Family Practitioner Services

HL Deb 04 July 1989 vol 509 cc1127-52

6.55 p.m.

Lord Hunter of Newington rose to ask Her Majesty's Government how they plan to meet the need for family practitioner services in the 1990s.

The noble Lord said: My Lords, during the past two years the House has debated a whole range of activities concerning health and the social services. The general feeling which has been on all sides of the House is that it is most important and urgent to get the health services on an evolutionary path which will give their development a base from which change can take place. A great deal of time has been spent discussing the hospital services, the public health services, the new preventive measures, innoculation and other procedures which are becoming so important and also the social services. The views of the House on the Griffiths Report were clearly stated.

The question tonight concerns family practice and I hope that the Government will be able to give a reassuring reply. If one goes back for a moment to the beginning in 1946 when the health service was introduced, it was stated: The main feature of the General Practice Service is seen as the development of health centres to be provided by the local authorities but with doctors and dentists working with them in contract with executive councils. At the outset, all doctors would be able to join the service where they were and to have private as well as public patients who in turn would have free choice of doctor. Remuneration would be fixed by regulations drawn up in consultation with the profession".

Essentially, however, general practice continued along the lines which it had done in the past.

The consequences are important. By the mid-1960s it was obvious that something had to be done to improve recruitment of doctors to general practice. The consequence was the introduction in the mid-1960s of what came to be called the general practitioners' charter. This had had a remarkable effect over the past 20 years. It has ensured that high quality graduates of the universities would choose general practice as their career.

The gateway to the service is the general practitioner. Are the new proposals by the Secretary of State likely to improve recruitment or not? What a courageous person he is even to take this risk. Now we are considering proposals which radically alter the position of the doctor in relation to his patient which it is claimed will improve the service to the patients. In fact, it is said, everything is being done for the benefit of the patients.

What changes have been taking place in the past 25 years in general practice? Certainly the intentions which I have indicated in 1946 have not been achieved. The principles of independent practice with individual contracts for doctors have been continued, and though there has been a variety of experiments in large group practices, there are still very many practices with two or three doctors working essentially in the same way as they did 25 years ago. Family practitioner committees have been pushed around and, having been connected with area health authorities, they then became answerable to the Secretary of State. Now a new relationship with regional authorities is envisaged. But the policy is not clear. The Government have also indicated that they want to make proper use of the professions allied to medicine, though so far there has been little more than talk.

The White Paper on the National Health Service makes a number of proposals about the future of general practice which have given rise to a great deal of discussion and comment. Most of the proposals are concerned with the financial and management aspects of practice and put pressure on doctors to do a more effective job for which they will be financially rewarded.

While one accepts that it is desirable and necessary to have financial controls of some kind, many of the proposals in the White Paper do not appeal in any way to doctors or to their patients. Prior to the development of the present White Paper there was a previous White Paper concerned with primary care services which envisaged that there would be a changing role for doctors, an increased commitment in preventive medicine and an additional role for the professions allied to medicine, particularly nurses, pharmacists and others, The object of this debate is to try to focus on some of the changes that are already taking place in practice which must be considered in relation to future plans.

Perhaps one of the most important of these is the fact that in the last two decades large numbers of women have qualified in medicine and many of them wish to combine marriage and having a family with their professional responsibilities. One would hope, therefore, that the organisation of practices should make it easy for women to do this; and this perhaps means a contribution, full-time or part-time, to a group practice which might be quite substantial in size. Under those circumstances they could take part-time duties and concentrate on preventative services like screening. This is a vitally important matter. Substantial resources have been spent on their education which should not be wasted.

A second major change is the change in technology. At the beginning of the National Health Service the focus of change and development was substantially on the hospital service. This tended to concentrate new developments and new technologies on that service, and the flow of change which had previously begun to take place in general practice was slowed. Much was done in the 1960s with the General Practice Charter to recruit people of quality to the service and they have contributed enormously in the past 20 years. Now, however, things are again changing. New technology is making a whole range of investigations possible in large group practices. The sending of patients unnecessarily to hospital is an expensive business whether or not the doctor has a practice.

I am sure that GPs and their patients would like to see a greater range of facilities and opportunities in practice and specialist investigations to take place in these practices. If necessary consultants could visit large group practices on specific days to see patients.

One of the most urgent needs is to find out whether this kind of thing is possible, practical, less costly and whether one can give a better service to the individual patient who requires care and attention, but not necessarily hospital care or hospital treatment. The old picture of the hospital where the patient is admitted into a bed no longer exists. It would be a tragedy if changes were taking place which made this kind of development more difficult. I therefore think that the ideas which have been generated by the Royal College of General Practitioners and others in the past few years should be urgently examined.

What are some other experiments that should be done before radical changes are made? One would have to consider, now that the Griffiths Report has been accepted in principle, whether the accommodation used for that purpose should be shared with the health service—although it might belong to the local authority or the health service. The people should be in contact.

The next most important matter is to recognise that most of the experience so far in the United States and this country with regard to audit, of which the Government and the profession have made so much, has been concerned with specialised procedures in hospital. A great deal of preliminary work requires to be done in general practice before the methods to be used can be defined.

One has to answer the question whether the independent contractor principle can be maintained without disadvantage. I think that the profession and the Government must face up to this situation. If one is going to create secondary care centres outside hospitals with a range of responsibilities and a range of professional interests, one has to consider the possibility that some posts should be full-time salaried posts. One has also to consider whether senior GPs in the future will be the managers of substantial family services and employ consultants on a part-time basis.

The next matter to consider is the future employment of women doctors. Surely the organisation of family practitioner services must be geared towards making the maximum use of women doctors in a range of occupations which can be fitted in with their commitments. I think that all family practices having one to three doctors should be linked directly and financially with large group practices. Secondary care centres will offer a range of facilities not available to the small practices. This seems to me to be more important and fruitful than linking GPs to specialist hospitals which are becoming more specialised every year. This may mean that the cottage hospitals, of which there have been so many, should now be replaced by modern centres which make full use not only of doctors and nurses but of the professions allied to medicine—for example, pharmacists, opticians and others—and which are linked to the social services.

Against that background we must ask the question: how do the White Paper proposals look? History is repeating itself in this short debate because although the original health services Bill was introduced to the House of Commons in March 1946, the House of Lords began the debate on 16th April, when Lord Moran regretted, any measures which might impair the efficiency of the general practice services".

However, the noble Lord welcomed proposals for the better co-ordination of the hospital services. The BMA, in commenting on that debate, said that it regretted the failure to integrate the medical services under the central health department and said that the administrative separation of the hospital, general practice and health centres should be the subject of experiment. That is exactly what they are saying now!

7.7 p.m.

Lord Pitt of Hampstead

My Lords, l am sure that we are all grateful to the noble Lord, Lord Hunter of Newington, for tabling this Unstarred Question and for the way in which he has spoken to it. I am very happy to follow the noble Lord.

Any projection of the family practitioner services in the 1990s involves a study of the White Paper Working for Patients and also the general practitioner's contract on which GPs are at present voting. If both of those are ageed, there will be large general practices with their own budgets contracting with hospitals, both public and private, for the provision of acute services. How these practices will deal with the elderly, the disabled, the mentally ill and the handicapped is not yet clear, because the Government have not said how they intend to provide community care. Nor is it clear how district nurses and health visitors will fit into the scheme of things as they are not mentioned.

General practitioners will, however, be encouraged to have large practices which will be run as businesses. The most important person in the practice will be the business manager. The practices will be computerised. The staff will know where the cheapest hospital services can be located and how quickly they can be made available. Since there is no mention of increased funding for the hospital services, one must assume that those services will remain underfunded.

The present underfunding has resulted in there being large waiting lists. Since the responsibility for providing services will now be placed on the general practitioner, he will be the one who will be blamed for the pain and suffering which patients endure while they wait for admission to hospital in order to receive the appropriate treatment. Moreover, the decision not to refer a patient to hospital will sometimes be viewed as having been taken not because the patient did not need referral but because of the cost involved.

It will no longer be easy for someone, for example, who suddenly feels ill, is about to faint or becomes giddy to receive treatment in hospital. He can no longer be sure that when he goes to hospital he will immediately receive treatment. I say that because, although accident and emergency services must be available, such a person will not necessarily be regarded as an emergency. While he may certainly have had an accident, the question of who will pay for such treatment will arise if he is treated.

Some practices will have their own budgets; but others will not. Those practices without their own budget will be restricted in their referrals to using only the hospitals with which their district health authority has contracts. They will not be able to use the consultants of their choice, unless those consultants happen to be in the relevant hospitals. I am sure that the Minister will tell us that the district health authorities will retain funds in order to meet the cost of referrals to hospitals other than those to which they are contracted. However, such referrals will be the exceptions; it is silly to think that such exceptions will be numerous. The vast majority of referrals would have to be to the hospitals with which the district health authority has contracts. The present situation, where the GP refers patients to known consultants, will be the exception rather than the rule.

As I understand it, there is also to be a downward pressure on expenditure on drugs. That is a form of cash limiting the provision of drugs. It is quite dangerous. Of course the drug bill needs to be reduced, and general practitioners should be helped and encouraged to control their prescribing so as to provide the needed medication at the lowest possible cost. However, it needs to be a co-operative effort and the present improved methods of informing doctors of their prescribing costs should be further improved and refined. Moreover, local co-operation with the establishment of local drugs and therapeutic communities, working closely with the local medical committee, should be encouraged. The use of such pressure should enable this objective to be achieved.

Limiting the amount available to individual doctors for the provision of medicaments for their patients can have serious consequences resembling those we know from contact in the field of social security. The difference, however, is that this could be a question of life and death, or at least the prolonging of an illness. Further, the present situation means that in order to save on the hospital drug bill—because that bill is cash limited—consultants tend to give a limited amount of drugs to the patient. In fact, they give the patient only enough to cover the period until he sees his GP. They refer the patient back to his own general practitioner for a prescription to cover the period in which the treatment needs to be continued.

The patient will now be squeezed in the middle as both consultant and GP will try to save money. The family practitioner committee will have greater supervisory powers over general practitioners and will be smaller and more managerially orientated. The present system of co-operation among the general practitioners, who are independent contractors, the representatives of the Government as paymasters and the general public as consumers will be abolished. In particular, the local authorities which, if Griffiths is to be implemented, will be responsible for community care, will no longer be represented on the family practitioner committees. I need only mention that fact to indicate how ill-advised is the present proposal for family practitioner committee membership.

In its comments on the White Paper Working for Patients the Royal College of Nursing stated three considerations as regards the challenge of the 1990s.

First, how we cope with the increasing health and medical demands of the elderly population which is now growing in size, growing older and consequently becoming more frail and dependent; secondly, how we maintain the shift in policy in priority towards health promotion and illness prevention, and the extension of care in the community; and, thirdly, how we meet both those challenges in the face of the increasing skill shortages which will affect every profession supporting medicine and the health service.

I agree with the Royal College of Nursing and I should like to add a fourth consideration. How can we provide resources to enable the community to benefit from the great advances in medical knowledge and medical skills which have taken place, which are currently taking place and which will continue to take place in the next decade and beyond? I look forward to hearing the Minister's reply.

7.17 p.m.

Lord Winstanley

My Lords, I listened with great interest to the fascinating review of the noble Lord, Lord Hunter of Newington, on the evolution of our family doctor service as it now is. The evolution of the service to the position that it has now reached leads us inevitably to the question of where we go now. I suspect that this debate is somewhat unusual in that the noble Lord who tabled the Unstarred Question does not know the answer, and nor, I suspect, do the Government. However, perhaps when he comes to reply the noble Lord, Lord Henley, will clarify the matter.

I must point out that on the Government Benches speakers in this debate appear to be conspicuous by their absence. I shall not make cheap gibes about that being due to the fact that they do not use the National Health Service because I know that many of them do. Indeed, very many of them use the health service; they value it and have a high regard for it. I suspect that their absence from the speakers' list is not because they do not use the service but because they are not altogether happy about the Government's proposals in this respect, and nor do they wish to come along and defend the proposals contained in the White Paper about which many of them are extremely suspicious.

The noble Lord, Lord Hunter of Newington, who decribed the evolution, saw it very much from the inside. I say that because during much of that period he was advising the Government professionally on many of these matters. However, I saw it from a somewhat different point of view; I was one of the general practitioners who was being subjected to this evolutionary process, and it was very interesting indeed.

The noble Lord was absolutely right when he said that initially, when the health service was first established after the Bill of 1946—it came into force on 5th July 1948—the general view was that the future pattern of general practice would be health centres; they would be provided and equipped by local authorities and general practitioners would practice in them. But that never became a reality for many reasons.

First, there was the question of cost. The capital cost of providing adequately equipped health centres up and down the country to the extent which would have been necessary was far too great. Secondly, staffing such health centres in the way talked about in those days so that doctors could work reasonable hours and take holidays and so on necessarily meant that in some areas it could be done only by having a full-time salaried service. I do not recommend such a service, but it is interesting to note that when the discussions on the new charter were taking place in 1960—the noble Lord, Lord Hunter, referred to the new charter—it was recommended that an experiment should be conducted in which general practitioners, if they so wished, could opt for salaried service. It never took place.

I greatly regret that we are not conducting experiments into some of the new ideas with which the Government have come forward. One cannot suddenly set out into the unknown, making changes in something that has evolved slowly over many years, without putting some of the proposals to the test to find out how they work.

I referred to the health centres. They did not happen. Instead, we had a gradual move towards group practice. Initially I was in single-handed general practice, the kind of general practice in which one genuinely was on call 24 hours a day, seven days a week. I did not have much experience of group practice. I remember when the political leaders of the medical profession and the officials from the Department of Health were trying to encourage us all to go into group practice, they were going around proselytising the cause and trying to explain to us how much better it was. The argument was an interesting one. It was true that if a number of general practitioners combined into a group they could share costs and as a result have much better equipped and staffed surgeries. That was at a time when ancillary staff were in short supply in most practices. The argument that was constantly used was that when one was in a group practice one did not have to be a universal genius. One could concentrate on what one knew best or was most interested in. It was said that Dr. A in a group could specialise in skin diseases, Dr. B could specialised in paediatrics and so on.

When I was first ejected from another place, having lost my seat, I became momentarily unemployed. I went back into practice, but I went back into a group practice, and fascinating I found it too. I found that the reality was somewhat different. It was not that Dr. A specialised in skin diseases and Dr. B in paediatrics; it was that Dr. A specialised in having Mondays off and Dr. B specialised in having Tuesdays off and so on. That admirable administrative re-arrangement made life very much pleasanter for the general practitioner. I accept that it probably made for a higher standard of practice for the patient because one had better equipment, staff and resources; but I nevertheless felt that something of the old human element of general practice tended to disappear. I am not sure that patients felt that that new development was as beneficial to them as it was to the doctors.

We have inevitably had some talk about cash limits being applied to family practitioner committee services. The noble Lord, Lord Pitt of Hampstead, who has vast experience of this matter, referred to it and so did the noble Lord, Lord Hunter. I do not believe that this or any government can predict with accuracy how many people will suffer from which diseases and at what cost in any future period. It means that family practitioner committee services must be demand led. That does not mean that there must be a bottomless pit or that if the money runs out no work can be done; and nor does it mean that we must not consider the expense and cost of things. Of course we must. When I look at the exercise upon which we are all told to embark in general practice of costing out everything, I fail to see how that costing will be done. At the moment all the thoughts are purely in terms of medical costs: how much is the cost of an appendectomy at this or that hospital? How much is the cost of a patient per day in this ward or that ward, and so on? Other costs are involved.

The noble Lord, Lord Hunter, mentioned preventive care. That was supposed to be an important element when we had the primary health care White Paper. It was all about how much more prevention we were going to do. If general practitioners are to do a great deal more with regard to preventive medicine and health education, how on earth do we cost it out? It takes time, and time costs money; but its benefits could be immense. They cannot be quantified in any kind of sum which any general practitioner whom I know could do, and that is so with other costs. We cannot consider only the costs to one government department. It is all the same pair of trousers even if it is different pockets.

For example, one may have a patient who is a working man, doing a heavy manual job, who is waiting for an operation on a hernia. It is not an urgent operation. He may think that it is urgent, but it is not classed as urgent. He has a wife and children. If he cannot work while he is awaiting the operation and he has to wait two years, the stake has to keep his wife and children for two years. Where does that sum come into the calculations which general practitioners are told to undertake to prepare themselves for the new deal upon which we are embarking? I do not understand how the scheme will work.

I agree entirely with the noble Lord, Lord Hunter, who mentioned the importance of Griffiths. How can the Government expect general practitioners to accept the new contract which has been offered—at the moment it has been rejected and is now going out to ballot—when they do not know what it will involve? What will happen in relation to community care? That is crucial to the general practitioner. Until he knows what that is, what will happen, how community care will be provided and by whom, he cannot possibly enter into a binding contract, because he does not know what his obligations will be.

I am delighted that the noble Lord, Lord Henley, has told us that the Government's response to Griffiths will come soon. It then became "very soon" and then we had "very soon indeed". I do not know what we shall get today, but at least we are going to get a response. We must have a response before we can go much further with some of these National Health Service reviews. The noble Lord, Lord Hunter, was also right about the possible impact on the employment of women in general practice of the new arrangements as at present envisaged. It has been pointed out by the General Medical Services Committee and others that the arrangements as they appear, the budgets and so on, will make it difficult for married women with children to return to active general practice. Many of those women are excellent practitioners. Their work is invaluable. It will be wasted unless we make special arrangements for it. The Government are introducing a scheme which will make special arrangements for not having it at all. It will make it disadvantageous to practices to have women working part-time. I am sure that that will be to the detriment of everything.

Our family doctor service, which, as has been said, evolved over many years, is now well nigh unique in the modern world. There are not many countries in which there is still one doctor who has total responsibility for a patient or a family. The increasing tendency in other countries is for specialisation: for the patient to go directly to this or that specialist. The idea put forward by the noble Lord, Lord Hunter of Newington, about secondary care centres where general practitioners in combination could have access to all types of special investigations so as not to waste hospital time and occupy hospital beds with patients who merely needed certain questions answering was an excellent one. I do not know how that system could evolve as a result of the White Paper that we have been considering.

That leads me to one further point about which the noble Lord, Lord Henley, might be able to say something. In the early days of the National Health Service we had a system of domiciliary visits—I have no doubt that they still exist—under which, if he so wished, the general practitioner could call out a National Health Service consultant who would see the patient in his or her home and then give the general practitioner direct advice as to how the case should be handled: whether in hospital or not, what special investigation should be carried out, what further arrangements should be made and how the case should be managed. That was an admirable system. A great deal of use was made of it in the early days. It was increasingly abused because of the logjam of waiting lists and shortage of hospital beds. General practitioners tended to use the domiciliary visits system merely as a way to pressurise the hospital to admit the patient, whereas in reality the purpose was to obviate the necessity of the patient going into hospital. It resulted in being a device to assist the general practitioner to jump the queue and have a patient admitted to hospital. He would say, "I will call the consultant out on a domiciliary visit" and the consultant would say, "Right, send him in and I will find a bed for him".

The purpose of such an arrangement was to avoid sending into hospital people who could safely, properly and effectively be treated at home. I hope that when he replies the noble Lord will tell us how we cost out domiciliary visits under the new budget system. They must cost something. Is there to be a penalty on a practice which calls out consultants to do domiciliary visits? The cost might be put against their budget. Nothing of that kind is explained.

Our family doctor service is well nigh unique in the world today. I do not wish to see us turning into the kind of society that has high powered and very efficient medicine, with computers and everything else, which has been described, but in which everybody is treated by a specialist. What people want is one doctor who is responsible for the whole of a patient, not a whole lot of doctors each responsible for different little bits of a patient. We have preserved that system in Britain almost uniquely. They do not have it in the Soviet Union, although they have secondary care centres such as that which the noble Lord referred to. They certainly do not have our system in the United States.

I very much fear what might happen if we plough on with the present White Paper proposals without first conducting pilot studies to see how some of them work. I grant that some might work but we need to make certain adjustments, if necessary, to make them work effectively. By that I mean in the interests of the patient rather than merely in the interests of budgets. That was a point powerfully made by the noble Lord, Lord Butterfield, in a foreword to the new publication of the Office of Health Economics, Measurement and Management in the NHS.

The criterion of the whole system and the whole basis of the National Health Service is, as the publication says, that the improved well-being of the patient must always be the primary consideration of those in the service. As the booklet by the Office of Health Economics points out, NHS budgets which are not based on that premise but which consider costs alone will not result in the most effective use of health care resources; nor will they result in the kind of family practitioner services which those of us who have worked in the family practitioner services would like to see continue in this country.

7.31 p.m.

Lord Brain

My Lords, I wish to thank my noble friend Lord Hunter of Newington for asking this Question and for his excellent historic introduction to the development of the National Health Service that we have today.

The noble Lord, Lord Winstanley, suggested that the Government might be able to give us an answer to the Question. I wonder. Mr. Roger Freeman said that he would return to Devon next year when more details of the contract and the White Paper were known. We are arguing blind at the moment. Perhaps during the last fortnight or three weeks since that remark, the Government have bought a pair of glasses. Perhaps the civil servants have taken off their dark glasses. Certainly the GPs, the patients and many members of the family practitioner committees feel that the Government are blind. The arguments are taking place in a thick fog and one is arguing about a contract where not only are the goalposts being moved every day of the week, but the playing field was not even marked out before the goalposts were set up. I hope that the debate will definitely give us some goalposts or at least the markings on the playing field.

The contracts are of great concern to all young doctors. The noble Lord, Lord Hunter of Newington, has already mentioned women doctors. I shall come to that later. He has also talked a little about the size of practice and similar matters. I wonder whether the idea of a really large group practice is the ideal. I have talked to a number of general practitioner friends who feel that a practice of about five doctors is the maximum for which the social relationships between the doctors and the understanding of the treatment is effective. By all means link two or three practices of five doctors in one building. But let them operate separately, on their own.

The point I wish to make now is why, when the Government are so keen on contracts for carrying out a task, and when they are trying to "privatise" things by contract, they have contracts with individual doctors. Why not contract with a group of people as a practice in order to provide a service to the patients in the area, and the appropriate number of clinics, back-up services and the rest of the facilities?

Why is there this insistence on individual contracts with doctors who then, because the contracts, as I understand it, are becoming much more detailed, have to spend two hours in the surgery or, as it is so often considered now, the office? They take an hour off in order to catch up with the paperwork, then they have to be on duty, then off duty, then on duty. How is that to be managed?

I happen to know a practice where there is no appointment system because the patients—I shall not use the modern jargon of "clients"—do not have telephones, they just drop in. A doctor is there all the time. It may not be their doctor but that does not matter because it is a large community with people coming from various overseas countries. It does not necessarily matter that they should see the same doctor each time, indeed there may be advantages in not doing so. But the practice does not run an appointments' scheme. It is no use somebody being on for two hours and then off. However, that is the system which some people seem to wish to force upon us in the new contracts.

What happens if we insist on certain people being in the surgery at certain hours? When are the domiciliary visits fitted in? What happens if something overruns or it is not convenient? There is a great deal in the White Paper about convenience to patients. What about convenience to doctors? It is a very stressful profession and they must have certain time which they can call their own when they can relax and think about things, consider their patients and not just be driven by a strict timetable.

The Government make much of payment by results, larger lists, the ability to change from one practice to another. That may well be a good idea. It was certainly pointed out to me that changing doctors sometimes means that ailments are cured more quickly. Mrs. Jones might come regularly once a month for her routine visit and her prescription.

She is seen regularly by her doctor. However, if he goes on holiday and his partner sees her or a trainee comes in or a locum takes over, and they see her, surprisingly something else may be spotted. Other treatment could be required, and that might be a good reason for changing doctors.

However, there are other reasons. I take the point made to me when I was staying with a young doctor friend in a rural area in Australia. He had built up quite a nice practice in the town, it was not falling away much but he noticed that some of his regular patients were not attending as they had previously. When one of them came in the doctor inquired and the reply was, "Oh, well, the situation is that the general store in the next town is much better. We go and see our doctor when we do our shopping". Perhaps with the new National Health Service advisory board, with all this expertise on supermarkets, we shall receive advice on where GPs should locate their practices. I think that that is important.

I could make many more broad points and good points on the 90 per cent. immunisation of people on a fictitious list because on current standards the list is always out of date. If one is using preventive medicine it is much better to do as the French do, for example, and say, "You cannot go to this section school unless you have the form which has been stamped saying that you have had the inoculations".

I wish to focus on the half of young potential GPs that we are now training, the women. They are most concerned about the new contract and the lack of understanding. After all, very often the women doctors will be the mothers of future doctors, men and women. There is a great hereditary principle in medicine. Many doctors come from doctors' families. I do not agree with the noble Lord, Lord Hunter of Newington that women doctors will become just people who run clinics and provide the services which are delegated to them by their partners, because the partners are bored by those activities. These women doctors are trained as doctors to care for men, women and children right the way across the profession. A comment was made to me only on Sunday by someone who is very close to a family practitioner committee. He told me that he had had women doctors come to him and say that they did not want to be considered as the woman doctor in the practice simply because the practice needed a woman doctor as the children and female patients liked to have a woman doctor. Those women doctors wish to be partners in a practice taking full responsibility.

The whole concept of the new contract must take into consideration the fact that women doctors can work hard. I know a number of women doctors who work very hard. However, they arrange their work so that if their children come home from school at half-past three, they are free from half-past three until an evening surgery when the children have gone to bed. They do not get tied with a contract which states that they must be in the surgery for three days a week at four o'clock and that if that is not the case they will not get paid the full amount. Women doctors work 20 hours and much more. However, perhaps because the present system has been a by a very few doctors, the contract is being changed. I believe that it would be much better to sort out the abuse.

There has been mention of medical audits. I support that, but what will the Government do if they find, having carried out medical audits on general practices, that less stressed, part-time, free thinking women doctors who have more time to care for their patients provide better medical care for those patients and there is a better recovery rate and less cost in the long-term than with other doctors? There is quite a possibility that statistics will show that that is correct because they show that full-time general practitioners have a very high suicide rate, heart attack rate and general breakdown of health. We must reduce the stress involved in the health service.

I shall not mention the problems that will arise as regards giving doctors practice budgets when they are not managers. We shall be totally in the hands of an employee, but that is another problem. There is much more to debate on this general topic of general practice and family medical services, but I am sure that we shall come back to it in the future. Nevertheless, I shall await with interest what the Minister has to say this evening.

7.42 p.m.

Lord Rea

My Lords, I fully agree with the noble Lord, Lord Hunter, that there is a place for a greatly enhanced role for primary care in the next decade and beyond. The Government's plans, as laid out in the White Paper and the revised contract, do not exactly make the imagination soar when thinking about the real needs of our steadily ageing population. In fact, I think they are largely irrelevant. However, it is clear that the Government have grasped the pivotal role of the general practitioner service in the functioning of the National Health Service. In a sense this is a great compliment to general practice. As the noble Lord, Lord Hunter, said, 25 to 30 years ago general practice was in a pretty moribund state. Its recovery is very much to the credit of the Royal College of General Practitioners, with its insistence on raising standards and making training for general practice obligatory.

As the noble Lord also mentioned, the recovery of general practice is also to the credit of another Kenneth, Kenneth Robinson, who was Minister of Health in 1965 to 1966 and who agreed to the doctors' charter which has been mentioned. Incidentally, this was originally the idea of the medical practitioners union. It allowed GPs to be partially recompensed for employing staff and investing in better premises.

The existence of viable primary care has been a major factor in keeping down the costs of the National Health Service. GPs indeed act as a filter to the more expensive part of the National Health Service—the hospital service. But, inevitably, as more has become technically possible in hospitals —other speakers have pointed that out—and there are more old people with more chronic illness, referrals to hospital have continued to escalate, both in regard to out-patients and in-patients. The aim must surely be to care for more people outside hospital. As one noble Lord pointed out, for this GPs and the primary health care team need more investment in new diagnostic technology in training and in the provision of more pairs of hands to help care for people in their own homes and in small hostels of sheltered accommodation. That is not a cheap option, but it is probably cheaper than building more hospitals and, in particular, staffing them.

The Government seem to me to be intent on curtailing the referral process. I think this is the main reason for the GP budget proposals. But I feel the Government have not planned adequately for the increased need for community care which will result from fewer patients being cared for in hospital. I find the budget proposals for large practices certainly very interesting, but as other speakers have pointed out, they are at far too early a stage of development as an idea to be promoted as a major part of a change in the National Health Service. They have yet to be realistically costed. Estimates on the size of the budget required fluctuate widely.

I echo the words of the noble Lord, Lord Brain, in asking whether the Minister has the most recent figures on this. I should be very interested to hear about that and the thinking behind it. However, I must say that most general practitioners are extremely sceptical at this stage as regards budgets. As the noble Lord, Lord Winstanley, pointed out, this is one of the many White Paper proposals which surely need careful piloting. Any commercial organisation carries out market research before committing funds to a new product or a new marketing strategy.

I feel the Government's proposals for family practitioner services, both in the White Paper and in the new contract, are mainly concerned with controlling costs rather than improving services. My noble friend Lord Pitt of Hampstead talked about the Indicative Drug Budgets which I shall describe as number four of the eight—I believe it is now nine—so-called working papers. Those papers appear to use the stick rather than the carrot in achieving economy in prescribing. The words "downward pressure" and "sanctions" are mentioned several times. There is, however, a small, rather uncertain carrot for those who succeed in meeting the family practitioner committee targets. It is that half the saving will be retained by the FPC, although not by the practice itself. I feel that is perhaps rather a distant incentive.

However, there are other effective ways of controlling drug costs. The new PACT scheme which my noble friend mentioned, which stands for prescribing, analysis and costs, has been running for just a year now. Each GP knows his or her prescribing costs in comparison with a norm. While they may know the costs, they do not know the benefits of their prescribing. That would be, admittedly, much more difficult to measure, but it would be very much more interesting. That would form part of what medical audit is about. However, already one effect of the PACT scheme is noticeable. There has been a steady increase in generic prescribing since the scheme started a year ago, from 36 to 39 per cent. However, if quicker results are required, rather than through the scheme in Indicative Drug Budgets, they could be achieved through, first, further instalments of the limited list in other therapeutic categories than the ones that have already been introduced. But this time I hope the Government will carry out this scheme in conjunction with the profession rather than despite them. Secondly, of course, if they were to operate a generic substitution policy in primary care for drugs whose patent life has expired—that is already done in hospitals—a great deal could be saved. However, I do not wish to travel down that road tonight, as we have been down it before and will probably go down it again.

As my noble friend has pointed out, in some health authorities there are worrying tendencies for hospitals to offload on to GPs more and more of their prescribing costs. Recently I received a letter from a consultant at my local hospital pleading with me to prescribe a very expensive drug for a man suffering renal failure. The patient would die for lack of the drug but the hospital budget cannot now stretch to supplying it.

As has also been mentioned, the new contract provides encouragement for GPs to carry out screening and health promotion activities. That is a laudable aim, and most of the activities included in the new contract were originally the idea of the Royal College of General Practitioners although that is not acknowledged in the White Paper or the contract. The way that payment for those activities has been incorporated into the pay structure is felt by many GPs to be unacceptable. Normally, if medical practice is expected to change in order to comply with government policy additional money is offered. Here it is not clear whether that is the case.

General practitioners feel that the Secretary of State has adopted a rather bullying approach. That applies particularly to his second-in-command, the Minister for Health. That approach has antagonised many doctors who might otherwise be friends of the Government. I believe that that will undoubtedly be reflected in the result of the ballot of GPs on acceptance of the revised contract which will be announced next week.

There is a strong feeling that if the Government were seriously interested in improving the health of the nation they could do far more at one fell swoop from the centre. For example, they could ban cigarette advertising and sports sponsorship by tobacco companies, increase the duty on cigarettes and alcohol, and progressively discourage the consumption of saturated fats through differential subsidies in the UK and urge similar measures on Europe. Doctors feel that they are being put in the position of changing people's faulty lifestyles when they could be much more effectively changed through government policy moves from the centre.

Patients value easy access to the advice of their GP. They expect accurate diagnosis and the unbiased guidance of their doctor through the complexities of the National Health Service. Above all, they value time to talk to their doctor. Consultants like to see referrals from GPs which are carefully evaluated with the initial investigations completed. That, and the increasing responsibility of caring For an ageing population, takes time. Screening and health promotion may or may not be good things, but patients will not accept a situation in which their own doctor has less time to listen to their problems.

All this suggests that much more thought should be given to encouraging and recruiting all grades of staff into primary health care. I particularly echo the words of the noble Lord, Lord Hunter, and the noble Lord, Lord Brain, about the need to make conditions more attractive for women.

7.54 p.m.

Lord Colwyn

My Lords, I apologise for not having put my name down to speak earlier. I was away yesterday and noticed the Unstarred Question which the noble Lord, Lord Hunter, had put down on the Order Paper only when I arrived at the House this evening. I also happened to bump into my noble friend the Minister, who implied that he might omit the planned reference to the dental services in the 1990s if there were no dental representative on the list of speakers.

Looking round, I think that it probably is a good idea that I should say a few words. I can take up the challenge of the noble Lord, Lord Winstanley, and say that on these Benches there is a vast amount of support for the Government's proposals in the White Paper. Noble Lords may notice as the debate continues that I am moving to the right. I do so in order than when my noble friend comes to reply the support will be visual as well as moral.

In the hope of some words of encouragement for my dental colleagues, whether general dental practitioners, in the hospital service or the community service, perhaps I may remind the Minister that the general dental service is and intends to remain the basis for primary care in the next decade. The proven efficiency and effectiveness of the dental services, despite financial cutbacks and, last year, the removal of the examination charges, has continued to treat more patients and reduce dental disease with proper implementation of advice on prevention and treatment. My colleagues in the general practitioner service, who must on average spend about 30 hours a week literally face to face with their patients—compared with 12 hours which doctors spend with patients—are increasingly taking on a role which involves advice on general health as well as specialised dental treatment.

I am aware that we are currently negotiating with the department the basis of a new contract that will take us into the 1990s. I am always delighted when my noble friend the Minister is able to give us some encouragement and confirm the Government's commitment to dentistry within the National Health Service in the foreseeable future.

7.56 p.m.

Lord Ennals

My Lords, as on so many previous occasions, the House is greatly indebted to the noble Lord, Lord Hunter. On a number of occasions he has opened health service debates. He is always impeccable in his timing and in his material. He has introduced his Question at a time when the Government are in a real dilemma as to how to pursue their campaign to take the National Health Service into the realm of total uncertainty. They are seeking to impose ideas which, as the noble Lord, Lord Winstanley, sahave not been tested; proposals, moreover, which are opposed almost unanimously by the medical profession.

I believe that the issues are acutely embarrassing to the Government. I was delighted to see the noble Lord, Lord Colwyn, take his place representing the serried ranks of Conservative peers with their enthusiastic support for the Government's proposals. I have looked through the proposals to see how much they say about dentistry and with what the noble Lord could disagree. It does not say anything about dentistry at all, which is why he felt that he had to say a few words. Even now, with his useful intervention, not a word has been said from behind the Minister in support of the proposals which we are discussing here. I believe that that is because there is no support from any who are involved in the provision of those services, nor for that matter from the public.

Only at the end of last month there was a Gallup poll which showed that 71 per cent. of people who knew anything about the White Paper disapproved of the proposals; 75 per cent. believed that the White Paper would result in cuts in NHS services; 58 per cent. of Conservative voters believed that the White Paper would result in cuts in NHS services; 73 per cent. of those replying believed that the proposals were the first stage in the privatisation of the NHS, and the majority of Conservative supporters took the same view. I think that there is a dilemma in the country, not just among doctors but also among the public.

At Question Time recently the noble Lord, Lord Henley, poured scorn on a suggestion of mine which followed the European elections, which were not a triumph for the Conservative Party. He congratulated me on managing to link the health service with how badly the Government had fared in those elections. I do not believe that I needed any congratulation. It was obvious. For almost all the people in this country the issue of health is a central issue. I doubt whether even Europe, or water privatisation, is at; issue on which people feel more strongly than about what the Government seem to be blundering into in the health service.

My second ground for congratulating the noble Lord, Lord Hunter, concerns the content of his speech. I share almost all his concerns. I agree with almost all of his comments about the need for improving services; the problems of small practices; the value of large practices; the role of women doctors, full and part-time, which has been touched upon by a number of those noble Lords who have contributed; the value of multi-disciplinary services; the interesting reference that he made to what he called, I believe, secondary health care centres—for me, that was a new term which, like the noble Lord, Lord Winstanley, I find of some considerable interest—the use of sophisticated information technology; the links between the general practice and the community services for which, as he said, we still await an answer to the Griffiths Report very soon; and the links with the family practitioner committees and all the uncertainties as the body responsible for them changes. I very much agreed with my noble friend Lord Pitt when he said that, as the Government's plans proceed, the most important person in the practice will soon be the business manager.

I am not a doctor, although most of those noble Lords who have taken part in the debate are general practitioners. The first time that I had a close relationship with GPs was in 1968 when I had the honour to follow Kenneth Robinson for a brief period as Health Minister. My arrival was in the wake of the general practitioners' charter. I should think—all credit to Kenneth Robinson, none to me—that that was probably the high point in GPs' relations with the department. If that is so, we are now very much at the low point of that relationship.

It seems to me quite extraordinary how the Secretary of State and his Minister, Mr. David Mellor, have mishandled their relationship with the doctors in almost every respect. As I have said, the GPs are strongly opposed to the White Paper proposals. They see them as leading to a worsening of the service to patients and driving a wedge between the GP and his patients. That is a very disturbing fact for them. The Royal College has also been very outspoken in its criticisms of the Government's proposals, as has also recently been the Association of Community Health Councils in its annual report. It said that: Government proposals to encourage doctors to compete for more patients would not help doctor-patient relationships because they would have less time for individual patients". That is also what the patient fears. The report also said that: there is still insufficient money for the NHS to provide the quantity and quality of services expected and needed by patients. Waiting lists were too long and operations were still being cancelled at short notice". Those comments have come from a variety of different organisations.

Opposition to the contract which the Secretary of State seems to be determined to impose upon the profession was commented upon very interestingly in the current 1st July issue of the British Medical Journal, which states: Ministers should not misread the close vote to reject the revised contract package for NHS general practitioners. It went on to show that both those who voted for the BMA's contractual agreement and those who voted against it were opposed to the Government's proposals. They were all opposed to the Government's proposals. The article stated: Out of 325 voting representatives the 166 who wanted no part of it defeated the 150 who were 'reluctantly' prepared to have the package priced by the review body". Several reasons were provided for opposing the original contract; including the Higher proportion of income from capitation fees, seen as rolling back the gains of the family doctor charter by leading to larger list sizes with poorer services for patients". There are so many reasons why it must be wrong to encourage doctors to have longer and longer lists. It cannot be good for the patient. It must have some worrying implications so far as concerns post-graduate education. The article also refers to: Rigid targets for immunisation and cervical cytology screening, which would be unachievable in many areas". GPs opposed, The two tier system of fees for night work with a lower fee for doctors or partnerships not doing their own visits". Another point that I find most extraordinary is the manners that have been shown by Ministers. In this House, those who speak for the department have the best of manners. I make no criticism whatever in that respect. But the Secretary of State and Mr. Mellor sometimes seem to set out almost consciously to antagonise the doctors. There was the reference by David Mellor to the "fisherman's tales" at the time of the argument about junior hospital doctors' hours which led to the Bill put through this House by my noble friend Lord Rea. There was also the reference by the Secretary of State to concern for their pocket books". He also said: You can't negotiate with trade union negotiators and have them come back and say the lads don't want it and try to re-open a debate which they themselves have commended to their own conference". I find that an extraordinary and aggressive statement to make. Why should they not reject what their negotiators have said? According to a letter on the subject: One of the main justifications for trade union reform, which is one of the oft-proclaimed achievements of this Government, was to promote democracy by returning power to the rank and file membership. By this mechanism decisions taken by trade union leaders would be a true reflection of their members' wishes. The Government have been only too happy to insist on national ballots of miners and dockers, and rejoiced when 'the lads' rejected their leaders' calls for strike action. But the same thing seems to be happening among doctors. What is meat for the gander—

Lord Graham of Edmonton

My Lords, what is sauce for the goose is sauce for the gander.

Lord Ennals

I thank my noble friend. He is always ready with the anachronism that I seek—but it is not an anachronism. That is something on which the Minister can comment when he replies.

I do not know why the Government behave in that way. I do not know why they set out to antagonise the doctors.

A fourth reason is the failure of the department to make progress on proposals for improving the services to which my noble friend Lord Hunter referred. The BMA has fought a long battle to secure advances in many fields and to improve general medical services. In many cases it has gone along with the attitude of the Royal College of General Practitioners. Some of those proposals were outlined to Ministers in 1985, but little progress has been made. I was looking at a letter that had been sent way back in December 1985 by Dr. Michael Wilson to the then Minister, Mr. Barney Hayhoe. It raised a whole range of issues including: the extension of the cervical cytology screening programme to include all women over 20, at three yearly intervals; developing a comprehensive scheme for paediatric surveillance based on general practice; encouraging general practitioners to undertake minor surgery for their NHS patients; … providing adequate funds for general practitioners to develop surgery premises; encouraging the introduction of computers to general practice"— a policy to which my noble friend Lord Hunter referred — reducing maximum list size; offering incentives to appoint additional partners; increasing the budget available for GP postgraduate education". The letter referred to a series of proposals which the profession has sought to discuss with the department and on which it has sought to make progress. The profession now complains that in most of those fields the department has simply not been willing to make progress.

I wonder why that is. Ideas went back and forth until the White Paper was produced. The proposals made by the Government in the White Paper were not even discussed with the Royal College of General Practitioners or the British Medical Association. So we have what seems to be an attempt by the Government not to come to any agreement with the doctors and not to listen to what they have to say about the health and welfare of their patients, but simply to impose their will upon doctors and patients. That is what they sought to do over the contract and we shall have to await the outcome. 'That is what they seek to do in the proposals in the White Paper which they put before us and the country without any willingness to discuss whether they are the right proposals. They are only willing to discuss the implementation of their proposals.

That is no way to go about negotiating an improved general practitioner service. I agree with the noble Lord, Lord Winstanley, that we have a unique GP service in this country. We must protect and improve it. The Government are in no way improving the service simply by exerting muscle as a means of negotiation. This is the time for proper negotiation—discussions, analysis, experimentation, tests and trials—and we must ensure that we get it right.

I invite the House to consider how long it took to bring about the GP charter in 1965, to which reference has been made. It was not done overnight or by diktat. It was done by careful discussion with those who knew their subject. I submit that in their handling of the doctors in general and the GPs in particular the Government are moving, into a field that they seem not to understand. The time has come to abandon the ways by which they have been proceeding. They must recognise that they have created great antagonism. It is with humbleness that they should go back to the doctors. I see that the Minister smiles, but it would not be out of place for them to go to the doctors and ask how they think the general practitioner services can be improved. The noble Lord, Lord Hunter, has raised this Question. I think it would be helpful for the doctors to have their say. Presumably the Minister will give his own reply.

8.12 p.m.

Lord Henley

My Lords, I should like to join with other speakers in thanking the noble Lord, Lord Hunter, for tabling this Question. We have had a very interesting debate as a result. I should not want to follow the noble Lord, Lord Winstanley, who said that he did not want to make cheap gibes and then proceeded to do so. I do not think that one can draw any inference about the beliefs of individual Members and noble Lords sitting on these Benches merely from their absence. I believe that it is unfair to imply, as did the noble Lord and the noble Lord, Lord Ennals, that they were not supporting the Government's proposals in the White Paper simply because they were not present in the Chamber. My noble friend Lord Colwyn stressed that he supported the Government's proposals.

I hope that noble Lords will forgive me if I do not follow some speakers through all the aspects of the White Paper, Working for Patients. It is a very big subject. It will be more profitable if I deal with many of the positive ways in which, in the words of the Question, the Government plan to meet the need for family practitioner services in the 1990s.

First, however, I should like to say a brief word about the Gallup Poll mentioned by the noble Lord, Lord Ennals. It is not surprising that the public have been alarmed and come out strongly against the proposals when one sees the horrendous propaganda from the BMA which has given a quite fictitious description of the likely effect of the reforms in White Paper. Those NHS reforms certainly do not mean privatisation, as I have said on many occasions in this House and as my right honourable and honourable friends have said in another place. Nor do they mean cuts in services. Modernising the running of the service will mean better services, improved patient care and greater choice.

We are providing and shall continue to provide record sums for the National Health Service but we must ensure that those sums are spent wisely. As other noble Lords have implied, it is clear that the family practitioner services are the front line of the National Health Service. They are used by some 1.2 million people every working day. They include the general dental, optical and pharmaceutical services as well as the family doctor service. In my reply this evening I shall concentrate principally on the family doctor service, although, as my noble friend Lord Colwyn has spoken, I shall also briefly mention dentists.

On average, every person in this country visits their GP some four to five times a year. Ninety per cent. of medical treatment is provided outside hospitals, the majority of it by family doctors. Universal quality care on this scale is a tradition of which the service can be proud and one which we intend shall continue through the 1990s and into the 21st century. Our commitment to the family practitioner services is clear from the substantial extra funds that we have invested in them. Since 1979 spending on the family practitioner services has risen by some 55 per cent. in real terms to well over £5 billion a year. The Government fully expect that that expenditure will increase still further in real terms over the next three years.

Her Majesty's Government do not believe that merely increasing resources by itself can ever be the whole story in providing a first-class health care service. We need to ensure that we get maximum value for the resources we put in. That means making sure that services continue to meet the needs of the growing numbers of elderly people in our population. It means, too, improving services in the inner cities and other deprived areas to bring them up to the level of the best. It means meeting the growing expectation that the health service should be about promoting better health, not simply treating sickness. It means making the service more responsive to patients' needs.

The family practitioner services of the future must be prepared to meet these demands. We started planning for this in 1986 when we issued our consultation document Primary Health Care—An Agenda for Discussion. In the light of responses to that paper, we set out a coherent action plan for carrying family practitioner services into the 1990s and beyond. That was the White Paper Promoting Better Health, which lies at the heart of our plans for developing these services. More recently though we have set out our plans for further developments, as part of our much wider review of the National Health Service, in the White Paper Working for Patients. The first step must be to provide new contracts for health care professionals. We have invested over 100 hours in detailed discussions with the family doctors' negotiators to try to agree a new contract for them. The new contract contains much for which the medical profession has been calling for years. It also contains much that must change to meet public expectations.

There is always resistance to change, even when it is for the good. Naturally we were disappointed that the agreement on the new contract reached by the Secretary of State and the doctors' negotiators was not accepted by a narrow margin at their recent conference. We shall await with interest the outcome of the ballot of all GPs, the result of which I believe comes out next week.

The proposals that we have put forward represent the most important reforms of the family doctor services since the charter for family doctors in 1965. Our reforms build on and carry forward the principles agreed with the profession then to produce a more patient-oriented service. They represent a good deal for doctors, and an even better deal for patients.

Our objectives are clear: we want to see the emphasis shifted from an illness service to a service which might be called a "wellness" service, which positively promotes better health and the prevention of ill health. That is why we intend to place a duty on family doctors under their terms of service to offer patients advice and assistance on maintaining a healthy lifestyle.

Lord Ennals

My Lords, perhaps I may interrupt the noble Lord. Does he recognise that there is a certain difference, in that what the Minister was doing in 1965 was meeting the wishes and proposals of the doctors? He is now going flatly against the wishes and proposals of the doctors.

Lord Henley

My Lords, as I stated, we have invested over 100 hours in detailed discussions. My right honourable friend has made concessions in his negotiations with the doctors and we await the result of their ballot.

The new contract is also designed to encourage doctors to take more account of patients' wishes. For example, we want doctors to be available to their patients for at least 26 hours a week—normally over a five-day period—and at times convenient to their patients.

To achieve these objectives we need to make changes to the way doctors are paid. This brings me to another of our objectives; namely, to relate doctors' pay more closely to performance. To achieve this we intend to introduce a number of payments related to the provision of specific services. For example, there will be a fee for providing minor surgery, another for child health surveillance services and another for arranging health promotion clinics. We shall also increase the proportion of a doctor's income represented by capitation payments. This will instil greater competition among family doctors and, by that means, encourage them to provide a wide range of high quality services geared to patients' needs.

Increasing the capitation element of doctors' incomes will not mean less time for patients, as the noble Lord, Lord Ennals, claimed. The average list size has been falling consistently in recent years. With a static population and a steady increase in doctors' numbers, it should continue to fall. This means more time for patients. It is not unreasonable that doctors who wish to increase income by taking on more patients should have to work slightly longer hours.

The subject of women doctors was raised by the noble Lords, Lord Winstanley, Lord Brain and Lord Rea. A particularly pleasing development in recent years is the increasing numbers of women graduating from medical schools. I believe that it is getting on towards 50 per cent., but I am open to correction on that. We believe that women doctors have a central role to play in the health service of the future. We believe that our new contract offers them a very good deal. All too often in the past women doctors have been considered second-class partners by their male colleagues in a practice. We wish to change that. We shall do so first by increasing the commitment of all doctors to the family service. This will help women doctors to be accepted as equal partners in the practice. Secondly, to help those who want a reduced commitment—for example because of domestic commitments—we intend to formalise job-sharing and part-time working arrangements. Doctors who opt to become part-timers in general practice will be able to work fewer hours each week, but their income will be only a little lower than that of a full-time doctor. We have also proposed to ease the qualification for a locum allowance during confinement. We believe that all this adds up to a significant improvement for women doctors.

The noble Lord, Lord Ennals, read very little about dentistry in Working for Patients, but in the previous White Paper, Promoting Better Health, he would have found much about dentistry. I have concentrated so far on general medical services. We regard the same objective as applying to general dental services. That is to say, the object is to promote preventive care. To this end we are in discussion with the dental profession about ways in which their contract of service ought to be changed to give expression to that principle.

As happens on virtually every occasion on which I rise to speak at this Dispatch Box, the noble Lords, Lord Winstanley, Lord Hunter and Lord Ennals, mention the report of Sir Roy Griffiths on Community Care. Noble Lords will appreciate how important it is that we have the framework right in this vital area. As noble Lords know, we have been giving the issue very careful consideration and are near to reaching a conclusion. As my honourable friend the Parliamentary Under-Secretary of State for Health has said recently in another place, we intend to bring forward proposals before the Summer Recess. I hope that that is a slight improvement on previous answers that I have been able to give the noble Lords.

Turning now to the issue of value for money, I said earlier that services are not improved simply by providing more resources. We must question continually the value we are getting from the present level of resources. There are two clear advantages in doing this: first, it will release money for use in new ways to improve patient care; secondly, and perhaps more importantly, it will bring about an all-round sense of being involved in an effective operation which is making maximum use of resources to provide a first-rate service. This can only serve to produce and maintain high morale among health carers, which, in turn, benefits patients.

I should therefore speak for a few moments on ways in which we seek value for money. A key area is prescribing. Before I speak about the new element in prescribing, the noble Lord, Lord Rea, mentioned the introduction of the selected list. This has saved some £75 million in the first year—money which can be better spent elsewhere in the National Health Service. The drugs bill is the largest single element—more than a third—of total expenditure on the family practitioner services. The cost of medicines is some £1.9 billion a year—more than the cost of the doctors who write the prescriptions. I welcome the support of the noble Lord, Lord Pitt, for the concept that there must be some control of expenditure on drugs. There are wide variations between and within practices, with some doctors prescribing up to twice as much as their colleagues. It is generally recognised that some of this is wasteful and unnecessary. Unnecessary prescribing means that there are fewer resources for those patients who really need help.

That is why we have brought forward proposals to introduce a system of drug budgeting for GP practices. The purpose is to instil a greater sense of self-discipline into prescribing. For this, doctors will need—and are already getting—accurate up-to-date comparative information about prescribing patterns, including their own. There have been exaggerated stories about these proposals and I hope to be able to set the record straight. Let me stress that these budgets will be "indicative" budgets. Thus there is no question that they will run out or that patients will not get the medicines they need. Doctors will still have the same prescribing freedoms that they have at present. The difference will be that, if their habits are consistently out of line with what their colleagues are doing, they will be required to explain why. If there is no good reason, they will be offered advice and guidance by other doctors about how to prescribe more effectively.

We also plan to give larger GP practices the opportunity to manage their own budgets for a large proportion of their work. We have received an encouraging number of preliminary inquiries in response to this initiative which will mean that GPs can shop around to obtain the best hospital treatment for their patients. Because budget-holding GPs will have the money to back their judgments, hospitals will need to become even more responsive to the needs of GPs and their patients in terms of quality of care, waiting times and costs. Practice budgets will be set at a realistic level, as will be prescribing budgets, taking account of the types of patients on practice lists. We shall ensure that doctors have no financial incentive to refuse any category of patient on their lists.

A key objective of all these reforms is to make the service more responsive to patient needs. The best way of doing this is to give patients greater freedom of choice over where and by whom they are treated. We shall shortly therefore be bringing forward regulations to make it simpler for patients to change their doctor. They will no longer need their existing doctor's permission or be required to write to their FPC and wait for authorisation. We shall also be requiring FPCs to publish comprehensive information about the GP practices in their areas and the services on offer. This will ensure that people have the information to make informed decisions about the most suitable doctor for themselves and their families.

The consumer also wants quality assurance. I am sure that most doctors, too, would like to know that they are providing a good service to their patients. That is why we intend to continue to press for improvements in quality through our proposals for what is generally known as medical audit. That is rigorous assessment by doctors themselves of the quality and outcomes of medical treatments. Our proposals are designed to ensure that good practice spreads and that more doctors come up to the standards of the best.

All these changes imply a new role for family practitioner committees. Their remit now is to manage the services for which hitherto they have had merely an administrative responsibility. In other words, for the first time, they will be given the means to exercise real influence over the £5 billion or so which passes through their hands to the practitioner contractors.

Family practitioner committees are already being prepared for these new tasks. We are currently in the process of strengthening the management of FPCs by appointing high-calibre general managers. We are also proposing that the FPCs themselves should be slimmed down from the current 30 or so members to 11 members—a crisper decision-making body. All the members will be appointed in a personal capacity for the skills and experience they can bring to ensure the best possible provision of health care.

Bearing in mind how long I have been speaking, I shall be unable to deal with all the points raised by noble Lords. However, I should like to touch on domiciliary visits, a point raised by the noble Lords, Lord Hunter and Lord Winstanley. We are sure that the idea of domiciliary visits has a superficial appeal. But as the noble Lord, Lord Winstanley, said, in practice the system became abused. In any case we feel that co-ordinated out-patient services and the high-tech diagnostic equipment that we now have make domiciliary visits impracticable and, frankly, not often in the patients' interests.

The noble Lord, Lord Ennals, mentioned a letter to a previous Minister of Health, the right honourable Mr. Barney Hayhoe, in 1985. The noble Lord very kindly sent me a copy of that letter yesterday. I feel that he is being slightly unfair. Many of the issues raised in the letter have now been covered by the original White Paper, Promoting Better Health, and various actions since then. I feel that it is too late at night to go into detail on all the matters raised, but I shall write to the noble Lord on that as soon as practicable.

These plans are our blueprint for the 1990s. They will take the family practitioner services into the future by building on their existing strengths which have developed over 40 years of the National Health Service but, as I have shown, have not developed sufficiently in the direction of active, systematic health care for the whole population. The result will be a service that not only meets the needs of the 1990s and beyond, but which meets them in a way that is more genuinely responsive to patients' needs and wishes.