§ Mr. John Maples (Stratford-on-Avon)
(by private notice): To ask the Secretary of State for Health whether he will make a statement on his plans for GP fundholding.
§ The Secretary of State for Health (Mr. Frank Dobson)
My announcement today of fair waiting lists for patients of all general practitioners is an attack on unfairness. It is not an attack on GP fundholding. The previous Government introduced the internal market into the national health service, creating a two-tier system in which patient was set against patient, and GP was set against GP. That was unfair to patients and repugnant to the doctors and nurses who had to apply the system, and it cost a fortune in extra paperwork.
At the general election, we promised to restore fairness to the health service, to end the two-tier system and to ensure that access to treatment is based on need, and need alone. We pledged to change the system so that no patients and no GP practices should suffer any longer from the unfairness introduced by the Conservatives. We are keeping that election promise.
From now on, all NHS trusts must operate a fair waiting list for urgent admissions, regardless of who is commissioning the care. With effect from 1 April 1998, when current contracts run out, all health authorities must establish common waiting time standards for all people living in their area. From the same date, health trusts must not offer preferential treatment to any particular group of patients from health authorities, regardless of whether they are patients of GP fundholders. Faster treatment must be provided only on accepted clinical or social grounds. That change will be fair to every patient, and will be more comfortable and acceptable for doctors and nurses to operate.
My announcement today has been welcomed by the British Medical Association, the Royal College of Nursing and the NHS Confederation. The National Association of Fundholding Practices has made it clear that it fully accepts the principle of fair waiting lists and that, if properly implemented, the new policy will benefit all patients.
In two thirds of all health authorities, the patients of non-fundholding practices have to wait longer for hospital treatment. What is not so well known is that, in the other one third, the patients of GP fundholders lose out under the present system.
We are determined to have a national health service which is fair to all patients. That fairness will be achieved through co-operation in place of the competition and division of recent years. It will be achieved by levelling up to the best that has already been achieved, not by levelling down.
In our general election manifesto, we recognised that the development of fundholding had brought advantages as well as disadvantages. We promised to remove the disadvantages. We are keeping that promise. A month ago, we set out to bring fairness to the financing of non-fundholder practices. Today, we are bringing fairness to their patients.
We are now consulting the professions and patient organisations on how best to develop a primary care system fit for the next century, in which doctors and 400 nurses can play a leading part in planning local health services for all the patients in their area. In this way, we hope to reconcile the better aspects of fundholding with fairness for all patients. We are discussing this with all the professionals involved, and will test out our proposals through pilot schemes in every part of the country.
The new system, like the announcement that I have made today, will be based on the principle that access to health care is based on need, and need alone. That is the principle of fairness, quality and equality on which the Labour party founded the health service. It is the principle of fairness, quality and equality on which we will run the national health service so that it is fair to every patient. Who could possibly quarrel with that?
§ Mr. Maples
Well, the chairman of the Association of Fundholding Practitioners for one, because he did so on the radio this morning. Perhaps the Secretary of State has got at him since, but this morning on the radio he was expressing considerable reservations.
What we have just heard is a prologue to the slow death of fundholding in the national health service. [HON. MEMBERS: "Hear, hear."] That is the authentic voice of the Labour party. It is happy that it is going to be abolished.
Fundholding has been one of the great successes of the NHS over the past few years. It has put money, power and responsibility in the hands of GPs. They are the people who really understand their patients' needs and who know their local hospitals and local consultants. More than half of GPs have voluntarily become fundholders. They account for more than 60 per cent. of all patients. There would be many more if the Secretary of State had not balked at the last wave. Doctors have voted the scheme a success.
We believe that the Secretary of State plans a slow death for fundholding because it does not fit his model. He knows best, and he plans to direct everything from Whitehall. The idea that individuals should be trusted to make decisions or take initiatives is anathema to him and his party. It is the beginning of the end for fundholding. [HON. MEMBERS: "Ask a question."] There will be some questions—do not worry.
If the Secretary of State does not believe us, perhaps he will believe the Audit Commission, which said:There is evidence that the direct involvement of GPs had led to improvements in service".The Organisation for Economic Co-operation and Development said:GPs seem to have done a better job of purchasing … GPs have been prepared to diversify providers, challenge hospital practices and demand providers".The King's Fund described fundholding as one of the major successes of the reforms, and an Edinburgh university study found that it had achieved savings.
Professor Glennerster, a former member of the Labour research department, said:All the dire predictions … were unfounded.. efficiency gains had more than outweighed costs.By any standard, fundholding has been a great success. The Secretary of State's excuse for beginning to dismantle it is that it has produced a so-called two tier NHS. Let us be clear that it is an allegation—[HoN. MEMBERS: "Question."] It is an allegation—
§ Madam Speaker
Order. I remind hon. Members that this is a private notice question and that the Member who 401 tabled it has to ask a question on the statement that has been made. Of course I allow hon. Members to make a preamble—that is absolutely right—but this preamble is rather long. I think we now have to have pertinent questions.
§ Mr. Maples
I am coming to the end of the preamble.
Equality is best pursued by maximising opportunities, not minimising them. Arguing about a two-tier health service is akin to saying that equality in human need is best achieved by starving everybody.
Why does the Secretary of State not extend the power held by fundholders to all GPs and all patients? Why not extend to everyone the advantages of a successful experiment? Will he give us a cast-iron assurance that his policy is not to destroy or neuter fundholding? Will he give a cast-iron assurance that GP fundholders will continue to be free to refer their patients to the consultants and hospitals of their choice? The Secretary of State wanted specific questions, but he is not making any note of them. Will he give a cast-iron assurance that GPs will have the power and the money to make those referrals?
Thousands of fundholding GPs and millions of their patients want answers to those questions. If the Secretary of State cannot give us those answers, we and they will know what we have long suspected—that he plans to end the most successful experiment ever in improving patient care and NHS efficiency. If that is what he plans and does, patient care will deteriorate, waiting lists will increase and he will go down in the history of the NHS as a vandal as well as a dinosaur.
§ Mr. Dobson
I think that the hon. Gentleman was better when he was asking questions. He should consider the interests of patients in his area. In his constituency, as in the constituency of the right hon. Member for Fylde (Mr. Jack), the shadow Minister, the patients of fundholding practices are treated more slowly than others. He should pay a little attention to the people whom he allegedly represents.
I assure the hon. Gentleman that what we have announced today has the support of the British Medical Association, which represents all doctors, the Royal College of Nursing and the National Health Service confederation. Mr. Rhydian Morris, who represents fundholders, has explained to me that they support in principle our effort to establish fair and common waiting lists, provided we do that effectively and deliver on our aims. We shall do that.
The hon. Gentleman's contribution shows that the Tories are not interested in patients or in fairness. They are still obsessed with institutions that they introduced, largely on the advice of a heroin addict and prescription fraudster. We are not prepared to continue that system. We shall replace it with a system that will be the product of consultation with all doctors, all nurses and all people involved in providing primary care. We need a decent primary care system that is fair to every patient of every practice. We shall bring that about.
§ Dr. Howard Stoate (Dartford)
Is my right hon. Friend aware that many GPs, including fundholders, are far from happy with the fundholding system as it stands? Is he 402 further aware that many GP fundholders entered fundholding only because they felt that they had to? Many of those fundholders are trying to get out of fundholding, because they know that it has not been best for their patients.
Is my right hon. Friend also aware that the Audit Commission report showed that 70 per cent. of GP fundholders were unable to manage their funds as well as they might because they did not have the necessary management expertise and skills available? Does he therefore agree that a far better model for primary health care provision would be locality commissioning, which would mean lower bureaucratic costs, better management expertise, a far better deal for patients and, above all, more efficiency for the NHS, using public funds most effectively for the benefit of all patients? That would also lead to equality in waiting lists, and therefore a better service to patients.
§ Mr. Dobson
I welcome my hon. Friend's contribution, drawing on his professional experience as a doctor. I assure him that our consultation on the future of primary care will include all representative organisations, including the representatives of fundholding GPs, who have said to our faces that they approve of the changes that we are making and of our approach to the further changes that we intend. We believe that that is the way forward. We want to carry the profession with us and do not want to force people to do things that they do not want to do. It is my belief that the bulk of the medical profession and the bulk of the nursing profession want to do the best by their patients. That is why they support what we have announced today.
§ Mr. Simon Hughes (Southwark, North and Bermondsey)
The Secretary of State is right. On all three points we support him, and on all three points the Conservative spokesman, the hon. Member for Stratford-on-Avon (Mr. Maples), is wrong. Fundholding, with the right to buy advance treatment, is wrong and unfair, and should go. That does not necessarily mean the end of fundholding. Fundholders support the announcement, and are clear that such advance treatment is unjustified. Fundholders' representatives, including the very man who was on the radio this morning speaking for fundholding doctors, have told me so to my face. The Secretary of State has our unreserved support, and I am delighted that he has been able to make the announcement.
The follow-up question that will be in people's minds is whether, given that we have abolished the two-tier system for GPs, the Secretary of State has in mind the abolition of the multi-tier system which results in shorter treatment times in certain parts of the country and much longer treatment times in other parts. How soon one is treated is, in effect, a national lottery. When will the other manifesto pledge to treat more people, and, by implication, to bring down waiting lists for all, be achieved?
§ Mr. Dobson
We are treating more patients. This year, we shall be devoting to patient care £100 million which would have been spent on bureaucracy. Of the £20 million that we will save from the bureaucracy of the eighth wave of fundholding, £10 million is being devoted to breast cancer treatment and £5 million to improvements in 403 children's intensive care. I thank the hon. Gentleman for his welcome for our proposals, but I have forgotten what his other question was.
§ Mr. Robin Corbett (Birmingham, Erdington)
Those of my constituents who did not have fundholding GPs and were told that they had to wait a minimum of nine months for treatment were very upset when they found out that patients of fundholding GPs had to wait only a maximum of six months, so they will commend what my right hon. Friend has said today. Will he include pharmacists in the consultation about primary care? They have an important role to play.
§ Mr. Dobson
On the latter point, I can assure my hon. Friend that we shall be consulting everyone involved about the future of primary care and how we can extend the roles of the various professions so that they meet the needs of patients who are feeling poorly. That is the most important thing that we can do.
I think that everybody realises that the present system is manifestly unfair. The bulk of people in this country are profoundly fair people and they want a fair system; they have an unfair system. Such unfairness was emphasised by James Johnson, the chair of the BMA's central consultants and specialists committee, when he said:The present two-tier system is manifestly unfair to patients.Even more important, he said:Elective surgery patients are no longer being treated on the basis of clinical need.We will put a stop to both those things.
§ Mrs. Virginia Bottomley (South-West Surrey)
Is the right hon. Gentleman aware that the real strength of GP fundholding has been to change totally the balance of power in the NHS towards the family doctor? Is not his real problem that, having so failed with the Chancellor of the Exchequer to get even the amount of money secured for this year by his predecessor, he has already been condemned by the BMA, so, rather than take any steps to help patients, he has thrown an ideological bone to his Back Benchers? It is a classic Labour party levelling down, not levelling up, and no patient will benefit.
§ Mr. Dobson
All I can say about funding is that, as a result of the decision announced by my right hon. Friend the Chancellor of the Exchequer, the NHS in England will gain £1.7 billion more next year in comparison with this year—the Budget set by the Cabinet of which the right hon. Lady was a member. If we are expected to take lessons from her about ways of organising the health service, I can only presume that she is saying that she was not one of the Tory Ministers whom Clive Froggatt came to see—before which, according to his memoirs, he used to shoot up.
§ Ms Julia Drown (South Swindon)
My constituents and I welcome my right hon. Friend's statement, as does the BMA—I have just come from a meeting with it. Does my right hon. Friend agree that his statement will be welcomed not only by the doctors and nurses he mentioned, but by many health care workers? As a former finance director in the health service, I was deeply affected by the internal market introduced by the previous Government.
404 Before the internal market, I could tell patients that, however difficult the financial circumstances of my hospital, they would be seen in order of clinical priority. If they had the most urgent need, they would be first to be seen by the doctor. It was deeply destructive to doctors, nurses and administrative staff who dealt with patients to turn that round and to have to say, "I am sorry, but it now depends who your doctor is." I welcome with open arms the return of a national health service in which, once again, patients are seen in order of clinical priority.[Interruption.]
§ Mr. Dobson
I thank my hon. Friend for her endorsement of my announcement today. It is revealing that her direct experience, like that of my hon. Friend the Member for Dartford (Dr. Stoate), of the problems caused by the internal market is received with mockery by Opposition Members—sorry, I should say Tory Members, in fairness to the Liberals.
§ Mr. James Paice (South-East Cambridgeshire)
The right hon. Gentleman will know that one of the benefits of fundholding has been that doctors could send patients to the hospital most appropriate for their needs and often most convenient geographically. In my constituency, many people live in one health authority, but the best and nearest hospitals are in a different health authority area. Will the Secretary of State answer the question put by my hon. Friend the Member for Stratford-on-Avon (Mr. Maples) and confirm that fundholding GPs will still be able to send their patients to the hospital most suited to their needs, or will there be some form of central direction of the hospitals they should attend?
§ Mr. Dobson
The hon. Gentleman ought to recognise that, until the Conservative party made its changes—[HON. MEMBERS: "Answer the question."] I am answering the question. Before the Tories made their changes, any GP in any part of the country could refer any patient to any hospital that he thought suitable. The Tory party took away that right and then started to hand it out as a privilege. We will ensure that all doctors are in the same position to look after their patients and exercise their clinical judgment, which the fundholding system took away from far too many doctors.
§ Laura Moffatt (Crawley)
As a nurse who worked in the health service for 20 years, may I share with my right hon. Friend what such an announcement will mean for my many former colleagues? I am so sad to hear the comments from Tory Members about ideological bones, because I can honestly tell my right hon. Friend that—
§ Madam Speaker
Order. I am sorry to interrupt the hon. Lady. I have tried to explain that when we are in Question Time hon. Members must ask the Secretary of State a question. I understand the hon. Lady's anxiety and keenness about the statement that has been made and I am sure that she endorses it—I would expect her to do so from the Government side of the House—but she must put a question to the Secretary of State and not make a long speech. I hope that we will soon have a debate on 405 the health service and I will be able to call anybody who wishes to make a statement. Meanwhile, let us have a question.
§ Laura Moffatt
Is my right hon. Friend aware that we desperately need some improvement in the morale of health service staff?
§ Mr. Dobson
I entirely accept the point made by my hon. Friend in her excellent question. [Interruption.] Well, there was more of a question than we had from the hon. Member for Stratford-on-Avon (Mr. Maples). My hon. Friend is right. The fact that doctors, nurses and others working in hospitals had to treat one patient unfairly compared with another was etched deeply into the morale of all concerned. They will be delighted that that rotten, unfair system is to end and be replaced by one that is fair.
§ Sir Richard Body (Boston and Skegness)
With respect, I wonder whether the Secretary of State has quite answered the questions from two of my hon. Friends. They asked whether fundholding doctors would still be able to send their patients to the consultant of their choice. The Secretary of State referred to the hospital of their choice. There is a distinction. Will he make it plain that, if his proposals are accepted, fundholding doctors will not be able to send their patients to the consultant of their choice?
§ Mr. Dobson
I am sorry, but the hon. Gentleman, for whom I have considerable respect, has missed the point. Fundholding doctors can keep sending their patients to the hospital of their choice and to the consultant of their choice, but neither the hospital nor the consultant can promise to treat them more quickly than another patient equally deserving of treatment.
§ Mr. Eric Illsley (Barnsley, Central)
I welcome my right hon. Friend's announcement, especially, as two years ago, the Sheffield hospitals trust refused all clinical admissions other than those of patients of GP fundholders. Is he aware that a GP fundholding practice in my constituency, which has made underspends of £300,000 over the past few years, has spent that money on buildings which now belong to that practice? Figures for the latest financial year show that practice with an overspend of 406 £80,000, which now falls to be met by the district health authority. Will my right hon. Friend put an end to such malpractice?
§ Mr. Dobson
As I understand it, any overspending this year will be taken from the practice's future budget, so things should even out. We want a system in which all practices get a fair share of the national health service resources. The measures that we announced about three weeks ago are intended to deal fairly in financial terms with non-fundholding and fundholding practices. That is what the representatives of the non-fundholders say they want, and so do the representatives of the fundholders.
§ Dr. Evan Harris (Oxford, West and Abingdon)
I, too, welcome the statement by the Secretary of State. From talking to former colleagues at the BMA this morning, I can confirm that they also welcome the abolition of that two-tier system. Is the Secretary of State aware that doctors are concerned about another two-tier system? Those people on long waiting lists who can afford to go privately can jump the queue, leaving those without means to wait even longer. Does he have any proposals to prevent waiting lists this year getting longer and longer for my constituents in Oxford and those of other hon. Members?
I remind the Secretary of State of the question from my hon. Friend the Member for Southwark, North and Bermondsey (Mr. Hughes). Can he say when waiting lists will come down by the 100,000 that he promised in the Labour manifesto?
§ Mr. Dobson
I am not making any wild promises about when waiting lists are coming down. I have been looking at the facts. At present, waiting lists are the highest that they have ever been in the history of the national health service. When we took over, they were rising faster than they have ever risen, and there is still a great deal of momentum behind that rise, so we cannot promise any short-term reductions.
If there is a harsh winter, I have said—and I take responsibility for it—that the first priority for the hospital service must be to deal with emergencies. If that means that the waiting lists must rise in order for the emergency demands to be met, I will take responsibility for it. That is what one must do when one is in government.