I say again that only 320 doctors replied. There is nothing wrong with that—that is a significant figure. I merely point out the difference between the two figures.

The survey is, in my judgment, in the judgment of doctors to whom I have spoken and in the judgment of the health authority in the area which I represent, deeply flawed. A survey dealing with out-of-hours working and stress on general practitioners was conducted a short while ago by Dr. Millard. It was a scientific survey, conducted with the full support of health authorities. It was designed specifically to be helpful in identifying GPs' specific problems.

The Liberal Democrat survey has a misleading title—"Down at the Surgery, all is not well". I do not believe that to be the position. If we were setting out to undertake a scientific survey of doctors' opinions, we would first take care about the questions posed. Having studied the Liberal Democrat survey, I must tell the House that it is barely literate. For example, the use of apostrophes is somewhat eccentric.

I would imagine that the objective of such a survey would be to try to identify particular problems within the GP service. That is what Dr. Millard did. As a direct consequence of the studies that have been undertaken by the health authority concerned, several initiatives have been taken.

First, to deal with the problem of out-of-hours work, an initiative has been taken to introduce co-operatives, so as to reduce the burden on individual doctors. Secondly, a stress counselling service has been introduced to help individual doctors who feel that they are in some difficulty. That is significant. Thirdly, a retired GP in Exeter has been recruited to provide a confidential service to individual GPs who feel in some way at risk.

I have no objections to a survey of the sort that we are discussing being conducted. If it were to be distributed to Members and health authorities, that would be extremely helpful. The reality is that the survey is full of the most bogus bar graphs, with which we are all familiar.

Mr. Harris

Surely my hon. Friend is not suggesting that the survey was politically motivated. He would surely acknowledge that it would be entirely out of character with all the surveys that the Liberal Democrats have conducted in the past.

Mr. Allason

Perish the thought that it should be politically motivated. But I suppose that I should give the Liberal Democrats some credit. In the middle of an industrial dispute over the specific issue of out-of-hours working, why not conduct a survey on the specific issue?

Of all the topics that are important to GPs, what is the one issue on which the questionnaire concentrates? The answer is out-of-hours working. It must not be forgotten that it was a voluntary exercise. Equally, we must not forget that we are talking about £6,000 to £8,000 a year for the individual GPs who undertake out-of-hours working. There is no obligation upon them, but there is a considerable financial incentive.

It is interesting that the document was compiled in the middle of an industrial dispute. Nowhere in the literature that I have read is it stated that the dispute has been settled. It was compiled at a time when all GPs were particularly concerned about the specific issue to which the survey relates. They are articulate and sophisticated, and they were given the opportunity to over-egg their case. In fact, they did not. Only a proportion of them were critical in their responses to the survey.

Mr. Harvey

The hon. Gentleman has said that the survey was conducted in the middle of the dispute. It was not. The survey took place after the dispute was ended. One of the questions was: Do you feel the new deal does anything to ease increasing patient expectations, your workload or the particular problems faced by rural GP's? The survey was conducted after the deal had been struck.

Mr. Allason

No. The hon. Gentleman is wrong. The survey was conducted before the British Medical Association conference took place and before any announcement was made. We now have an example of how badly drafted the survey was. It should have referred to the deal on offer. The deal had not been accepted when the survey was conducted.

I move on to the publicity that was generated by the document. As I have said, it was not sent to health authorities or to individual Members. What was the priority for the document? In fact, it went to the media. The media were presented with press releases that described doctors working sometimes 120 hours a week.

I was concerned about that, and I telephoned the health authority in the area I represent and asked, "Do I really have GPs working 120 hours a week in my health authority area?" The response was, "Absolutely not. If there is one doctor in Torbay who is working 120 hours a week, we would like to hear urgently from that doctor. It is not the case." There are doctors, however—I spoke to one yesterday—who occasionally clock up 100 hours a week. That is not, however, 100 hours of continuous working, but 100 hours on call. I suggest that there is a considerable difference.

I do not object to the fact that the survey was conducted, although the questions are clearly politically weighted. I am surprised that so few doctors participated, given the opportunity that they were offered and the political climate as negotiations took place. I am disappointed with the way in which the issue has been exploited and presented to the media.

Individual patients are obviously concerned when they are told that their doctors are so stressed, so overworked and so under pressure that they are unable to give a good service, and individual lives may be put at risk. That is not the case. In my judgment, in the judgment of certainly one health authority, and in the judgment of the doctors to whom I have spoken, the survey has no scientific value.

It would seem that the only doctor directly quoted is one who is well known for opposing every type of national health service reform. He has had publicity going way back in opposing particular reforms.

The average GP sees between 35 and 40 patients a day. In a built-up urban area with perhaps a factor of deprivation, he may be seeing between 70 and 80 a day. That is not entirely satisfactory, and health authorities recognise that. Initiatives have been taken to try to improve doctors' work loads.

Those work loads are in part a consequence of the higher expectations that patients—quite rightly—have of their doctors. Patients pay a considerable amount into the national health service and are entitled to a high standard of care from their GP, but there is, of course, the problem of inappropriate calls made to doctors, and every GP will have a funny, or perhaps tragic, story of someone who needs nothing more than a couple of Anadin but nevertheless calls his doctor in the middle of the night. That is very frustrating for doctors.

The emphasis of the report was on out-of-hours terms and conditions, and doctors took the opportunity to air many of their grievances. One can well understand that, but the situation as portrayed in the media and by the Liberal Democrats is not wholly accurate.

In south Devon, the situation has improved considerably, thanks to initiatives to reduce pressure on GPs and improve out-patient care. In March 1982, when out-patient waiting lists were examined, 53 per cent. of people on those lists were seen within 13 weeks, 32 per cent. had to wait between 13 and 26 weeks, and the rest waited even longer. That situation had changed dramatically by March 1995, when 91 per cent. of the waiting list was seen within 13 weeks and just 7 per cent. were waiting between 13 and 26 weeks. Those figures reveal the efforts made to relieve the pressure on individual doctors and waiting lists at the health care trust there.

I recognise that doctors have a difficult job—no one would want to minimise the pressures on them—but to suggest that people's lives are at risk on a daily basis, or that there is a crisis at GPs' surgeries, is a betrayal of the trust of the individual doctors who work extremely hard to make the health service work.

I accordingly urge my hon. Friend the Minister to assure the House that he is aware of the way in which the survey was conducted, and that the questions were weighted. I also ask him to assure the House that he has been in touch with health authorities and GP representatives to hear their side of the distorted arguments that have been presented.

11.2 am

The Minister for Health (Mr. Gerald Malone)

It is a pleasure to address the House on matters of substance, even though the debate is based on a survey which—here I agree with my hon. Friend the Member for Torbay (Mr. Allason)—has less substance than the issues themselves.

Had I not been aware of the contents of the survey and their lack of credibility, my hon. Friend would have done the House and me a service by analysing them. I shall deal with that matter in due course.

In general terms, our family doctor service is second to none. That is true of the country as a whole and I believe it to be true of Devon and Cornwall too. I can reassure general practitioners that the Government place a high value on them, to the extent that we are building a primary-care-led national health service based on general practice, which is a fundamental change. We are committed to removing obstacles that may inhibit delivery of the services that GPs work so hard to provide.

My hon. Friend the Member for Torbay asked me to make sure that I was aware of what was happening in Cornwall and Devon and was personally familiar with the views of GPs and health authorities there. I am aware of them, not only from what I hear at the Department but at first hand, because one of the first visits I undertook on being appointed to my post was to GP practices in Exeter and Truro, where I was impressed by the enthusiasm and dedication of all those whom I met.

Those doctors proceed with enthusiasm and dedication despite the stresses and strains of their working life, which, I readily acknowledge, are not unusual in a time of change such as that which we have asked GPs to accept. What I found in Devon and Cornwall was not very different from what I found elsewhere. There are stresses and strains, but they are being dealt with.

Much of the debate today has centred on out-of-hours work, and it may be helpful if I say a few words about that. Much work has already been done to deal with the concerns that GPs have raised and which the Liberal Democrats have mentioned today, some of which were highlighted in the Devon and Cornwall survey. The new arrangements for GP out-of-hours care, recently accepted in full by the British Medical Association, will ease the burden on GPs—one of the points made forcefully by the hon. Member for Truro (Mr. Taylor).

The proposals are designed to encourage GPs to co-operate more in providing out-of-hours care. I know, for example, that the South and West Devon health commission is negotiating with the local medical committee and local GPs to facilitate GP co-operatives. Similar work is under way in Cornwall with the aim of securing a countywide arrangement.

The proposals will also offer special help to rural isolated GPs. Much has rightly been made of the problems faced by such GPs. It is important to put in context the funding for special arrangements, which I want to be delivered flexibly so that the particular interests of GPs in rural areas are duly noted.

I have seen from some press reports in Cornwall and Devon that there is a suggestion that the fund is merely to be divvied up among all doctors, at some £1,500 a head. That is reportedly a comment from a chairman of one local medical committee, but it is not our intention. No decision has yet been taken. Indeed, discussions will be taking place tomorrow between representatives of the general medical services committee and my departmental officials. I hope that we can come to a solution that will adequately recognise the special burdens imposed on doctors in rural areas.

The new settlement will also encourage patients to make more appropriate use of GP services, which I acknowledge is important. I cannot quite understand the idea that the patients charter has suddenly led to a new tranche of demand that did not exist previously. I do not imagine that, in the isolated rural cottages of Cornwall and Devon, the first thing that someone does at 3 am when he is feeling ill is pick up a copy of the patients charter and decide how to proceed.

Frankly, many of the arguments to the effect that the patients charter is provoking the difficulties now facing GPs in relation to out-of-hours calls are fanciful. It is right that patients should understand what they can expect from their GP services, but the charter acknowledges that patients have to exercise their rights responsibly when approaching their GPs.

Local initiatives are already under way. In June 1995, before we reached the settlement, the Cornwall and Isles of Scilly health authority produced a leaflet entitled "Changes to Emergency GP Services", which was directed at patients. It was distributed to every GP practice in the county. I am extremely anxious to secure a campaign conducted in conjunction with the medical profession to ensure that the public is well aware of how they should properly use GP services to reduce the personal out-of-hours work load of GPs.

I deal now with some of the points about increased bureaucracy and paperwork. I assure the House that we are making strenuous efforts to reduce the weight of bureaucracy on GPs. The Liberal Democrats are, I am sure, well aware of the recent efficiency scrutiny entitled "Patients not Paper", which was carried out by a team that included four GPs—so there was a practical input into the study—and two primary care managers. The result was a number of recommendations, most of which will be fully implemented as soon as possible and, likely as not, by the end of next year.

I should like to highlight three points. There will be a reduction in claim forms by 1,700 per average practice, which is a tremendous clear-out. The bureaucracy associated with GP health promotion schemes will be cut, reducing data requirements from 122 to eight items. The flow of mail into practices will also be reduced, and the quality of communications will be improved.

I well understand that, as we seek to make the health service more accountable, there can be a natural accretion of bureaucracy, which Ministers occasionally have to curb. We intend that there will be less mail demanding statistics from GPs when he or she opens their surgery door in the morning and looks through the mail.

Mr. Allason

Is my hon. Friend aware of the information technology initiative in south Devon, which will mean that, by 1997, 80 per cent. of GPs will be on line in a health network? That too is intended to reduce bureaucracy, because it will be possible to gather statistics centrally—information relating to individual health care will be transmitted on that network. Does he not agree that to reach the target of 80 per cent. by 1997 will be quite an achievement?

Mr. Malone

I am pleased to hear that. That scheme is part of a national initiative. Introducing technology to reduce paperwork is extremely important. Indeed, it will do more than reduce the paperwork—it will free more practice staff to provide additional support.

I am delighted to hear what my hon. Friend says and to tell him that, as part of a national initiative, that scheme is playing its part. More than £242 million was spent in 1989–90, and more than £542 million last year—more than double—on staff, nurses and other support, including technology, which illustrates our commitment to primary care. So my hon. Friend the Member for Torbay is quite right: IT is one area in which there is substantially increasing support.

In Cornwall in particular, considerable financial support has been given by the family health services authority for the improvement of GP premises by means of grants totalling £300,000 in 1994–95 and by the commitment of £250,000 for 1995–96.

Recruitment is extremely important. I acknowledge that the Government must keep it under observation, and, where there are concerns, must address them. There are some valid concerns about GP recruitment. I readily acknowledge that there has been a decline in the number of trainees in recent years. There are a number of reasons for that.

One is that, with the reduction in junior doctors' hours in hospitals, there are more places available in the hospital sector than there are ultimately in general practice. However, there were 1,400 trainees throughout England in April 1995, which is still a significantly higher number than is needed to sustain the number of GPs overall. Of those, 243 were in the south and west region—the highest number of trainees in any region in England.

I notice that the hon. Member for Truro said that, on average—I think that he used this figure—there are four or five applicants for every post. If that is so, and they are well qualified, that is a good thing. It is better than the old days, when sometimes there were 120 applicants for every post—most of them not able to get jobs.

I agree that a balance must be struck. We must be concerned to ensure that the GP environment will attract top-flight people and be flexible, to reflect the point rightly made by the hon. Gentleman and his hon. Friend the Member for North Devon (Mr. Harvey) that, considering the percentage of women entering the profession—51 per cent. of students are female—it is important that we have a practical understanding of how that percentage will operate in the work force, and what flexible arrangements we will have to put in hand. There is a real work force issue that needs to be addressed, and work needs to be done.

As for specific recruitment difficulties in the south and west and in Devon, I can tell the House that a young GP self-help support group has been set up, through which newly qualified partners can offer help and support to each other. In Cornwall, funding has been made available for an advisory service for new GPs, whereby all new doctors are contacted by a doctor in another part of Cornwall who can act as their mentor and confidant. So at that important moment when doctors are embarking on general practice, support is available. I welcome such initiatives, especially in Devon and Cornwall.

Throughout the country, we want closer working between new health authorities and GPs, and there is an opportunity for that as we move towards 1 April and the integrated health authorities come on stream. I know that Devon FHSA is encouraging GP practices to show innovation and initiative for the improvement of patient care. Good ideas are circulated to all practices to raise standards throughout the country. Cornwall FHSA meets quarterly with consortia of GPs—fundholding and non-fundholding—to discuss purchasing issues and address local problems, and I very much welcome that.

The Government have a policy of introducing fundholding, and it has been successful in Cornwall and Devon, but we do not take the view, and I am glad that the authorities in Cornwall and Devon do not either, that it should be done in isolation. I very much welcome what is in hand there to share best practice among fundholders and non-fundholders.

The hon. Members for Truro and for North Devon mentioned the patients charter. I very much support what the patients charter has done; it has brought substantial improvements to the quality of services provided for patients throughout the NHS, and in the areas represented by the hon. Gentlemen, because it has given a focal point and a target to which everybody needs to aspire. Three quarters of GPs now have their own practice charters—beyond what we publish on a national basis—or are in the course of developing them.

The patients charter is about doing things differently, thinking about patients as individuals, listening to what patients want, and providing a more patient-focused service. I should have thought that the whole House would welcome that. It need not necessarily cost money—in fact, doing things more efficiently and effectively can often save it. For example, looking back at the figures for 1994–95, GP fundholders in Devon achieved savings of almost £2 million in their budgets, which will be spent on other forms of patient care.

In April 1995, there were 11 GP fundholding practices in Cornwall FHSA, covering 24 per cent. of the population. Although take-up was slow—I understand the reasons: small practices and rural areas—it is moving ahead, and 36 per cent. of the population are likely to be served by fundholding practices from 1 April next year. In Devon, the equivalent figure is 44 per cent. of the population; an increase on the previous uptake of 14 per cent.

So I welcome the fact that, although some general practitioners may fill in surveys in a slightly different way, they are rather optimistically taking hold in Cornwall and Devon of the advantages offered by the Government's policy, and ensuring that they exercise their new freedoms and responsibilities for the benefit of their patients.

But the situation goes further: total fundholding projects are being considered in south and west Devon. A consortium of five practices is in its shadow year as total fundholders, and will go live from 1 April 1996. I very much welcome that as a way forward.

Much was made earlier in the debate about a survey. My hon. Friend the Member for Torbay told us a little about it. I would like to tell the House yet more about it, because clearly my hon. Friend, and my hon. Friend the Member for St. Ives (Mr. Harris) understood perfectly well that the survey was not politically motivated. None the less, they might be interested in knowing its genesis. In fact, it was a style survey which came from something called the "Health Campaign Pack" published by the Liberal Democrats. It explains how to conduct surveys. It is a jolly interesting style.

Mr. Matthew Taylor


Mr. Malone

I shall allow the hon. Gentleman to tell us how well he followed the template when I have at least gone some way into the rather interesting territory that it explores.

The pack explains how to carry out surveys. It says: In particular, the survey should publicise results which show opposition to the Government's policies and support for our alternatives. Well, that is rather interesting—hardly the detached exercise that Liberal Democrat Members were trying to suggest.

I have read the survey, and I have also read the style guide. It is interesting that the survey compares exactly with the style suggested. It says: Nora Batty and the Liberal Democrat team wrote to local doctors and dentists—the people in the front-line caring for patients". It is some sort of "Last of the Summer Wine" style—or, perhaps, in the Devon and Cornwall area, it is "Last of the Summer Cider". The key responses all assume a result. They include: Eighty per cent. of local doctors think the Government's record on the NHS is either bad or very bad. Stamped across the key responses is the phrase: Insert your own figures.

Mr. Harris

Does the interesting document from which my hon. Friend is quoting advise local Liberal Democrats that the survey slips and questionnaires should be accompanied by a health warning?

Mr. Malone

I think the document comes with its own health warning. I was interested to read the style questionnaire. It mirrors precisely the questionnaire that was sent out in Devon and Cornwall. The Liberal Democrats take some pride in that. Although the report was supposed to be detached, the House will understand its purpose and genesis.

I know that the hon. Member for North Cornwall wishes to make a few remarks, so I will conclude by reiterating the Government's commitment to a primary-care-led NHS. It is all about decision-making. That is what our policies have facilitated. The ability of doctors to decide what should be done for their patients is as relevant in Cornwall and Devon as in the rest of the country. Doctors are taking up that initiative with vigour.

I take this opportunity to thank GPs in Devon and Cornwall from the Dispatch Box. I understand that they face challenging and difficult times as more responsibility is given to them. To judge from what they tell me—they are seldom slow to express their views—although there are challenges and issues that we still need to resolve, and I hope shall resolve, they understand that the Government have put them in a leading position in the NHS and given them responsibilities that reflect their professional skills as never before. That is the basis on which we move towards a primary-care-led NHS.

There is one point in the survey with which I agree. The report says that actions speak louder than words. I suggest to the House that the actions of the Government in putting right the difficulties that general practice faces speak far more loudly than the words in the survey.

11.21 am
Mr. Paul Tyler (North Cornwall)

My colleagues and I are grateful to the Minister for 94 per cent.—a rough figure—of his speech, in which he referred to the substance of the issue. We endorse the points he made about the dedicated service that GPs give in Devon and Cornwall, as they do in other parts of the country.

The Minister is obviously better briefed by his Department than by Conservative central office. The report to which he referred was published after our survey. It was therefore entitled to take our survey as an example of what could be done in other parts of the country. The Minister got it the wrong way round.

Let us get back to the substance. Several hon. Members have attacked the survey this morning. That is not our purpose. We wish to examine the feelings and anxieties among a key part of the health service of this nation. GPs are the gatekeepers for the whole health service, perhaps especially so in more remote rural areas.

That was recognised in the White Paper published last week by the Secretary of State for the Environment and the Minister of Agriculture, Fisheries and Food. It said: Most health care is provided through primary care, especially by GPs. We recognise that rural doctors can have smaller practices based in more than one location and may therefore need additional financial support. A number of allowances are payable to support GPs in rural areas. The rural practice payment scheme, for example, reflects the costs and pressures of practices in more sparsely populated areas. Precisely. I accept that the Government have endorsed our view that rural practices have special needs. That is at the centre of the debate today, and at the centre of our survey.

The points that the Minister made about fundholding practices are similarly well recognised. It is more difficult to qualify for fundholding in rural areas. That is one of the problems that lie behind the resources problem. I noticed that one hon. Member, in a Freudian slip, referred to fund-raising practices. There is a feeling among many GPs in smaller practices that they now have to devote so much time to finding ways to fund their activities that they cannot give so much attention as they would like to their patients.

Mr. Allason

Will the hon. Gentleman give way?

Mr. Tyler

No. I have very little time, thanks to the hon. Gentleman's late intervention.

The hon. Member for St. Ives (Mr. Harris) referred to recruitment. I was glad to hear the Minister respond positively on the issue. We all recognise that there is a difficulty with recruitment. The hon. Member for St. Ives may not have been in Cornwall when our survey was published.

One of the most fascinating things was that, contrary to our expectations, a number of authorities and GPs said that, in several respects, we underrated the severity of the crisis. The family health services authority in Cornwall, for the first time ever, is having to recruit in other EU member states for GPs. That has never happened in Cornwall before, although I understand that it has happened in other parts of the country. That is a simple litmus test of the severity of the recruitment problem.

In the few minutes that I have left, I wish to underline the views that GPs have expressed to us, to the public and to other GPs. The hon. Member for Torbay (Mr. Allason) may not know that Dr. Green, the local medical committee chairman for Devon, is one of the principal spokesmen for the profession. I understand that he comes from the hon. Gentleman's constituency.

In response to our survey—not as part of it—he said: In my own town, Paignton, there have been resignations from two practices in the last year and a further early retirement for stress induced health. Eleven and 12-hour days are commonplace, followed by a night on call and another 11-hour day. The level of alertness required by this special profession cannot be sustained over time.

Mr. Allason

Will the hon. Gentleman give way on that point?

Mr. Tyler

No. The hon. Gentleman intervenes late in the debate, having arrived late. I have only three minutes left.

Mr. Allason

On a point of order, Mr. Deputy Speaker. Is it appropriate for an hon. Member to identify a particular constituent and not allow his Member of Parliament to respond, when—

Mr. Deputy Speaker (Mr. Michael Morris)

Order. It is perfectly proper.

Mr. Tyler

Dr. Green also said: GPs work within a contract which allows new work to be added relentlessly to the working day. In recent years, we have seen Health Promotion, Early Discharge Schemes, annual reports and returns, and medical audit. No money has followed the patient into this work to allow extra staff to be employed, and where fees have been increased, the money is insidiously clawed back through the pool payment scheme. Furthermore, GPs have no ownership of this work, as the value to patients has yet to be shown.

Mr. Allason

On a point of order, Mr. Deputy Speaker.

Mr. Deputy Speaker

I hope that it is more genuine than the previous one.

Mr. Allason

It certainly is. I spoke to Dr. Philip Green yesterday evening, and I want to protest at the misrepresentation of his views.

Mr. Deputy Speaker

That was no more a point of order than the previous one. The hon. Gentleman knows that there are means of making such protestations which are in order. I hope that he will not trouble the Chair any further with bogus points of order.

Mr. Tyler

The chairman of the LMC in Cornwall, Dr. Andy Stewart, whom I know well, a young and dedicated doctor, has written as follows, since seeing the situation develop: To expect one doctor to work all day, all night and then all the next day, is totally unreasonable and just plain irresponsible. Exhausted and tired doctors should not be allowed within a mile of a sick patient. Tired doctors can make mistakes and mistakes in our trade may just turn out to be fatal. An airline pilot or bus driver would not be allowed to work for longer than 24 hours without a break because of the risk of endangering life through tiredness. So why are we so superhuman that we don't need sleep and a break from incessant stress? Another doctor from Devonport in Plymouth—not a rural area, but he suffers the particular stresses and strains of the inner city—says: In the past few years expectations have risen, fuelled by the Government's 'charter mentality'. This expectation has come from both the public and from management, which sometimes engage themselves in doing things of dubious value … At the end of the day, the day's work isn't finished, and the return to a normal life is impossible. You can imagine what it's like telling a disappointed son/daughter that you can't take them to scouts, guides or whatever. It is like letting down the other half of you. This is not just a survey. It clearly contains the outspoken, but perfectly proper, views of a dedicated profession in a part of the country where one might think that the problems are more easily resolved than in the major cities.

We are grateful to the Minister for his positive reply to our debate today, and I know that the general practitioners in Devon and Cornwall will be as well. But the most important function of the House is to ensure that we can articulate in a public place at a national level the concerns of those who serve us so well. I hope that this morning's debate has done that, and I hope too that we will see real progress in the directions to which the Minister referred, because it cannot come too soon.

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