HL Deb 21 April 1986 vol 473 cc968-74

3.40 p.m.

Baroness Trumpington

My Lords, with the leave of the House, I should like to repeat a Statement being made by my right honourable friend the Secretary of State for Social Services in another place. The Statement is as follows:

"With permission, Mr. Speaker, I should like to make a statement about primary health care services.

"These are the services provided outside hospital by family doctors, dentists, pharmacists and opticians and by the community nursing and other related services. They have never been comprehensively reviewed in the 40 years since the 1946 National Health Service Act. Yet they account for nearly a third of total spending on the health service and over a million people use the services every day.

"The Government are now carrying out a comprehensive review of primary health care. With my right honourable friends the Secretaries of State for Wales, Northern Ireland and Scotland, I am today publishing a discussion document which will form the basis for extensive consultations throughout the country. The Government's main objectives are to raise standards of care and to make services more responsive to the needs of the public. The document we are publishing discusses a number of ways of achieving those objectives.

"So far as family doctors are concerned, the introduction of a good practice allowance would reward both those doctors providing the highest standards of care and provide an incentive to others. This is in line with proposals made by the Royal College of General Practitioners. An allowance on these lines might recognise such features as the range of services provided, including preventive activities; the doctor's personal availability to his patients; and the achievement of particular targets for the levels of services such as vaccination.

"The Government also believe that the public is entitled to more information about the different types of services that doctors provide to enable patients to make better choices when seeking a general practitioner. Together with arrangements that would make it easier for patients to change doctors, this would further help to raise standards and make the services more responsive to the needs of the public. This process would be assisted if (as is also discussed in the document) more emphasis was placed on capitation payments in the doctor's remuneration system, so as to increase the financial value to the doctor of the individual patient.

"Among other proposed changes is a new flexible retirement system which would mean that, as now, doctors could retire at 60 but with a compulsory retirement age of 70. It is also proposed to end the 24-hour retirement rule where doctors are able to retire and rejoin the heath service 24 hours later, collect a lump sum payment and in some cases draw both pension and pay in full.

"One effect of these changes would be in inner cities where there is a disproportionately high number of elderly doctors. Although there is some outstanding work already done there, it is particularly important to raise standards in inner cities. This will entail attracting some younger doctors, and to help achieve this the discussion document suggests the possibilities of providing financial incentives within the remuneration system; of adjusting the allowances paid to doctors for practice premises in order to compensate for the higher cost of accommodation in inner cities; and of experimenting with different forms of contract.

"As regards dental services, the discussion document outlines ways in which patients could be more sure of getting the full range of National Health Service treatment. To help patients choose their dentist it suggests that the restrictions on advertising might be further relaxed, and to improve value for money the Government will act upon the recommendations of the committee which it set up to consider the problem of unnecessary dental treatment. The discussion document also examines ways in which greater emphasis could be placed on preventive measures, and it outlines retirement arrangements similar to those discussed for doctors.

"The Government also believe that pharmacists could and should play a larger part in the provision of comprehensive primary care services. The Nuffield Foundation recently published the report of an inquiry which shows some of the ways this can be achieved. Much has changed since the pharmacist's main function was to make up medicines himself, and he should now be enabled to make better use of his skills in advising patients and doctors on the use of medicines.

"Among other matters dealt with in the document are ways of improving the procedures for dealing with complaints against family practitioners and the extension of informal conciliation arrangements for dealing with less serious complaints. The document also proposes an independent study of the quality of primary care services in England, initially in one or two areas.

"I am also publishing today the report of a review of community nursing services in England carried out by a team led by Mrs. Julia Cumberlege, chairman of the Brighton Health Authority. Among the matters on which the team has made recommendations are the establishment of neighbourhood nursing services; ways of making better use of nursing skills; and the training, of community nurses.

"The Government intend that there should now be wide consultation on the discussion document and the Cumberlege Report, taking account also of documents published by other bodies such as the Royal College of General Practitioners and the Nuffield Foundation. We want to hear the views of all those who are interested in raising the standards of primary care, whether as providers or users of the service. To carry forward the review, Ministers will be holding a series of consultation meetings not only in London but in several major cities outside like Birmingham, Manchester and Newcastle. We will be inviting to these meetings the professional bodies like the British Medical Association, the British Dental Association and the Pharmaceutical Society. But we also want to take evidence from voluntary organisations, the statutory health service agencies, and organisations concerned with the interests of consumers.

"These proposals have been put forward for discussion and the consultations will last until the end of the year. At this stage, therefore, final decisions have not been taken. Many of the primary health care services are already provided to a high standard but the Government believe that further improvements are possible. It is for this reason that we have embarked on the first overall review of these services for 40 years."

My Lords, that concludes the Statement.

Lord Ennals

My Lords, may I first thank the noble Baroness for repeating the Statement made by her right honourable friend in another place. I am sure she will understand that we welcome the fact that there is to be major consultation over a considerable period of time rather than a rushing in, as has sometimes been the case, and that your Lordships, will wish to have the opportunity of a debate on many of the important recommendations that are contained in the report.

Perhaps I may also say that I welcome the Cumberlege Report on neighbourhood nursing. Just to add another paper to it: apart from the Nuffield Report, which is a third one, it would be nice to see the Binder Hamlyn Report, which we have asked for over the past two years. I think that would provide some useful information.

Is the noble Baroness aware that we on these Benches will welcome any reasonable steps that may be taken to ensure, first, that general practitioners play a much fuller role than they do at present in preventive medicine and in health education; secondly, to ensure the creation of higher standards of GP service and a fixed retirement age? I was delighted to hear the Statement which was made about this and about the ending of the 24-hour retirement racket, which really was disgraceful.

We shall support any proposals which oblige doctors to provide more information to patients about the range of services provided by their practice and give patients the opportunity to choose their own general practitioners, and proposals to improve what is often a very inadequate service in the inner city areas, as the noble Baroness said. I hoped that perhaps she would say a word about rural practices, because there are problems in the rural areas as well as the inner cities. We shall also support steps to enable women to be treated by a female doctor if required. Perhaps the noble Baroness will say whether that matter is dealt with in the report, which obviously I have not had a chance of reading.

We welcome also any proposals to enhance the role of the trained nurse, especially in screening, vaccination and innoculation, and we shall study very carefully the Cumberlege Report to which reference has already been made. May I say how much I welcome the recommendations in the Cumberlege Report that the health advisory service in future should cover primary health care as well as other aspects of the health service.

Perhaps I may add a further question: is the Minister aware that cuts in the hospital service—and at the moment I am much concerned about planned cuts in clinical services at Guy's and the Maudesley psychiatric centre of excellence—add additional burdens on to the general practitioner? The Labour Benches will press for major cuts in prescription and other charges and we shall implement them when we have the opportunity to do so. The same applies to the establishment of practice consultative committees involving patients as well as members of the primary health care team. As regards dentistry, perhaps I may ask the noble Baroness whether the document says anything about progress in fluoridation either by water or by fluoride milk.

Finally, in regard to pharmacists, is the noble Baroness aware that under legislation now being considered in another place some smaller pharmacists—that is, those issuing fewer than 16,000 prescriptions a year—fear quite considerable financial loss and possibly closure rather than gaining the opportunity which they would like to have of providing a better service? We shall return to that point when the Bill comes before your Lordships' House. Meanwhile, perhaps I may say how much I welcome a document which we shall all want to study with very great care.

Lord Kilmarnock

My Lords, we on these Benches would also like to thank the noble Baroness for repeating this long-awaited Statement. I think I am right in saying that it has been two years in the pipeline; so certainly we were entitled to expect something which we could get our teeth into, and we seem to have received it. I understand that there is a joke going round in the medical profession that this Green Paper is referred to as a gangrenous paper owing to the length of its gestation. But finally we have it. I think that the noble Baroness expected to be quizzed on the Binder-Hamlyn Report, and I shall oblige her by asking whether there is any reason why she should not now publish it in conjunction with the Green Paper (which I see appears in a tasteful blue cover) and the Cumberlege Report, which we also welcome.

As the noble Lord, Lord Ennals, has already said, without having read these documents it is obviously impossible to make intelligent comments. We shall judge the consultation paper against our own firm criterion, which is that we are opposed to any steps that would artificially stimulate private practice and risk the creation of a two-tier primary health care service. We believe that the British public want a good-quality family doctor service within the NHS. It is interesting that since the foundation of the NHS only 1 per cent. of private consultations in the primary care sector have taken place in the private sector, which seems to indicate that the public want a good public service.

Regarding the contents of the Statement—and I shall confine myself to what it says—we agree that most of the proposals of the Royal College of General Practitioners are sensible and to be supported. We certainly agree that wider and better publication of practice information is desirable and that there should be less difficulty, or rather no impediment, about changing one's doctor. We welcome the move toward a firm date of retirement in the medical profession. We also welcome the reference in the Statement to better use of pharmacists' skills. I should like to ask the noble Baroness whether she accepts the pharmacists' own proposals as embodied in what I think is called the pharmacists' charter.

None of these proposals means much unless the Government are prepared to put some money where their mouth is. Will the Government give serious consideration to a development fund for pilot schemes in the development of primary health care? The Government refer in the Statement to ancillary services. Do they accept that an extension of ancillary services in the surgeries is vital to good primary care, and will funds be available to stimulate this? Will the Government undertake to provide enough money—and this is a very important point—for more effective screening against cervical cancer, which is now reaching epidemic proportions and involves women younger than ever before? Is there a possibility that a target can be set for the screening of all women over 20 every three years, for example? Can the Government give us an indication of some target which they may have in mind for that?

The role of the consumer is important. Will the Government confirm that members of the Community Health Council are to be granted observer status on family practitioner committees?

Finally, I associate myself with what the noble Lord, Lord Ennals, has said about a debate. Will the Government offer us a debate on this important consultation document in their own time? I know I shall be referred to the usual channels, of which I form part and in which I shall play my part, but will the noble Baroness put some pressure also on her noble friend the Government Chief Whip?

Baroness Trumpington

My Lords, I should like to thank both the noble Lords, Lord Ennals and Lord Kilmarnock, for their welcome for this discussion document. Perhaps I may point out immediately to the noble Lord, Lord Kilmarnock, that it is a discussion document and not a Green Paper. Of course a debate is a matter for the usual channels, and I have no more influence over my usual channels than has anyone else, which is right and proper.

The findings of the Binder-Hamlyn Report, to which both noble Lords, Lord Ennals and Lord Kilmarnock, referred, have been taken into account in preparing today's document, but the debate has now moved on. With regard to female doctors, the discussion document mentions the demand from ethnic minority groups for women doctors especially in inner city areas and suggests that more might be done to ensure that women doctors are available to such groups.

The system of regular ministerial reviews of the plans drawn up by regional health authorities helps to ensure that hospital plans affecting community health services are fully discussed with the relevant district health authorities and the family practitioner committees.

The discussion document suggests that health authorities in areas where dental health is poor should consider the benefits of fluoridation with particular care. As regards the pharmaceutical services, the new chemists' contract is settled policy and will be implemented as soon as possible. As your Lordships know, the Bill which provides the necessary primary power had its Second Reading on 15th April. One of the objectives of the new contract is to provide a sound foundation for the development of the pharmacist's role. The discussion document is about that development. The new contract will provide an improved level of financial support for essential small pharmacies.

As to the question of more or less money for primary care, raised by the noble Lord, Lord Kilmarnock, spending on primary care has increased under this Government and will continue to do so. Some proposals will cost money, some will lead to savings, and many will improve value for money. The overall effect on expenditure will depend on the outcome of the consultation and the precise nature of the changes introduced. We are interested in hearing proposals of all kinds. That is the object of the discussion document. We shall listen to any suggestions for improving services. The proposals that I have seen so far are not very specific about how money will be spent, for instance, on a primary care fund. We need to avoid superficial remedies that consist of throwing money at problems without providing detailed solutions. It is my sincere hope that the discussion period will result in detailed solutions to any problems that are at present around.

Lord Auckland

My Lords, this is a very welcome Statement. However, as my noble friend has said, we have not yet had an opportunity of studying the consultative document. I should like to put to her two questions. With regard to people who move into new areas, particularly rural areas, will the document lead to any improvement in information services, explaining to people how they can obtain the services of a new doctor? This is sometimes quite a problem, especially in rural areas. Does the report contain any fresh information concerning this matter?

On the matter of trained nurses, can my noble friend the Minister say what kind of treatment they will be able to give? I believe that at the moment they can carry out ear-syringing and give injections and that kind of thing. Will they be able in future to do any diagnostic work?

Baroness Trumpington

My Lords, most authorities are, I believe, aware of the problems in rural areas, not only for doctors but also for other primary care services. Those matters will, of course, be taken into account in the consultation period. As to my noble friend's question concerning nurses, there are recommendations in the Cumberlege report about extending the role of the nurse and about limited prescribing by nurses. It is, however, important to read the supporting text so as to see these recommendations in the proper context. Then there can be an informed discussion of what it is sensible to aim for. I must tell my noble friend that the Government have not reached any decision yet.

Lord Somers

My Lords, like other noble Lords, I welcome the Statement. I wish to make just one point. The Statement mentions, among other things, the relaxation of the present controls on advertising. This would be a mistake. Advertising has today reached such a ludicrous standard of exaggeration of the facts that no one with any sense believes anything he reads in advertisements. A far better method of publicity is the doctor's or the practitioner's own work. If he does good work, this will soon become known in the neighbourhood where he works. That would be a far more desirable way of spreading knowledge of his talent than any form of advertisement which people might believe, or might not.

Baroness Trumpington

My Lords, I thank the noble Lord for the expression of his views which, I am sure, will be listened to, together with all the others, when my right honourable friend the Secretary of Slate is examining the conclusions drawn from this discussion period.

Lord Ennals

My Lords, perhaps I may thank the noble Baroness for the way in which she has dealt with the questions that have been put. I should like to mention two small points that arise from what has been said. Can the noble Baroness give an assurance that the local authorities will be included in the consultation process? She did not mention this; so that is why I ask the question. Secondly, can she give a slightly clearer idea of the timescale of the operation? I see that comments have to be received by 31st December, 1986 and that there will have been a series of meetings conducted by Ministers in different parts of the United Kingdom. Is it envisaged that we shall start seeing changes fairly early next year? Is it anticipated that there may have to be legislation, or can all this be done without legislation?

Baroness Trumpington

My Lords, with regard to the noble Lord's first question, the answer is, yes; the local authorities will be included. As regards the second part of the question, we propose to launch a structured consultation exercise and use the discussion document as an extended agenda at public hearings, some of which will be chaired by Ministers. We intend that these meetings will be part of a much wider public debate on the future of primary care. Given the wide range of issues, the consultation period will last until the end of the year, as I have already said. We shall then enter into negotiations with the professions concerned and, depending upon the outcome of the consultations and negotiations, we shall introduce any necessary legislation. All this amounts to a lot of talk; it is very difficult to pinpoint time.

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