HC Deb 15 October 1996 vol 282 cc591-606 3.30 pm
The Secretary of State for Health (Mr. Stephen Dorrell)

With permission, Madam Speaker, I should like to make a statement about the Government's proposals for the development of primary health care services.

The Government have always accorded a high priority to the development of NHS primary care. The last 17 years have seen substantial extra resources flow into the primary care sector, and those resources have al lowed general practitioners to extend the range of care provided within their surgeries. More GPs are working within the NHS, employing more nurses and therapists, and there has been an unprecedented investment programme in GP surgery buildings. There has been a continued steady growth of NHS dentistry, and a greater recognition of the role of pharmacists in the delivery of health care.

The development of GP fundholding has also changed the relationship between primary and secondary care, and has allowed GPs—both fundholders and non-fundholders—to use their knowledge of their patients' needs to improve the efficiency and responsiveness of NHS care. From next April, 58 per cent. of the population will be covered by a fundholding GP.

Despite this record of achievement, however, there remain areas of weakness that need to be addressed. Some inner-city areas have not fully benefited from the development of NHS primary care, and many have argued that the statutory framework for the delivery of primary care is now holding back some desirable service developments.

Against that background, I asked my hon. Friend the Minister for Health to enter into consultations with patient groups and the primary care professions, and with others interested in the future of primary care, to develop proposals that will allow the continued development of NHS primary care.

The conclusions of my hon. Friend's consultations were set out in the Government's document "Primary Care—The Future", which was published this June. Similar discussions were held in Scotland and Wales, and similar conclusions were reached. The Government are committed to address the full range of issues set out in that document, and we will make a full response to them around the turn of the year.

One of the key conclusions of my hon. Friend the Minister for Health's consultations, however, concerned the need to encourage local flexibility in the delivery of primary care services. This conclusion matches the conclusion of the Government's 1994 Green Paper "Improving NHS Dentistry".

Therefore, the Government are today publishing a White Paper entitled "Choice and Opportunity" that sets out our proposals for changing NHS legislation to allow greater flexibility in the delivery of NHS primary health care. We intend to introduce a Bill covering these changes at the earliest opportunity.

The proposals do not envisage a new blueprint for NHS primary care. Our approach will be to enable NHS practitioners and local health authorities to develop new ways in which to deliver and improve primary care. Participation will be voluntary, and practitioners who wish to do so will be able to continue to practise under existing arrangements.

In the case of general medical and dental practitioners, the legislation envisaged in the White Paper will allow practitioners and health authorities to propose pilots to test the practical implications of different types of contract. For GPs, these might include practice-based contracts, recognising the important part which nurses and therapists play within the primary health care team. Alternatively, they may involve GPs working as salaried employees, freeing them from the task of running a practice to concentrate on clinical work.

For GP practices that do not wish to pilot new forms of contract, but seek ways of developing services within the existing contractual framework, our proposals will provide health authorities and boards with greater freedom to reward GPs who offer an enhanced service to their patients.

Dentists will also have the opportunity to pilot new approaches to the delivery of care. These might include local contracts to provide greater incentives for offering treatment in areas of greatest need; new ways of ensuring accessibility to services; or contracts for groups of practices.

If pilots are successful, it will be possible to implement more widely the approaches that have been tested in this way. But we must be sure that, in testing new approaches, we do not lose the best of the existing arrangements. Pilots will be monitored and the results will be evaluated.

One principle will be inviolate. Services provided by practitioners in any pilot approved under this legislation will be provided on NHS terms. Family doctor services will remain free at the point of use. Dental services will be subject to the same charging regime as other general dental practitioner services. Patients will retain the same registration rights as at present.

My hon. Friend the Minister's consultations highlighted the potential for community pharmacists to play a greater part in encouraging the better use of medicines, giving advice to the public and health promotion. The White Paper sets out proposals to remove the legal restrictions that prevent health authorities and boards from rewarding community pharmacists who provide a higher standard of service to their patients.

The legislation will also introduce greater flexibility for health authorities and boards in purchasing community pharmacy and optometry services, and resolve an anomaly which prevents NHS community pharmacies from providing certain services for patients who live just over the border in a neighbouring health authority or board area. The proposals will not affect dispensing services and patients will still have the right to take NHS prescriptions to the community pharmacy of their choice.

Finally, the legislation will address a long-standing problem with the appointment of GPs to practices by implementing the recommendation in the chief medical officer's report "Maintaining Medical Excellence" that appointments to single-handed practices should be made only where at least one candidate meets the standards set out in the job description.

Our primary care system is the envy of the world. These proposals support and build on that success story. There is no single template; our aim is to provide choice and opportunity for those GPs and dentists who want to develop and improve services to pilot their ideas. All our proposals rely on the commitment and enthusiasm of health care professionals who have played a leading part in their development. We look forward to continuing to work closely with them as we take forward this agenda.

Mr. Chris Smith (Islington, South and Finsbury)

I welcome some of the specific proposals in the White Paper. Everyone will welcome the removal of the requirement to make an appointment to a single-handed practice, no matter how bad the applicant, and will be astonished that it has taken so long to put that absurdity right.

We welcome the Secretary of State's rediscovery of the importance of cottage and community hospitals and the particular role that they can play in helping patients to recover from major surgery. Will he therefore explain why the Government have closed 245 such hospitals in the past five years? We welcome the proposals for salaried GPs employed, for example, by NHS community trusts, and particularly those proposals to help to solve the acute problem of GP recruitment in inner city areas.

I also welcome the Secretary of State's sudden and apparent conversion to the vital principle of equity in the NHS. In appendix A of the White Paper he writes: It will be important not to create inequity of resources for patients of different practices. I quite agree. Where, then, has he been these past five years when so many of the changes made by the Government have quite deliberately created inequity in the NHS? Does he now realise that the creation of two tiers of service for patients is unacceptable in a comprehensive national service? Does the Secretary of State accept what Derek Smith, chairman of King's Healthcare, said on 25 July—that a two-tier health service is now "an everyday reality"? How can the Secretary of State have woken up so belatedly to the reality of what is happening in the delivery of health care?

In relation to dentistry, paragraph 4.7 of the White Paper says: patients should continue to have a right to choose the dental practitioner from whom to receive dental treatment". Does the Secretary of State not recognise, however, that for many people national health service dentistry has in a very real sense ceased to exist altogether? Does not this reveal that what he is doing in much of the document is starting to repair some of the damage that the Government have caused in the first place? It is a bit like an arsonist saying sorry and starting to rebuild the very house that he has destroyed. Is not the whole document an admission that single practice fundholding is not necessarily the panacea that the Government have always claimed it to be?

Does the Secretary of State realise that, this afternoon, the Government have for the first time recognised that GP commissioning is happening and is providing real benefits to GPs and patients alike? Will he now embrace Labour party policy on GP commissioning as the way forward?

One proposal in the document fills Opposition Members with particular alarm. Paragraph 2.4 talks of a salaried option for GPs, either within partnerships or with other bodies Paragraph 8 of appendix A states: Ordinary contracts would be used when services were provided outside the NHS". Does not that reveal that the Government's real agenda is allowing primary care GP services to be provided by private commercial companies? Would not the proposal tear at the very roots of the public service ethos of general practice?

The GP service, with its fierce independent professionalism, has been the foundation stone of the NHS for 50 years. The relationship between GP and patient has been uniquely important for the British health system, but that relationship will be fundamentally undermined if GPs are employed and their services provided by private sector companies ranging from pharmaceuticals to supermarkets. The professional integrity of the GP must be sustained and the Government's proposal puts it at risk.

We applaud the Secretary of State's conversion to the cause of equity, to the importance of cottage hospitals, to the need to solve the problems of the inner cities and to the value of GP commissioning, but I urge him to think again before he goes down the road to a privatised commercialised GP service. Opposition Members want none of it.

Mr. Dorrell

I begin by welcoming the hon. Gentleman to his new responsibilities. I believe that in an earlier brief he was told to think the unthinkable. I am not sure that he was regarded as a great success there; I hope that he will prove to be a more flexible thinker about health policy.

The hon. Gentleman asked me first about equity of resources. Listening to him, it was hard to remember that it was this Government who introduced the weighted capitation system, precisely to ensure that the historically inequitable distribution of resources as between one part of the country and another was remedied. It is this Government who, every year since the implementation of the reformed health service management structure, have moved the funding of the health service closer to the targets provided by that weighted capitation formula.

So I do not accept for one moment the idea that we have not, consistently and in practice, been interested in dealing equitably with the resources of the health service, directing them to the areas of greatest health need. Indeed, this was one of the very subjects that my hon. Friend the Minister for Health discussed in the primary care listening exercise: to ensure that resources in the primary care world flowed in a more equitable direction. That was one of the principal objectives of the more flexible management system that I have described and which we are committed to introducing.

The hon. Gentleman also asked me about cottage hospitals. Of course it is true that hospitals in various parts of the country will open and close facilities. I am sure that the hon. Gentleman can quote examples of certain hospitals closing when they come to the end of their useful lives. But there are not many Health Secretaries who can report to the House that they have been to Devonshire, or anywhere else, and opened two brand new hospitals on the same day. That is exactly what I did earlier this year.

The Government have been developing new community hospitals, and the fundholding scheme, which the hon. Gentleman loves to hate, has been one of the most effective mechanisms for reopening and underpinning the viability of cottage and community hospitals in the national health service.

That brings me to the principle of GP choice: the choice exercised by the general practitioner as to the best model of care to meet the needs of his or her patients. That is the principle on which this document is based. We look for new ways of delivering high-quality primary care which reflect the ideas of those who have to deliver that care.

The hon. Gentleman's party likes to espouse this cause, but then immediately makes it clear that it would remove from the table the one option that has been chosen by GPs serving 58 per cent. of the patients of this country—namely, the fundholding scheme. How can the hon. Gentleman deploy rhetoric in favour of GP choice while at the same time supporting the abolition of the fundholding scheme that has been chosen by a majority of the GPs of Britain?

Finally, the hon. Gentleman likes to raise the Aunt Sally of privatisation. I made it crystal clear in my statement that I am talking about producing a different way of delivering NHS primary care on the same terms as NHS primary care is currently available—the same charging regime for dentistry, free in general practice. Interestingly, the hon. Gentleman this afternoon avoided the simple proposition that the whole of NHS primary care since Nye Bevan's original NHS Act 1946 has been delivered by private contractors responding to contracts with the national health service—

Mr. Rhodri Morgan (Cardiff, West)


Mr. Dorrell

Not all independent. The pharmacist Boots is a profit-making company—

Mr. Morgan

Not private.

Mr. Dorrell

I was under the illusion that it was private. Boots delivers a key NHS service as an NHS pharmacy. It is a contractor delivering an NHS service. So the hon. Member for Islington, South and Finsbury (Mr. Smith) is completely wrong to say that these proposals would let the private sector into NHS primary care for the first time. Ironically, the proposals would let trusts, the public sector, into NHS primary care for the first time. Until now, NHS primary care has been the exclusive preserve of private contractors delivering an NHS service in response to an NHS contract. I want to make that contracting regime more flexible, the better to meet the needs of patients.

Dame Jill Knight (Birmingham, Edgbaston)

Did my right hon. Friend notice an historic, perhaps even unique, event on the radio this morning, when the chairman of the British Medical Association gave his full backing to the White Paper? Is not that a first and does not it make complete nonsense of much of what was said by the hon. Member for Islington, South and Finsbury (Mr. Smith)?

Can my right hon. Friend be a little more specific about the services he envisages will be provided by optometrists? He said that he wants shared care and an extension of services for patients.

Mr. Dorrell

I am grateful to my hon. Friend. She is right to say that it is unusual, if not unique, for me to appear on the "Today" programme alongside Dr. Sandy Macara and receive his unqualified blessing for my proposals, as I did this morning. I am pleased to say that his support is reflected not just by the British Medical Association but by the British Dental Association and the other professional groups that my hon. Friend the Minister for Health consulted.

The purpose of my hon. Friend's exercise was to develop a consensus in the professions about how primary care can best develop. That was reflected in the document that we published in June and it underlies the legislative proposals that I have announced this afternoon. It would be nice if those on the Opposition Front Bench shared in the consensus with those who are responsible for delivering services to patients.

As for the role of optometrists, there will be major opportunities to integrate optometrists more effectively into the primary care team; to consider the relationship between optometrists and general practitioners to ensure a proper flow of information; and to consider the arrangements for referral from optometry to the secondary care services. Those are the options for the development of optometry in integrated NHS primary health care and we shall cover them in more detail later this year in the document to which I have referred.

Mr. Simon Hughes (Southwark and Bermondsey)

Of course I join the Secretary of State in wanting a higher quality and more accessible health service that is tailored to the needs of different communities. That would be a good step forward. There are, however, differences of view between him, some of his colleagues and people in and outside the House about whether all is right with the health service at the moment, and the changes that are needed.

I ask the Secretary of State for five simple assurances. Can we have the resources that it is objectively agreed the health service needs? Can we have the additional staffing that is regarded as necessary even by independent pay review bodies? Can we have some national co-ordination, which does not currently exist? Given the announcement today in particular, can we have an assurance that the new primary care system will be free from commercial profit-making at the expense of the health service? Can we be assured that companies, whether Tesco or Asda, Tarmac or Wimpey, will not be able to employ people in the health service and make profits for the private sector at the expense of patients?

Mr. David Congdon (Croydon, North-East)

What about Boots?

Mr. Hughes

Not Boots, which is a drug company that deals with pharmacists; I mean any company that could employ GPs.

Mr. Dorrell

The hon. Gentleman raises a huge range of issues that I cannot deal with in any substance in an answer to a question. We shall continue to ensure that the staffing is available to deliver the kind of service we describe. I must point out, as the Prime Minister did a few moments ago, that we have seen a huge growth in NHS staffing since 1979—[Interruption.]—in clinical staffing, and we have also seen a huge increase in the resources available to the health service, including £4.8 billion over and above inflation in this Parliament alone. Staffing and resources continue to be key concerns of any Health Secretary, as does proper co-ordination.

The hon. Gentleman seems to believe, somehow, in a pure service with no profit motive, which is the only sort that he conceives can be of benefit to patients. Life is much more complex than that. Boots delivers an NHS service: the NHS pharmacy service. Boots and every other NHS pharmacist deliver that service for a profit. The independent contractors who deliver NHS general practice also do it for a living—that is to say, for a profit. Drug companies that sell drugs through the dispensing service do it for a profit. I am interested in a proper reward for those who deliver an efficient, high-quality service for the patient. Provided that I am satisfied that those tests are passed, I am willing to consider proposals made with the support of the professional staff concerned.

Several hon. Members


Madam Speaker

Order. The last hon. Member who put a question asked five questions. That is totally unfair, but I allowed him to do so because he speaks for his party on these matters. That was the only reason. Given the number of hon. Members who seek to put questions on this statement, I cannot be fair and call them if we have long questions and long answers. I am sure that the House will oblige: I want brisk questions and brisk answers.

Sir Roger Sims (Chislehurst)

As my right hon. Friend will realise, an increasing role will need to be played by nurses, particularly district nurses, health visitors and practice nurses. It is now four years since Parliament approved legislation to enable nurses to prescribe yet we are still waiting for the evaluation of the first pilot sites. Will my right hon. Friend give more priority to nurse prescribing and expedite its implementation?

Mr. Dorrell

My hon. Friend is on to an important point. Some real benefits can be secured through the extension of nurse prescribing provided that it is done in a properly evaluated and disciplined way. The Government are committed to that process. The practice-based contract concept—one of the specific objectives of this legislation is to allow that concept to be developed—will allow broader scope for nurses to deliver primary care services, subject to proper medical oversight. That will allow the development of the independent professional nursing practice that my hon. Friend seeks. It is an attractive option, but it must be introduced in a properly disciplined and controlled way.

Mr. Hugh Bayley (York)

The Secretary of State sought to reassure the House that the Government provide for a fair and equitable distribution of NHS resources through their capitation funding formula, but he has forgotten that that funding formula applies to hospitals, not to primary care, which is the subject of this statement. Is he aware that present funding for Cornwall health authority provides enough money for one GP for every 1,660 people in Cornwall, while the funding for Rotherham provides only for one GP for every 2,250 people? What will he do to distribute primary health care money equitably? If he does not distribute it equitably, all his proposals for buying in care from salaried doctors will mean nothing, because the purchasers of care will not have the money to do it.

Mr. Dorrell

The hon. Gentleman clearly was not listening to what I said. I specifically said that the extension of the weighted capitation basis of funding to primary care was one of the issues that my hon. Friend the Minister for Health raised in the listening exercise and is one of the issues that we are working on.

Mr. David Sumberg (Bury, South)

Will my right hon. Friend confirm the vital importance of GP fundholding to primary care? Is he aware that Bury has one of the largest numbers of fundholders in the country? When I meet those fundholders next month, may I confirm that the reports in the press about a change in Labour party policy are totally untrue, and that the Labour party remains committed to abolishing fundholding and all the services that it provides? In the unlikely event of a Labour Government, that step would do great damage to my constituents.

Mr. Dorrell

My hon. Friend may be interested to know that today I was given a document entitled "The Labour Party Policy Handbook 1996"—dateline October 1996. My hon. Friend will be interested to hear that it is in loose-leaf format, so clearly a certain flexibility is intended. With that caveat, the document—it was published within the last 14 days, so it is hot off the press—says that it is Labour party policy to replace fundholding with GP commissioning. I understand the word "replace" to mean that one thing will take the place of another—in other words, fundholding will be abolished. Every GP fundholder, servicing 58 per cent. of patients in this country, should take that into account as we approach the election. The Labour party would abolish fundholding—the option that has been chosen as being in the interests of 58 per cent. of patients.

Mr. Barry Jones (Alyn and Deeside)

Will the Secretary of State assure us that the worrying closures of community pharmacies will cease? Is he aware that pharmacies fear the abolition of retail price maintenance and that I have received many petitions about the matter? Supermarkets can close community pharmacies.

Mr. Dorrell

The question of retail price maintenance falls outside the specific responsibility of the Department of Health, and I do not accept that its abolition has inevitable consequences for the viability of the pharmacy network.

I am committed to the development of NHS pharmacy as a key element of primary health care. One simple statistic makes that clear: 3 million people go to pharmacists every day for some kind of health or health-related product. It is a key element in the primary health care team and in the delivery of an integrated national health service in Britain.

Mr. Andrew Rowe (Mid-Kent)

I am at least as great a supporter of the purchaser-provider split as Dr. Sandy Macara, but my right hon. Friend may be aware that in west Kent we are suffering badly as a result of the purchasing authority's failure to control the over-expenditure of fundholding GPs. That is seriously damaging the morale of non-fundholding GPs and provider trusts, which are performing extremely well. Will my right hon. Friend give a commitment to investigate how that situation may be improved in future, and how we may mitigate the damage done so far?

Mr. Dorrell

I shall certainly look at the position in Kent, as my hon. Friend has suggested. The responsibility to live within a fundholder's budget rests primarily with the fundholder rather than with the health authority. If there is a problem with over-spending fundholders in my hon. Friend's constituency, the principal responsibility for addressing it rests with the fundholders. However, I shall examine that issue.

Mr. Dafydd Wigley (Caernarfon)

I welcome the Government's much-needed U-turn on community hospitals. Does the Secretary of State agree that every town of any size should have a proper, modern community hospital, that that will be facilitated and that the private finance initiative, which has held back many community hospital schemes, will not be used in that way any longer? Local authorities should be allowed to proceed without going down that delaying route.

Mr. Dorrell

The hon. Gentleman is wrong on both counts. The PFI does not hold back community and cottage hospitals: it is the means by which community and cottage hospital projects may go ahead, if there is demand in the area, without having to wait for the capital flow to be approved by the Department of Health and the collective processes of Government.

As to the hon. Gentleman's allegation that this is a U-turn, the most powerful weapon for re-establishing and expanding support for community and cottage hospitals in Britain is the GP fundholding scheme that the Government introduced in 1991. Fundholders, acting on behalf of their patients, have made it clear that they want local community hospitals and are prepared to be involved in the management of medical cover within those hospitals in order to ensure more local care delivery to their patients. That approach is dead right, and I am happy to endorse it.

Dr. Charles Goodson-Wickes (Wimbledon)

My right hon. Friend will be aware that I practised as a physician in the national health service for a number of years. However, he may not be aware that I was on the receiving end of NHS services for much of the recess and thus was able to do a good deal of consumer research. Apart from the superb accident and emergency and in-patient treatment that I received, the most profound and agreeable aspect of my treatment—

Mr. Dennis Skinner (Bolsover)


Dr. Goodson-Wickes

NHS, and it always has been for every member of my family. There was superb liaison between GPs, district and community nurses and pharmacists—it could not be better. Is that not an example of Conservative policies raising the level of service for the benefit of the whole community?

Mr. Dorrell

I am pleased to welcome my hon. Friend back from whatever problem he encountered. He is a clear example of the NHS having worked successfully. I am pleased also to be able to congratulate him on his recovery. His experience—the service he received—is the experience of the huge majority of NHS patients. People regularly say, "I have been lucky." But people who receive high-quality care from the NHS are not lucky; it is the overwhelming experience of the majority of NHS patients.

I am pleased to join my hon. Friend in recording the fact that the care delivered by today's practitioners and professional staff within the NHS is without historical parallel. It is better than it has ever been. It is the Government's determination that it should continue to get better. We shall continue to give those within the NHS the tools to ensure that that happens.

Mr. Skinner

Is the Minister aware that there is a clear distinction between those who have treatment in the NHS and praise the nurses and the doctors for helping them to get well, and those who take a political stance in the knowledge that, after 17 years of Tory rule, NHS staff are fed up with the way in which the Government are ruining the health service?

Is it not true that most cottage hospitals have been turned into private nursing homes to be run by friends of the Tory party? It is a licence to print money. There are more beds in private nursing homes than there are in the entire NHS. Will the right hon. Gentleman deny that?

Mr. Dorrell

It is certainly true that we have seen a huge growth in the number of care beds for the elderly in private nursing and residential homes. We know that 80 per cent. of them are supported by public funds. There is a delivery of quality care to elderly people which was undreamed of 20 years ago. The hon. Gentleman should talk to the staff of the NHS. He will find that the huge majority of them are proud of the service that they deliver. Of course they want to deliver more service, but they recognise that the service that they have been delivering has been developing and growing and treating more patients year by year since 1979. They deliver and they know that it is a growing service.

Mr. Nicholas Winterton (Macclesfield)

Having had to use the services of a non-fundholding practice during the summer recess on two occasions, may I vouch for the excellent quality and speed of service that such practices provide? Having visited a community pharmacy at its request to see the valuable job that it does, may I endorse what has been said about the vital part that such pharmacies play in the community?

To pick up the point of the hon. Member for Alyn and Deeside (Mr. Jones) about the problems that they will encounter as a result of the activities of the superstores—may I say that I have managed to obtain the services of a salaried dentist for my constituency, there having been inadequate NHS dentistry?—I can vouch for the flexibility of the NHS, which appears to be the main feature of my right hon. Friend's statement. Am I right in saying that the Government have pledged to spend more on the NHS above the rate of inflation for every year that we Conservatives are in government after the next election?

Mr. Dorrell

My hon. Friend is right in almost everything that he has said. In particular, he is right to say that we are committed to continue to support a growing and more flexible health service. As he rightly said, flexibility is the main purport of the proposals that I have announced this afternoon.

Rev. Martin Smyth (Belfast, South)

I endorse the comments about community pharmacies, which want to play a bigger role. The Minister has said, "if pilots are successful". He has said also that they will be monitored and the results will be evaluated. Is that an admission that, at an earlier stage of reform of the NHS, pilot studies were not evaluated and that we went down the road of reform far too fast without having the facts before us? Is a plea being made for more certainty on this occasion?

Mr. Dorrell

When we introduced pilot fundholding in the National Health Service and Community Care Act 1990, a number of general practitioners who saw the fundholding scheme in operation decided that they wanted to join it. They saw how they could deliver best care to their patients. That was their evidence. The numbers have grown, and now 58 per cent. of patients are covered by the fundholding scheme. I regard pilot fundholding as having succeeded.

The majority of GPs now want to apply the scheme to the benefit of their patients. I have set out in my statement the way in which we intend to pilot a range of different contracting models to ascertain which ones best deliver the claims made for them. What we shall probably find, I suspect, is that some will work in some areas and others will work in other areas and people will learn by the experience of having piloted them.

Mr. John Marshall (Hendon, South)

Will my right hon. Friend congratulate GP fundholders, such as Dr. Brian Golden in my constituency, who have used the opportunities presented by fundholding to perform many more minor operations in the surgery rather than the hospital; who have widened the number of clinics on offer; and who have substantially reduced waiting lists? Is this not the sort of progress that most people welcome, even if the Opposition want to get rid of it?

Mr. Dorrell

My hon. Friend is right on every count. Fundholding has been a huge success. That is not to undermine the point made by my hon. Friend the Member for Macclesfield (Mr. Winterton)—that there are plenty of high-quality GPs who choose not to be fundholders.

Mr. Kevin Barron (Rother Valley)

What about the 42 per cent?

Mr. Dorrell

I was just talking about them, if the hon. Gentleman will contain himself in silence for a moment.

There are non-fundholding GPs who also deliver high-quality service—that is perfectly true—but fundholders have been at the cutting edge of the changes in the relationship between primary and secondary care, and some of them have delivered stunning improvements in the quality of care that they deliver to their patients.

Mrs. Alice Mahon (Halifax)

Does the Secretary of State agree that one service that GPs need to retain is the right to send patients to the hospital of their choice? What will he do about the right and the choice of GPs who want to send their patients to the Hillingdon hospital trust if they happen to be over 75 years of age? What choice will GPs in Halifax have to send patients to the new hospital when it is built and the number of beds is reduced from 850 to 500? Will that be a cut-off point based on age?

Mr. Dorrell

The position in Hillingdon is that the patients who are being talked about are those who live in the environs of Mount Vernon hospital, for whom there is an elderly assessment unit at that hospital. If local GPs want to shift the resources and the service from Mount Vernon to Hillingdon, that is something that they can negotiate, but it does not make much sense to provide the facility at Mount Vernon and send the patients to Hillingdon. That is the proposition that we are asked to endorse this afternoon, and frankly it seems to me to be pretty silly.

In terms of GP choice, the best way for a GP to ensure that he or she can refer his or her patients to the hospital of choice is by becoming a fundholder, because a fundholder is free to place the contract with whichever hospital they choose. If a GP is not a fundholder, every health authority is under an obligation to discuss with its GPs where facilities are provided. On other occasions, the hon. Member for Islington, South and Finsbury is very fond of pointing out that there is a range of different models for consulting GPs, between the health authority and GPs, which have grown up throughout the country and are not fundholding. Fundholding gives the doctor the right to decide all these other models, which the hon. Gentleman quite rightly on other occasions—

Ms Tessa Jowell (Dulwich)

indicated dissent.

Mr. Dorrell

The hon. Lady cannot just dismiss them, because all her friends on the Labour Front Bench like to talk these schemes up. There seems to be a bit of a muddle about what Labour policy is. These commissioning schemes allow GPs to be consultees, whereas fundholding allows them to decide it for themselves.

Mr. Congdon

May I welcome the extra flexibility that the White Paper provides for community pharmacists, whether they make a profit or whether they are Boots? Does my right hon. Friend agree that community pharmacists often provide a valuable service to people whether or not they have recently visited their local GP? Will he consider further measures to extend the range of drugs that pharmacists can dispense without prescription?

Mr. Dorrell

As my hon. Friend knows, that matter is subject to constant review. It is important that drugs that do not need, from a medical safety point of view, the control of prescription access should not be on that list when they do not need to be. That is subject to regular review, but I am sure that my hon. Friend would not wish those decisions to be made on anything other than medical safety grounds.

Mr. Nigel Spearing (Newham, South)

Is it not unfortunate that a significant proportion of resources provided by health authorities are now based on deficit and debt? Is the Minister aware that his departmental answer to me of 22 July refused to provide figures showing the degree of NHS debt on the basis that they were not suitable for publication? He has not, as he knows, replied to my letter on that subject of 31 July. Will he be present himself in the House tomorrow evening to answer an Adjournment debate on both those particulars of failure?

Mr. Dorrell

I cannot undertake to be present in the House to respond to the debate, but I shall undertake to ensure that I know what will be said before it is said.

Mr. Max Madden (Bradford, West)

What proposals are contained in the White Paper for tackling the drugs crisis now gripping much of Britain, including our inner cities, particularly with regard to the national provision of drug treatment centres and guidance to GPs and pharmacies to prescribe methadone, thereby reducing hard drug dependency?

Mr. Dorrell

The range of services provided to people suffering from drug abuse is subject to national monitoring and some national guidance in ten-ns of protocols and the kind of services which are most effective. Evidence is collected nationally, but it is far better that the service should be designed locally. The more flexible contracting regime which will be delivered by the proposals may well have a significant role in ensuring that we are better able to meet the needs of the type of patient whom the hon. Gentleman describes.

Mr. John Gunnell (Morley and Leeds, South)

What new money goes with these proposals? It is all very well for the Secretary of State to tell us that he will legislate as soon as possible, but what new money, not in the health service already, will accompany the proposals, which clearly depend upon adequate resources?

Mr. Dorrell

I have not come to make an announcement about money this afternoon; I have come to make an announcement about proposals for legislative change. But if the Government's record is anything to go by, it will be a lot more than £100 million.

Mr. Richard Burden (Birmingham, Northfield)

The announcement has some welcome aspects, but initiatives in primary care are unlikely to be effective if they are grafted on to a system of contracting that encourages short-term thinking when already too many community services do not know what they are doing from one year to the next. Will the Secretary of State review the time scales of contracts so that we have proper commissioning rather than short-term fixing year on year?

With regard to money. may I press the right hon. Gentleman on one specific issue? Appendix A refers to money for the pilots being ring-fenced. Is that new money and, whether or not it is, how much will be ring-fenced?

Mr. Dorrell

It is not new money and does not need to be new money, because we are talking about the delivery of primary care services to existing patients with existing practitioners. We are talking about ring-fencing the existing pool system for the remuneration of doctors and dentists so that the individual doctor and dentist does not have his remuneration undermined or distorted by the development of the pilots. That is what ring-fencing means in that context.

The hon. Gentleman repeats the assertion that the Government are in favour of short-term annual contracts. We have said repeatedly, and I said it again in May this year when I published some material on improving the efficiency of NHS bureaucracy, that I am in favour of a medium-term perspective in the contracts. I certainly am not in favour of an artificial requirement that every contract should be placed for one year. That never has been the Government's policy, however often it is asserted from the Opposition Benches that it is.

Mr. William O'Brien (Normanton)

What advice does the Secretary of State have for GPs who are concerned that there is a shortage of acute beds in hospitals for the mentally ill, particularly in the Wakefield area, where the Secretary of State knows that the amalgamation of two hospitals will reduce the number of acute beds?

Mr. Dorrell

I have repeatedly made it clear, and it is being delivered by the NHS, that we need to deliver acute hospital beds for those who are acutely mentally ill, just as we need to deliver acute hospital beds for those who are acutely physically ill. I am not in favour of continuing to provide many long-stay isolated mental illness beds in traditional mental illness hospitals when better models of care are available which provide proper support in the community, nursing home support for people who need nursing homes and a range of other facilities, but, where people need acute mental illness beds, those are being provided, often in acute mental illness units that have been the result of the investment boom of which the Pritne Minister spoke when answering questions earlier.

Mr. Ronnie Campbell (Blyth Valley)

The Secretary of State has said that he praised fundholders, but in our region we have evidence of fundholders refusing to put old people on their practice lists. In fact, they are not even refusing them. They are throwing them off the list and other doctors who are not fundholders are having to pick them up. That is not good enough, and will the Secretary of State do something about it?

Mr. Dorrell

If the hon. Gentleman made that accusation with a name attached to it outside the House, it would be a serious charge of professional misconduct.

Mr. Campbell

I will bring the case to the Secretary of State.

Mr. Dorrell

The hon. Gentleman should indeed bring the case to me, because, if he does so, he will find it referred to the General Medical Council for unethical conduct.

Dame Elaine Kellett-Bowman (Lancaster)

Is my right hon. Friend aware that my local district general hospital, the Lancaster royal infirmary, will shortly be the first hospital to incorporate a dedicated blood transfusion service? Will he consider doing us the honour of opening it?

Mr. Dorrell

I should be delighted to respond to an invitation that my hon. Friend presses on me and I hope that it will be possible to fit it into my schedule.

Madam Speaker

That was not referred to in the statement that I heard.

Mr. Nick Ainger (Pembroke)

Will the Secretary of State take the opportunity to apologise to the hundreds of thousands, if not millions, of people in Britain who are deprived of primary dental care? In my constituency, a small group in the town of Milford Haven have had to band together and hire a mini-van to transport themselves 30 miles to a dentist who will treat them. That is not uncommon throughout rural Wales. Will the Secretary of State give us an assurance that his measures in the White Paper will deal with that major problem—in one constituency in north Wales, there is no NHS dentist at all—and that we can return to the position 10 years ago when, in my constituency, every dentist was providing NHS care, whereas now we have only three?

Mr. Dorrell

My hon. Friend the Member for Macclesfield says that he already has a salaried dentist in his constituency. The hon. Member for Pembroke (Mr. Ainger) asks that we return to the position of 10 or perhaps 17 years ago. He would like to return to the position 17 years ago in NHS dentistry. That would mean a reduction of roughly one third in the number of NHS courses of dental treatment delivered.

Mr. Ainger

indicated dissent.

Mr. Dorrell

It is no good the hon. Gentleman shaking his head. Adult courses of dentistry received and paid for in NHS terms have risen from 17 million in 1979 to just short of 25 million in 1995. That is an increase in NHS dentistry activity of 46 per cent. It is an inconvenient fact, given the sort of assertions that the hon. Gentleman likes to make. I would not argue—I do not argue—that there are no problems in NHS dentistry. That is why we are introducing the proposals to make the system more flexible, but the hon. Gentleman should not assert that NHS dentistry is in retreat—

Mr. Ainger

It is.

Mr. Dorrell

It is no good saying that it is. I have quoted the facts to the hon. Gentleman. The facts are that there were 17 million courses of treatment in the time that he referred to as a golden age and that there are 25 million courses of treatment now.

Mr. John Battle (Leeds, West)

I do not know where the Secretary of State gets his facts, but many of my constituents cannot get an NHS dentist because the NHS dentists have pulled out and gone private. How will the White Paper help those constituents? Is not this word "choice", which Ministers utter, an increasingly empty word that means the Hobson's choice of going without because, in practice, NHS dentistry has been privatised?

Mr. Dorrell

The hon. Gentleman is wrong. I have shown clearly that it is not true to say that NHS dentistry is being privatised. I acknowledge that there are problems with the provision of NHS dentistry, which is why we have introduced these proposals to make the regime under which NHS dentistry is provided more flexible and to allow health authorities to target resources on areas where there is a problem with access.

Earlier this year, my hon. Friend the Minister for Health announced changes in the remuneration of dentists under the present contractual arrangements. Resources will be targeted specifically on dental services for children to ensure that that provision receives priority. We are responding to problems of access to NHS dentistry as they arise. My hon. Friend the Member for Macclesfield referred to another example of how that is being done.

Neither of the assertions of the hon. Member for Leeds, West (Mr. Battle) is true. It is not true to say that NHS dentistry is a service in retreat. It is true to say that there are some problems, but we are dealing with them.