§ The Secretary of State for Health (Mr. Stephen Dorrell)
I beg to move,That this House pays tribute to the role that GP fundholders have played in kick-starting and developing innovative practice in both primary care and the acute sector; welcomes the advances that fundholding has brought to many patients; accepts that fundholding has acted as a lever to improve services; and consequently remains committed to the further development of GP fundholding.The Government have selected the subject for debate this afternoon for a simple reason: we believe that it is important to expose the double-speak that passes for Labour's health policy. That is true across the whole field of health policy, but it is particularly true of fundholding. I intend to remind the House of the claims that Labour makes for its health policy, and then to examine the reality of those claims in the context of its approach to fundholding.
Labour says that it favours empowerment of GPs, yet it remains opposed to the system that brought about the greater empowerment of GPs. Labour says that it favours innovation, yet when it sees it in the context of fundholding practices, it immediately retreats into verbiage about a "two-tier service". Most of all, Labour says that it is in favour of a system based on choice and diversity and encouraging professionals to develop their own approach to the profession that they practise. The hon. Member for Peckham (Ms Harman) shows in her decisions about her own family that she holds that principle dear, but Labour as a whole remains resolutely opposed to putting that principle into effect within the NHS.
§ Mr. Michael Fabricant (Mid-Staffordshire)
Is my right hon. Friend aware that virtually every general practitioner in the Mid-Staffordshire constituency is a GP fundholder? Is he equally aware that they are fundholders because they believe that it helps them to be better doctors and to make the sorts of choices that GPs ought to be making? They live in fear at the thought of a Labour Government, who would oppose GP fundholding, getting in and abandoning it.
§ Mr. Dorrell
My hon. Friend is precisely right. I shall quote some of the speculations of the hon. Member for Peckham on why my hon. Friend's constituents have opted for fundholding. He gave us the answer first: they opted for it because they believe that it is the best way to improve the care that is available to their patients and, furthermore, to give full expression to their commitment to the principles of the national health service.
§ Mr. Ronnie Campbell (Blyth Valley)
Is it not true that the patients of fundholders are getting preferential treatment for operations in hospitals? We have some evidence of that. Is it not a two-tier system?
§ Mr. Dorrell
It is also true that 70 per cent. of the patients in the hon. Gentleman's constituency are covered by fundholding practices. That reflects the choice made by GPs operating in that health area on how best to serve the interests of their patients and to ensure that an improved national health service is delivered, not just to their patients but to those of all GPs operating in the NHS.
§ Mr. Simon Hughes (Southwark and Bermondsey)
I want to pursue the question asked by the hon. Member 153 for Blyth Valley (Mr. Campbell). A psychologist working in the NHS with whom I spoke on Sunday confirmed that GP fundholders get preferential treatment for their patients from him and his colleagues at the hospital, not because they want it but because they have the resources to buy it. Will he confirm that that is the position and that the perception in every health authority is that those who have the funds call the tune?
§ Mr. Dorrell
The hon. Gentleman's intervention is based on a total misapprehension of the position. He can substantiate his proposition that the patients of a particular doctor have an unfair advantage only if the resources available to that doctor to deal with the patients on his list are more generously provided than the resources available to NHS patients as a whole. Within a fundholding practice, a doctor or group of doctors make choices about the use of resources, which certainly allow them to improve the NHS care available to their patients—that is why they do it. That is done on the basis not of an unjust allocation of resources but of better use of the resources available to them.
§ Mr. Dorrell
I will not give way now, but I will do so again later.
Last October, the right hon. Member for Derby, South (Mrs. Beckett) accepted an invitation to speak to the National Association of Fund Holding Practices. For once, that brought a Labour health spokesman, the predecessor to the hon. Member for Peckham, not up against Ministers, whom the Opposition no doubt think are easy conventional targets, and not in a television studio, but face to face with fundholding GPs—individual doctors committed to the principles and future of the national health service, who had decided that it was in the interests not merely of their patients but of their commitment to the health service as a whole to opt for fundholding. It is interesting to examine what the right hon. Lady said when she was face to face with an audience of fundholders:We want genuinely to pay tribute to the role that you as fundholders ) … have played in kick-starting and developing innovative practice in both primary care and the acute sector.[HON. MEMBERS: "Ah.] My hon. Friends should wait, because there is more to follow. She continued:We understand and welcome the advances that fundholding has brought to many patients.I cannot detain the House with the entire speech, although there was some good stuff in it, but she also said:I do accept that fundholding has acted as a lever to improve services.
§ Mr. Dorrell
No, I am going to make my point.
Those three sentiments, every one of which I agree with, have been brought together by the Government in the motion. The motion that the House is invited to agree is no more than the bringing together of those three sentiments out of the mouth of the right hon. Member for Derby, South, coupled with the obvious policy conclusion that, if it is that good, we had better have more of it.
154 When Labour Members later this afternoon choose to substitute, if that is what they vote to do, the words of the amendment tabled by the hon. Member for Peckham, they will be voting against the words spoken by their health spokesman of only three and a half months ago. It must be relatively rare for the Government to table a motion for debate in the House the sentiments of which were drafted exclusively by the person who held the shadow health portfolio until only months ago.
It is properly described as hypocrisy for the Labour party to endorse a spokesman who went to Harrogate to talk to fundholding GPs in October last year and then invite hon. Members, as no doubt the hon. Member for Peckham will in a few minutes' time, to reject those words when safely away from the audience of fundholders.
§ Mrs. Alice Mahon (Halifax)
The right hon. Gentleman referred earlier to verbiage about two-tier services. Does he recall that I wrote to him in November and sent him a copy of a letter from a GP in my constituency? At that time, there were no GP fundholders in Halifax. The GP complained that when he desperately needed clinical psychology services for a patient, he was told by the trust to which he tried to refer her that there were no services for anyone who was not from a GP fundholding practice. The only service available was a Relate counsellor. He pointed out that that was not what he wanted and had to wait a considerable time before the health authority eventually referred the woman to a BUPA hospital. Is that not a classic example of two-tier fundholding? Why should that patient not have access to a service to which GP fundholders' patients have access? Why should she have to wait?
§ Mr. Dorrell
The hon. Lady said that there were virtually no fundholders in her constituency. In fact, the health authority that covers her constituency will, from next April, have 44 per cent. of its patients covered by fundholders. She is not precisely right.
§ Mrs. Mahon
On a point of order, Madam Speaker. The right hon. Gentleman must get it correct. That is not true in Halifax. It is no good using somebody else's constituency.
§ Madam Speaker
That is not a point of order. I am sure that if the right hon. Gentleman is incorrect about fundholding in the constituency of Halifax, he will make a correction.
§ Mr. Dorrell
As you know, Madam Speaker, health authority and constituency boundaries are not precisely the same. The health authority that covers the hon. Lady's constituency—and this is what I said—will, from next April, have 44 per cent. of patients covered by fundholding practices.
§ Mrs. Mahon
Will the right hon. Gentleman guarantee that patients in my constituency who need a clinical psychologist will be able to get one as quickly as would GP fundholders' patients?
§ Mr. Dorrell
I will guarantee that in the hon. Lady's constituency, just as in the rest of the health service, 155 where fundholders use resources to develop or open new services—that is what innovation means—it creates precisely the pressure that she wants to ensure that both the patients of other fundholders and the patients of all other GPs participate in an improving general level of service in the NHS.
§ Mr. Dorrell
I wish to make progress, if I may.
I return to the words of the motion—the words first spoken by the right hon. Member for Derby, South to the National Association of Fund Holding Practices. On 24 January 1996, two weeks ago, I quoted those words in the House and the hon. Member for Fife, Central (Mr. McLeish) said, "This is old hat." Three and a half months is a long time in Labour party politics. He was wrong; it was not old hat. It was a flash of inspiration. St. Paul travelled the road to Damascus; the right hon. Member for Derby, South travelled the road to Harrogate. Converts are always welcome.
The right hon. Member for Derby, South is not old hat; Labour's policy on fundholding is old hat. Yet again, the Labour party is on the wrong side of an argument. It is the repeated experience of Labour and Labour Members in the past 20 years. They fought against privatisation of nationalised industries, and history passed them by; they fought for unilateral nuclear disarmament, and history passed them by; they fought against a framework of law for trade unions, and history passed them by; and they fought—how they fought—against GP fundholding, and history is in the process of passing them by on that subject as well.
§ Mr. John Marshall (Hendon, South)
Does my right hon. Friend agree that the principles of GP fundholding are the same as the principles of grant-maintained schools—that the budget is delegated downwards? Does he find it strange that a person who approves of, and is willing to use, a grant-maintained school opposes the principle of GP fundholding?
§ Mr. Dorrell
I have already said so, and I agree that identical principles underlie fundholding and grant-maintained schools.
The way to improve a state-provided service is to encourage a diversity of approach in the professions and encourage the professions responsible for delivering the service to try new ways to deliver the service. The hon. Member for Peckham endorses that principle by her private action yet refuses to apply it in the portfolio for which she has policy responsibility.
§ Mr. Dorrell
I want to make progress. I will give way to the hon. Member for Hampstead and Highgate (Ms Jackson) in a few moments.
I want to begin at the beginning of fundholding. My right hon. and learned Friend the Chancellor of the Exchequer was the Minister responsible for introducing fundholding. He did it for a simple reason: he wanted, and wants, to make the national health service more accountable to its patients. He wanted to accept the 156 challenge implicit in the rhetoric about patient-centred care and a flexible health service responsive to its patients, and make those phrases real.
The hon. Member for Peckham made her approach to the subject clear from the start. She said thatthere is no support among GPs for the concept of fund-holding practices."—[Official Report, 15 March 1990; Vol. 169, c. 687.]Six years later, the evidence on that subject is decisive. She was wrong.
From 1 April 1996, more than half the patients of NHS general practitioners will be served by fundholding GPs. The hon. Member for Peckham was wrong then in her predictions, just as she is wrong now in her policy prescriptions.
§ Mr. Dorrell
I have undertaken to give way to the hon. Member for Hampstead and Highgate in a moment.
The hon. Member for Peckham is now wrong in a different sense, because she now makes a different charge. On 9 November 1995, in Doctor magazine, she said:Fundholding was not a GP idea. It was imposed on doctors".That is insulting to the half of NHS GPs who have opted for a voluntary fundholding scheme. It implies that a few letters from me and my predecessors have led them to adopt a scheme that they believe is damaging to their patients and the NHS. Further, I believe that it is a wilful misrepresentation of the facts.
In saying that, the hon. Member for Peckham knows perfectly well that the fundholding scheme is voluntary, that more than half of NHS GPs have opted to join that voluntary scheme and that the words of her 1990 prediction are on the record, and she feels the urge to explain them away. She will have to think of a better explanation if her remarks are to carry any conviction.
§ Ms Glenda Jackson (Hampstead and Highgate)
Is there not another similarity between grant-maintained schools and doctors' fundholding? The imposition of both was fiercely opposed by the professionals— schoolteachers, governors and parents, and certainly the majority of doctors—yet both groups were aware that the only way to provide the necessary educational and medical services was to take the money that the Government were offering them in only one way.
I refer the Secretary of State back to innovative practices. There is little that is innovative about elective surgery, but last year the Whittington hospital in my constituency issued a directive that all elective surgery must stop, save for patients of GP fundholders. If that is not a two-tier system, perhaps the Secretary of State could explain what it is.
§ Mr. Dorrell
The hon. Lady is simply wrong, as I said in replying to the hon. Member for Fife, Central. [Interruption.] She is wrong about that fact, just as the hon. Gentleman was wrong to describe the comments of the right hon. Member for Derby, South as "old hat".
The hon. Member for Hampstead and Highgate is wrong because she has said that GP fundholders have more resources available to them to care for their patients than other GPs in the health service. That is not true. 157 The resources available to GP fundholders are provided on exactly the same basis as the resources that are available for other forms of patient care.
§ Rev. Martin Smyth (Belfast, South)
I share the Secretary of State's views about the improvement that GP fundholding has made. The fault with the two-tier system lies not so much with the GP fundholders as with the providing authorities, which are leaving much elective surgery until the end of the year because they can then obtain the roll-over from the health authorities. Is that not the real issue, as the KŐrner statistics show?
§ Mr. Dorrell
The hon. Gentleman makes a very good point. He is correct in pointing out what is happening in different parts of the country where GP fundholders are finding better ways of using the resources at their disposal. As a result, the standard of service that GPs are delivering to their patients—which is measured in waiting times and in a variety of other ways—is being ratcheted up. I do not apologise for that fact: fundholding and the other reforms were introduced partly to improve patient service.
The hon. Gentleman is quite right to point out the second-stage effect. Once a fundholder has found a way of improving the care available to his patients, the system is deliberately established to apply pressure to other fundholders—and to purchasing health authorities acting on behalf of non-fundholders—to raise the quality of service, leading to a relentless improvement in the quality of care that is available across the health service.
I shall return to the question that troubles the hon. Member for Peckham. Why was her prediction wrong and why do more than half of the doctors now plan to be fundholders from the beginning of April? If she will not accept my explanation of why people are opting for fundholding, perhaps she will listen to the words of some independent and friendly advisers. Howard Glennerster said that GP fundholdinghas produced a shift in the balance of power back to general practice for the first time this century.That is the reason why GPs are opting for fundholding.
§ Mr. Dorrell
It is not just Howard Glennerster. I do not intend to quote Julian Le Grand today, but perhaps I shall return to him on another occasion. Brian Abel-Smith, the former special adviser to Lady Castle, who was one of the last Labour Health Secretaries of State, said:Fundholding represents a major transfer of power from specialists to GPs".The same theme was picked up by Kathy Jones writing for the Fabian Society. The hon. Member for Fife, Central might do well to read some of the Fabian Society material as it is rather more inspired than some of his speeches. Kathy Jones said:Fundholding gives GPs leverage over hospital doctors, changing the balance of power between them.Those three quotations are from three different sources, each of them putting the finger on the real reason—not the cosmetic reason that the hon. Member for Peckham 158 prefers, but the real reason—why GPs are opting for fundholding. Not just those commentators but the 13,500 GPs who will be fundholders from April understand the shift in emphasis that has occurred in the national health service as a result of the introduction of fundholding.
Does the hon. Member for Peckham believe that all those people—all 13,500 GPs and all those advisers—are knowingly undermining the health service? Are they all engaged in a conspiracy to break up a service to which they have given their lives? That is absurd. I have quoted the evidence I have about the support for my policy from people responsible for actually delivering the service. The question I am putting to the hon. Lady and her hon. Friends is whether they believe that all those people who are opting for those changes are doing so because they share the suspicion that that is a desirable way of breaking up the health service. That is the charge the hon. Member for Fife, Central levels at me, but—much more damagingly for him—he is levelling it at 13,500 GPs operating in the national health service.
§ Mr. Deputy Speaker (Mr. Michael Morris)
Order. It is no good Back Benchers standing up for the whole afternoon when it is clear that the Secretary of State is not giving way.
§ Mr. Dorrell
The quotations that I have offered, and I could have chosen a thousand others, demonstrate why doctors are opting for fundholding. They are doing so because fundholding is a means of delivering the objective that so often in the past has been espoused by Opposition Members as a desirable health policy objective—the empowerment of GPs and the strengthening of the role of GPs in the health service.
§ Mr. MacShane
May I tear the Secretary of State away from his Oxford Union practice, which will be useful when he is in opposition, and bring him to the point about GP fundholders? In my part of the world, and I hope that the Secretary of State will listen, it is GP fundholders themselves who are concerned about the fact that if they nominate someone for a hip replacement at the Royal Hallamshire hospital in Sheffield it will be done in 12 weeks, but if a non-fundholding GP down the road does the same—and they are all in the same business— the person has to wait 52 weeks. GP fundholders are also concerned that if they put money into private hospitals, it is denied to NHS hospitals that have to provide accident and emergency cover, which the private hospitals do not.
My right hon. Friend the Member for Derby, South (Mrs. Beckett) went to Harrogate, and I invite the Secretary of State to come to Rotherham to meet fundholders and to hear the problems and questions that they would like to put to him. They are worried, whether he likes it or not, that he is creating a two-tier service.
§ Mr. Dorrell
What I am doing is supporting a system that has led to a bigger shift of power in the health service, away from the institutions and towards the GPs, than we have seen at any time since 1948. That has been a matter of common exchange between hon. Members on both sides of the House. That aspiration has been accepted— empowering GPs because they are the people who are 159 closest to the patients, and allowing them to act as guides and advocates for patients finding their way around the health service.
Spokesmen on both sides of the House have argued that GPs are well placed to design a patient-centred service. The hon. Member for Peckham goes beyond that and has talked about the importance of the development of a broader range of services in primary care. She is right about that too. We have a broader range of provision of post-operative care, shared care arrangements, emergency care arrangements and better provision for GP support for cottage hospitals. All those are important examples of the developments of primary care. What the hon. Lady does not deal with is the fact that the introduction of the fundholding scheme is the biggest single step forward to the delivery of those objectives since 1948.
§ Mr. Charles Hendry (High Peak)
Will my right hon. Friend come to north Derbyshire to talk to fundholding doctors, including the brother of the hon. Member for Rotherham (Mr. MacShane), about the way in which fundholding benefits the patients of all doctors? Is he aware that in Glossop, because of the way in which fundholders have introduced new surgery cases and new activities at the cottage hospital, waiting lists for ear, nose and throat treatment have fallen from 20 weeks to four and for general surgery from up to 30 weeks to a maximum of eight, not just for patients of fundholders but for all patients? That shows how everybody has benefited.
§ Mr. Dorrell
My hon. Friend is right, and a three-part tutorial might be beneficial. I might go to Rotherham and take the brother of the hon. Member for Rotherham (Mr. MacShane) with me to examine the role of fundholding in strengthening the voice of primary care within the national health service.
The hon. Member for Peckham used her defence to my argument in a television programme which I saw before I came into the House today. She said that fundholding is not necessary to the delivery of those improvements in primary care, or to the strengthening of the voice of GPs. I ask the House to pause for a moment and consider that argument. For a quarter of century, speeches have been made in the House, from both sides, about the importance of GPs and about how the NHS must deliver a more patient-centred basis of care. Nothing happened. Then we introduced fundholding and it started to happen.
Is it reasonable to assume that there is a link between those two events, or was that just a massive coincidence? Were the two events entirely unconnected? Would all the changes have happened anyway? Is that the hon. Lady's argument? The changes did not happen for a quarter of a century, but they happened on precisely the day that fundholding was introduced. Is that purely a coincidence? That is what the hon. Lady asks us to believe. The GPs know the answer and on 1 April this year over half of them will be fundholders. They are voting with their feet, and they are not voting for the hon. Lady's arguments.
§ Mr. Richard Burden (Birmingham, Northfield)
Can the Secretary of State explain how it is in the interest of patient care to have millions of pounds locked away, unused, in underspends for GP fundholders? In Birmingham, there is a £10 million underspend and the regional executive has suggested that the health authority borrow money from fundholders to get the waiting lists 160 down. That may sound fine, but is it a good idea for the NHS to be in hock to its own fundholders rather than putting the money to use at the time it is needed, through properly allocated resources?
§ Mr. Dorrell
The hon. Gentleman must decide whether he believes the speeches that his hon. Friends have made over a quarter of a century about the best way of using health service resources.
§ Mr. Dorrell
I shall come to that argument in a moment.
Does the hon. Member for Birmingham, Northfield (Mr. Burden) believe that the patients' interests are best served by empowering GPs to make decisions in their patients' interests, or does he prefer leaving those decisions to the regional health authorities which we have introduced legislation to abolish? That is the choice. The hon. Gentleman prefers to make great speeches about a primary care-led NHS. He likes to talk about devolving power to enable GPs to act as patients' advocates, but he backs away from the hard facts.
§ Mr. Richard Tracey (Surbiton)
Does my right hon. Friend agree that, given that 50 per cent. of the country will shortly be covered by GP fundholders, the Opposition are boxing themselves into a potential crisis? The chairman of the National Association of Fund Holding Practices, Dr. Morris, has said that if Labour ever comes to power and takes the steps it has threatened, those GPs will leave the NHS.
§ Mr. Dorrell
If the hon. Member for Peckham pursued the policy that she is committed to pursuing, GP fundholders would have a difficult decision, as my hon. Friend rightly says.
The hon. Member for Peckham likes to use another argument; she points to the success—Labour's amendment points to this—of commissioners. On that point at least, I can agree with the hon. Lady. There are, of course, many GPs who are not fundholders but who are improving care as commissioning GPs. The hon. Lady should listen to the commissioning GPs to find out what caused the changes that have allowed their commissioning approach to be effective. Numerous commissioning GPs will tell her, if she listens, that it is the introduction of fundholding that has changed the terms of trade—the terms of the relationship between the primary and secondary sectors. That has made possible the success of the commissioning schemes which the hon. Lady likes to endorse.
The reality of the commitment by the hon. Member for Peckham to replace fundholding with commissioning is that it is bad news not only for fundholders and their patients, as my hon. Friend the Member for Surbiton (Mr. Tracey) said, but for the commissioners. The commissioners are taking advantage of the change in the relationship that the fundholders have brought about. That is a key argument which the hon. Lady prefers to fudge. Indeed, Labour is trying to fudge its way out of an embarrassment. Labour Members know that they are caught in a policy position that does not work. They must decide quickly whether they are prepared to opt for and 161 to back the fundholding scheme, which would be the best way to convert their fine words about empowering GPs into reality, or whether they confine their ambitions to fine prose and press releases, in which case they can continue their policy of abandoning fundholding.
§ Mr. Dorrell
No, I will not give way, because I want to make progress. I may give way later.
Another objective to which the Labour party declares its firm attachment is innovation. Labour is right. Health care is a developing activity and it is important to maintain innovation. There are hundreds of examples of innovations that have been introduced as a result of the initiatives taken by fundholders. However, every one of those is under threat if we accept the two-tier argument that has been the chant from Labour during the debate.
The guts of the two-tier argument are that nobody can have the benefit of an innovation until everyone can have it. That is an absurd argument. What Labour seems completely incapable of understanding is that it is in the nature of an innovation that it is new and has to be done somewhere first. Furthermore, the problem is compounded by Labour's naive belief that standards can be identical in every part of the country, for every patient, all at once. Everybody knows that that cannot be true even in a static service; it is doubly untrue in an evolving service. The key issue that the House must address is not how to make the service identical for every patient everywhere—that is an undeliverable objective—but how to maintain the pressure right across the service for continuing improvement. That is the key question, and general practitioner fundholding is a key part of our commitment to seeing relentless and continuing pressure for improvement within the national health service.
That point is the key distinction between Labour's approach and the Government's approach. Labour values uniformity above all. Labour Members talk of diversity and choice, and they use the language of individual responsibility and initiative, but in their actions they opt unerringly for the uniform formula. That absolutist vision represents the hypocritical face of the Labour party. Labour Members say that they favour innovation and diversity, but they set their face firmly against the most effective way in which to bring those factors about.
The most hypocritical aspect of the whole story is the position of the hon. Member for Peckham. We know that she does not believe this absolutist claptrap; we know that she favours a policy of diversity and choice. We know that she understands that the best way to deliver high-quality social services is to encourage professional people to develop their own approach and to allow responsible citizens to choose which professionals best meet their needs.
We know that the hon. Member for Peckham is opposed to the imposition of a single unchanging formula, regardless of local preferences and choices. We know all that because she has opted her own family out of the politically correct formula for education and has exercised her right to choose the best education for her son. [Interruption.] This is not a cheap point. We applaud that action and we think that the hon. Lady is right to have 162 taken it. What she has to explain to the House and to the country this afternoon is why she continues to oppose the application within the national health service of those principles which, by her actions, she endorses in the education of her own children.
§ Ms Harriet Harman (Peckham)
I beg to move, to leave out from "House" to the end of the Question, and to add instead thereof:pays tribute to the role all GPs have played in developing innovative practice in both primary care and the acute sector; regrets that the system of GP fundholding leads to two-tier health care and a massive increase in bureaucracy; believes that the unfairness of the internal market should be ended and GP fundholding replaced by GP commissioning in which all patients get excellent primary care, access to hospitals on the basis of clinical need, and in which all GPs have a say in the planning and development of primary and hospital care.".I welcome the debate and the chance that it gives us to talk about what is really happening in primary care. The Secretary of State has clearly forgotten the advice of the Maples memorandum. He has proved again today that no news about the NHS is good news for the Tories. Any time that he wants to use Government time to debate the NHS and our policies, we shall be happy to oblige.
The Government motion is a disgrace. It congratulates only fundholding GPs; it has nothing to say about all the other GPs who are working hard for their patients. Our amendment, which I commend to the House, pays tribute to the efforts of all GPs who are struggling, despite this Government, to improve patient care.
§ Mr. Jacques Arnold (Gravesham)
Was the hon. Lady aware, before my right hon. Friend the Secretary of State made his speech, that the Government motion, almost in its entirety, was drawn from three quotations from a speech by the right hon. Member for Derby, South (Mrs. Beckett), her predecessor? Was she aware of that, yes or no? If she was not, that is incompetent; if she was, how can she and her colleagues oppose the motion? If they oppose it, it is clear that Labour spokesmen say one thing, but vote in exactly the opposite direction.
§ Ms Harman
It is clear, from the speech that the Secretary of State quoted, that my right hon. Friend the Member for Derby, South (Mrs. Beckett) was proposing all the points that we make in our amendment. I quote from the press release that went with the speech. My right hon. Friend said:Labour's proposals are to end a two-tier system of primary health-care provision … Fundholding"—hon. Members should listen to this point—has improved GP services for some, but at the expense of others.That is our case.
I am glad that the Secretary of State mentioned the points that I made in 1990 because we warned then that the Tory internal market in the NHS would lead to unfairness for patients. We said that it would lead to costly bureaucracy for doctors and fragmentation of NHS provision. The experience of patients and doctors has borne out our warnings. Labour rejects the internal market now as we did in 1990, and we will end it.
§ Mr. Keith Mans (Wyre)
The hon. Lady keeps making the point about the so-called two-tier service that 163 she believes fundholding to be. Will she confirm, in that case, that she believes that before fundholding was introduced, there was a single-tier service throughout the health service, despite the fact that across the country, people were waiting different times for the same operation?
§ Ms Harman
No, there were not. Clinical need determined priority before the internal market, but now it is cash before care. The hon. Gentleman is wrong.
We shall replace GP fundholding by GP commissioning—a system that will benefit all patients, not just a few, and will give all GPs the opportunity to commission care.
§ Ms Jean Corston (Bristol, East)
Is my hon. Friend aware that last week I met a member of the Avon fundholders group? I asked him what innovations he could provide under fundholding that he could not have made available before. He told me that his practice now offered psychological counselling two nights a week and that that would have been impossible before he was a fundholder. However, locality commissioning in south London has enabled non-fundholding surgeries to provide psychological counselling five days a week between 10 am and 3 pm. So fundholding allowed that GP to provide a service that must surely be available to non-fundholding GPs.
§ Ms Harman
My hon. Friend is absolutely right. In his speech today, the Secretary of State sought to perpetuate the idea that innovation takes place only in fundholding practices and that all other GPs are letting their patients down. We reject that and GPs are right to be angry.
The Tories want GPs to compete. They want to be divisive, but Labour wants GPs to work together in the interests of their patients. I shall set out four principles, and the primary care system should measure up to them. We heard nothing about the principles and objectives for primary care from the Secretary of State, so we shall hear whether he agrees with these. The system should provide equal access for all patients; it should make the best use of NHS resources; it should help to provide stability within the NHS so that it can grow; and it should play a part in local health strategies to improve the health of local people.
The Government's policy of fundholding fails on all those counts. It has created a two-tier service; it has added to the mountain of management bureaucracy and red tape; it prevents hospitals from planning for their services; and it cuts across any chance of strategic planning for health gain.
The Secretary of State claimed that fundholding is the fount of innovation in primary care. That is a sectarian and partial view. The Government see no merit whatsoever in the work of non-fundholders. There are hundreds of examples, but I shall mention just a few. Dr. Helen Groom, a GP in Gateshead, has set up a nurse 164 assessment unit for men with prostate problems. That is innovative and the Secretary of State should welcome it. Dr. Robin Singer, a GP in Enfield, has set up a new service to treat cataracts and a twilight nursing service. The Secretary of State should welcome that. Why has he not done so?
§ Mr. Dorrell
I did. I said in my speech that there was no difference between the hon. Lady and myself on the benefits that commissioning GPs have brought to their patients. However, the hon. Lady has to explain how that would have been possible had the relationship within the health service not been changed by fundholding.
§ Ms Harman
We are talking about GPs innovating within their own practices. That has nothing to do with GPs buying hospital care and managing their budgets. Non-fundholding GPs do not control their budgets; they are simply improving primary care in their surgeries. However, we have had some success today because we have forced the Secretary of State, against his motion, to recognise that all GPs are doing a good job, whereas previously he wanted to concentrate on fundholders— to divide and rule.
The Government's claims for fundholders do not stand up. They claim that fundholders improve efficiency, responsiveness and quality of care. Angela Coulter, director of the independent King's Fund centre, says that those claimsare in general not supported by the evidence.The Tories claim that fundholding has been the mechanism for reducing prescribing costs, but the British Medical Journal says:Early reports of the effectiveness of fundholding in curbing prescribing costs has not been confirmed in its longer term study.".There is one thing about GP fundholding on which the Government like to stay silent and everyone else agrees. A two-tier system is an inevitable part of GP fundholding. Some patients are fast-tracked for hospital appointments, while others have to wait longer.
The Secretary of State for Health has always denied that unfairness. This afternoon, it was not clear whether he was denying it or admitting it as his line of argument was somewhat confused, but in the past he has denied the unfairness. He said:The role of fundholding is not to allow a two-tier service",but the evidence tells another story.
I have here a bulletin sent out by the hospitals in Sheffield. It shows the two-tier service in action. The first column reveals that cardiology patients of non-fundholders wait 26 weeks for an out-patient appointment, and the second column sets out the waiting time for patients of fundholders. Instead of waiting 26 weeks, patients of fundholders wait only 12 weeks. Dermatology patients of non-fundholders wait 26 weeks, while patients of fundholding GPs wait only nine weeks. [Interruption.]
§ Mr. Dorrell
Perhaps the hon. Lady would prefer to make her own speech in her own way, but she is illustrating the force of my argument. Is it wrong to improve the service available to the patients of fundholders? If it is not wrong to improve the service to the patients of fundholders, is it then wrong to apply 165 pressure, as the hon. Lady and many others will do, to improve the service available to all patients of the health service? The hon. Lady is highlighting how fundholders are improving standards and that leads to pressure for improvement across the board. While she is talking about waiting times, she might also recount to the House how waiting times for out-patient and in-patient care have tumbled over the past five years, not least under the pressure created by fundholders.
§ Ms Harman
Hospitals, not GP fundholders, carry out operations. The document also deals with hip replacements in Sheffield. It no longer matters who is in greatest pain and needs a hip replacement and who finds it most difficult to get upstairs and has to sleep on the sofa on the ground floor because they cannot get to the bedroom. What matters is whether or not the patient's GP is a fundholder. In Sheffield hospitals, patients of non-fundholders have to wait up to 52 weeks for hip replacements, but patients of fundholding GPs, even if their condition is less serious, have to wait only three months.
The Secretary of State said that he wanted to know what was wrong. I shall tell him: it is the unfairness of a two-tier system. We are not talking about advantages won by GP fundholders; they are not carrying out the hip operations. The system simply provides unfair access to our hospitals.
Did the Secretary of State know about the position in Sheffield? Did he know about the two-tier bulletin for waiting times in Sheffield? Does he defend it?
§ Mr. D. N. Campbell-Savours (Workington)
On a point of order, Mr. Deputy Speaker. Will you ensure that Hansard shows that the Secretary of State said, from a sedentary position, "Yes, I do defend it"?
§ Mr. Deputy Speaker
It is not for the occupant of the Chair to determine what Hansard reporters record.
§ Mr. Alan W. Williams (Carmarthen)
On a point of order, Mr. Deputy Speaker. My concentration during the debate has been badly upset by the hon. Member for Hayes and Harlington (Mr. Dicks), who at no stage has tried to intervene, but continually barracks from a sedentary position. Will you call him to order?
§ Mr. Deputy Speaker
In an ideal world, there would be less barracking from both sides of the Chamber, from both the Back and Front Benches. It has been a lively debate so far.
§ Ms Harman
My hon. Friend the Member for Workington (Mr. Campbell-Savours) is absolutely right.
166 In the debate that the Secretary of State has called today, he has just endorsed the two-tier waiting-list system. That is a disgrace.
It is the same story across the country. In Scotland, the Glasgow royal infirmary issued a letter proposing to give priority to the patients of GP fundholders. In King's College hospital in my constituency in London, there are extra surgery sessions for fundholding patients only. As my hon. Friend the Member for Halifax (Mrs. Mahon) said, it is the same in Halifax. I have a letter that was sent to a GP in her constituency from St. Luke's hospital. It states that
we are not able to respond to your recent request to provide a psychology assessment/treatment service for your patient, and I am, therefore returning your letter of referral … We are only able to provide services…where we have contracts with fundholding practices".When the Secretary of State responded to one of my hon. Friends, he tried to say that a new system was being developed. What is being developed is not a new system, but unequal access to an existing system. It is not just that the internal market is unfair; it is too expensive to ran and it piles bureaucracy on to bureaucracy. Every GP fundholder has to have his own set of contracts and has to have a business manager in the practice. Each fundholding practice now employs a business manager who is paid twice as much—if not three times as much—as the practice nurse. The hospitals have to employ more managers to negotiate with the fundholder managers and the bill is huge—at least £80,000 extra in administration costs for each fundholding practice. With the current number of fundholders, that amounts to an extra £212 million a year on bureaucracy. There is no contribution to patient care, just more bureaucracy.
With the multiplicity of GP fundholders, there is no chance of developing what we want to see: an overall strategy for health services in each area. It is impossible for hospitals to plan from one year to the next. Like unfairness, instability is driven into the system by GP fundholding. We do not criticise the patients of GP fundholding; we do not criticise the fundholders. GP fundholding was not the idea of doctors; it was forced on them by the Government and there is still widespread opposition to it among GPs.
The Secretary of State misrepresented GPs' views. A survey in 1995 by Pulse magazine found that more than three quarters of GPs wanted fundholding abolished; half of all the fundholders wanted the scheme abolished. The GPs joining the fundholding scheme are not giving a vote of confidence to the fundholding scheme; many are simply trying to do the best for their patients in an unfair system. Unless GPs become fundholders, they have no right to choose where patients go for treatment; unless GPs become fundholders, they have no say in the planning of local services. Two thirds of GPs object to fundholding in principle, but half of them said that if other practices in their area started to become fundholders, they would have to apply too.
Because the fundholding scheme is fundamentally flawed, many doctors across the country are working together to remedy its defects. They are trying to make fairness in an unfair system; they are trying to make sense out of a senseless system. They are struggling to overcome bureaucracy.
In Hertfordshire, GP fundholders have tried to instil some strategy into the fragmentation of the NHS market. A joint strategy working group there incorporates 167 fundholders and non-fundholding GPs, public health, Hertfordshire health agency and the local medical committee. The group has created a Hertfordshire-wide policy where the fundholders agree to purchase within the policy.
In Winchester, an attempt has been made to mitigate the two-tier system by using fundholders' budgets to pay for operations for the patients of non-fundholders, who would otherwise have to wait until after April for their operations. In Newham, GPs have tried, single-handed, to influence the purchasing decisions of the health authority by combining to create the Newham Innercity Multifund.
§ The Minister for Health (Mr. Gerald Malone)
I am grateful that the hon. Lady has at last decided to give way on a constituency point. Does she not understand that if the fundholders had not been in a position to manage their budgets to make savings, the money would not have been available for health care in my constituency? That is the point.
§ Ms Harman
No, that is not the point. The situation was unfair: neither the GP fundholders nor the non-fundholders found it acceptable, so they all got together to pool their resources so that the fundholders could help out the non-fundholders in an unfair system. That is an example not of the system working, but of good people on the ground trying to mitigate the unfairness of the Tory system, and I applaud them for that.
All the examples that I have given show GPs struggling to improve their care for patients despite the problems of fundholding. The Labour party will build on their work and will replace fundholding with GP commissioning— a framework for primary care that will allow all GPs to have a role in shaping local health services.
All GPs will have substantial new powers and opportunities under Labour's scheme for GP commissioning. First, all GPs will be able to refer their patients to the hospital or specialist they want so that GPs can ensure that their patients are in the right hands without the tangle of red tape. Secondly, Labour offers all GPs an enhanced role in the planning and public health functions of the health authorities. GPs and the health authority will team up to commission health care. There are a number of models, so the relationship between the two can be flexible. But, under our system, health authority commissioning decisions will have genuinely to reflect the views and experiences of local GPs. GPs will have the chance to innovate, while bureaucracy can be cut and strategic planning maintained.
GP commissioning is, as the Secretary of State acknowledged, already evolving throughout the country: more than 60 commissioning groups are in operation, representing more than 5,000 GPs and covering 11 million patients. The range of commissioning models is still developing. In Nottinghamshire, a commissioning group has been established by 200 GPs, caring for nearly 400,000 patients. They have achieved many improvements in patient care. In Tamworth, first-wave fundholders frustrated with the limitations of fundholding have taken up commissioning instead. Working with non-fundholders and the South Staffordshire health commission, they have created a health commissioning group. They say that commissioning is the way in which the NHS should work in the future.
168 The Tory internal market in the NHS creates division. It sets patient against patient, doctor against doctor and hospital against hospital. Today, the Secretary of State has sought to manufacture further division with his motion. He has tried to play fundholding GPs against non-fundholding GPs. He realised that it did not work and so he backed off. His strategy, however, is widely understood. One fundholding GP, Dr. Marcoolyn, observed that the Governmentare never happier than with divide and rule situations.When they cannot find those situations, they create them.
The debate should not be about dividing GP from GP or fundholders from non-fundholders. It should be about what the Government could be doing to improve primary care, but the Tories are fixated on one divisive ideological model for primary care—GP fundholding. Their only new ideas for primary care are that GPs should take on casualty work to help out the hospitals because of the hospital crisis, and backing private GPs to set the standard for all other GPs. We have, "Dorrell backs private GPs"— an interesting suggestion that he did not introduce in the debate today. Perhaps we shall hear that he has thought better of it.
The Tories are prisoners of their own policies, and they are afraid to listen to the experience of GPs and patients. Labour is moving forward, listening to GPs and patients and building on the best practice of all GPs to create a primary care service fit for the millennium. The Tory party is not interested in patients, the state of the NHS or the condition of Britain. It is interested only in clinging on to power. The Tory party has, as evidenced today, shut down the business of government and is simply trying to act like a propaganda machine, and is using the House to do so. [Interruption.] In effect, this has been an Opposition—
§ Mr. Deputy Speaker
Order. I understand that an hon. Member used the word "hypocrite" in relation to another hon. Member. If that is correct, will the hon. Member please withdraw the word immediately?
§ Mr. Terry Dicks (Hayes and Harlington)
It was another word, but if the context is offending you, of course I withdraw.
§ Mr. Deputy Speaker
Order. I would be grateful if the hon. Gentleman would speak slowly and clearly so that I can hear.
§ Mrs. Marion Roe (Broxbourne)
It is extremely helpful that we have the opportunity today to expose the differences between the Government and the Labour party 169 on GP fundholding. It is about time that we began to hear what the Labour party proposes for health care. I make my contribution to the debate not only as Chairman of the Select Committee on Health but as the Member of Parliament for Broxbourne, and I shall outline the health services that are available to my constituents in Hertfordshire.
It will not be a surprise to anybody to hear that, during the Select Committee's inquiries into priorities in the national health service—both in the drugs budget and in purchasing—the role of GP fundholders was brought to our attention. In the NHS drugs budget inquiry in 1994, we received evidence that focused on GP fundholders' management of their budgets. We were informed that fundholders had consistently spent considerably less on drugs than had non-fundholders, despite their budget allocation being set on an identical formula. We were given examples. In Mersey, although real costs had increased, 70 per cent. of fundholders had reduced their prescribing costs in relation to their set budgets. In the five months from April to August 1993, Oxford regional health authority published figures that showed a 9 per cent. difference above permitted target growth for fundholders as against non-fundholders.
§ Mrs. Roe
Not at the moment. When I have finished this point, I shall give way to the hon. Gentleman.
Lincolnshire showed a 2 per cent. lower rise in drugs costs between fundholders and non-fundholders. In Derbyshire, fundholders underspent their budgets by 1 per cent. Non-fundholders overspent theirs by 8 per cent.
We were given three reasons for those results: first, the incentive of being able to reinvest the resulting savings for the benefit of patients; secondly, the ability to contract directly for the minimal use of expensive drugs emanating from hospital prescribing; and, thirdly, the self-imposed commitment required in fundholding health plans to show improvement in the quality and value for money of the delivery of health care. I should also add that we were assured that, in attempting to reduce prescribing costs, fundholders accept that rational prescribing does not necessarily mean cheap prescribing, but the financial incentive and necessary commitment make fundholders much more aware of the general headings under which drug expenditure can be reduced. Effective and appropriate prescribing with a value for money principle must be a worthwhile goal that we would all support.
§ Mr. Galbraith
The hon. Lady raises a matter about which there is some evidence rather than just opinions. She will be aware that much of the evidence that she quotes is for the first year of fundholding. A significant reduction in prescribing costs was confirmed in a paper published in the British Medical Journal in 1993. Perhaps she has not read the paper that was published in the BMJ on 9 December last year. I quote from the abstract of the conclusions, which says:Early reports of the effectiveness of fundholding in curbing prescribing costs have not been confirmed in this longer term study.170 The claims that she makes were for the first year only, and were due to GP fundholders being given more money at the start. They were not borne out in the longer term.
§ Mrs. Roe
I am grateful to the hon. Gentleman for drawing that to my attention, but I should explain to him that, during the course of our inquiry, evidence was given to us that showed that on many occasions doctors were handing over a prescription to a patient to get them out of the surgery, which I understand had frequently been the case in the past, and the emphasis was on more appropriate prescribing—not just the budget itself— to benefit the patient.
In its purchasing inquiry, the report of which was published in January 1995, the Health Select Committee questioned five fundholders. When asked:What changes have you made to secondary care services since becoming involved in commissioning and what changes are you expecting in the next 3 to 5 years?",the East Shropshire GP commissioning group replied— the reply is headed "Impact on Secondary Care"—We have virtually eliminated any waiting time for GP direct access physiotherapy. We have influenced the nature of the outpatient experience for patients, driving towards innovative 'one stop' clinics whereby the patient gets everything necessary for operation work-up done in one afternoon rather than up to four visits to hospital. In the next three years, if we still exist, we would expect to achieve much closer integration of the secondary and primary services, possibly with clinicians moving out from the hospital base into the primary care setting.We would hope to achieve better communication between consultants and GPs, better measurement of outcome and better quality standards in the purchasing contracts, based upon following an individual patient through the system (not currently possible on the information available to the district health authority)".Surely all of us, especially patients, would approve of that statement.
I was pleased that the hon. Member for Peckham (Ms Harman) drew attention to the innovative ideas that we are implementing in Hertfordshire. We feel that we lead the field in the provision of high-quality health care. My Broxbourne constituency contains 15 GP practices with a combined list size of 97,185; 11 practices are fundholding, and have a combined list size of 92,935. GP fundholders comprise 73 per cent. of practices in Broxbourne, and serve 96 per cent. of all patients. Their combined budgets in 1995–96 amount to nearly £15 million.
I have no doubt that GP fundholders can claim to be at the leading edge of implementation of the Government's policy of a primary care-led national health service. From the start of the scheme, they have developed services in their own surgeries that are convenient for patients, avoid inappropriate use of hospital facilities and provide better value for money. For example, there are outposted out-patient clinics where hospital consultants hold regular clinics in different specialties. That helps to develop GPs' specialist skills, and has frequently led to jointly agreed protocols for hospital referral. Fundholders have also contracted for, or directly employed, physiotherapists, counsellors, dieticians, chiropodists, nurse practitioners and other professionals, and carry out an extended range of minor surgery procedures in their own surgeries.
§ Mr. Campbell-Savours
May I ask the hon. Lady a question that my hon. Friend the Member for Peckham 171 (Ms Harman) asked the Secretary of State? The hon. Lady, who chairs the Health Select Committee, has seen the Sheffield document that showed two different waiting lists for the same discipline in a certain hospital. Does she accept that a two-tier system operates there?
§ Mrs. Roe
I have not seen that document. It has been displayed across the Chamber, but I have not had an opportunity to read it. I was going to make the point that in Hertfordshire there is no two-tier system. If the hon. Gentleman visits my constituency, I will demonstrate to him that the system there is operating very effectively for the benefit of patients. I shall, of course, look at the document, and I am sure that my colleagues on the Select Committee will do the same. [Interruption.]
§ Mr. Deputy Speaker (Sir Geoffrey Lofthouse)
Order. The hon. Member for Workington (Mr. Campbell-Savours) has been in the House long enough to know what the procedures are.
§ Mr. Deputy Speaker
If the hon. Gentleman knows the procedures, he should not have crossed the Floor as he just did.
§ Mr. Campbell-Savours
On a point of order, Mr. Deputy Speaker. If I may say so, I am entitled to sit on the Conservative Benches.
§ Mr. Deputy Speaker
The hon. Gentleman knows the procedures of the House full well. He knows that he should not have crossed the Floor of the House with that document.
§ Mrs. Roe
I am told that a number of other hon. Members wish to speak. I have already given way twice; my hon. Friend will be able to catch your eye later, Mr. Deputy Speaker.
Through an innovative and flexible approach to health care, GP fundholders in my constituency have now made available an extensive range of diagnostic investigations and screening including blood tests, electrocardiograms, audiology screening before referral to an ear, nose and throat surgeon and ultrasound screening. They are working increasingly closely with hospital colleagues in developing protocols for referrals, treatment and discharge. They have increased the number of community and practice nursing staff to cope with the increased work load as hospital lengths of stay shorten, more day-case surgery is undertaken and the move from secondary to primary care settings accelerates.
Most GP fundholders place contracts with trusts on a "cost per case" basis, which has led to improved procedure-based costing by trusts and to more timely 172 communications. That is very important. Fundholders are also working closely with the Hertfordshire health agency in developing joint approaches to contracting, and in reviewing the appropriateness and effectiveness of different treatments.
Those of us who represent Hertfordshire constituencies are proud of the way in which the whole local medical profession is delivering health services to our constituents. I assure the hon. Member for Workington that no two-tier system operates in my area: equity of service for all patients is an acknowledged priority. Moreover, there are four total-purchasing pilot projects in the county, which will begin purchasing all health services in April.
§ Mrs. Roe
No. I want to finish my speech.
Given my experience as the Health Select Committee Chairman and my work in the constituency, I believe that GP fundholders are doing an excellent job in putting the interests of their patients first and ensuring that they receive a high-quality service within the NHS. There is no doubt that fundholders are a success, and also very popular with patients. They have set a standard for others to follow, and I believe that they should be encouraged and assisted to flourish and develop in the future.
§ Mr. Alan Simpson (Nottingham, South)
I feel very privileged to speak in the debate, mainly because I have done what the Secretary of State suggested and listened to some of the comments of GPs who are members of the non-fundholding consortium that operates in Nottingham. On the basis of those comments, I shall address the seven deadly simplicities offered by the Government in defence of their policy on fundholding, and the four more sensible options that might result from adopting the same course as the non-fundholding group in Nottingham. It may help hon. Members to know about the non-fundholding consortium's structure. It has an elected committee of 13 general practitioners, who represent more than 200 GPs in the city. Between them, they cover more than 400,000 patients. The consortium has proved so successful that it is contracted to advise Nottingham health authority on its purchasing policies.
The consortium's objectives were set out about a year ago by Dr. Doug Black, Dr. Alan Birchall and Dr. Ian Trimble in the British Medical Journal. They said that they couldcollectively offer more time and knowledge to the contracting process while minimising the impact on clinical workload. As a large purchaser with low management costs the group has secured access to quality secondary care which is equitably available to all patients, preventing the development of a local two tier service.It is in that context that I shall deal with the first of the simplicities and inaccuracies that the Government offer us.
The Minister for Health recently said that GP fundholders' savings far outweighed their administrative costs. It was on that basis, he said, that fundholding saves money. Let me refer him and hon. Members to last year's Audit Commission report. Paragraph 37 pointed out that, of the £19 million-worth of savings that had been made by fundholders, 173 35 per cent. had been spent on premises and 25 per cent. on office furnishings. One Nottingham GP pointed out in Pulse that the report showed that
of the £19 million of fundholders' savings actually spent by 1993/4, less than 20 per cent. was spent directly on patient care. If this pattern continues, fundholders will re-invest less than £13 million of the 1993/4 savings on patient care.He added that, if that trend continuesfundholding will have resulted in nearly £90 million … being withdrawn from patient care in a single year.That is a pattern not of value for money spending, but of a profligate waste of money. In Nottingham, 75 per cent. of general practitioners are non-fundholders. The administrative costs in Nottingham are the lowest in the Trent region. That achievement is a direct result of the non-fundholding consortium's role and contribution.
The second magical myth that the Government have peddled is that fundholding reduces drug spending. A recently completed study in Nottingham shows, however, that, over a four-year period, fundholding GPs' prescribing bills have been rising faster than those of non-fundholding GPs. It is an objective fact that, in Nottingham, non-fundholding GPs' cost for drugs per prescribing unit is almost £3 less than that of fundholders. Although non-fundholders lay claim to that and view it as a virtue, they also point out that, if the House genuinely wanted to understand the key issues in prescribing costs, it should not simply compare fundholders with non-fundholders but should consider the extent to which any savings are dwarfed by the power and pressure exerted by the pharmaceutical companies in relation to the total drugs bill. A different way of pursuing substantial savings on the drugs bill would be to link hospital and prescribing budgets at district level. That would offer direct incentives for consultants to work alongside their GP colleagues to promote more effective use of budgets.
The third fantasy that we were offered is that fundholding is popular with GPs. Last year in Nottingham, however, not a single GP moved from non-fundholding to fundholding. A meeting that was scheduled to be held on the invitation of the Health and Safety Executive, to promote fundholding, had to be cancelled because it could not attract GPs to attend—such is the measure of fundholding's popularity. All that must be viewed against the backcloth of nearly five years of direct financial incentives to GPs to opt out of non-fundholding status.
I did not understand the Secretary of State for Health when he said that the funding arrangements for fundholder GPs did not differ from those for non-fundholder GPs. The consortium in Nottingham tells me clearly that fundholders are paid on an activity basis, that non-fundholders are paid on a capitation basis and that Government rules restrict the way in which non-fundholders can use any savings that they make collectively. The aim of the unequal approach to funding is to drive GPs out of the non-fundholding sector.
The fourth Government myth is the notion that fundholding is popular with patients. A Which? report last year pointed out that about 59 per cent. of patients did not know whether or not their GP was a fundholder. We can all understand and excuse that: it will not necessarily be 174 the biggest issue in a person's life. What was more significant was that the survey accepted that lack of knowledge and asked patients whether they were getting better or worse access to their GP. It found that more fundholding GP patients were having difficulty in gaining such access than non-fundholding GP patients. So the claim that fundholding is popular is itself somewhat dubious and does not stand up.
The Government then tell us that fundholders influence service provision. In some cases, they do—evidence of a two-tier system can be seen in the Sheffield list—but they do so at the cost of other patients. Ironically, some of this is beginning to boomerang on Government policy. The National Association of Fund Holding Practices recently surveyed its members and found that a high proportion of them were experiencing increasing prices because of demands by trusts, after purchasing budgets had been set. Their members were having to pay increased moneys to purchase the extra services that they wanted. That is hardly a sensible way of dealing with serious, overall reductions in patient waiting lists.
Again, in Nottingham, the non-fundholding consortium's role has been precisely what the Secretary of State wished: to exercise a collective role in reducing patient waiting lists. It has been astonishingly successful. I identify just three of the sectors where there have been amazing results. At the Queen's medical centre, a teaching hospital in my constituency, the waiting lists for non-urgent, out-patient operations went down considerably. For example, the waiting list for ear, nose and throat operations went down by 30 per cent., in the ophthalmology department it went down by 48 per cent. and in the orthopaedics department it went down by 15 per cent. Overall, waiting lists have gone down by 14 per cent. That is what can be achieved by GPs acting collectively in non-fundholding consortiums.
The sixth claim that the Government make is that fundholding promotes change through market forces. Again, the evidence from fundholders is that it takes a huge amount of time to negotiate contracts. Many of them are simply signing copycat contracts that have been written by the hospital trust. Fundholding has not shifted the basis of leverage in terms of innovation. GPs tell me that, although they have a sense of what they can do in terms of patient care and meeting patient needs, if they are drawn into individual contract negotiations, they do not have the time or expertise to view the broader picture and to assimilate epidemiological evidence. That task must be done at a collective level.
The seventh, and the last, of the fabulous myths and simplicities that we have been offered is that fundholding ensures that the NHS is primary care led. The simple fact is that, in negotiations between a GP and a hospital, an individual practice is dwarfed by the power of the large providers, and their ability to set the agenda.
In Nottingham, the non-fundholding consortium proposes that an elected group of GPs should share the responsibility for Nottingham's budget with the executive of Nottingham health commission. That would give an innovative, primary-care edge to the whole purchasing process.
The real excitement about the debate that we should be having lies in the possibilities beyond the fundholding absurdity. Again, Nottingham has come up with an exciting idea—that of a total commissioning project based 175 on four assumptions. The first is the shared fiscal responsibility that I have already mentioned. That would be not an abrogation of responsibility, not a "grab it for yourself and run as far as you can" notion of responsibility, but the establishment of a common and collective responsibility for commissioning, in the interests of all patients.
The second requirement is that the absurdities and inconsistencies between the funding offered to different GPs should be removed. The consortium wants us to understand the need to accelerate the move towards capitation-based budgets at regional, district and practice level.
Thirdly, the House should acknowledge the value of allowing for virement between budgets at a district level. If drug budgets are overspent, money now automatically comes out of next year's health service allocation. There is already a direct linkage, but virement at a local level would offer incentives for consultants to work with GPs to get the maximum out of the budget, in the interests of all their patients.
Finally, the group asks for funding for information technology advances. It is a recognition of the fact that if the different elements can act collectively, they can get far more out of the system, in the interests of patients, than if they all set off down separate paths.
The group has carried out costings for the project, showing that there would be an overall saving of £3 million, compared with any equivalent move to push an extension of fundholding. That is the local Nottingham advantage that would arise simply from any such approach. If we extended the idea across the country, to the 60 or more commissioning units set up by non-fundholding practices, the benefits would be spread even more widely.
We must recognise that the choice is between being stuck in a system that will increasingly confer benefits only on the few, and the opportunity of delivering substantial benefits to the many. The new approach that I have described would not be a question of "no change"; it would bring substantive change for the vast majority of people and prospective patients, and we must consider that.
Of course Labour must scrap GP fundholding, but the real debate—the debate that we should be having now— is about how to replace it with a national programme that incorporates the visionary lessons, and a far more efficient system, that are already being learnt both in Nottingham and by other GP non-fundholding commissioning groups across the country. The challenge is to weld those into a national strategy to restore the structure of a single-tier national health service.
§ Dame Jill Knight (Birmingham, Edgbaston)
I am glad to have the opportunity to make a brief speech in support of the motion. Fundholding has a proven record of success, and it is one more milestone on the road of the Government's achievements in modernising, improving and enhancing our British health service. It cannot be said often enough that our health service today is better than it has ever been in the whole of its history.
Fundholding has indeed done all that the motion says it has. Fundholding doctors know from experience how advantageous it has been for patients, in enhancing primary care and in giving doctors the tools with which to improve their practices.
176 Doctors who have learnt the advantages at first hand have been talking to their friends, and fundholding is soaring. At the beginning of 1991–92 only 7 per cent. of practices were fundholding. In two months' time the proportion will be 51 per cent. That alone, quite apart from anything that my right hon. and hon. Friends or I may say, is a clear sign of how much the GPs like fundholding systems.
Fundholding has brought so many advantages to patients that I have time to list only a few of them. The range of treatment now available has now improved so much since fundholding started. The quality of care has improved and, as the Opposition agree, waiting lists are much shorter. There has been a reduction in bureaucracy, and services such as chiropody, which is most important for elderly people and makes all the difference to their lives and to whether they can get about without pain and discomfort, have improved.
The minor operations done by doctors in their practices since fundholding began have also helped a great deal. I could also say much about dermatology, because I was closely involved for a long time as the president of one of the groups of people in my area who suffer from skin diseases. Treatment for all such conditions and many others are now available within practices.
That has made a tremendous difference to the burdens that hospitals have to bear. Hospitals today are carrying out more and more complicated operations and treatments, and they need all the alleviation of their work load that can be provided. Fundholding has made an important contribution there. As my hon. Friend the Member for Broxbourne (Mrs. Roe) said, doctors can now negotiate directly with hospital consultants in a way that was not possible before. That, too, has been a help.
Practice nurses are important, because their presence has improved primary care. I was amazed when I learned that since fundholding was introduced the number of practice nurses has increased by 261 per cent. That is marvellous news. I spoke to a practice nurse recently, and she was eulogistic in her support of what had happened in fundholding practices.
Doctors have been able to use the savings to improve their waiting rooms, and in other small ways whereby patients' comfort can be increased. That is most important. Fundholding has given doctors a power over their own domain that they did not have before.
I have always felt that those nearest the point where money is spent, those who know the score and know the specific problems, should decide how money should be allocated. That is equally true of school budgets. Those, too, are better decided by heads and governors than by education committees. Doctors running practices know better than health authorities where money is most needed and how it should be spent.
The Labour party disagrees with all that—at least, I think that it does. It is sometimes difficult to figure out what Labour Members are really saying—especially now we know that, although the motion uses the words of the right hon. Member for Derby, South (Mrs. Beckett), the Labour party apparently proposes to vote against what she said.
177 Labour's response to the fact that the treatment of patients is very much better than it was is absolutely typical. Labour cannot deny that patients are receiving much better treatment. Indeed, Opposition Members are not advancing that argument—
§ Dame Jill Knight
I said that I would make a brief speech. The Opposition are whingeing and whining that patients of doctors who are not fundholders are disadvantaged. The argument is not that patients of fundholding practices are getting a bad deal. Those patients are getting such a good deal that it infuriates the Labour party because the service for everybody else is not improving as well.
§ Dame Jill Knight
I understand that constant attention is paid to ensuring that money is as fairly allocated as possible between fundholding practices and non-fundholding practices. The difference is that fundholding practices are managing their money much better.
Conservative Members want the benefits that patients of fundholders receive to be spread all over the place. There is no absolute ban on the number of doctors who can become fundholders. There is a stipulation about the size of the practice, but many doctors have overcome that problem by amalgamating with other practices. The Government have not said, as one would think from listening to Labour Members, that nobody else is allowed to become a fundholder because the number is limited. Conservative Members are trying to spread far wider the undoubted benefits of fundholding, which is absolutely right and proper.
The Opposition will have problems if they rubbish fundholding. Although their argument today has not been that fundholding is wrong, they still want to get rid of it. That is extraordinary. The Labour party should recognise that the British Medical Association has given fundholding the seal of approval for good housekeeping, and patients most certainly approve of it.
I am sorry that the hon. Member for Nottingham, South (Mr. Simpson) could not wait to hear the rest of the debate and has already left the Chamber as I wanted to raise a particular point with him. He said that patients were not very keen on fundholding. If patients are receiving so much better treatment from fundholding doctors, why should they not be keen on the system? They are very keen indeed.
The support for fundholding among doctors who have experienced it is undeniable. The National Audit Office has approved of it; the Public Accounts Committee has said what a good system it is. The hon. Member for Peckham (Ms Harman) seemed to imply that the King's Fund did not approve of the system. I wonder whether she has read the 1994 report which evaluated NHS reforms and described fundholding as one of the major successes of the reforms. So how can the hon. Lady suggest that the King's Fund is not in favour of fundholding?
178 It is clear that the Labour party will meet strong opposition to its policy to abolish fundholding. I wonder whether it will include that policy in its manifesto at the next election.
§ Dame Jill Knight
Good—that will mean many thousands more votes for us. What a good idea that is. [Interruption.] Labour Members are stuck with it now. They will have to put it in the party's manifesto. Will they argue with the BMA, doctors, patients and the King's Fund? They should ask themselves whether all those people can be wrong. Labour is in a tizzy—it is in a mess.
I am sorry that the hon. Member for Peckham has left the Chamber as I should have liked to draw her attention to the many instances in her speech when she seemed to be facing both ways. For instance, she complained that money which ought to be used for patients was wasted in fundholding practices on management, but at the same time she had to admit that those patients got better care than any patients of non-fundholding practices. She cannot have it both ways, although she loves to try.
I do not know what the Labour party intends to do, although it has proposed some alternatives—joint commissioning came up again today. So far as I can gather, there is little support for that among doctors who happen to be in the Labour party. I read that the Labour party is suggesting shadow budgets. Labour Members are so used to being shadows that they advocate them even for doctors. Long may they continue being shadows.
If the Labour party removes real money—I understand that that is what having shadow budgets means—real control will go as well. Running a medical practice is not a game of Monopoly, and Labour Members had better understand that. Other Members wish to speak, so I will conclude my speech. I strongly support the motion.
§ 6.5 pm
§ Mr. Simon Hughes (Southwark and Bermondsey)
Anybody without prior knowledge of the subject who heard this debate would have thought that it was a dialogue of the deaf and would probably have left without being further enlightened. Although the benefits and disbenefits of fundholding have been cited, nobody so far has explained what fundholding is intended to achieve. I shall describe why I think that the debate has so far been a dialogue of the deaf.
The position of my right hon. and hon. Friends is clear from the amendment that we tabled. Although Madam Speaker did not select it for debate, it is on the Order Paper and sets out what we believe. There are problems with the other two expressions of party opinion. The Government motion, which is fine so far as it goes, does not admit that there is anything wrong with the system at all.
The Labour party's amendment, which rightly points to the failures of the system, does not specifically address the question asked by, for example, the hon. Member for Birmingham, Edgbaston (Dame J. Knight). Does it imply the abolition of fundholding? I have read the Labour party policy document and I know that it proposes the replacement of fundholding with commissioning, but the question of abolition is not answered. Fundholding GPs would want to know the answer to that question.
179 Despite this rather unsophisticated debate, it is none the less obvious why there is such a difference of view. It is clear that the system that the Government set up to devolve power to GPs by giving them budgets enabling them to buy their own health care for a specific list of activities—obviously not forms of acute care and the like—has been welcomed by some GPs, who see it as an advantage. It is also abundantly clear that the system has produced innovation and a knock-on effect on the way in which other practices are organised.
Disparity of treatment in some areas—described in the document to which the hon. Member for Peckham (Ms Harman) referred, and which, courtesy of the hon. Member for Workington (Mr. Campbell-Savours), has found its way to the other side of the Chamber—has arisen because when hospitals are deciding who is first on the list for treatment, they have to make a choice between keeping fundholding practices happy and keeping the local health authority happy. Non-fundholding GP practices do not have the individual clout of fundholding practices as customers in the marketplace. For example, if GP fundholders do not get put first in the list, they may take their business to another provider or trust. Therefore, the trust will lose out and its budget and prospects will be reduced. That is why there is a difference.
It may be true that the formula for allocating money in terms of patients is more or less similar, but the providers are dealing with two different sets of people—GPs, who are buying services directly, and the local health authority, which is the indirect purchaser. The health authority is likely to continue to be a purchaser, as the local health authority for the place where the trust is will probably be providing either community care services or acute services from a hospital. It is quite explicable as to why there are benefits for many patients and for fundholders. Fundholders get to the top of the list in some places, even though that is not written into the system and is not part of the defined difference between fundholding and non-fundholding GPs.
The hon. Member for Nottingham, South (Mr. Simpson) made a good speech and asked some pertinent questions. He alluded to the fact that proper criticisms can be made of the fundholding system. My right hon. Friend the Member for Yeovil (Mr. Ashdown) visited the Mid Devon Family Doctors commissioning group in Cullompton last autumn. One of the doctors at that practice, Michael Dixon, wrote to me enclosing the group's document. The introduction illustrates why at present there is a two-tier system. If the Government would accept only that, we could make some progress.
§ Mr. Hughes
He has certainly defended the system, but he has not formally accepted—so far as I am aware—that there is a two-tier system. The introduction to the Mid Devon group's document states:We are quite happy with the pluralist system of purchasing, which allows for GP commissioning groups and fundholders, but the unnecessary and unreasonable bias in favour of fundholding must end. No-one doubts that historically fundholders have been over-funded. Furthermore, they, but not GP commissioning groups, are provided gratis with money for management and computers from outside funds (approximately £35,000 per practice). It is also unfair that fundholders are able to substantially increase their expenditure on practice staff over non-fundholders by committed overspends on their staff budgets. It is neither fair nor ethical that underspends 180 (which averaged £59,000 per practice in Devon last year), can be spent on furniture, equipment and buildings to the financial benefit of the practice and the partners themselves.According to that document, 99 per cent. of fundholders in Devon use underspend money in that way. The national figure is 75 per cent. The document continues:Doubly absurd are the present rules whereby the local Health Authority (and thus indirectly the patients of non-fundholding practices) have to pay out for any fundholding practice that overspends.That is true. If a fundholding practice overspends, the tab gets picked up by the health authority, which has to divide the rest of its budget between other practices. That is clearly unfair, and the Government ought to recognise that.
My hon. Friend the Member for North Devon (Mr. Harvey) received a letter from Dr. Mark Beer of Chumleigh in my hon. Friend's constituency. Dr. Beer quoted from a letter from Dr. Rosemary MacRae of Rainford, St. Helens, that was published in the December issue of Financial Pulse, entitled:Why should GP fundholding savings become 'assets'?Dr. MacRae's letter states:I regret I was not appalled to read that a retiring partner is entitled to a share of assets bought from fundholding savings … I merely read it with cynicism and resignation.It seems unjust that money allocated as such can be 'saved' and invested in assets that become the property of the GP. It suggests too much money was allocated in the first place, the services bought were not comprehensive, or there has been inordinate waste in the way patient care has been financed in the past.Dr. Beer wrote to my hon. Friend, saying:Would your Health Spokesperson be interested in this …? I am appalled by the implications as I am sure most of the population would be. There should be questions in the House!I have now posed that question in the House, and I hope the Minister will respond to it. Can he explain how certain people can stack up assets by buying that advantage while others lose out because the total amount of health service money allocated in any area is, by definition, limited?
There is no secret about the Liberal Democrats' position and policy. I believe that the Minister has been sent a copy of the policy document approved at our conference last autumn and entitled, "Building on the Best of the NHS". The document sets out our proposals for unifying the service in the way we have set down in our amendment. Very simply, the document states that there should bea unified system of funding for all GPs … All GPs would be allocated funds by their joint commissioning agencies on the same basis as the joint commissioning agency are allocated funds by the Department of Health.That could happen in one of three ways for the individual doctor and practice. First, the doctor would be able to manage his budget independently, although subject to strict accreditation and the expenditure of annual savings in accordance with plans agreed with the health authority. The important thing about that is that GPs and the health authority must agree on a way forward. Secondly, the doctor could manage his funds as part of a consortium. Thirdly, if those options were not acceptable, the local health board could be asked to manage the budget directly as the GP's agent.
There are two fundamental planks on which we will go forward. First, we need negotiation between the health authority and GPs as to what the plan for the area should 181 be within which GPs work. GPs must also retain the right to buy out of the local authority area if they wish to do so. Secondly, fundholding would therefore be able to continue. In answer to the hon. Member for Edgbaston, we would not propose to abolish fundholding, and she is right to ask Labour the same question.
The Government must come clean about the fact that the present system is unfair, even if—although I am rather sceptical about this—they may not have intended that to be so. Labour must come clean as to whether it would abolish fundholding. We believe that there is a way forward which recognises the increased power of GPs, but requires them to be partners with all the other GPs and the health authority in their area in planning the provision for all of the services that they provide as part of the primary care service in this country.
§ Mr. Jacques Arnold (Gravesham)
When I first stood to become a Member of Parliament in 1987, I fought the election on the proud boast that the Government had not only replaced health funding lost through inflation, but had gone on to spend an extra 50 per cent. per annum on the health service. Today, that figure is 72 per cent. over and above inflation.
I could not help thinking, however, that that increased money did not seem to have the right effect for my constituents, who, as patients, felt helpless in the face of the vast monolith of bureaucracy. It seemed to me that the most obvious thing was to try to get the clout in obtaining health care as close to the patients as possible. That is precisely what fundholding practices are all about, and the concept is central to the NHS reforms.
We have heard time and time again today the allegations about a two-tier NHS. I wish to bring the House's attention to the independent evaluation of fundholding conducted by Professor Glennerster of the London School of Economics, who said categorically that arguing for the abolition of fundholding on the ground that it causes a two-tier service is perverse. He said:It is akin to the philosophical paradox that equality in human needs can best be achieved by starving everyone. Equality is best pursued by seeking to maximise opportunities, not to minimise them—levelling up not down".That is precisely the point.
The particular opportunity to which I wish to draw attention—very rapidly—is obtaining service locally. When I became a Member of Parliament, the Gravesend and North Kent hospital was being reorganised—along with two hospitals in the constituency of my hon. Friend the Member for Dartford (Mr. Dunn)—under the old-style NHS, the idea being to centralise departments.
When I asked how that helped my constituents who had to travel a long way, the answer was, "Consultants must be all together, nice and cosy. Your patients must travel long distances at great inconvenience, and queue up for their appointments. As consultants, our time is more important than that of the general public who are to be served." Basically, it was the "We know best" syndrome.
Consultants said that the best health care could come only from centralised hospital provision via consultants, but that idea was completely blown when I went to see the Marshlands practice, the first fundholding practice in 182 my constituency. I was fascinated to find that it had contracted for a consultant physician to come in once a week, a surgical consultant to come in fortnightly, and a neurological consultant to come in monthly. I asked how that could be possible in the light of what the consultants had said. I was told, "It is simple. If we wave a cheque, the consultants come running. They are just like anyone else. They respond to funding."
What happened in that case? The patients were seen by experts in the local surgery in their own village. It took less time, cost less, and the practice found it had a 50 per cent. saving in the budget. What happened to the saving? It went towards clearing the hip replacement queue in the practice. All the patients in the queue were dealt with immediately. It also went on investment in equipment and skills, so yet further patients were seen in-house without the need to travel long distances to hospitals.
For example, the practice bought cystoscopy equipment, the consultant handles it locally, and the treatments are done locally. Minor operations are done locally. Investigations such as computerised tomography scanning and those using exercise electrocardiographs are done locally. As a result, that surgery alone—there are many more now—is seeing 25 per cent. more patients, and seeing them faster. Fundholding is for the greater convenience of the patients. In the process, the practice has unclogged hospital waiting lists in our area.
In the constituency of Gravesham, more than half of my constituents are served by fundholding practices. If fundholding were abolished, patients and GPs would be dismayed. I intend to circulate the speech of the hon. Member for Peckham (Ms Harman), because she demolished Opposition education policy last week, and she is demolishing their health policy this week. That is a gift sent from St. Paul's girls school—the well-known public school—to the Tories.
§ Mr. Sam Galbraith (Strathkelvin and Bearsden)
GP fundholding is an untested political experiment, so for this debate I thought I might peruse the literature for its effects—old habits die hard. Interestingly, while there is much in the literature, most of it is no more than assertion and opinion. It lacks any scientific rigour or fact. I will deal with some of those assertions, but then I hope to come to the few facts we have.
I gather from the hon. Member for Gravesham (Mr. Arnold) that general practice fundholding brings medicine closer to the patients. I find it ludicrous to suggest that the fact that one holds a budget makes one closer to the patient. However, there is just as good an explanation of something that makes one more distant from the patient. The doctor-patient relationship is based on trust. Once one imposes a financial constraint on it, that trust is lost, and, if anything, the relationship is further apart.
The Secretary of State and others said that there were new initiatives in GP fundholding, thereby decrying non-fundholding practices, as though they do not have new initiatives. However, the so-called new initiatives in fundholding are all completely untested and untried. That was one of the great problems. Are they of value? Are they appropriate? That is something we have not even begun to consider.
183 A third claim about GP fundholding is that it will help us to achieve the priorities for the health service. That was claimed by Geoffrey Scaife, the chief executive of the national health service in Scotland. I find such claims ludicrous. The priorities include cancer, accidents and coronary artery disease. A GP might see three cancer patients in his or her practice each year, so how on earth can he or she make choices about priorities and how those should be delivered by fundholding? That is ludicrous.
The fourth claim made by the Secretary of State was that somehow or other GP fundholding is more efficient. On that we have some evidence—no more assertions. The hon. Member for Broxbourne (Mrs. Roe), the Chairman of the Select Committee on Health, touched on that. She sought to describe how GP fundholders have reduced their drugs budget more significantly than non-fundholders. There might be reasons why that happens throughout general practices that become fundholding. Time does not allow me to go into detail about why the costs and amounts they were given might have been overestimated. Much activity was also underestimated in the practices.
Let us apply the argument to the drugs budget, and the evidence that fundholders are more effective. We must not talk about assertions, beliefs and political dogma—let us look at the evidence.
There was some initial evidence from the British Medical Journal, which I quoted earlier. I saw the Minister laughing when the BMJ was mentioned, as though that made the evidence invalid. He ought to know that it is a scientific, not a house, journal. The conclusion of the original paper from Bradlow and Coulter in the BMJ edition 1993;307:1186–9 was:
Fundholding has helped to curb increases in prescribing costs".That was the conclusion mentioned by the hon. Member for Broxbourne.
There were many reasons why that might have been so, however, and the curb in increases might have fallen off, so a follow-up study was carried out, which was reported in volume 311 of the BMJ on 9 December 1995—again by Brown, Surender, Bradlow, Coulter and Doll. Their conclusion was:Early reports of the effectiveness of fundholding in curbing prescribing costs have not been confirmed in this longer term study".That is the evidence, never mind any more assertions. That shows us that the needs and pressures of patients are the main determinants of clinical practice—not the organisation and the budgets, but the necessity for managing and treating patients in the best way. That is what we can conclude from that report.
Fundholding is bureaucratic, two-tier and grossly unfair, and the quicker we abolish it the better.
§ Mr. Bob Dunn (Dartford)
Every Conservative Member should issue a press release headed, "Labour will destroy success". The commitment today from the hon. Member for Peckham (Ms Harman) that GP fundholding will be abolished by a future Labour Government, in the unlikely event of that ever occurring, has to be headline news in every constituency where fundholding has been successful.
Last July and August, I undertook a survey in the communities of Longfield and New Barn in my constituency, where one of the first local practices to 184 receive fundholding status is situated. Three hundred and eighteen households replied by post saying that they supported fundholding and were happy with it. Only one household returned a form saying that it was not. That speaks volumes.
Of course, it is incumbent on Opposition Members to say where they are coming from. Every speech from an Opposition Member has been from a two-tier opponent. They are elected here to represent their constituents, but 200 of them are sponsored by trade unions, including the hon. Member for Peckham and her number two, the hon. Member for Fife, Central (Mr. McLeish), who is on the Front Bench now. They are sponsored by the health union, Unison.
The Labour Front Bench receives between £200,000 and £300,000 a year to fund the party's health team from Unison, which is opposed to our reforms, as it has been since 1979. So, when Opposition Members speak, I have to speculate whether they are speaking for their constituents or for the health union that sponsors them.
I am still waiting for the hon. Member for Peckham to honour her pledge thatthe information will all be placed in the Register of Members' Interests"—meaning how much Labour receives from Unison. It was not placed on the Register in November or December or January, or, so far, in February. I know that the hon. Lady has been busy lately with one or two internal problems, but she ought to honour her commitment. There is no point in Labour Members looking at the ceiling for inspiration, because they will get none. Her commitment is in black and white.
The Labour party is committed to abolishing NHS trusts, removing control of our hospitals and health service from a local level and taking powers from GPs, because, as ever, it wants to centralise NHS decision making. By removing powers from local doctors, it would create a wasteful and unnecessary tier of bureaucracy. It attacks NHS managers, while supporting the increase in bureaucracy that its own proposals would create.
It is not only Conservative Members who are in favour of fundholding; doctors and patients also favour it. But let us return to what the right hon. Member for Derby, South (Mrs. Beckett), said in The Observer of 19 March 1995. She said that the Labour partyremained firmly opposed to fundholdingFor her, the abolition of fundholding was "not up for consultation". That was the case then, as it is now.
Fundholding doctors are able to pioneer improvements in patient care locally. They demand improved performance from hospitals in their communities, and use their budgets more efficiently, ploughing savings back into improved patient care. The facts speak for themselves. Like my hon. Friend the Member for Gravesham (Mr. Arnold), I shall make sure that every GP in my community receives a copy of my speech and that of the hon. Member for Peckham, so that they will know once and for all that Labour will close down GP fundholding for ever. However, it will not get the chance.
§ Mr. David Hinchliffe (Wakefield)
When the hon. Member for Dartford (Mr. Dunn) has calmed down and gathered his senses, perhaps he will read my speech and understand why I am opposed to the consequences of fundholding in my constituency.
185 I am pleased that the Minister for Health and the Secretary of State for Health are here, because they know full well that we have concrete evidence of a two-tier system at Pinderfields hospital, the main NHS provider in my area, that has arisen directly from fundholding. They know the simple reasons for that.
Wakefield health authority has overspent its budget for patient services by £483,000, that being the last figure available. At the same time, up to the end of November, the last available public figure, GP fundholding shows an underspend of £749,000 on the hospital and community services budget. The Pinderfields trust contract from Wakefield health authority projected 5,100 more finished consultant episodes than the current contract—5,100 people who, rightly, have been treated at Pinderfields hospital against the existing overspend. Fundholders have 1,500 more than the contract—against an underspend.
The policy of Pinderfields and Wakefield health authority is, rightly, treatment on the basis of patients' needs, but consultants at the hospital are, understandably, choosing to treat the patients they know that they will get paid for.
I spoke yesterday, with my hon. Friend the Member for Normanton (Mr. O'Brien), to a highly respected consultant, whom I have known for many years, and who has worked at Pinderfields for nearly 30 years. I hope that the Minister and the Secretary of State are listening. He said that the consultants have the management figures, know the reality of the existing overspend and know where the money is coming from. He continued: "Most of them do private work. They wouldn't do that for nothing, and they won't do NHS work for nothing."
If there are two budgets, and the patients have similar needs, consultants will pick the patient from the budget from which they know that they will get paid. They are picking the patients from fundholders because their budget is underspent. They can get paid for treating those patients. That is why in Wakefield—and elsewhere, including Winchester, Salisbury and other places represented by Tory Members—a two-tier system is arising directly from the existence of GP fundholding.
We have been told that GPs are choosing fundholding. I have talked to GPs. I will give the Secretary of State the name of a non-fundholding GP who told me that he is being forced into fundholding because his patients are getting a second-rate deal because of the situation at Pinderfields hospital.
I do not blame the hospital, the health authority or fundholding GPs. I blame the Government, because they have undermined fundamental principles that have underpinned the national health service since the 1940s— equity, fairness in treatment and the idea of treatment according to patients' needs. Fundholding completely undermines those principles. That is why I oppose the whole process.
§ Mr. Henry McLeish (Fife, Central)
I have torn up the speech that I had intended to give because there has not been a debate in the House recently in which the Government have conceded so much to the Opposition in so short a time. [Interruption.] I understand the instinctive reaction of Conservative Members, but it has been truly extraordinary.
186 We are puzzled about why this debate was called. This is a Government debate on health, an unusual event in the House. They could pick the subject and the timing to try to defend, laughably, their record. We are still puzzled about what the true intention was. They can shake their heads and laugh in an agitated manner, but the Government have screwed up on a health debate for the second time in two weeks. The proper epitaph for the debate, as Oscar Wilde might have said, is, "To lose one debate, Mr. Worthing, may be regarded as a misfortune; to lose both looks like carelessness." That sums up the Government's predicament.
I must be specific and make sure that when GPs and the public read about the debate, they know what the Government have conceded. It has not been a happy afternoon for the Secretary of State. He may have been cajoled into the debate by the right hon. Member for Peterborough (Dr. Mawhinney). It is a political issue and it has blown up in their faces.
First, the Secretary of State has conceded that there is a two-tier service under GP fundholding. He tried to wriggle out of every question that was posed to him about that, but the only logical conclusion was that he not only condoned GP fundholding and a two-tier service but was actively encouraging it.
Secondly—this will be the issue for the 60 per cent. of GPs and the 60 per cent. of patients not covered by fundholding—the motion, despite the attempts to play around with its words, was deeply offensive, insulting, aggravating and provocative to nearly half the nation's GPs. It is offensive to me, but that is less important than the fact that it is offensive to GPs.
The so-called one-nation Secretary of State for Health has conceded on the Floor of the House that fundholding is about not one nation but two nations—two types of GPs. GP fundholders are destined for the first division and the rest for the second division. The only distinction between the Government and us is that we want all GPs to be in the premier league. It seems inconceivable that we should have a Government who want to have two classes of patients and two classes of GPs. That is essentially what they have agreed this afternoon.
The third issue for the Secretary of State, which was thrown up by my hon. Friend the Member for Peckham (Ms Harman) earlier in the debate, was the headline "Dorrell backs private GPs" in Pulse on Saturday 18 November 1995. Where does the Secretary of State stand on some of those issues? He pretends that he is part of the right-wing rabble that has concocted some of the Government's health policies, but privately, in debates at the universities, he is a one-nation health spokesman. He cannot have it both ways. He must tell us why he wants to support private GPs. His statement that theprivate sector will set a standard that the population of patients will very properly expect the NHS to matchwas offensive to most GPs.
Will the Secretary of State return to the Dispatch Box and tell GPs, as the Government are trying to tell teachers and schools, that they are all incompetent—that none of them fulfils the standards that the national health service has set? I suspect that he will not, because it is wrong to attack almost 50 per cent. of GPs along with 50 per cent. of GP fundholders, who do an excellent job on behalf of patients. The hallmarks of Tory health policy as it affects primary health care are that it is particular, exclusive, divisive and partisan.
187 The debate has defined the Government's position on primary health care; they have not moved on. All the contributions by Conservative Members, including the speech by the Secretary of State, were about right hon. and hon. Members who want to be stuck in time. The debate has moved on in the health service, in primary health care and in fundholding, and it has moved on politically.
§ Mr. McLeish
The Secretary of State cannot have it like that, because the debate is moving on.
Let me do some more defining. We are concerned about the challenges of today and tomorrow, but Conservative Members are still concerned with the problems of yesterday. They are prisoners of their political propaganda, and it is a tragedy.
§ Mr. McLeish
My hon. Friend says that it is not, but I shall be more generous than she has been from a sedentary position.
General practitioners seek leadership from the Government, but they get a Government who table a motion that merely congratulates 50 per cent. of GPs and excludes all other GPs in the primary health care service.
§ Mr. McLeish
It is. The Government cannot wriggle off the hook that they are now on because of their incompetent performance tonight.
As my hon. Friend the Member for Peckham said earlier, we do not want to pick out GP fundholders or people involved in locality commissioning and set one against another. That would be destructive and wasteful, but it is the hallmark of the Government.
When the Minister of State replies, why does he not congratulate Dr. Aneez Esmail, a commissioning GP in Manchester who has 70 per cent. generic prescribing, way above the average for fundholders, saving the NHS thousands of pounds? Dr. Esmail has set upa practice based counselling, acupuncture and homeopathy service, a joint clinic with a consultant psychiatrist, a Tele-medicine link clinic with a dermatologist and a drug rehabilitation clinic.That shows that there is no monopoly of wisdom in fundholding in progress, innovation or ideas.
Why are the Government so partisan and blinkered that they cannot lift their eyes above a policy that they adopted two or three years ago, which they are now trying to use to divide GPs and as a political stick to beat everyone else who might not whole heartedly endorse it?
We know that the Minister of State will not praise in his speech anyone who is not a GP fundholder. The tragedy about 16 years of Conservative Government is that, once wedded to an argument, it is impossible to get them ungripped from it. It is a tragedy that we cannot make progress.
188 It has not always been like that. Take one of the Secretary of State's early speeches. As long ago as 30 July 1995, an article appeared entitled "Dorrell freezes Bottomley's NHS reforms"—God, some of them needed freezing. It stated:In his speech to the Conservative Political Centre Summer School in Cambridge, Mr. Dorrell promised development of the family doctor service—the 'jewel in the crown' of the NHS—and stressed that the Government's favoured GP fundholding scheme 'was not the only model'.Well, well—saying one thing and doing another.
Tonight the Secretary of State supported a partisan, particular, divisive motion. A few months ago, he said that fundholding was not the only model. The Secretary of State needs to convince us that there are other models and that he is thinking about them.
§ Mr. McLeish
I was in the Chamber for the whole debate, and I did not hear much praise being lavished on non-fundholding GPs.
I return to the speech of 29 July 1995, reported in the article of 30 July 1995. The Secretary of State said that there would beno preconceptions, no closed minds, no rejections of ideas because they weren't invented here".He said those words far from the House, but some day he must be brought to account for suggesting one thing at a Conservative party summer school and then using completely opposite words in the House this afternoon. [Interruption.]
§ Madam Deputy Speaker (Dame Janet Fookes)
Order. Before the hon. Gentleman continues, may I say that I have noticed an increasing tendency for a sub-debate to take place between the two Front Benches? I would prefer that to stop.
§ Mr. McLeish
The Government debated GP fundholding and lavished praise on GP fundholders but, while definitive policies are being poured down everyone's throats, we find the following quotation from a speech by the Secretary of State in a press release entitled "Department of Health/Looking After Health in the New Millennium", issued on 8 January 1996, four weeks ago:The time is now ripe to take this process further. I have therefore asked Gerry Malone to lead an examination of the options for the future of primary care within the NHS.We have not heard much about that in the House. Perhaps the Minister of State will elaborate. He has been charged with the responsibility of considering primary health care. It creates the impression that he may want to consider other options.
§ Mr. McLeish
I think it is a crime if those words are used in press releases issued by the Department and the Government pretend in the House that there is only one favoured option and that those who do not subscribe to it are second-class GPs and second-class patients. That is why we are angry about the sheer hypocrisy of the Government.
189 The Government want GPs to believe that the Conservative party stands for a one-nation health service. Every action, every comment in the House, undermines that idea. It is ridiculous that, in 1996, four years away from a new millennium, the Government are bogged down—becalmed. They do not know what to do because they are fixated with a one-party policy for the future of primary health care.
In his reply, the Minister should convey to us that he is not fixated by one idea to the exclusion of others and he should try to convince us that he has moved on. If the Government do not move on, when Labour is in government in a few months' time we shall certainly have a one-nation primary health care system that treats all patients and all GPs with equal respect and fairness.
§ The Minister for Health (Mr. Gerald Malone)
That was pretty thin gruel from the hon. Member for Fife, Central (Mr. McLeish), trying to make a case out of very little.
This has been an astonishing debate, in which the Opposition blamed Ministers for coming to the Dispatch Box to speak about Government policy. We have now reached the extraordinary position where an Opposition Front Bencher, from a sedentary position, was worried about what was happening to the national health service when Ministers were at the Dispatch Box, not running the health service from Richmond house. I am glad that Opposition Members believe that we are so effective from day to day, but the purpose of coming to the House was to concentrate on fundholding, a part of the Government's policy that has been criticised by the Opposition.
Before the debate we did not know what the Labour party was saying about fundholding; now we do. The soft soap that we have heard Labour spokesmen deliver to GP fundholders when trying to cosy up to them to suggest that there will be no abolition—the soft words of change, and promises to restructure budgets—has now been replaced with the harsh words of abolition. If the debate did one favour to the public debate about fundholding and the health service, it was to clarify Labour's position.
When the hon. Member for Peckham (Ms Harman) was out of the Chamber, the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith) made wild commitments on her behalf. He shouted, "Hear, hear," and was on record as saying that abolition of fundholding would appear in the Labour party's manifesto before the next election. I wonder whether the hon. Lady will endorse those comments. She will not, so I do not know where that leaves the hon. Gentleman. If the Labour party's claims that it will abolish fundholding are not reflected in the manifesto that it will put before the public, what words will it use to describe this debate?
The Labour party advanced three arguments to support its opposition to fundholding. The first was the absurd old chestnut that it is a two-tier system. It is not a two-tier system, and my right hon. Friend the Secretary of State did not say that it was.
§ Mr. Malone
I have debated that subject with the hon. Gentleman before. Last time I challenged him to 190 produce evidence of two-tierism in his constituency and he said that he would name names and present cases. However, we have heard nothing about it. We examined one case that he presented and we found no basis to it.
§ Mr. Hinchliffe
I ask the Minister to look at the Wakefield situation. He knows as well as I do—as I said in my brief contribution to the debate—that it is a two-tier system. If he comes to Wakefield, I will introduce him to GPs and to consultants who will show him at first hand why there is a two-tier system, for the reasons that I gave a few moments ago.
§ Mr. Malone
I should not have bothered giving way to the hon. Gentleman. I did so during the last debate and I asked him to write to me about specific cases. However, he did not bother to do that, so I shall treat his recent invitation in that light.
The position is clearly set out in the 1991 guidance on fundholding, which I shall repeat for the benefit of the House. In 1991, guidance was agreed with the medical profession which, according to the Labour party, is unanimously opposed to the process. That guidance stated:Common waiting lists should apply for all urgent cases and no hospital should offer contracts to one purchaser which would disadvantage patients of another".Labour Members persistently and obdurately refuse to understand the next point. The guidance continued:However, hospitals can offer spare capacity to anyone who wishes to purchase it. If GP fundholders or health authorities choose to purchase some of the spare capacity so that patients may be seen more quickly, this does not disadvantage other non-urgent patients whose waiting times are unaffected".If GP fundholding and conventional purchasing are exercised in different ways, there will be different results. However, that does not undermine the equity of the national health service for one second.
§ Ms Harman
Will the Minister admit that the 1991 executive letter expressly allows two-tier waiting lists for non-urgent cases? Will he repeal that circular and issue a fair waiting list circular so that, whether they are emergency, urgent or non-urgent cases, clinical need is the only determinant of priority in the national health service?
§ Mr. Malone
The hon. Lady makes an absurd point. If there is any distinction in the way in which GPs purchase health care for their patients, there will be differences. People get their priority placing on waiting lists as a result of clinical need. I point out to the hon. Lady that if patients' conditions change while they are waiting for an operation, they are entitled to return to their general practitioner and be accorded priority. We have absolutely no truck with the Labour party's principal argument that a two-tier system is in place.
We heard another old chestnut about massive bureaucracy. I shall give the House the facts. The management of GP fundholding costs 2 per cent. of the funds of which GPs ultimately have charge. They have been able to deliver consistent efficiencies of 3.5 to 4 per cent., which can be returned in patient care. Better resource management will lead to an increase in both patient care and the facilities in GPs' surgeries for the delivery of patient care. That is another nail in the coffin of the Labour party's argument.
191 Labour Members talked a lot about commissioning. I believe that commissioning has become the Labour party's comfort blanket. It sounds like a very comfortable compromise—and the way the Labour party put it forward, it certainly is. It is fudge and mudge. The Labour party confirmed that it is a step towards a national system.
I pay tribute to the achievements of individual practitioners, be they fundholders, commissioning practitioners or non-commissioning practitioners—that happens occasionally across the system. The Labour party cannot ignore the fact that those achievements are driven by the power of fundholding and the power of budgets. On Friday, a fundholder told me—I think that this says it all—that one GP with a budget is worth 10 GPs sitting on a committee somewhere. The Labour party's model would return us to the old days of discussions around tables and no possibility of defining what would be done to benefit patients. It is an old argument which has failed in the past. The Labour party is now putting forward an out-of-date concept: it wants to return to the old national systems.
Let us accept for a moment that perhaps the Labour party is right. Let us assume, for example, that there is some two-tierism in the national health service. A member of the public might say that, if there is a two-tier system and if we argue that fundholding is providing a better service than non-fundholding, it seems extraordinary to opt for a policy that abolishes the system that is delivering better care. The Opposition cannot get away from that fact. The hon. Member for Strathkelvin and Bearsden said that there was no evidence to support that argument, but the matter is being researched and the evidence is growing.
The hon. Member for Strathkelvin and Bearsden referred to an article from the British Medical Journal. I have read that article, and I looked rather quizzical when he made his observations because I know the narrow base on which that research was founded. Further evidence will be published soon showing that the fundholding practitioners can make real savings from the prescribing budgets and that those savings will continue over time. Of course they will plateau; it would be unreasonable to assume that they could continue year after year.
I wonder what the position of the hon. Member for Southwark and Bermondsey (Mr. Hughes) is with regard to this debate. He argued precisely for what we are doing with the accountability framework. He said that he opposes fundholding in the way that we have introduced it. He is in favour of a little of what we do—his party opposed it before—and he also opposes what the Labour party proposes. It is the typical Liberal party "push me, pull you" approach. He is the custodian of a policy that his policy officers recently described as "barmy". He failed to take account of the fact that, in the accountability framework, when general practitioners are fundholders— either in the conventional sense or in the total sense— they must share their information with health authorities and they must discuss and agree their public plans, which are placed on the public agenda, before they are put in motion.
At a time when the whole health profession is looking very positive about developing the arguments on future primary care, the Labour party has decided to take a step backwards. The Government are conducting a debate with the health service to define the boundaries of primary care and what new challenges it will face. We are interested in that debate, but the Labour party is not. We are taking the 192 debate forward not just with fundholders but with doctors and other health care professionals who are responsible for the delivery of primary care. That is the way forward.
Tonight, the Labour party has chosen to demonstrate that it simply wants to abolish all that has been achieved. New Labour may have new policies in other areas, but the lesson we can take from the debate today is that new Labour does not want them in the health area; it wants to return to national systems in a determined effort to abandon all the progress that has been hard won by general practitioners who have been improving services up and down the country.
When the Labour party started the debate against primary care reforms in the NHS and when it first decided that it was against fundholding, the situation was very different and only a small minority was engaged in fundholding. Now the Labour party is setting itself against the 50 per cent. of the population who receive primary care, and setting itself against a large proportion of GPs. The people and the GPs will have heard the message that the Labour party has delivered today.
§ Question put, That the amendment be made:—
§ The House divided: Ayes 246, Noes 320.196
|Division No. 43]||[6.59 pm|
|Ainger, Nick||Cook, Frank (Stockton N)|
|Ainsworth, Robert (Cov'try NE)||Cook, Robin (Livingston)|
|Allen, Graham||Corbett, Robin|
|Anderson, Donald (Swansea E)||Corbyn, Jeremy|
|Anderson, Ms Janet (Ros'dale)||Corston, Jean|
|Armstrong, Hilary||Cousins, Jim|
|Ashton, Joe||Cox, Tom|
|Austin-Walker, John||Cummings, John|
|Banks, Tony||Cunliffe, Lawrence|
|Barron, Kevin||Cunningham, Jim (Covy SE)|
|Battle, John||Cummingham, Roseanna (Perth & Kinross)|
|Beckett, Rt Hon Margaret||Dalyell, Tarn|
|Bell, Stuart||Darling, Alistair|
|Benn, Rt Hon Tony||Davies, Bryan (Oldham C'tral)|
|Bennett, Andrew F||Davies, Rt Hon Denzil (Llanelli)|
|Benton, Joe||Davies, Ron (Caerphilly)|
|Bermingham, Gerald||Davis, Terry (B'ham, H'dge H'I)|
|Berry, Roger||Denham, John|
|Blair, Rt Hon Tony||Dewar, Donald|
|Blunkett, David||Dixon, Don|
|Boateng, Paul||Dobson, Frank|
|Bradley, Keith||Donohoe, Brian H|
|Bray, Dr Jeremy||Dowd, Jim|
|Brown, Gordon (Dunfermline E)||Dunwoody, Mrs Gwyneth|
|Brown, N (N'c'tle upon Tyne E)||Eagle, Ms Angela|
|Burden, Richard||Eastham, Ken|
|Byers, Stephen||Etherington, Bill|
|Caborn, Richard||Evans, John (St Helens N)|
|Callaghan, Jim||Ewing, Mrs Margaret|
|Campbell, Mrs Anne (C'bridge)||Fatchett, Derek|
|Campbell, Ronnie (Blyth V)||Faulds, Andrew|
|Campbell-Savours, D N||Field, Frank (Birkenhead)|
|Canavan, Dennis||Fisher, Mark|
|Cann, Jamie||Flynn, Paul|
|Chisholm, Malcolm||Foster, Rt Hon Derek|
|Church, Judith||Foulkes, George|
|Clapham, Michael||Fyfe, Maria|
|Clark, Dr David (South Shields)||Galbraith, Sam|
|Clarke, Eric (Midlothian)||Galloway, George|
|Clarke, Tom (Monklands W)||Gapes, Mike|
|Clelland, David||George, Bruce|
|Cohen, Harry||Gerrard, Neil|
|Connarty, Michael||Gilbert, Rt Hon Dr John|
|Godman, Dr Norman A||Miller, Andrew|
|Godsiff, Roger||Mitchell, Austin (Gt Grimsby)|
|Golding, Mrs Llin||Moonie, Dr Lewis|
|Grant, Bemie (Tottenham)||Morgan, Rhodri|
|Griffiths, Nigel (Edinburgh S)||Morley, Elliot|
|Griffiths, Win (Bridgend)||Morris, Rt Hon Alfred (Wy'nshawe)|
|Grocott, Bruce||Morris, Estelle (B'ham Yardley)|
|Gunnell, John||Morris, Rt Hon John (Aberavon)|
|Hail, Mike||Mowlam, Marjorie|
|Hanson, David||Mudie, George|
|Hardy, Peter||Mullin, Chris|
|Harman, Ms Harriet||Murphy, Paul|
|Harvey, Nick||Oakes, Rt Hon Gordon|
|Hattersley, Rt Hon Roy||O'Brien, Mike (N W'kshire)|
|Henderson, Doug||O'Brien, William (Normanton)|
|Heppell, John||O'Hara, Edward|
|Hill, Keith (Streatham)||Olner, Bill|
|Hinchliffe, David||O'Neill, Martin|
|Hodge, Margaret||Orme, Rt Hon Stanley|
|Hoey, Kate||Pearson, Ian|
|Hogg, Norman||Pendry, Tom|
|Home Robertson, John||Pickthall, Colin|
|Hoon, Geoffrey||Pike, Peter L|
|Howarth, Alan (Strat'rd-on-A)||Pope, Greg|
|Howarth, George (Knowsley North)||Prentice, Bridget (Lew'm E)|
|Howells, Dr. Kim (Pontypridd)||Prentice, Gordon (Pendle)|
|Hoyle, Doug||Primarolo, Dawn|
|Hughes, Robert (Aberdeen N)||Purchase, Ken|
|Hughes, Roy (Newport E)||Quin, Ms Joyce|
|Hutton, John||Radice, Giles|
|Illsley, Eric||Randall, Stuart|
|Ingram, Adam||Raynsford, Nick|
|Jackson, Glenda (H'stead)||Reid, Dr John|
|Jackson, Helen (Shef'ld, H)||Robertson, George (Hamilton)|
|Jamieson, David||Robinson, Geoffrey (Co'try NW)|
|Janner, Greville||Roche, Mrs Barbara|
|Jones, Barry (Alyn and D'side)||Rogers, Allan|
|Jones, Ieuan Wyn (Ynys Môn)||Rooker, Jeff|
|Jones, Lynne (B'ham S O)||Rooney, Terry|
|Jones, Martyn (Clwyd, SW)||Ross, Ernie (Dundee W)|
|Jowell, Tessa||Ruddock, Joan|
|Kaufman, Rt Hon Gerald||Salmond, Alex|
|Keen, Alan||Sedgemore, Brian|
|Kennedy, Jane (L'pool Br'dg'n)||Sheerman, Barry|
|Khabra, Piara S||Sheldon, Rt Hon Robert|
|Kilfoyle, Peter||Shore, Rt Hon Peter|
|Liddell, Mrs Helen||Short, Clare|
|Litherland, Robert||Simpson, Alan|
|Livingstone, Ken||Skinner, Dennis|
|Lloyd, Tony (Stretford)||Smith, Andrew (Oxford E)|
|Llwyd, Elfyn||Smith, Chris (Isl'ton S & F'sbury)|
|McAllion, John||Smith, Llew (Blaenau Gwent)|
|McAvoy, Thomas||Soley, Clive|
|McCartney, Ian||Spearing, Nigel|
|Macdonald, Calum||Spellar, John|
|McFall, John||Squire, Rachel (Dunfermline W)|
|McKelvey, William||Steinberg, Gerry|
|Mackinlay, Andrew||Stott, Roger|
|McLeish, Henry||Strang, Dr. Gavin|
|McMaster, Gordon||Straw, Jack|
|MacShane, Denis||Sutcliffe, Gerry|
|McWilliam, John||Taylor, Mrs Ann (Dewsbury)|
|Madden, Max||Taylor, Matthew (Truro)|
|Mahon, Alice||Thompson, Jack (Wansbeck)|
|Mandelson, Peter||Touhig, Don|
|Marek, Dr John||Trickett, Jon|
|Marshall, David (Shettleston)||Turner, Dennis|
|Marshall, Jim (Leicester, S)||Walley, Joan|
|Martin, Michael J (Springburn)||Wardell, Gareth (Gower)|
|Martlew, Eric||Wareing, Robert N|
|Maxton, John||Watson, Mike|
|Meacher, Michael||Welsh, Andrew|
|Meale, Alan||Wicks, Malcolm|
|Michael, Alun||Wigley, Dafydd|
|Michie, Bill (Sheffield Heeley)||Williams, Rt Hon Alan (Sw'n W)|
|Milburn, Alan||Williams, Alan W (Carmarthen)|
|Wilson, Brian||Young, David (Bolton SE)|
|Worthington, Tony||Tellers for the Ayes:|
|Wray, Jimmy||Mr. Jon Owen Jones and Ms Ann Coffey.|
|Wright, Dr Tony|
|Ainsworth, Peter (East Surrey)||Currie, Mrs Edwina (S D'by'ire)|
|Alexander, Richard||Curry, David (Skipton & Ripon)|
|Alison, Rt Hon Michael (Selby)||Davies, Chris (L'Boro & S'worth)|
|Allason, Rupert (Torbay)||Davis, David (Boothferry)|
|Amess, David||Day, Stephen|
|Ancram, Michael||Deva, Nirj Joseph|
|Arbuthnot, James||Devlin, Tim|
|Arnold, Jacques (Gravesham)||Dicks, Terry|
|Ashby, David||Dorrell, Rt Hon Stephen|
|Ashdown, Rt Hon Paddy||Douglas-Hamilton, Lord James|
|Atkins, Rt Hon Robert||Dover, Den|
|Atkinson, David (Bour'mouth E)||Duncan, Alan|
|Atkinson, Peter (Hexham)||Duncan-Smith, lain|
|Baker, Nicholas (North Dorset)||Dunn, Bob|
|Baldry, Tony||Durant, Sir Anthony|
|Banks, Matthew (Southport)||Eggar, Rt Hon Tim|
|Banks, Robert (Harrogate)||Elletson, Harold|
|Bates, Michael||Emery, Rt Hon Sir Peter|
|Batiste, Spencer||Evans, David (Welwyn Hatfield)|
|Beggs, Roy||Evans, Jonathan (Brecon)|
|Beith, Rt Hon A J||Evans, Nigel (Ribble Valley)|
|Bellingham, Henry||Evans, Roger (Monmouth)|
|Bendall, Vivian||Evennett, David|
|Beresford, Sir Paul||Faber, David|
|Biffen, Rt Hon John||Fabricant, Michael|
|Body, Sir Richard||Fenner, Dame Peggy|
|Bonsor, Sir Nicholas||Field, Barry (Isle of Wight)|
|Booth, Hartley||Fishburn, Dudley|
|Boswell, Tim||Forman, Nigel|
|Bottomley, Peter (Eltham)||Forsyth, Rt Hon Michael (Stirling)|
|Bottomley, Rt Hon Virginia||Forsythe, Clifford (S Antrim)|
|Bowden, Sir Andrew||Forth, Eric|
|Bowis, John||Foster, Don (Bath)|
|Boyson, Rt Hon Sir Rhodes||Fowler, Rt Hon Sir Norman|
|Brandreth, Gyles||Fox, Dr Liam (Woodspring)|
|Brazier, Julian||Fox, Sir Marcus (Shipley)|
|Bright, Sir Graham||Freeman, Rt Hon Roger|
|Brooke, Rt Hon Peter||French, Douglas|
|Brown, M (Brigg & Cl'thorpes)||Fry, Sir Peter|
|Browning, Mrs Angela||Gallie, Phil|
|Bruce, Ian (Dorset)||Gardiner, Sir George|
|Bruce, Malcolm (Gordon)||Gamier, Edward|
|Budgen, Nicholas||Gill, Christopher|
|Bums, Simon||Gillan, Cheryl|
|Burt, Alistair||Goodlad, Rt Hon Alastair|
|Butler, Peter||Goodson-Wickes, Dr Charles|
|Butterfill, John||Gorman, Mrs Teresa|
|Campbell, Menzies (Fife NE)||Gorst, Sir John|
|Carlisle, John (Luton North)||Grant, Sir A (SW Cambs)|
|Carlisle, Sir Kenneth (Lincoln)||Greenway, Harry (Ealing N)|
|Carrington, Matthew||Greenway, John (Ryedale)|
|Carttiss, Michael||Griffiths, Peter (Portsmouth, N)|
|Cash, William||Grylls, Sir Michael|
|Channon, Rt Hon Paul||Gummer, Rt Hon John Selwyn|
|Chapman, Sir Sydney||Hague, Rt Hon William|
|Churchill, Mr||Hamilton, Rt Hon Sir Archibald|
|Clappison, James||Hamilton, Neil (Tatton)|
|Clark, Dr Michael (Rochford)||Hampson, Dr Keith|
|Clarke, Rt Hon Kenneth (Ru'clif)||Hanley, Rt Hon Jeremy|
|Clifton-Brown, Geoffrey||Hannam, Sir John|
|Coe, Sebastian||Hargreaves, Andrew|
|Colvin, Michael||Harris, David|
|Congdon, David||Hawkins, Nick|
|Coombs, Anthony (Wyre For'st)||Hawksley, Warren|
|Cope, Rt Hon Sir John||Hayes, Jerry|
|Cormack, Sir Patrick||Heald, Oliver|
|Couchman, James||Heath, Rt Hon Sir Edward|
|Cran, James||Heathcoat-Amory, David|
|Hendry, Charles||Maclennan, Robert|
|Higgins, Rt Hon Sir Terence||McNair-Wilson, Sir Patrick|
|Hill, James (Southampton Test)||Maddock, Diana|
|Hogg, Rt Hon Douglas (G'tham)||Maitland, Lady Olga|
|Horam, John||Major, Rt Hon John|
|Hordern, Rt Hon Sir Peter||Malone, Gerald|
|Howard, Rt Hon Michael||Mans, Keith|
|Howell, Rt Hon David (G'dford)||Marland, Paul|
|Howell, Sir Ralph (N Norfolk)||Marshall, John (Hendon S)|
|Hughes, Robert G (Harrow W)||Marshall, Sir Michael (Arundel)|
|Hughes, Simon (Southwark)||Martin, David (Portsmouth S)|
|Hunt, Rt Hon David (Wirral W)||Mates, Michael|
|Hunt, Sir John (Ravensbourne)||Mawhinney, Rt Hon Dr Brian|
|Hunter, Andrew||Merchant, Piers|
|Hurd, Rt Hon Douglas||Michie, Mrs Ray (Argyll & Bute)|
|Jack, Michael||Mills, Iain|
|Jenkin, Bemard||Mitchell, Andrew (Gedling)|
|Jessel, Toby||Molyneaux, Rt Hon Sir James|
|Johnson Smith, Sir Geoffrey||Monro, Rt Hon Sir Hector|
|Johnston, Sir Russell||Montgomery, Sir Fergus|
|Jones, Gwilym (Cardiff N)||Needham, Rt Hon Richard|
|Jones, Nigel (Cheltenham)||Neubert, Sir Michael|
|Jones, Robert B (W Hertfdshr)||Newton, Rt Hon Tony|
|Jopling, Rt Hon Michael||Nicholls, Patrick|
|Kellett-Bowman, Dame Elaine||Nicholson, David (Taunton)|
|Kennedy, Charles (Ross,C&S)||Norris, Steve|
|Key, Robert||Onslow, Rt Hon Sir Cranley|
|King, Rt Hon Tom||Oppenheim, Phillip|
|Kirkhope, Timothy||Ottaway, Richard|
|Kirkwood, Archy||Page, Richard|
|Knapman, Roger||Paice, James|
|Knight, Mrs Angela (Erewash)||Patnick, Sir Irvine|
|Knight, Rt Hon Greg (Derby N)||Patten, Rt Hon John|
|Knight, Dame Jill (Bir'm E'st'n)||Pattie, Rt Hon Sir Geoffrey|
|Knox, Sir David||Pawsey, James|
|Kynoch, George (Kincardine)||Peacock, Mrs Elizabeth|
|Lait, Mrs Jacqui||Pickles, Eric|
|Lamont, Rt Hon Norman||Porter, Barry (Wirral S)|
|Lang, Rt Hon Ian||Porter, David (Waveney)|
|Lawrence, Sir Ivan||Portillo, Rt Hon Michael|
|Leigh, Edward||Powell, William (Corby)|
|Lennox-Boyd, Sir Mark||Rathbone, Tim|
|Lester, Sir James (Broxtowe)||Redwood, Rt Hon ohn|
|Lidington, David||Rendel, David|
|Lilley, Rt Hon Peter||Renton, Rt Hon Tim|
|Lloyd, Rt Hon Sir Peter (Fareham)||Richards, Rod|
|Lord, Michael||Riddick, Graham|
|Luff, Peter||Robathan, Andrew|
|Lyell, Rt Hon Sir Nicholas||Roberts, Rt Hon Sir Wyn|
|McCrea, The Reverend William||Robertson, Raymond (Ab'd'n S)|
|MacGregor, Rt Hon John||Robinson, Mark (Somerton)|
|MacKay, Andrew||Roe, Mrs Marion (Broxbourne)|
|Maclean, Rt Hon David||Ross, William (E Londonderry)|
|Rowe, Andrew (Mid Kent)||Thompson, Patrick (Norwich N)|
|Rumbold, Rt Hon Dame Angela||Thornton, Sir Malcolm|
|Ryder, Rt Hon Richard||Thurnham, Peter|
|Sackville, Tom||Townend, John (Bridlington)|
|Sainsbury, Rt Hon Sir Timothy||Townsend, Cyril D (Bexl'yh'th)|
|Scott, Rt Hon Sir Nicholas||Tracey, Richard|
|Shaw, David (Dover)||Tredinnick, David|
|Shaw, Sir Giles (Pudsey)||Trend, Michael|
|Shephard, Rt Hon Gillian||Trimble, David|
|Shepherd, Sir Colin (Hereford)||Trotter, Neville|
|Shepherd, Richard (Aldridge)||Twinn, Dr Ian|
|Shersby, Sir Michael||Tyler, Paul|
|Sims, Roger||Viggers, Peter|
|Skeet, Sir Trevor||Waldegrave, Rt Hon William|
|Smith, Sir Dudley (Warwick)||Walden, George|
|Smith, Tim (Beaconsfield)||Walker, Bill (N Tayside)|
|Smyth, The Reverend Martin||Wallace, James|
|Soames, Nicholas||Waller, Gary|
|Spencer, Sir Derek||Ward, John|
|Spicer, Sir James (W Dorset)||Wardle, Charles (Bexhill)|
|Spicer, Sir Michael (S Worcs)||Waterson, Nigel|
|Spink, Dr Robert||Watts, John|
|Spring, Richard||Wells, Bowen|
|Squire, Robin (Homchurch)||Whitney, Ray|
|Stanley, Rt Hon Sir John||Whittingdale, John|
|Steen, Anthony||Widdecombe, Ann|
|Stephen, Michael||Wiggin, Sir Jerry|
|Stern, Michael||Wilkinson, John|
|Stewart, Allan||Willetts, David|
|Streeter, Gary||Wilshire, David|
|Sumberg, David||Winterton, Mrs Ann (Congleton)|
|Sweeney, Walter||Winterton, Nicholas (Macc'f'ld)|
|Sykes, John||Wolfson, Mark|
|Tapsell, Sir Peter||Wood, Timothy|
|Taylor, Ian (Esher)||Yeo, Tim|
|Taylor, Rt Hon John D (Strgfd)||Young, Rt Hon Sir George|
|Taylor, John M. (Solihull)|
|Taylor, Sir Teddy (Southend, E)||Tellers for the Noes:|
|Temple-Morris, Peter||Mr. Derek Conway and Mr. Patrick McLoughlin.|
|Thompson, Sir Donald (C'er V)|
§ Question accordingly negatived.
§ Main Question put and agreed to.
That this House pays tribute to the role that GP fundholders have played in kick-starting and developing innovative practice in both primary care and the acute sector; welcomes the advances that fundholding has brought to many patients; accepts that fundholding has acted as a lever to improve services; and consequently remains committed to the further development of GP fundholding.