PROVISION OF PRIMARY MEDICAL SERVICES

HC Deb 08 July 2003 vol 408 cc1027-51

'In the 1977 Act, after section 16CB (as inserted by section 162 above) insert— 16CC Primary medical services

1. (1) Each Primary Care Trust and Local Health Board must, to the extent that it considers necessary to meet all reasonable requirements, exercise its powers so as to provide primary medical services within its area, or secure their provision within its area.
2. (2) A Primary Care Trust or Local Health Board may (in addition to any other power conferred on it)—
1. (a) provide primary medical services itself (whether within or outside its area);
2. (b) make such arrangements for their provision (whether within or outside its area) as it thinks fit, and may in particular make contractual arrangements with any person.
3. (3) Each Primary Care Trust and Local Health Board must publish information about such matters as may be prescribed in relation to the primary medical services provided under this Part.
4. (4) A body on which functions are conferred under this section must cooperate with any other such body in the discharge of their respective functions relating to the provision of primary medical services under this Part.
5. (5) Regulations may provide that services of a prescribed description are, or are not, to be regarded as primary medical services for the purposes of this Part.
6. (6) Regulations under this section may in particular describe services by reference to the manner or circumstances in which they are provided.".'.—[Mr. Hutton.]

Brought up, and read the First time.

Mr. Hutton

I beg to move, That the clause be read a Second time.

Madam Deputy Speaker

With this it will be convenient to discuss the following:

Government new clause 27—General medical services contracts.

And the following amendment thereto: (a), after 'appropriate', insert—

'(4A) No direction issued under subsection (1) shall involve payment based on rewarding contractors for reaching a target number or target proportion of treatments given.'.

Government new clause 28—Government medical services: transitional.

Government new clause 29—Abolition of pilot schemes.

New clause 40—Definition of personal medical service—

'In the 1977 Act, in section 29(2), leave out "adequate" and, after "attendance", insert "to meet their clinical needs".'.

Government amendments Nos. 270 to 299, 268, 269 and 300.

Mr. Hutton

Following the recent decision by doctors in the British Medical Association to approve the new general medical services contract for family practitioners, the Government are taking the earliest possible opportunity to legislate for the necessary implementation. These clauses were not laid during earlier stages of the Bill's passage because we did not want to prejudge the outcome of the BMA ballot. As it turned out, 79.4 per cent. chose to support the new contract: 31,945 GPs cast a vote, which was a 70 per cent. turnout. That indicates the strength of support for the change.

Mr. Lansley

Will the Minister tell the House when the clauses and amendments were drafted? It may not necessarily have pre-empted the ballot, but it would have informed the House—notwithstanding the requirement for a positive vote in the ballot—if the clauses and amendments had been available for scrutiny earlier.

Mr. Hutton

As the hon. Gentleman will understand, these amendments have been through several iterations in the Department and were not finally ready to be tabled until we were satisfied—as the BMA and the NHS Confederation were—that they provided the right legal framework to deliver the new contract. That was not until Thursday. I apologise to hon. Members and the House for the fact that the documentation that we sent out on Thursday did not reach them until Monday. That is regrettable and I apologise to the hon. Gentleman and other right hon. and hon. Members who take a close interest in these matters. We were genuinely trying to be helpful in that regard. I am sorry if it did not end up like that. To help Members understand the clauses, I wrote to them with an explanatory note last week. I hope that, despite the delays in reaching them, it has turned out to be at least some help for this afternoon's debate.

In general terms, the new clauses are designed to achieve two things: first, to implement the new GMS contract as agreed overwhelmingly by general practitioners; and, secondly, to make provision for putting personal medical services arrangements on to a permanent basis, as originally envisaged in the 1997 Act, in order to reflect the success of PMS as a means of providing primary care services.

In order to effect these changes, we need to give primary care trusts additional powers to commission primary medical services. In the process, our objectives have been to simplify the existing legal framework, to minimise the volume of secondary legislation—an inevitable by—product, I am afraid—and to make the new arrangements more straightforward for family doctors, patients and NHS organisations.

New clause 26 replaces the existing duty on PCTs and local health boards to make arrangements for the provision of general medical services with a new duty to provide or to secure the provision of primary medical services. The primary care trust or the local health board can meet this duty by entering into general medical services contracts, personal medical services arrangements, through providing the service itself, or by commissioning services from other health care suppliers. New clauses 27 and 28 provide for the making of the new GMS contract and for the necessary transitional regulations.

New clause 29 and amendments Nos. 278 to 282 will remove the pilot status of personal medical services arrangements and place PMS in the mainstream of delivering primary care services in the NHS. To do that, the power to make pilot schemes will be repealed, and sections 28C to 28E of the National Health Service Act 1977 will be commenced. As part of that process, several amendments will be introduced to sections 28C to 28E, simply to bring them up to date and, in particular, to reflect the changes made to the GMS provisions.

Amendments Nos. 284 to 291 will amend clause 166 to provide for a single list of performers in primary medical services to be held by primary care trusts, replacing the existing three-list structure set out in the Health and Social Care Act 2001. It is a helpful streamlining of those arrangements.

Amendments Nos. 292 to 295 will amend clause 167 to extend the assistance and support provisions to general medical services and personal medical services. Remaining amendments cover minor and consequential amendments and list the associated repeals.

That is what each new clause and amendment does in a nutshell. I would now briefly like to explain that while the new clauses make significant and important changes to the old GMS arrangements, the new GMS contract will retain many of the features of traditional general practice. For example, primary care trusts and local health boards will be under a duty to secure or provide within their areas the provision of primary medical services, to the extent that the trusts or boards consider that necessary to meet all reasonable requirements. It is that legal responsibility to ensure a comprehensive package of commissioning arrangements in respect of primary medical services that underpins the very important patient services guarantee described in chapter 6 of the agreement. We have made copies of the framework agreement available in the Vote Office for right hon. and hon. Members to consult.

Patients need to be assured that the new contractual arrangements do not deny them access to services, and they will not. The new arrangements do not envisage any diminution of the services currently provided under GMS contracts. Indeed, it is envisaged that most practices will continue to deliver the full range of additional services. Where they do not, the PCT must step in, and it is in those cases that a patient might need to go to another provider for certain services. The PCT will therefore have a power to commission services through other arrangements, including providing the services itself, if necessary. However, patients can expect the PCT to ensure that they continue to be offered at least the range of services that they currently enjoy under the existing GMS arrangements. That is the patient services guarantee.

All GMS contracts must include a duty to provide essential services, including the management of patients who are ill, or believe themselves to be ill, for the duration of that condition; care for those who are terminally ill; and the management of chronic disease. Where additional services such as minor surgery are provided for patients—that will be the case in all PCT areas, albeit that every practice may not provide such services—existing practices in the PCT or local health board area will start off with a preferential right to provide such services and will normally be expected to do so.

We are also retaining list-based general practice. In future, a patient will not be registered with an individual GP but will still be registered with a practice. A practice-based contract, rather than an individually based contract, will provide much more flexibility for the practice to decide how it delivers services. That will be a helpful degree of flexibility that we will provide for busy family doctors. For example, it will enable nurses to be contracting partners in the practice, which is not possible at the moment.

Once registered with a practice, the patient will continue to have the right to request to be seen by the doctor of their choice. That is important for patients who value seeing their own GP, and I certainly count myself among that number. The PCT will also retain its ability to help patients who, for whatever reason, cannot register with a general practice. It will retain the ability to assign patients to general practice but can additionally, for example, arrange to provide primary medical services itself where that is an appropriate solution.

Sir Patrick Cormack

My constituency has only two practices in which the doctors themselves provide all the out-of-hours services. All the rest contract out that provision. Will that situation change as a result of the Bill? I know from experience that patients prefer to see a doctor from the practice to which they are assigned, rather than some locum from far away.

6.15 pm

Mr. Hutton

I agree with the hon. Gentleman that those are important issues, and patients value that provision highly. The situation will change under the new contract that we have agreed with the BMA and the NHS Confederation. Essentially, it will be for GPs to choose whether to provide an out-of-hours service directly. The new contract will not remove the requirement to provide out-of-hours services, but it will change who has the responsibility to organise the delivery of that service. At the moment, GPs must provide it, and some provide it directly themselves. They will continue to be able to do so if they wish to, but increasingly, for a variety of reasons—including work- life balance and other lifestyle issues—GPs do not want that onerous responsibility to fall entirely on their practices. They are happy for the service to be delegated, which is what happens with GP co-ops and other providers. The agreement provides for the PCTs to take on the principal responsibility for organising local out-of-hours services. I hope that they will be provided by patients' own GPs in many cases, but that will have to be decided locally.

Dr. Andrew Murrison (Westbury)

Does the Minister agree that the Government are putting several new duties on primary medical care providers, which makes the out-of-hours provision mentioned by my hon. Friend the Member for South Staffordshire (Sir Patrick Cormack) impossible, if GPs are to achieve a work-life balance?

Mr. Hutton

I have significant sympathy with that view, which is why the new agreement reached with the BMA and the NHS Confederation provides for the solution that I have just described. GPs will be able to opt out of the responsibility of providing out-of-hours services, mainly for the reasons that the hon. Gentleman suggests. It is important that we do not lose sight of the fact that family doctors voted overwhelmingly for the new contract. It is the right contract for the future of primary care and it strikes the right balance between the need to ensure that patients have access to effective services and that doctors have the chance to lead their own lives and balance their work with their family and other responsibilities. That is our aim.

There has been some misunderstanding about the out-of-hours aspect of the agreement. Headlines in some newspapers claimed that there would be no 24-hour family doctor service. That is not what the new contract is all about. Such provision in the future will be the responsibility of the PCT or local health board, and that is where the responsibility should be located, not—as at present—with the busy family doctor.

Sir Patrick Cormack

How will patients be affected? I presume that as far as they are concerned, the service will continue to be provided through the general practice.

Mr. Hutton

Yes, that is how it is likely to be arranged. The usual arrangement of providing a telephone number for out-of-hours services will continue. One of the clauses that we shall discuss later provides for a new obligation on PCTs to provide such information to everyone in the area they serve. I would expect PCTs and local health boards to send out notes reminding people that the 24-hour services still exist and providing the telephone number. Some practices will decide to provide those services themselves and some will use other out-of-hours services providers, such as GP co-ops or private companies, which provide such services to many GPs now. Whatever the arrangements are, the maximum amount of information must be available to people locally, so that they know when and who to ring. That will be the responsibility of the PCTs.

We will also retain PCTs' ability to make decisions about the suitability of general practitioners to provide primary medical services. We are simplifying the legislative process, but retaining all the effective and necessary controls, by merging the current multiple list system into a single list of primary care performers. The detail of the new contract is set out in the agreement document, called "Investing in General Practice", which was published on 26 February. Copies of it have been placed in the Library and the Vote Office.

The new contract will be accompanied by a substantial additional investment of nearly £2 billion for primary care services across the UK. Funding will increase from £6.1 billion this year to £8 billion by 2005–06. That is 11 per cent. per year, each year, for the next three years.

To implement the contract, it has been necessary to make significant amendments to the legislative basis on which general medical services are presently provided, and to repeal a significant amount of primary as well as secondary legislation. It is intended that, after the implementation and commencement of these provisions, the volume of delegated legislation will be less extensive and more transparent than at present. Subsections (5) and (6) of proposed new section 16CC, as inserted by new clause 26, provide regulation powers to clarify what should and should not be considered to be primary medical services. This power could be used, if necessary, to maintain a national range of primary medical services across all PCTs and local health boards.

New clause 40, tabled by the hon. Member for Oxford, West and Abingdon (Dr. Harris), seeks to amend a primary care trust's duty to secure primary medical services and to require PCTs to meet the clinical needs of patients. His new clause removes the reference to "adequate" care. The existing duty set out in section 29 of the 1977 Act requires every primary care trust to make arrangements with individual medical practitioners to provide personal medical services, and for the recipients of those services to receive adequate personal care and attendance". The PCT duty in proposed new section 16CC replaces that duty, and is intended to be no less stringent than the duty in the existing legislation.

The duty on PCTs is to provide services to the extent that they consider necessary to meet all reasonable requirements. There was some discussion about this issue in Committee, as I am sure the hon. Member for Oxford, West and Abingdon, and the hon. Member for West Chelmsford (Mr. Burns) and the other Conservative Members on the Committee, will remember. They will probably not recall every nuance of the debate—I certainly do not—but I remember that this was registered as a problem. There was, for example, concern that the duty to commission primary dental services was not properly aligned with the duty to provide primary medical services. We have tried to deal with that particular problem in a subsequent amendment, which I shall come to in a moment.

I had hoped that the wording of the duty in respect of primary medical services would provide a more direct read-across, which would satisfy the hon. Member for Oxford, West and Abingdon, following our discussions in Committee. As I said, we have tried to take on board the concerns that were expressed at that time. The similarity in wording for medical and dental services is appropriate because the provision of services by the PCT goes towards the fulfilment of the Secretary of State's duty under section 3 of the 1977 Act with regard to primary medical services.

The problem with the new clause tabled by the hon. Member for Oxford, West and Abingdon is that it seeks to amend a section of the 1977 Act that we are about to repeal, so it would be difficult for me to accept it.

Dr. Evan Harris

We tabled that new clause at what we reasonably thought was the last minute, but it became clear yesterday when the Minister tabled his new clause that this was going to be the case. I accept what he has just said.

Mr. Hutton

I am grateful to the hon. Gentleman for that, because we have taken away the comments that he and other hon. Members made and tried to amend the Bill to reflect their concerns. There is a problem with new clause 40 and I am grateful to him for clarifying that point. I assume that that means that he will not want to press the matter to a vote.

Sadly, I also have a problem with the hon. Gentleman's amendment (a) to new clause 27, because it seeks to remove the ability of the Secretary of State to issue payments based on rewarding contractors for reaching a target or target proportion of treatments given". The United Kingdom has one of the most successful vaccine programmes in the world, with high levels of uptake. It has been achieved by the hard work of general practitioners and enforced by the system of targeted financial incentives. The target payment scheme incentivises levels of uptake that protect children not only individually but collectively in the wider community, especially those for whom immunisation is contra-indicated. Removing the target payments could have a negative effect on vaccine uptake, and could perpetuate coverage that is insufficient for the protection of the wider community.

I understand the hon. Gentleman's wider objections to targets; he and I have debated the matter extensively across the Floor of the House and elsewhere. I believe, however, that he is pursuing the wrong issue here. This particular method of incentivising achievement in primary care and general practice has worked; it has helped to protect the health and safety of children. On this issue, therefore, he might not have chosen the strongest ground on which to fight his battle.

Dr. Harris

I accept the Minister's invitation not to go into the whole issue of targets in this debate, but in my speech I shall go into the reasons why, even if this system worked, it would give rise to major problems. Can he provide any evidence that the incentive payments for those vaccination targets have provided the cover that exists—questionable and dodgy though it is, because of other factors—or does he simply think that the system must be working because the incentive scheme exists and we have reasonable coverage? Is there any evidence?

Mr. Hutton

I think that there is, and I should be happy to write to the hon. Gentleman setting out some of the trends involved in immunisation so that he can form his own view on the matter.

On the future of this type of payment, the new contract makes it clear that we will be discussing with the BMA how we can use the target payments more effectively in a way that meets general practitioners' concerns—I acknowledge that such concerns exist—and encourages even higher uptake, protecting children from potentially life-threatening diseases.

Mr. Lansley

The Minister's exchange with the hon. Member for Oxford, West and Abingdon (Dr. Harris) did not touch on a particularly difficult issue relating to the contract and the target payments. The Minister will be aware that, in respect of this particular set of targets, exception reporting for informed dissent does not apply. The effect of that is that GPs are operating under a financial incentive to raise their level of compliance, regardless of the fact that parents might choose for their children not to have a particular vaccination. I have been consistent in my support of the childhood immunisation programme—including vaccinations for measles, mumps and rubella—but there is a serious question mark over this practice, as perceived by patients.

Mr. Hutton

I certainly accept that, and I have taken part in some of the discussions with the BMA on precisely that issue. In the light of the new agreement, we clearly need to continue to discuss it with the association. I am talking here about the general principle, however, rather than about how the details of the payment mechanisms are working.

Mr. Lansley

It is in the contract, on page 8.

Mr. Hutton

It is, but it is also clear from paragraph 2.11 of the agreement that we shall continue to discuss the detail of those arrangements with the BMA. That is the only point that I am trying to make.

The second of the two principal purposes of these amendments is to make changes to the legislation on personal medical services—the alternative to general medical services. We have already considered the amendments necessary to implement the agreement between the BMA and the NHS Confederation for a new GMS contract. We have also looked at the new duty on PCTs to provide or secure the provision of primary medical services as set out in proposed new section 16CC. This will have an impact on other areas of primary care, including PMS schemes. The intention of new clause 29 and amendments Nos. 278 to 283 is, therefore, to provide the legal basis for changes to PMS that are, in the main, consequential to the new GMS contract.

We are taking the opportunity to bring local PMS contracts into the mainstream of primary medical services. It is our intention that all existing PMS pilots will become mainstream with effect from 1 April 2004. The National Health Service (Primary Care) Act 1997, which was introduced by the previous Conservative Administration and supported by the then Labour Opposition, introduced the concept of personal medical and dental services, and inserted new sections 28C, 28D and 28E into the 1977 Act. However, the concept was considered at the time to be very different from the traditional national GMS agreements, so a period of piloting was provided for in part 1 of the 1997 Act.

Personal medical service pilot schemes are voluntary—rightly so—and are intended to give GPs, nurses and primary care trusts the flexibility and opportunity to innovate by offering different options for addressing primary care needs that have to be met locally. It was always the intention, however, that, provided that PMS proved successful, the system would be made permanent. It has proved to be successful and we are therefore repealing part 1 of 1997 Act in respect of England and Wales. PMS will continue under the permanency arrangements that were set out in the 1997 Act. In other words, the legal basis of PMS switches to sections 28C to 28E of the 1977 Act. This also applies to personal dental service arrangements.

This means that decisions can be made locally rather than nationally about individual schemes, now that we have moved beyond the pilot phase. The House will be aware that individual PMS schemes need to be approved by Ministers, but I believe that that is no longer necessary, and that we can move beyond that sort of centralism. The intention is that under the general transitional powers in the Bill we will issue an order that allows existing PMS agreements to continue, but automatically changes the legislative basis of those contracts to the 1977 legislation. All things being equal, that will have no impact at all on PMS providers unless there are variations to their PMS agreements. We are also making a number of other changes to the provisions in sections 28C, 28D and 28E, which are largely technical and reflect some of the changes brought about by the new general medical services contract provisions.

6.30 pm

That concludes the formal substance of my remarks, but I think that this is an important moment for primary care. We have had a strong, positive endorsement of the new contract from family doctors, and the House now has the means to give effect to it. I hope that Members on both sides of the House will support our new clauses, which command the support of the BMA and the NHS Confederation.

Mr. Burns

May I begin by thanking the Minister? In Standing Committee, it emerged that large parts of the Bill relied heavily on the Government's regulation-making powers. We did not know how the Government intended to use regulations to build on the nuts and bolts of the Bill—this is not a criticism—because they were not yet in a position to share their views with Opposition parties or anyone else. However, towards the end of proceedings in Committee, the Minister said that he would seek to introduce new clauses and amendments on Report to incorporate the GP contract in the Bill, and gave a commitment to make available to Committee members explanatory notes and a briefing on the Government's proposals. That commitment was honoured, and the briefing and notes arrived yesterday morning. Of course, it would have been better and more convenient to have them over the weekend, but not getting them then was not the end of the world. In the first post yesterday we received an extensive briefing from the Minister, which will certainly assist us during today's proceedings. I thank the Minister for going to the bother of keeping us informed.

As the Minister will be aware, five new clauses and 32 amendments have been tabled on the GP contract, so incorporating it in primary legislation constitutes an extensive addition to the Bill. The Minister was factually correct when he said that it had taken two years to get a GP contract, but he did not say that it had had a chequered history. The Government have had to make significant changes to the initial contract that they hoped to persuade GPs to accept. Dr. John Chisholm, chairman of the BMA's general practitioners committee said: The profession has given a clear mandate for change. A large majority of general practitioners—eight out of ten—want the new contract to be introduced". Significantly, Dr. Chisholm continued: While I am delighted by the overwhelmingly supportive vote in favour of the new contract, I am in no way complacent. The negotiations have been difficult and there are GPs who do not have confidence in parts of the new contract. The negotiating team is in no doubt what their concerns are and there is much work to be done during the implementation phase of the contract. This will begin immediately. Dr. Chisholm summed it up 100 per cent. accurately. A number of GPs have misgivings, and those who supported the contract despite their misgivings probably did so because they thought that it was important to resolve the issue. I hope that during the implementation of the contract, everyone will work together to seek to iron out any problems, concerns and difficulties that arise.

I do not want to detain the House for long, but I should like to raise a number of matters with the Minister. If he catches Madam Deputy Speaker's eye and responds to my questions later in the debate, I shall be grateful; equally, given the time pressure on our proceedings, I shall fully understand if he thinks it better to write to me rather than using up time that other hon. Members could use to contribute to the debate.

First, as the Minister's briefing and the amendments demonstrate, the proposals, like other proposals that we debated earlier, will involve considerable regulation-making powers. I suspect that I will get the same old answer, to the effect that those powers will be subject to the negative procedure rather than the affirmative, but I would appreciate it if the Minister confirmed that my assessment is right. I will not repeat the speech that I made a little earlier about the affirmative procedure, save to say that, as, sadly, the sadly was not here for my contribution, I would immodestly recommend for once that he read it tomorrow—[Interruption.] I am grateful to my hon. Friend the Member for Tatton (Mr. Osborne), who obviously enjoyed my speech and understood the wisdom of it, but I shall spare the House a repetition—the Minister can read it.

The Minister has said that the measures before us will simplify the legislative base—despite the new delegated powers, the overall volume of delegated legislation after implementation will be less than it is now. I would welcome confirmation that that is the case, but I am intrigued to learn how regulation will be reduced. I am old enough to have heard Governments of all political persuasions claim that there will be less regulation, and that less regulation means better government. I am cynical about those claims because, when it comes to the crunch, they are never realised. I would appreciate the Minister's comments on that.

I should now like to deal with one or two specific issues arising from new clause 26. Subsection (4) of proposed new section 16CC, as the Minister will know, specifies that a PCT or a local health board must co-operate with any other such body in the discharge of their respective functions". The explanatory notes state that that subsection imposes a duty on PCTs and local health boards in Wales to co-operate with other bodies. If the provision is intended specifically to deal with cross-border co-operation, why has it been drafted so widely? Is it intended to cover other instances in which co-operation is required? If that is the case, can the Minister explain what those instances will be, and in what sort of situations he envisages a need for such co-operation? Finally, will he confirm that the provision will mean that English PCTs and Welsh bodies have a reciprocal duty to co-operate with one another?

Turning to enhanced services, new clause 27 inserts a number of new sections into the National Health Service Act 1977. The Minister referred to the changes that the Government will make to that Act through their amendments. However, the explanatory notes state that under proposed new section 28Q, a general medical services contract is a contract for primary medical services, as specified in paragraph 2.8 of the new GMS contract. However, it may also include enhanced services on the boundary of primary and secondary care such as specialised services in areas like drug and alcohol misuse, sexual health and depression. Where the new GMS contract does not provide for enhanced services, will the Minister confirm how and by what mechanism those services will be available to patients? I am sure that he will agree that this is a matter of critical importance. From the outset, there must be no misunderstanding about how the Government envisage this part of the Bill working.

On the question of pay, proposed new section 28T allows the Secretary of State or the Welsh Assembly to make directions regarding payments to be made under the new contract. Will those directions provide for the minimum income guarantee? Can the Minister confirm that the Government do not intend to place a time limit on the minimum practice guarantee? Again, if the Minister can give some more information on that point, it will go a long way towards satisfying our quest for knowledge and will send a message beyond this Chamber to those who may have some concerns or uncertainty about what is a very important matter and a crucial part of the contract.

Finally, proposed new section 28T(3) states that the payments will be made by reference to compliance with standards or the achievement of levels of performance". Will the Minister provide more detail about the standards and performance targets intended under the regulations?

The Minister will be relieved to hear that I do not intend to reopen the debate pursued with such skill in our Opposition day debate yesterday by my right hon. and learned Friend the Member for Folkestone and Hythe (Mr. Howard), the shadow Chancellor, and by my hon. Friend the Member for Woodspring (Dr. Fox), the shadow Secretary of State for Health. I do not want to cause the Government embarrassment for a second day running, but I should be grateful if the Minister would expand on the question of targets.

In his concluding remarks, the Minister said that he hoped that hon. Members on both sides of the House would accept the Government amendments and, in effect, the new GP contract. I assure him that the Opposition broadly accept the GP contract. I have no intention of asking Opposition Members to divide the House on this matter. However, I should be grateful if the Minister will provide me, when it is practicable and sensible to do so, with answers to my questions.

Dr. Evan Harris

I begin by offering my apologies to you, Madam Deputy Speaker, and to the Minister, for my slightly delayed arrival. There was a lobby of social services users—appropriately enough—from my county this afternoon. They are waiting for me to lodge a petition this evening, which I shall do if I am able to catch your eye when the time comes. I was detained with them, and I regret missing the beginning of the Minister's speech. However, I understand that, in the bit I missed, he set out in general terms the issues relating to the background of the new clauses.

I am keen to speak to amendment (a), tabled in my name. The Minister began to deal with that, and the hon. Member for South Cambridgeshire (Mr. Lansley), in his perceptive style, also made a substantial part of the contribution that I was going to make. However, I also have a number of questions with which I hope that the Minister will deal, given the Committee style of our proceedings today. I should be grateful if he ensures that he is able to cover them. By way of advance notice, I can tell him that he will find some of the matters that I want to raise among the questions that I placed on the Order Paper yesterday. They were not selected for debate, but I am grateful that a starred amendment was selected, given its late submission.

I share the gratitude expressed by the hon. Member for West Chelmsford (Mr. Burns) for the fact that we have some explanatory notes, even if we did not get much warning that they were coming and had little time to read them before the deadline for tabling amendments. As I said in respect of the programme motion, it is not very satisfactory that a large chunk of new clauses and amendments should be presented with so little time to consider them before the debate. Even so, like the hon. Gentleman, we must do what we can with what we are given.

With regard to amendment (a), the Minister rightly recognised that it raises concerns about incentive payments in general terms. However, he—and the hon. Member for South Cambridgeshire—were both right to recognise that it relates specifically to incentive payments for vaccinations and immunisations, especially childhood immunisations.

6.45 pm

The problem is that, if the system works, it will be of questionable ethics. If it does not work, it will be unnecessary. The Minister has argued that, if GPs were not paid to meet a target, some people would not receive the vaccination that they needed, even after a consultation. Effectively, therefore, there is a third person in the consultation room with the doctor and the patient, or the patient's parents. That third person is the doctor's accountant.

In general terms, I do not think that that is how a doctor-patient relationship should be conducted. It seems to me entirely wrong that GPs should entertain the notion that, if seven out of the next 10 patients do not end up with being immunised after their consultation, they—the GPs—will miss out on a significant amount of money. It is not an item of service payment, or a payment per immunisation, as the payment kicks in once a threshold is reached. If a doctor is on the cusp of achieving that incentive, the risk is that that factor will creep into the consultation.

The Minister would consider that to be a success. Like me, he believes that immunisation, where clinically inappropriate and in the absence of contraindications, is a good thing. Even so, it is not appropriate for a GP's recommendation to be backed up—in force or in any other way—by the promise of payment for reaching a particular target. That is not the relationship of equipoise that ought to exist. Doctors and patients should not have these incentive payments and targets in mind.

If the Minister is arguing that the system works and that doctors are right to chase payment in the consultations, that is not an ethical basis for giving treatment. If the system does not work—if it is not a relevant factor in increasing the number of immunisations—then what is the point in having it? Indeed, I would go further and state that not only is the system pointless, it is damaging. Even if a GP is not influenced by the equation that states that, to reach the threshold, he needs to get seven of the next 10 patients immunised, the perception that he is being influenced still exists. To a great extent, that will undermine the doctor-patient relationship.

Informed patients—and patients in general—may well be concerned that their doctors will be influenced by the incentive payment. That is especially the case in an area such as immunisation, where the recommendation is being given not to a competent patient—that is a patient with capacity—or even to a Gillick-competent patient, but to a patient without capacity, whose parents must make a decision.

That is an especially sensitive area. We are talking about treatments that are given to healthy people, and it is understandable that some parents may feel that an unnecessary intervention is being made in respect of a healthy child. It is always more difficult to see the need for such an intervention than for treatment for a person who is symptomatic.

In addition, many parents and patients may be aware that they benefit from herd immunity and consider that they do not need the immunisation because they can rely on others. That is not an approach that I recommend, but it is a serious concern.

Mr. Lansley

Before the hon. Gentleman moves off this point, does he share my concern about the incentive payment mechanism? The mechanism is not specified in the contract, which states only that it will be the subject of further discussion and that exception reporting does not apply. Moreover, under the new contract, GP practices will be able to opt out from providing additional services, at a cost of just over £1,000 of the global sum. Does the hon. Gentleman agree that there is a risk that practices that are unhappy with the ethical position presented in the contract may simply choose to opt out of the arrangement? Would not that undermine our ability to deliver this additional service?

Dr. Harris

Quite so. Immunisation levels are so marginal that we cannot run that risk. The Minister may say that he cannot run the risk of removing incentive payments, but I hope that he will give me some comfort by assuring us that if the system is pursued, it will be changed. There is less of an argument against having a threshold for the number of consultations, so that GPs will be incentivised to consult patients. However, if patients refuse or reject standard immunisation, even with no good clinical reason, that should not penalise the doctor. The Minister could achieve the improvement of access to immunisation that he wants and ensure that there is a proper call and recall system by setting incentive payments—if they have to happen—at a proportion of the eligible population receiving those consultations.

In fact, that should be the default position and the Minister should have to justify his current position on two grounds. First, there should be clear evidence that a threshold for immunisation payments given works. It is not good enough to look at trends without having an adequate control group to determine what would happen over time if the threshold payment system did not apply. Indeed, the Minister might consider a test whereby in some parts of the country some practices did not operate an incentive scheme for immunisations given, so they would not be penalised when people without good clinical reasons refused immunisation. Simply to cite trends coincident with the introduction of incentive payments is the same sort of logic as he and I both reject when people cite increases in the incidence of autism at the time the MMR vaccine was introduced. If the test is not controlled, such arguments do not have a rational scientific basis. Where there is better evidence—as there was in that case—it should be cited. I urge the Government to show convincingly that there is evidence that the scheme works.

Secondly, the Minister needs to show that he can overcome the ethical objection that I identified and the public relations problem—people who have lost confidence in the system—before he proceeds with the incentive scheme.

In Committee, the Minister said that it would be unwise to try to amend these provisions because GPs had just come to an agreement, so any amendments would undermine that agreement. That cannot be right. First, it is the right of the House to make amendments to legislation. Secondly, GPs are still not happy about some aspects. As we know from the recent BMA meeting, incentive payments are one such matter. I should be grateful if the Minister provided some explanation and a defence of his position in response to those charges.

I have a few more questions that relate to the Liberal Democrat amendments that were not selected. Can the Minister explain why subsection 28U (2) of the new clause states "may" rather than "must"? One would have thought that regulations were definitely needed to make provision for all the points listed under subsection (2). Indeed, a series of questions flows from that and we should try to deal with them if we had time.

Subsection (3) refers to regulation of the circumstances in which a contract or or contractors may decline to accept a person as such a patient; or…may terminate his or their responsibility for a patient". Will the Minister explain how that will work? Can he confirm whether the provisions are merely a translation of the existing arrangements? If so, he will know from representations made to him and from the health ombudsman's report that that is not satisfactory. Like many other Members, I certainly know of patients in my constituency who have been struck off their GP's list with no reason, even where—as is true in the majority of circumstances—there is no question that it would damage the patient's interests to know the reason.

Often the reason is that the patient has made a complaint. The Minister knows that that is an unacceptable basis for striking off. He knows that the BMA guidelines sent out by family health services authorities, health authorities or whatever they are called nowadays make it clear that the practice is unacceptable. I have an example from my constituency. In a conciliation meeting, a GP told a patient that they should not have complained to their GP if they wanted to stay in the practice. That is unacceptable.

The Minister has an opportunity to toughen up the regulations. There is an argument that the reasons for which patients can have their relationship with their GP terminated should be limited. That is not just on the ground of natural justice but because it can be so damaging for a patient to be treated in that way, especially when they do not receive a good reason or even any reason at all. Unfortunately, that is a problem in the culture—I speak as someone who has practised as a doctor. It is on the wane, but it still exists; GPs and other doctors still find it hard to adjust to having their treatments questioned. However, that is part and parcel of a modern NHS with empowered patients, and the regulations must keep pace.

Will there be provision for an appeals process that is open and transparent? It should allow the patient to be reinstated in the practice without GPs automatically saying that they cannot possibly have the patient back because the termination process means that the GP-patient relationship is irrevocably broken. That is a circular argument and such a fallback position cannot be right. I should be grateful if the Minister explained his thinking about that.

Subsection 28U (6) states that a GMS contract must contain provision requiring the contractor or contractors to comply with any directions given by the appropriate authority"— which, as we know from reading the regulations, is the Secretary of State in England— for the purposes of this section as to the drugs, medicines or other substances which may or may not be ordered for patients in the provision of medical services under the contract". At short notice, it is difficult for me to determine whether that is a brand new provision or a translation of existing provisions. Can the Minister clarify that point?

Mr. Hutton

There is a risk that I might forget that point in my summing up. The provision is a continuation of the existing legislative arrangements; it is not new.

Dr. Harris

I checked in the table provided by the Minister to determine whether that was the case. It states that the provision replaces schedules 10 and 11, which are, as we know from our debates on Sildenafil, infamous. Is the provision a direct translation? Sildenafil, or Viagra, probably offers a good example, although I do not want to go too far down that path.

Sir Patrick Cormack

Why not?

Dr. Harris

Because I know that other Members want to speak and I do not want to provoke Members into reopening that debate.

Can the Minister tell us whether it would be a breach of contract, or a breach of the terms and conditions of a general practitioner under a GMS contract, for a GP providing primary care services under a GMS contract to prescribe something that the Secretary of State has put under schedules 10 or 11? At present, that is not a breach of terms and conditions because GPs can provide such drugs privately; indeed, they have to do so if they are not to be out of pocket, because they are not reimbursed. In effect, that is rationing. I do not object to rationing itself, but it should be explicit. Normally, if rationing is an issue, it is possible for prescribing freedoms not to be limited and the GP has to explain, within the reimbursement process, what is going on. There may be exceptions, where reimbursement for such a prescription is appropriate, but the blanket provision in the regulations that the subsection may herald could go further than schedules 10 and 11.

I accept that the matter is technical and that the Minister may not be able to address it at present. If we were in Committee, I should ask him to write to me before Report. However, perhaps he can address that point, as several practitioners have raised it.

Proposed section 28R deals with the power to set out in regulations the primary medical services that a GP must provide under a GMS contract. In the third column—headed "replaces"—of that very useful table in the explanatory notes, the Minister explains that proposed new section 28R will replace a description in section 29 of the National Health Service Act 1977. The explanatory notes do not specify any provision; they refer to the agreement on essential services in paragraph 2.8. However, among other things, section 29 of the 1977 Act states: Regulations may provide for … securing that the arrangements will be such that all persons availing themselves of those services will receive adequate personal care and attendance, and the regulations shall include provision". It goes on to provide further specifications.

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New clause 26 has been written in very vague terms, so it waters down the obligation in the Bill to ensure that patients can refer to something when protesting that the essential services are insufficient to fall within the remit of the primary legislation. I should be grateful to the Minister if he reassured me about the absence of any description in primary legislation in respect of what must be provided to meet reasonable needs.

Why are such things not still defined in the new arrangements? If they were defined, future negotiations could allow something that patients have a right to expect beyond the current definition of adequate personal care and attendance to be moved from paragraph 2.8 of the GP contract, which deals with essential services. Does the Minister accept that removing section 29 of the 1977 Act without replacing it with a similar duty represents a dilution, unless I have missed something? That brings me to the Government's amendments on primary dental contracts.

Sir Patrick Cormack

The hon. Gentleman has been speaking for 20 minutes now.

Dr. Harris

I have got amendments in this group, and it is reasonable to speak for 20 minutes. The hon. Gentleman made the point earlier that we did not have enough time in Committee. I will ensure that I end my speech shortly, so that he has a chance to speak, but I have a specific question on the Government's amendment on dentistry.

The Minister has chosen to accept some of the arguments made in Committee about the fact that the definitions in clause 161 were inadequate. He now proposes to delete from clause 161 the words it is reasonable to do so and insert, necessary to meet all reasonable requirements, exercise its powers so as to. I should be grateful to the Minister if he clarified whether that addresses the point made in Committee about the language used. Is the word "necessary" the significant addition? If it is, I should like to thank him for making that concession. I should like him to deal with the description of services set out in clause 161 for primary dental services and identify—I may have missed it—where the similar general description of the reasonable requirements that it is felt necessary to meet for primary medical services appears in the new provisions.

My last point relates to proposed new section 28U(3), where the Government's description refers to a power to make regulations setting out the relationship between contractors and their patients. Those relationships are covered in chapter 6 of the NHS Confederation/General Practitioners Committee agreement. The legislation refers to issues relating to termination of the relationship between patients and GPs. I have mentioned patients being the struck off the list. However, I am a bit concerned whether chapter 6 of that agreement is the way by which the proposals that the Government floated in the Labour party about a contract between the patient and the GP may be enforced.

I should like the Minister to clarify whether chapter 6 of that agreement could be used, if amended in future, to make patients agree to stop smoking, stop eating or start exercising before they can continue to get services. Perhaps the Minister will welcome the opportunity to put that idea to rest, because a number of people have read into the consultation that the Minister is undertaking in the Labour party that that may be the result.

We recognise that, overall, the contract represents a good deal for GPs, especially in financial and work load terms, but that is not the same as saying that it represents a good deal for patients because, especially in respect of the number of hours that GPs have to work, there is a zero sum gain. If GP work load is reduced, the services that patients can get from their GPs at a one-stop shop, holistically, are inevitably reduced.

The Government say that GPs will no longer have to provide out-of-hours services if they choose not to do so. Indeed, they will be paid for their other services even if they choose to drop that responsibility. GPs will be paid more, even if they do less, so patients will get less of a service from their own GPs. I understand that there are not enough GPs and that there are not enough hours in the day for GPs, but I hope that the Government will accept that patients would not have voted for the new contract, even if GPs thought that accepting it was the only thing that would allow them to cope with their work load. Until there is a significant number of new GPs, patients and GPs will not benefit from the new contract.

Sir Patrick Cormack

I will certainly be briefer than the hon. Member for Oxford, West and Abingdon (Dr. Harris). I do not dispute for a moment that all the points that he raised were very pertinent and should be addressed. Again, the terrible time constraints under which we have to debate this very important Bill have been underlined.

I regard the Minister as a very honourable and extremely decent man, and I know that he has the interests of patients very much at heart. That is not in dispute, but I am very concerned about one aspect of the contract in particular. I touched on it in an intervention, as did the hon. Member for Oxford, West and Abingdon towards the end of his speech. What concerns me is the service that patients will receive.

I fully understand the need for the contract. I completely support my hon. Friend the Member for West Chelmsford (Mr. Burns), who spoke eloquently from the Opposition Front Bench. He said that he supported the Minister and that he would not seek to divide the House. I am glad about that, and I certainly would not wish to do so. I hope that no one will do so on this issue. However, while it is possible to go through life without going into hospital, it is virtually impossible to go through life without needing the services of a doctor, so we are dealing with a part of the Bill that affects every man, woman and child in this country. I believe in the NHS. If we are to have a national health service worthy of the 21st century, it is crucial that the services provided by GPs—family doctors—are of the highest possible excellence.

I am surprised that no Labour Back Bencher is present for this important debate, but I do not wish to make too much of that. Let me just say that, when the right hon. Gentleman answered my questions most courteously, he did so with a disturbing imprecision. When I asked him about the relationship between the patient and the practice and where the PCT kicked in, he did not give me a terribly clear answer. It is crucial that the patient looks to the practice with which the patient is registered for all services, both those within and without hours.

If there is a contractual arrangement that the practice does not provide out-of-hours services, that should be fixed up between the PCT and the practice, so that the patient has absolutely clear information. We have to remember that, although there are some hoaxers and malingerers, most patients who need a doctor out of hours are genuine people who are alarmed and need a service. The last thing that they want is a plethora of telephone numbers or a sheaf of papers. Those people are often elderly. They are sometimes old, distressed and even confused. A doctor is needed for the husband, the wife or the child in the middle of the night, but how is that doctor obtained? I should be most grateful to the Minister if he addressed that point and told us how such things will work.

I have a rural constituency—not as large as some of my colleagues' rural constituencies, but quite large. I have had experience of patients who are registered with practices that rely for virtually all their out-of-hours services on agencies. If the patient gets a doctor who has no idea of the geography of the area, who takes a long time to reach them, who does not know the patient and knows nothing of his or her medical history, it is hardly reassuring. Any agency that provides an out-of-hours service for a practice should have all their cars equipped with satellite navigation, which is simple these days—I have it myself, and I find it helpful when I am driving around an area that I do not know. It would be most reassuring if when people made a telephone call they knew that the doctor would arrive on their doorstep in pretty sharp time.

This aspect of the contract worries me. It is underlined by something that was said to me by the wife of a GP in my constituency a little while ago. I was shocked—perhaps I am too old-fashioned—that she said, "Of course, medicine is not a vocation any more. It's just a job." I am naive and idealistic enough to believe that the element of vocation is terribly important and should still exist. Of course doctors deserve private lives as much as anybody else, and of course they have great pressures on them—many of them work in practices whose lists contain thousands of names. Of course it is incumbent on us to ensure that they have a contract that allows them to have decent private time and decent private lives. Nobody makes a man or woman become a doctor, however, and the element of vocation is important. When somebody has a sense of vocation, as most of us in this place do, hours sometimes have to be forgotten.

I trust that the Minister's answer will reassure me satisfactorily—because this would also reassure my constituents—that however the new arrangement works, the patient will still feel registered with a practice, that if illness strikes in the dark hours of a winter's night a doctor can be summoned, will be summoned and will appear in reasonable time, and that the quality of care will be commensurate with that given by the doctor who regularly sees the patient at the surgery. That is what I and my constituents are concerned about, and I am sure that the same applies to the constituents of every Member in every part of the House.

I thank the Minister for what he has done. I appreciate the information that he got to us—albeit a little late, but that was not his fault—and, I have absolutely no doubt about his personal integrity or desire to ensure that the quality of medicine is the highest possible. I have these worries, however, and I hope that he can reassure me. When he winds up this all-too-brief debate, I hope that he will be able to give me that reassurance, so that I can pass it on to my constituents.

Mr. Lansley

I am grateful for the opportunity to contribute to this short debate on an important subject. I feel confident that the Minister will have a few minutes in which to reply fully to the points raised. I thought that my hon. Friend the Member for West Chelmsford (Mr. Burns) was generous to the Minister in contemplating that he might respond to some of the questions asked subsequently. It seems to me that the Minister has lived with the subject of the general medical services contract for some time, and I would be surprised were we to raise issues to which it was not within his competence to reply. I hope that he will reply in substance to our points.

My purpose is not to speak about the construction of the legislation and the new clauses and amendments, but about what lies beneath them: the new contract and how that it is to be framed. The debate gives us an opportunity for such discussion. It does not depend on the documents sent to us by the Minister, which I received on Friday in the House, but on the "Investing in General Practice" document, which, as the Minister rightly told us, was published in February. There has therefore been scope to think about these issues, but none to raise them. That is why I am disappointed that we did not get an opportunity prior to this to do so. It seems rather last-minute.

7.15 pm

Let me run through my points, some of which have already been mentioned. The first was rightly raised by my hon. Friend the Member for South Staffordshire (Sir Patrick Cormack). Much as we might be putting into legislative effect the framework for the contract negotiated between the NHS Confederation on the one hand and the GPs committee of the British Medical Association on the other, we are the guardians of the interests of the public, and, in that respect, of the interests of patients. I hope that my remarks will not be interpreted wrongly—both those organisations have the interests of patients at heart, too, but the final responsibility rests with us.

My hon. Friend expressed the concerns that have been raised in the right way, and I do not want to add to them, except to say that this is not simply about out-of-hours cover. The out-of-hours issue is terribly important, and I know that the Government will have thought long and hard about the extent to which practices can opt out of it; offering a timetable of 31 December 2004 for opting out is bold. I hope, however, that we will not find in the latter stages of next year or the early part of 2005 that, in practice, primary care organisations are seeking to provide out-of-hours cover for a high proportion of practices that are not willing to take it up, or a high proportion in rural areas in particular that are not willing to take it up, and that the alternative service models that are being developed simply cannot cope. I hope that we do not arrive at that, and I am sure that the Minister will give us some comfort that he feels confident about the scale—and the relative modesty of the scale—of opting out by practices, as it will be very difficult if it is much more than Ministers anticipate.

The second point, particularly in relation to rural areas, is the patient services guarantee. The patient services guarantee to which the Minister referred, I understand, is a guarantee for the primary care organisation to have a continuing responsibility for the provision of services under the existing contract. It is not, however, a guarantee that those services will be provided by the existing practice, because, of course, the practice in question has the ability to opt out of additional services. Therefore—this is particularly relevant in rural areas—if the service is being provided by other practices, other primary care providers or by the primary care organisation itself, provision may be in a number of different places. A considerable difference of substance exists between receiving one's essential services from a single practice, and, in respect of additional services, perhaps having to go to a more remote town or city to access a range of different services. In relation to provision for rurality, sparsity and special allocations of funds to reflect the costs of travel and the like in rural areas, I hope that the Minister will think hard and keep a weather eye on the extent to which the patient services guarantee leads to deterioration in the level of service or access to service for patients, whether in rural areas or anywhere else, and that he will be willing to intervene if necessary to boost some of the enhancements to practices, particularly in rural areas, if it proves that the incentives are not sufficient.

I want to echo two points made by the hon. Member for Oxford, West and Abingdon (Dr. Harris). I have been concerned about a case in my constituency, as other Members will be, involving the circumstances under which practices have the right to remove patients from their lists. He referred to that in the text of new clauses, but, of course, it reflects paragraph 6.29 in the contract. Of course, we know that patients may be removed if they are violent and that primary care organisations have to take responsibility in such circumstances. Paragraph 6.29 clearly says: Removal from a list will follow a transparent process that normally would include a warning to the patient before removal". That is quite right. The subsequent sentence is less clear and gives rise to a specific concern. It says: When a patient is removed, practices will be required to give specific reasons to the patient as to why the removal has occurred, though it is accepted that, in certain specific circumstances, a statement to the effect that the relationship between the patient and the practice has irrevocably broken down will suffice.

What are the "certain specific circumstances" in which such a situation could occur? I suspect that they applied when my constituent was removed from a list. That process affected not only him but his wife and family because the practice's decision that the relationship with him had broken down meant that the whole family were effectively treated as though their relationship had broken down. The family live in a rural area, so the distance that they must travel to an alternative practice is substantial. My constituent believed that there was no underlying reason behind his removal from the practice. I suspect that it happened because he made a complaint, as the hon. Member for Oxford, West and Abingdon mentioned. That should not be sufficient to allow removal because there should be a formal and transparent process. I want to know the specific circumstances in which patients may be removed.

On immunisation, I have said that it is surprising that exception reporting for informed dissent will not be applied to the target payments. I have a technical question. Amendment No. 299 will disapply section 53 of the National Health Service Act 1977 under which every practitioner who is under contract to provide personal medical services should be enabled to offer child vaccination and immunisation services. Will the Minister explain why that provision must be removed?

I want to make a further point about the structure of the contract itself, although perhaps I should have raised it with the British Medical Association because it worries about such things. I earlier expressed concern about the extent to which information technology systems in the NHS are being centralised and said that the responsiveness of the IT system to individual customers was being removed. I fear that the same will be true of information management and technology systems for practices. The BMA and general practitioners might feel comfortable at the moment that they will enjoy the benefits of centralised standardisation, purchasing and funding for the provision of IT systems and the telecommunications to support that, but GPs will not be the customers. I wonder whether the BMA is entirely confident that GP practices will be able to exercise the same control over their service providers that they do at present. They currently spend their own money and obtain their systems from a range of competing providers that meet the necessary protocols of standardisation—the systems need to be able to talk to each other. There should be a customer-contractor relationship between a practice and its service provider, but that will not exist in future.

I am worried by paragraph 5.16 of the contract. It is an obtuse, yet important, part of the structure of remuneration and it relates to the adjustment of the list size for list inflation. Up until now, the registered population has tended to exceed the population estimates of the Office for National Statistics. In future, primary care organisations will rely on new census population estimates. It will come as no surprise to the Minister that there are places throughout the country—the most prominent are Westminster and central London, but the same can be said of the city of Cambridge—in which there are significant discrepancies between population estimates from the 2001 census and the figures anticipated. If those statistics affect the allocation of resources to primary care organisations and their practices under the contract, I am worried that structural problems with census population data will lead to problems with the contract. I hope that the Minister understands that caveats might need to be entered against that.

I asked the Minister earlier about order-making powers. He said that the negative procedure would be used; I assume that he meant in all cases. I imagine that many orders that arise from the Bill would not need to be considered using the affirmative procedure, but I urge the Government and those in another place who care deeply about the structure of legislation to look hard at Government new clause 26. It contains order-making powers to prescribe services that are, or are not, to be regarded as primary medical services and to define how they should be delivered. That is one of the central issues behind the new structure of contracts for personal medical services and general medical services. It would not be excessive for Ministers to give an undertaking that such orders at least would be considered under affirmative resolution. It would be undesirable if Opposition parties had to pray against orders so that something so central to the contract's structure could be debated.

Mr. Hutton

I warmly thank hon. Members who contributed to the debate for their remarks. I am grateful to the official Opposition and the hon. Member for Oxford, West and Abingdon (Dr. Harris) for their general support for the new contract. However, I am afraid that I shall lower the tone by saying that the hon. Gentleman's reluctance to express anything like enthusiasm for the decision taken by 80 per cent. of GPs to embrace the new contract was typically curmudgeonly. Although it has nothing to do with the amendments, it is not the case that patients would not have voted for the new contract, although neither the hon. Gentleman nor I can prove that.

The new contract represents a significant development for primary care that will allow us to provide a better range of primary care services than at present. The arrangement is good for GPs and everyone who works in primary care but it has been exclusively driven by our one simple desire to improve the range of primary care services available to the people of this country. I think that people would overwhelmingly vote for that if they were given the opportunity, but I hope that the hon. Gentleman understands from our previous debates that we do not suggest extending the democratic franchise quite that far—we have enough on our plate with NHS foundation trusts.

It is important to bear in mind one or two basic facts and figures about primary care. Much of the debate has been focused on the importance of out-of-hours services, and I agree that they are central to many people's perception of the comprehensive nature of NHS services. GPs and practice staff in primary care deal with about 250 million consultations each year, and 90 per cent. of all patient journeys in the NHS begin and end in a family doctor's surgery. The work done in primary care will certainly be central to the success of the national health service well into the future. I do not question the commitment of the hon. Member for South Staffordshire (Sir Patrick Cormack) to the national health service because he, like me, wants it to be a success. It is important that the issues raised by the hon. Members for South Staffordshire, for South Cambridgeshire (Mr. Lansley) and for Oxford, West and Abingdon are addressed properly as we move toward implementing the new agreement.

There is no doubt that there are risks. Perhaps the most difficult aspects of the agreement were the out-of-hours provisions. I know from my work as a constituency MP that our constituents place a high premium on around-the-clock access to a GP, 24 hours a day, seven days a week. It is a defining characteristic of our primary care services. I can give the hon. Member for South Staffordshire the assurances he seeks: we will implement the agreement to ensure that there is no loss of access to out-of-hours services. That is intrinsic in the agreement that we reached with the NHS Confederation and the British Medical Association. They recognise the importance of the service, too.

7.30 pm

I have had the benefit of talking to many GPs about the new contract. Without exception, they all want the out-of-hours services, and the quality of those services, maintained because doctors care deeply about the wellbeing of their patients. They will not accept for a second a diminution in the quality of out-of-hours services. I am sorry if my answer was not to the hon. Gentleman's satisfaction, but it will be the responsibility of primary care trusts, in discussions with their local practices, to finalise, over the course of the next year or so, the arrangements that will need to be put in place locally to provide comprehensive out-of-hours services. That will include a proper setting of standards to be met. The arrangements governing accessibility of the service, who comes out to deal with a call and how quickly he or she arrives are important and will need to be put in place. It is a big job, but we have worked actively with primary care trusts to ensure that the hon. Gentleman's constituents, like mine, are not put at risk or disadvantaged. I am sorry if my original answers were not precise enough, but I assure him that that is how we intend to proceed. We would not accept anything less.

The hon. Member for West Chelmsford (Mr. Burns) mentioned the technical aspects and asked me to give an example of how we are reducing the burden or the volume of secondary legislation. I gave him one example and am happy to give him others in due course. He asked how enhanced services will be provided if not through GMS or PMS. They can be provided through the additional third route of directly commissioned PCT services and the services of additional providers can also be used. He also asked whether the minimum practice income guarantee would be covered by directions under proposed new section 28T. It will be. The minimum income guarantee will continue beyond 2006. It is not time limited.

On subsection (4) of proposed new section 16CC, I can assure the hon. Gentleman that the duties are reciprocal. It is not one-way traffic. The duties are broadly designed to deal with some of the cross-border issues that he mentioned, including the need to move to single commissioning of primary care services in those areas if possible.

The hon. Member for Oxford, West and Abingdon asked a number of questions. I am afraid that I shall have to write to him. I hope that he does not mind. He did invite me to go down that path and I intend to take advantage of that get-out. He kept referring to "U2", which is one of my favourite bands. I did not realise we were debating that today, and I am happy to discuss it with him another time.

The hon. Member for South Cambridgeshire asked pertinent questions. Given the time left, I shall have to write to him with further details. I am more than happy to meet hon. Members who contributed to the debate to discuss primary care services at any time in the future. I am also happy to arrange for them to be briefed by my officials, if they would find that helpful. The hon. Gentleman referred to the difficult issue of removing patients from practice lists and how we could deal with that. He is right to refer to sections of the February agreement that attempt to deal with the problem. We intend to use the regulatory powers to set out some of those issues in secondary legislation. It is not an entirely satisfactory state of affairs for any patient to be declined registration or to be removed from a practice. As the hon. Member for Oxford, West and Abingdon said, professional practice guidelines have been set out and we hope people will follow them.

The debate has been helpful. I am grateful for the support expressed for the Government new clauses. I look forward to discussing related issues in due course.

It being six and a half hours after the commencement of proceedings on the programme motion, MR. DEPUTY SPEAKER proceeded to put forthwith the Questions necessary for the disposal of business to be concluded at that hour, pursuant to Order [this day].

Question put and agreed to.

Clause read a Second time, and added to the Bill.