Primary Health Care

HL Deb 25 November 1987 vol 490 cc637-47

5.28 p.m.

Lord Skelmersdale

My Lords, with the leave of the House, I will now repeat a Statement that has been made in another place by my honourable friend the Minister for Health on primary health care services. The Statement was as follows:

"With permission, I will make a Statement about the Government's plans for improving the primary health care services. These plans are set out in the White Paper entitled Promoting Better Health which has been published today. Copies are available from the Vote Office.

"The primary care services—those provided outside hospitals by family doctors, dentists, pharmacists, opticians, community nurses and others—account for nine-tenths of all patient contacts with the National Health Service. They cost over £5,000 million a year.

"In 1986 the Government set out their proposals for improving primary care. These attracted over 2,000 written comments and were the subject of public consultation meetings chaired by Ministers in different parts of the country. We are grateful to all those who commented and to the Social Services Committee of this House for its constructive report published earlier this year. The White Paper includes a detailed response to that report.

"The consultations showed a wide measure of support for the government proposals, in particular for placing the promotion of better health at the centre of the stage. The White Paper shows clearly the amount of preventable disease in this country and it contains many proposals for tackling this problem. These include: the setting of targets for family doctors to achieve higher levels of vaccination, immunisation and cervical cytology screening; more health promotion sessions in general practice; a greater role in health education for pharmacists; regular health checks for particular groups, such as the under-fives and elderly people; a new contract for dentists which will encourage prevention; an extension of the primary care team to include chiropodists, physiotherapists and others; action to see that the skills of community nurses are better used, in connection with which we are issuing today a circular to English health authorities advising on the steps to be taken following the Cumberlege Report on Community Nursing. To achieve these aims we shall be making general practitioners' contracts more sensitive to actual performance and will look to family practitioner committees to monitor more vigorously the contracts they have with family doctors.

"The White Paper also emphasises the needs of the consumer of primary care services. In particular it sets out ways of giving people much more information with which to choose their practitioner and of making it easier for people to change doctor. It also provides improvements in complaints procedures.

"The various measures the White Paper sets out—which include also compulsory retirement for the older doctors and dentists and more effective improvement of primary care premises—will affect all parts of the country. We expect them to bring particular benefits to inner cities and other deprived areas. In addition, the White Paper sets out the Government's intentions for improvements specific to such areas; for example, by paying particular attention to their dental, pharmaceutical and community nursing services.

"All primary care professionals have a part to play in the improvements we seek, and the White Paper describes our intentions for each part of the service. The Government have already made provision for a large increase in expenditure on the family practitioner services and are prepared to invest substantially more on top of this. In many cases the actual amount will depend on the outcome of the negotiations that will now take place with each of the practitioner professions. The White Paper makes clear our intention to proceed quickly with the introduction of blood glucose testing strips for diabetics.

"Expenditure on family practitioner services has already risen by £1.5 billion or 43 per cent. in real terms since 1978/79. This is reflected, for example, in the increase of nearly 4,000 to over 30,000 in the number of general practitioners and a consequent fall from over 2,200 to less than 2,000 in the average number of patients on each doctor's list. To achieve the strategic development set out in the White Paper will mean giving still greater priority to the services as a whole, and we have therefore thought it right also to look carefully at priorities within them.

"We have concluded that it is reasonable to secure some additional resources for development by asking those who can afford it to pay for sight tests and to meet somewhat more of the overall cost of dental care through a system of proportional charges extending also to examination costs, for which at present no charge is made. The proportional charge system will be simpler and will relate patient charges more directly to the costs of the particular treatment. It will benefit regular attenders who look after their teeth, some of whom will have no increase or may even pay a little less. Current exemptions from dental charges will of course continue for children, adults on low income, expectant and nursing mothers and certain other groups. National Health Service sight tests will remain free for children, those on low income, the blind and partially sighted and other specified categories.

"Existing plans already provide for additional expenditure by 1990–91 of some £570 million in real terms. This will be further increased by the substantial extra resources that the Government will make available to finance the improvements I have described today. Towards the additional expenditure as a whole, the extra payments which people will make towards dental care and sight testing will contribute some £170 million by 1990–91.

"The necessary legislative provisions, together with other measures in the health field, are contained in a Bill which will also be published today. The proposals in the White Paper and the Bill will generally apply throughout the United Kingdom, but my right honourable friends the Secretaries of State for Scotland, Wales and Northern Ireland will be considering the ways in which certain of our proposals will require to be adapted to the particular circumstances of these countries.

"Our proposals will enable people to make more informed choices of practitioner, will give them access to higher quality services and above all will place the greatest emphasis on preventing illness and promoting positive good health. I believe it is a strategy which will be widely welcomed and supported".

That concludes the Statement.

Lord Ennals

My Lords, I thank the Minister for repeating the Statement made in another place. Will he accept that it is not possible to divorce primary health care from the general state of the National Health Service? Will the Minister also accept that the underfunding of the service and the consequent intolerably long waiting lists and waiting times which are now at a record level greatly affect the burden imposed by waiting patients on general practitioners and other members of the health care team? Is the Minister also aware that the inadequacy of community care provisions for the elderly, the disabled, the mentally handicapped and the mentally sick also imposes burdens on the family practitioner teams which can be very costly indeed?

Before I come to a series of concerns and criticisms of the Statement and the White Paper I wish to say that there are some aspects which I welcome. I welcome the greater emphasis on disease prevention and health education by doctors. I welcome the decision to make blood glucose testing strips for diabetics available on prescription. That matter has been raised in your Lordships' House before. I welcome the provision for earlier retirement for some GPs who are still serving at a very great age.

I also welcome the greater role envisaged for pharmacists in health education as set out in the Nuffield Report. We shall certainly need to consider and then debate the important proposals in the White Paper but I say straightaway that I am totally opposed to the ending of free eye tests. They have been a feature of the service since its commencement. I am sure that all my noble friends feel the same way.

Last year almost 12 million people had their eyes tested. The 30 million people who wear glasses require regular eye tests. If people are to be deterred by what may well be a £10 charge, how many cases of glaucoma or cancer may not be discovered and dealt with? In such cases people would be referred to the hospital eye service, which is at present under very great pressure.

Will the Minister also accept that I am no less opposed to the ending of free dental tests? I deeply regret the proposed action to discourage patients from regular visits to both dentists and opticians. Why were these two proposals not mentioned in the consultative document? Who during the course of consultation proposed that that action should be taken? Was it the dentists or the opticians, for example?

The Statement refers to the important new monitoring tasks of family practitioner committees. In which case why in the past has the budget of family practitioner committees been cut to the tune of 600 staff posts? How will they fulfil the new tasks now imposed upon them with their depleted staff?

The Statement refers to capitation fees for GPs. We shall want to examine that more closely, because one asks whether this measure, with increased opportunity for patients to change their doctors—I must say I welcome that—will lead to longer patient lists for some general practitioners? Is not this the time to bring together more formally the family practitioners and the district health authorities, as was recommended in the careful report by the Select Committee, instead of talk about further co-operation and so on? Is anything said in the White Paper as regards the deputising services for GPs, about which there is considerable concern? Finally, the White Paper seems to put forward a very unsatisfactory response to the Select Committee's recommendation on the implementation of Section 7 of the Disabled Persons (Services, Consultation and Representation) Act 1986.

From this side of the House we shall look forward to the opportunity of debating this very important White Paper.

Lord Winstanley

My Lords, we on these Benches also wish to thank the noble Lord for repeating this important Statement. Perhaps we may also say how very glad we are to see the White Paper at long last. I think we have been waiting for it longer than whoever it was waited for Godot.

I hope that the Minister will accept that the uncertainty of waiting for the White Paper has been very damaging. It has halted long-term planning and has perhaps had a paralysing effect on those who provide primary care service. We are aware that part of the delay was caused by the unfortunate illness of the Secretary of State. We hope that he is soon restored to full health, not only for his own sake but also so that he can assist in tying up some of the loose threads which are hanging from the White Paper.

Like the noble Lord, Lord Ennals, we subscribe entirely to the final paragraph of the Statement, which summarises the broad aims. We are entirely at one with the Government on those aims. However, we may have certain differences on the means whereby the aims are to be achieved. In particular, I echo what the noble Lord has said concerning the provision of blood sugar testing strips for diabetic patients. That is something for which noble Lords on these Benches have been asking for many years.

As regards charges, the Statement and the White Paper are quite specific about a charge for eye tests. They are a bit more ambiguous concerning dental examination charges. The words are, a system of proportional charges extending also to examination costs, for which at present no charge is made". Does that mean that dental examinations will not be free? We know that eye tests will not be free. Therefore, presumably dental examinations will not be free.

We have never greatly relished the high charges for dental treatment or for spectacles. However, we have greatly supported a system enabling people to discover without charge whether they require either. It is a retrograde step to go back on that provision. However, I notice the provision will only affect, in the words of the Statement, "those who can afford it". Who those people will be, I am not entirely sure.

It seems from much of the Statement that there is to be a move, so far as the remuneration of general practitioners is concerned, towards a system of item of service payments. Perhaps the noble Lord will remember that those first came into being many years ago when Kenneth Robinson was the Minister for Health under what was called the new contract.

There were certain advantages to item of service payments. I am bound to say that a special item of service payment to a general practitioner for doing something which every general practitioner ought to do in any case seems to me to be a bit different. However, in general we have no objection to that system.

Perhaps the noble Lord can tell me, if we are moving more to item of service payments, whether we are phasing out any others. I know, and agree, that elderly general practitioners are to be compulsorily retired. Some of them whom I know are 95 years of age and are still alleged to be working. How much work they actually do, I do not know; I know that they draw the pay for it. It is proper that they should retire. However, there is no mention in the Statement of any intention to phase out seniority payments. I benefited from seniority payments to general practitioners, but it does not seem wholly logical that a general practitioner should get extra pay merely by getting older. Perhaps the noble Lord can tell us whether seniority payments will be phased out.

We await the Bill and we await the obvious opportunities to explore the many matters which are uncertain in further debate on other occasions.

5.45 p.m.

Lord Skelmersdale

My Lords, I am grateful to the noble Lords, Lord Ennals and Lord Winstanley, for their reception of the Statement. The White Paper which it introduces is a long and complicated one which sets the Government's practical and comprehensive programme for primary health care for many years to come. In passing, let me say that the review process started by the Green Paper 18 months ago was the first such review of that type of care for 40 years.

The noble Lord, Lord Ennals, is quite right in saying that we are looking at one specific part of our health service and that the parts cannot be divorced. Nonetheless, I think it is true to say that different parts of the service need different remedies in order to make each part perform effectively.

The White Paper does not set out hard and fast rules. It describes what the Government want to achieve over a period of time. Discussions will need to be conducted, particularly with doctors and dentists, on matters which are not likely to be swiftly resolved. However, some things are quicker to be resolved and, as the Statement says, they are the subject of a Bill which was introduced in another place today.

Not surprisingly, both noble Lords zeroed in on charges for dental inspection and the removal of free sight testing. The Government's aim of targeting resources where they will be most effective is well known. As I have said, children and those on low incomes will not be affected in any way. The noble Lord, Lord Ennals, may be interested to know that 30 per cent. of sight tests will continue to be free under the system which we have in this country for children and those on low incomes.

There is no evidence that any lasting effect will occur in dental and optical health as a result. Dental charges already exist and it is fairly unusual for an adult to have a dental inspection without incurring such charges if he or she is liable. It is also reasonable for the more expensive treatments to attract the highest charges. At the moment they do not and that must be wrong. Those changes are all fully justified and will enable us significantly to increase the resources available for promoting good health, preventing disease, raising standards and making the primary care services more responsive to the consumer.

I think that noble Lords should not lose sight of the fact that £5 billion is spent every year on primary care services. Since 1979 expenditure has risen by 43 per cent. in real terms. Perhaps more importantly for the immediate future it is expected to rise by a further 11 per cent. in real terms over the next three years.

On top of that, the Government are prepared to invest substantial extra resources. Obviously a proportion of those resources will arise from the £170 million which the introduction of the two charges on which noble Lords have commented will raise. There is no reason to believe that patients will be deterred by having to pay a small charge. I think that those charges will probably be less than £10 in the case of sight tests given every three years and something of the order of £3 at today's prices for a dental inspection.

The noble Lord, Lord Ennals, asked why we were increasing capitation fees. Currently 47 per cent. of a doctor's income comes from capitation fees. We intend to increase that to 50 per cent. Increasing that proportion is one method of increasing competition among doctors and encouraging them to provide services which are more responsive to patient needs. Our intention is that the payment of capitation fees, for which a basic core of health provision is expected, will be complemented by incentive payments designed to encourage the provisions of services targeted at specific health care objectives. Those are all matters which will have to be settled in the discussions with doctors to which I have referred.

The noble Lord, Lord Ennals, asked whether family practitioner committees could cope with their new responsibilities and whether they would have the necessary resources. We now have a strong team of FPC chairman and members possessing the necessary qualities of leadership for that expanding role. We shall increase the funds made available to them to enable them to carry out these new functions efficiently and effectively.

On the question whether family practitioner committees should come under district health authorities, as I have said, the role of the FPCs is to be strengthened under these new arrangements. The Government have no plans to bring them under other health authorities. I think it might be a mistake because we have already agreed that different sectors of health care in this country need different remedies. I also believe they need different overseeing agencies.

The noble Lord also asked about deputising services. We are keeping a close eye on their effectiveness and the amount of use that doctors make of them. I am particularly concerned in this and if the noble Lord or any other noble Lord has worries about any part of the country I shall be very glad to look into them.

The noble Lord, Lord Winstanley, spoke about dental charges. I am advised that 45 per cent. of dental examinations will remain free. As I have said, we expect the rest to attract a small charge of about £3.

Lastly, the noble Lord asked about seniority payments. This is one of the matters we shall be discussing with representatives of the professions. I have no doubt that the noble Lord will advise us that there are some other allowances whose usefulness is questionable. Clearly, seniority payments are a candidate for review.

It was St. Paul, I think, who copied Confucius by saying: Give me a child until he is seven and he will be mine for life". As regards dental and optical care this is a very valuable point to bear in mind, because the testing of children will remain free.

Lord Boyd-Carpenter

My Lords, in the light of the indignation of the noble Lord, Lord Ennals, about dental and optical charges, can the noble Lord remind your Lordships under what government and at what time charges under the health service were first introduced for teeth and spectacles?

Lord Ennals

Not for inspection at all, my Lords.

Lord Skelmersdale

My Lords, I am afraid not. I think charges for teeth were introduced by the government of which the noble Lord, Lord Ennals, was a staunch supporter.

Lord Ennals

My Lords, but not for testing.

Lord Kilmarnock

My Lords, we obviously have a great deal to digest in this White Paper so this is not an appropriate moment to ask a lot of questions. However, there are a couple which I should like to put to the noble Lord and the first is this. Will the setting of targets for family doctors to achieve higher levels of vaccination, immunisation and cervical cytology screening lead the Government to look again at the no-fault compensation idea? Is this not particularly relevant in relation to vaccination and immunisation if there is an intention that a larger section of the populace should receive these services?

The second point is this. I was pleased to hear about the intention to expand the role of pharmacists in health education. I see in the White Paper that there are some additional allowances for them for certain activities. Would the noble Lord agree that perhaps one of the greatest ways in which the role of the pharmacy could be expanded would be if there were some allowance towards the improvement of the pharmacist's premises as well as the doctor's premises. There is a great deal of difficulty for the pharmacist in providing counselling and matters of a slightly sensitive nature in the present premises in which he operates. Will the Government look into that?

Lord Skelmersdale

My Lords, on the second point, pharmacists are to a great extent self-employed and to a great extent also they own their own premises. Therefore, they are quite different from doctors in that respect.

Lord Kilmarnock

My Lords, some doctors own their own premises and are also self-employed.

Lord Skelmersdale

My Lords, yes, but they are custom-built for a rather different kind of operation. They are not what you might call shop-bound as opposed to being people-bound like community health centres.

As regards no-fault compensation, I said in answer to an Unstarred Question in your Lordships' House the other day that the Government would continue to keep this matter under review, but they certainly would not consider it with any seriousness until after my noble and learned friend the Lord Chancellor had completed the judicial review which he is conducting at the moment.

Lord Somers

My Lords, the Statement is very good so far as it goes but it does not deal with what I feel is one of the crying evils of the health service today: that is, the appalling time which so many people have to wait in order to get a bed in a hospital. Can the noble Lord tell me if there is any plan in the mind of the Government about either enlarging the present hospitals or possibly building new ones? I understand, too, that part of the difficulty is due to the lack of nurses. Have the Government any plans for possibly recruiting more nursing staff?

Lord Skelmersdale

My Lords, regarding waiting lists, or more importantly waiting times, I most certainly agree with the noble Lord. We have had discussions in the House over recent weeks on the subject of the Government's waiting list fund, where special moneys have been given to health authorities which have shown that they can use funds wisely in order to reduce their waiting lists. In the Autumn Statement the other day my right honourable friend the Chancellor of the Exchequer announced that the second year's money would be increased from £25 million to £30 million for the next financial year.

As regards the lack of nurses, I think this is rather wide of the Statement. If the noble Lord will allow me, I will take him aside at some convenient moment and explain the plans of the Government to him.

Lord Peston

My Lords, at a rough glance there is a lot of very good sense in the White Paper, but the remarks made about sight testing are absolutely outrageous. Indeed, seeing them placed in the context of raising resources, they are even more outrageous. Perhaps I may ask the noble Lord to remember that there is a perfectly good way of having the better-off provide more resources for the health service and it is called income tax. To introduce user charges here is not justified in any way whatsoever, and it seems to me to be a most doubtful thing.

I should like to ask the Minister whether expert opinion in this field supports his view that no damage to the nation's eyesight is likely to follow from the introduction of these measures. I look around your Lordships' House and it seems to me that the majority of people wear spectacles, and therefore I worry even more.

That was a rather controversial question for the Minister, but one which is less controversial is this. As regards the medicines Bill and the reforms in pharmacy and where those reforms require primary legislation, are the Government open to persuasion and will they be willing to accept amendment of the Bill, when it reaches us, in order to allow certain important developments to take place, notably in pharmacy?

Lord Skelmersdale

My Lords, I am a member of a Government who do not actually believe that income tax ought to exist at all. It was of course a temporary tax put on I believe, by the Duke of Wellington.

Lord Boyd-Carpenter

My Lords, it was Pitt first of all.

Lord Skelmersdale

My Lords, I am advised by my noble friend that it was Prime Minister Pitt, so it is even longer ago. This temporary arrangement has gone on for far too long. I believe that if one wants to raise taxes one can do it by other means, such as value added tax. I do not think on this particular aspect of health care taxes that would be the appropriate way to do it. The Government have decided that people should pay for services where they are able to do so.

So far as pharmacies are concerned, we are not discussing the Bill this afternoon and it will come before your Lordships' House for full examination—whether dental or otherwise—in due course. Of course, if the noble Lord would like to put down an amendment to that Bill, I will consider it in the normal way.

The question does allow me to answer a point made by the noble Lord, Lord Kilmarnock—who I notice has gone. We propose to provide funds to improve the standard of services and premises in inner city areas so far as pharmacies are concerned.

Lord Colwyn

My Lords, as a dental surgeon perhaps I may say that generally I welcome the Statement made this afternoon. However, I am disappointed to see that yet again the Government intend to look to the general ophthalmic and dental services to generate additional resources for the important developments in the primary care field.

Yet again, it is the dental services which are going to be nobbled in this way. In real terms charges have doubled since 1979 and it seems that dentistry will again be used to subsidise other aspects of the health service.

The present charging system is very difficult. We welcome a change in that system and the proportional charge which is talked about. However, there is no mention of a ceiling to the proposed charges. At present, there is a ceiling of £115 and we shall be very upset if that is increased in any way.

Finally, we shall also be very concerned if the proposed changes in the Health and Medicines Act remove the present statutory responsibility for the health authorities and change it to a discretionary power on their behalf. We shall be very concerned if that changes because we feel that that will be a retrograde step in the overall improvement in children's dental health.

Lord Skelmersdale

My Lords, I am grateful for the first half of my noble friend's remarks. I am not quite sure that I am as grateful for the second half. The provision of dental services has led to considerable improvements in dental health in recent years. For example, in 1983 more than half of all five year-olds had no dental decay at all, compared with under a third 10 years earlier. Improvements have been felt by all age groups, and the Government therefore believe it is right to shift the emphasis from treatment to health promotion. The Government welcome the health authorities' current flouridation initiatives and will continue to promote dental awareness and regular attendence at the dentist.

I do not believe it is fair to say "yet again". As I have already explained, the Government have already announced that they will make available over half a billion pounds extra in real terms over the next three years for the primary health care services. What we are talking about in this White Paper is money over and above that.