HL Deb 09 November 1989 vol 512 cc1022-46

7.5 p.m.

Lord Ennals rose to move, That an humble Address be presented to Her Majesty praying that the regulations (S.I. 1989 No. 1897) be annulled.

The noble Lord said: My Lords, before moving the Motion standing in my name on the Order Paper, perhaps I may say that I have been informed that there are some errors in the drafting of the regulations. Perhaps the noble Baroness can tell me whether it is the intention to bring the regulations forward in an amended form or in what way the errors will be dealt with.

Baroness Hooper

My Lords, I confess that the noble Lord has taken me somewhat by surprise. Perhaps I may come back to him on that point, or is an answer a prerequisite for starting our discussion?

Lord Ennals

My Lords, I gave notice to the Minister's office that I intended to ask the question because I was anxious that we should know whether or not we were to have a further debate on the issue. Not to worry. I shall not go in detail at this stage into the errors that have been drawn to my attention.

It is hardly necessary for me to tell the House that it is not my intention to divide the House on the Motion. However, I and my noble friends on whose behalf I speak felt that it would be wrong to allow the regulations to go through your Lordships' House without critical comment on the Government's handling of the nation's general practitioners. Those criticisms are on four grounds.

First, we have some major criticisms of the new contract which has in a quite unprecedented way for the first time in history been imposed on general practitioners against their will. Secondly, it has been done crudely by the Secretary of State, who seems to me to gain pleasure from insulting the medical profession gratuitously, indicating an extraordinary degree of personal ignorance about the way in which general practitioners go about their work.

Thirdly, on these Benches we take great exception to the way in which the Secretary of State is using public money to justify his side of the argument with the doctors. I had hoped to produce the advertisement I have with me for the benefit of all those noble Lords who would be on the government side of the House —but there are none apart from the Minister. It is quite scandalous that public money which should be used for the purposes of the National Health Service should be used by the Secretary of State for full-page advertisements justifying his arguments. He may say that the BMA has used its own advertisements. It has indeed. Those advertisements have been paid for from money raised by doctors who believe in the cause that they argue. If the Secretary of State needs to involve himself in costly advertisements, they should be paid for by the Conservative Party and not by the Government. I hope that this is not the last that we have heard of the issue because I believe it to be a scandalous misuse of public money.

Fourthly, I and my noble friends are concerned at the way in which the Secretary of State has dealt with the issue. We are concerned because we fear that it may be a precursor of what may be the Government's plans to impose an unwanted reorganisation on the National Health Service and on a public who time and time again have told the Government that they are convinced that their proposals will provide a worse service to patients.

Dr. Michael Wilson, chairman of the BMA's General Medical Services Committee, has said that the package which is contained in the regulations: includes features that are unethical, misguided, ill-conceived, premature and wasteful". I suppose that one could find other terms, but that is a pretty strong condemnation of the action taken by the Secretary of State against the general practitioners.

Let us face it, opinion polls show upward of 70 per cent. of the general public giving the thumbs down to the White Paper proposals. As concerns the GP contract, in an 82 per cent. poll of general practitioners conducted on the basis of a secret ballot, the contract was rejected by 76 per cent. to 24 per cent. An 82 per cent. poll is a substantial indication of the views held by general practitioners about the way in which they should conduct their own life within their own profession.

The Secretary of State recently suggested that, because the doctors decided against industrial action and mass resignation, they were somehow coming round to accepting the contract that was being enforced upon them. I have no evidence to suggest that that is true or that there has been any change in the views of general practitioners concerning the contract. There should be no criticism of doctors who decide that their duty dictates to them not to take industrial action and not to resign. It is because of their dedication to their services that they have not done so, but do not let the Government imagine for one moment that that somehow or other lessens the strength of feeling against what has been imposed upon them.

If the Secretary of State believed his own claim that general practitioners were changing their view he would proceed to secure the agreement of the BMA rather than acting by edict. He appears to think that they are coming round to his point of view and that if he gives it a little time he will perhaps be able to negotiate a settlement. I do not believe that he believes his own claim. I think that he enjoys the sound and smell of battle. I believe —I say this from my own experience —that this is no way to run a national health service.

Perhaps I may come back to the objections to the contract itself. The main objection is that by increasing the capitation element in the pay formula from 46 per cent. to 60 per cent. the Government are encouraging general practitioners to increase the number of patients on their lists. I am sure that that is a fundamentally wrong decision. When I was Secretary of State from 1976 to 1979 the objective was to bring down the number of patients on GP practice lists. That objective was worked out with the profession because GPs knew that they could give a better service to their patients —give more time to individual patients —if they could have shorter patient lists. We were working in that direction.

The present Government accepted that objective and succeeded to the extent that average list sizes were down from 2,229 in 1979 to 1,928 in 1989. I hope that they will not be embarrassed if I say that that is a good achievement in the right direction. Of course it has been achieved by an increase in the number of general practitioners, but the new contract gives financial inducement to GPs to increase their lists, thus inevitably reducing the time that a GP has to give to his patients. That is an inevitable result.

A recent study by Wilkin & Metcalfe discovered that as patient lists lengthen from 2,000 to 3,000 patients the average contact time per patient for a general practitioner falls from 30 minutes to 20 minutes a year. There are already 3,000 practices with more than 2,500 patients per GP. I hope that the Minister will give us an assurance that there is no intention to go back on the process of shortening GP lists. Perhaps she will explain how the new contract will do anything other than lengthen them.

It is encouraging and sensible that an increasing number of women GPs are restricting themselves to lists which are 35 per cent. below the average length. Women GPs are particularly strong in their opposition to the principles of the new contract. In my view that is no wonder; it conflicts with the principle of not having excessively long lists.

I wish to turn now to the gross misrepresentation by the Secretary of State of the performance of general practitioners. It is true that there are good and bad performers. There are in any profession and in any section of a profession. My impression is that general practitioners want to encourage the good performers and to raise the standards of the profession by using such inducements as will persuade the lazy minority to come up to the standards of the best. On balance, this country is very fortunate to have a high percentage of dedicated doctors in general practice. I do not believe that any country in the world has a better standard of general practice than we have in Britain and I do not want to see it lost.

Doctors are incensed —rightly in my view —by what the Secretary of State has said about them. He complains that the doctors have been critical of his proposals both in the contract forced upon them and on a wider front in the NHS White Paper. But I believe that he has brought it upon himself. He behaves as if he always knows best. He is arrogant and often insulting in the language that he uses in discussion and negotiation with and about general practitioners. In my view, his information is often gravely at fault. I want to give five examples.

First, the Secretary of State said: The averge GP works an average of 38 hours per week in general practice". The fact is that GPs spend an average of 73 hours a week on duty, during which time 38 hours spread over the week are spent providing general medical services for patients and a further five hours are devoted to other health-related activities. If the Secretary of State believes that that is wrong, let him bring the evidence to set up against the assessment already made.

Secondly, the Secretary of State said: Doctors will be more available at times convenient to patients —for at least 26 hours a week … Some doctors are very shocked by our suggestion that they should work five days a week and 26 hours a week". In fact the vast majority of GPs work at least five days a week and spend, as I said, 73 hours on duty. Doctors are rightly concerned that the rigidity which the new contract will impose upon their working pattern will mean that many doctors will be forced to work for an unbroken period of 12 days when they are on call for the two days intervening at the weekend.

Thirdly, the Secretary of State said: There will be more professional staff in the surgery such as practice nurses, chiropodists, counsellors and physiotherapists". But the money available for employing practice staff is to be cash-limited from 1st April 1990. There will be more professional staff in the surgery only if the cash limit is set high enough to pay for them. We shall no doubt come to the issue of cash-limiting general practioners when we come to the Bill, if we are offered a Bill in the Queen's Speech.

Fourthly, the Secretary of State said: the average GP receives £65,000 a year". That is a very unfair statement. It is wrong. This year GPs will earn on average £31,105. The rest of the money that they receive will remiburse them for the expenses that they incur in running a practice. I am thinking of staff salaries, medical supplies, telephone, postage, stationery, professional literature, subscriptions, accountancy expenses, premises, car and depreciation of equipment. Those are all professional responsibilities which enable a GP to do the job required of him. Therefore, to say that the average GP receives £65,000 a year as though he is now in the ranks of the higher paid in industry is grossly unfair. More than half of the money he receives inevitably goes on practice costs.

The fifth and final example that the Secretary of State gave was, We will, and must, change bureaucracy". He has had a good deal to say about bureaucracy. In fact the new contract will not reduce bureaucracy. It will indeed add to the paperwork done by health authorities and GPs. Many of the new regulations will require numerous returns to be made.

I echo the words of Dr. Curtis speaking for the British Paediatric Association. He said that, the proposals have been ill-thought out, not properly worked through and I am appalled at the rate at which they are instituted". But, of course, Mr. Clarke always knows best. I do not know the views of the Secretary of State on the principal issues that so deeply divide the Cabinet, and this is no occasion on which to speculate upon them. So far as I know the Secretary of State is a loyal Minister. I am not certain whether he is still as ambitious as he was. But his pattern of behaviour in handling the medical profession, and this particular issue that I raise tonight, suggest that he believes that in everything he knows best. He blips the critical doctors as his boss blips all her critics with her handbag. He does not believe in genuine negotiation which, after all, always means a degree of compromise.

It seems at present that he is planning to impose, with the massive majority that exists in another place, a new health package, which is not only rejected by the profession but by the public too. Therefore, I believe that the GPs' contract, and the way in which the Secretary of State has handled it, could well be a precursor of the way in which the Secretary of State will handle the problems relating to the health service.

It was my view that these concerns should be expressed —even though there were few on the Government Benches to hear them —before the Government proceed along their route of conducting policy in relation to the health service regardless of the attitude of the professions and regardless of the attitude of the public.

Moved, That an Humble Address be presented to Her Majesty praying that the regulations (S.I. 1989 No. 1897) be annulled.—(Lord Ennals.)

7.23 p.m.

Baroness Robson of Kiddington

My Lords, I rise to support the noble Lord, Lord Ennals, in his prayer to annul. All of us, I believe, agree that the one thing we are terribly proud of in our National Health Service is our general practitioner and family doctor service. It exists in hardly any country in the world to the extent that it exists here, and it is the envy of many countries. I can speak with some feeling having been born and brought up in Sweden, which is well known for its good medical practice. The one thing Sweden no longer has is a family doctor service. They managed to kill it off after the war. There is nothing they have regretted as much. We have a wonderful service. It is only 7 per cent. of the health service budget, and we want to preserve it.

I agree with the noble Lord, Lord Ennals, that the new contract endangers the position. I am concerned, as he is, that the move is away from a practice allowance to a capitation fee. I believe that the Government have done this because of their obsession with competition. It is like going back to the bad old days at the beginning of the National Health Service when pay was wholly by way of capitation. It was decided long ago that such a system of remuneration destroyed co-operation between GPs. They hardly spoke to one another. The feeling was, "If I let him go to see my patient I am likely to lose the patient and he will get the capitation fee".

The practice allowance was brought in to improve the position. The contract now proposes that the capitation fee should be raised from 45 per cent. of remuneration to 60 per cent. How do we know that it will not be raised again to 70, 80, 90 or 100 per cent., and we are back where we were without co-operation between general practitioners?

This change has two further worrying implications. First, as the noble Lord, Lord Ennals, said, it will inevitably be a move towards increased list sizes so as to maximise the doctors' income. Doctors are human beings. They have all the natural desires to improve their standard of living. During the last 20 years, with the support of the profession and of governments, a reduction of the average list size, as has been stated, has been achieved. We all agree that the ideal list is something like 1,500. That reduction has been wholly beneficial but it will not continue. The increased emphasis on capitation fees will provide an incentive to keep list sizes high and mitigate against taking on new partners.

Despite the reduction in list sizes, people —and many general practitioners —still complain that GPs are too pushed to give adequate time to each individual patient. However, the new contract will also increase the range of services that GPs will be required to provide for their patients. Most of these services are highly desirable. But how are they to be achieved? By cutting further the time available for an individual patient.

Secondly, and this concerns me particularly, there is the impact on the position of women GPs, which will be highly detrimental. As a woman I am delighted that today 22 per cent. of all GPs are women. The ideal we should work towards is that each group practice should have at least one woman partner. Many women GPs work part time in the service because of family commitments, and the new contract has inbuilt disincentives for part-time and flexible working arrangements.

At present for a 20-hour week, plus one night a week on call and every third or fourth weekend on call, the practice allowance is roughly £15,000 a year. Let us assume that the practice pays the female GP £18,000 a year for her contribution. The cost to the practice is £3,000 a year. Under the new arrangements a part-time female GP will bring allowances of only £6,000 a year or less. Under the new arrangements it is not difficult to see that the opportunities for part-time employment are going to contract.

I have a personal interest in this subject. My youngest daughter is a general practitioner. She achieved her part-time partnership a couple of years ago, and she is a partner in a practice. I doubt whether she would have been offered the post if she could not have started until after 1st April 1990, and she is already being pressurised by her partners to take on a full-time commitment. She has three small children. She is a first-class GP, but she cannot at this time commit herself full time. This is yet another incentive for existing partners to increase their lists instead of taking on a female part-time general practitioner.

Finally, I should like to refer to the problems created in the contract by the new system of bonuses for vaccinations and cervical smears. It introduces lower bonuses for 70 per cent. vaccination and 50 per cent. smears and higher bonuses for 90 per cent. vaccination and 80 per cent. smears. This will inevitably favour those GPs who practice in an area of more socially conscious and better educated populations against those practices in socially deprived areas. Yet these are exactly the people who need the sevice most.

Another problem faced by this innovation is how one defines a target population, particularly in areas where there is a great movement of people such as the inner cities. In my county of Oxfordshire, which is not a deprived area, the targets set by the Government were shown to be unrealistic. A review by Dr. Martin Lawrence on the prevention rates in 45 practices found that only one achieved the 90 per cent. target for immunisations. In inner cities, according to Polnay and Horn, only 5 per cent. of children attending child health clinics had completed a full course on schedule.

The Government will no doubt argue —and I would agree —that these figures show the need to take urgent action. However, it will not be done by putting the onus solely on the doctors. There are many good provisions in the new contract —for example, the need to give a proper medical examination to all new patients and the need to visit elderly patients regularly. Those are marvellous things. However, it will not work under the existing conditions. I therefore have great pleasure in supporting the Prayer.

7.31 p.m.

Lord Kilmarnock

My Lords, in one sense it seems superfluous to be debating these regulations this evening after the Secretary of State has declared his intention to impose them, and the decision of the family doctors' professional bodies not to leave the NHS or to go slow as a result. I assume that the noble Lord, Lord Ennals, in accordance with the usual practice of the House is not going to push his prayer to a vote. If I am right, what the noble Lord has given us —and we must thank him for this —is the opportunity for a few reflections on this less than happy episode in the Government's relations with general practice.

As the noble Lord, said, the Government have taken expensive space in the national press to acclaim the benefits that patients will derive from the new contract. Some of the innovations will be good news for the general public; others which are not mentioned, such as the retirement age of 70, will command wide support. But the government advertisement says nothing of the background issues that led to such bitter conflict with the profession. All that is swept under the carpet.

I was not in favour of the scare tactics adopted by the BMA, but there are a few points which cause legitimate concern. First there is the question of population targets for preventive measures. Although rewards for these have been set within two bands, in my view it remains unfair to link doctors' remuneration to invasive procedures which may go against the wishes and convictions of some of their patients, to say nothing of the widely differing demographic characteristics of different practice populations which can make the targets very difficult to achieve.

There can be little dissent from the value of immunising children or checking on the over 75s. Many doctors will want to move in those directions in any event. However, making payment dependent on the success rate raises both practical and ethical problems. Patients acquire patient status on a voluntary basis and it is very important that this principle should not be contravened. It is reasonable for GPs to seek to persuade, but their remuneration should not depend on it.

Indicative budgets for drugs aroused comparatively little opposition, and I have always supported the extension of generic prescribing wherever it is sensible with well-tried products. However, it would be quite possible for an efficient general practice to be successful in detecting moderate to severe hypertension in its adult population and to control raised blood pressures, for example, almost entirely with older generic and therefore relatively cheap drugs. But the toll in side effects compared with what might have been expected from more modern and more expensive medication could be considerable and could be hidden from view until possibly revealed by medical audit.

It is worth pointing out to the Government that medical audit may not always go the way they would like in regard to reducing costs but may suggest the need for more, not less, expenditure on one or other aspect of the service under review.

The question of raising the capitation proportion of remuneration to 60 per cent., to which the noble Lord, Lord Ennals, and the noble Baroness, Lady Robson, referred, is not included either in the government advertisement. I am not as opposed to it as some critics —and that would include the noble Lord, Lord Ennals, and the noble Baroness, Lady Robson. There is little doubt that the large, efficient practices will be able to cope partly by laying off part of the workload on an expanding support staff. There are many procedures which can be very well carried out by practice and community nurses, and I for one would like to see an increase in their numbers. In the long run there is no reason why patients should receive less time, given that the total number of doctors and the total number of patients are not going to vary greatly.

There is a very real concern that the smaller practice, with a list of 4,000 to 5,000 patients and with one or two part-time partners who may be women —and I am bound to say that I agree with the noble Baroness, Lady Robson —will suffer and be forced to amalgamate or go out of business. I should like to ask the noble Baroness what cushioning, if any, the Government are proposing to provide for them. Smaller practices will often be in deprived or rural areas. Can she spell out what will be done to prevent their going to the wall? Will the contract be modified if this seems to be happening? It is very doubtful, in my view, that a single, inflexible contract on these lines can accommodate the very wide range of different types of practice that we have in this country. I should be grateful to hear something about that matter from the noble Baroness.

Despite these and other anxieties, it is likely that GPs, through their own professional good conscience, will ensure that the contract works as well as possible. That does not mean that it is the right or the best contract. Apart from the details, there are two major criticisms of it. The first is that its origins lie not in the recent White Paper Working for Patients but in an earlier paper Promoting Better Health which was published in 1987. It is therefore backward-looking and tinkers with the existing arrangements, quite damagingly in some respects, without addressing the radical proposals of Working for Patients which will presumably be embodied in the legislation that we believe we are due to see shortly.

Perhaps even more importantly the proposed contract has had a thoroughly disorienting effect on family doctors and their morale and has distracted their attention and that of their professional bodies and the media from the very interesting possibilities of the budget-holding idea. I am opposed to the Government's proposal for self-governing hospitals for technical reasons which I will not go into here. We shall have plenty of time for that when we get the Bill. On the other hand, the budget-holding proposals seem to imply interesting possibilities for a quite significant shift of emphasis from secondary to primary care, leading possibly to the revival of community hospitals for minor surgery, strokes, convalescence and care of the geriatric and dying—all of which I support. Family doctors in future could have much more control over these kinds of intermediate services on a more human scale for their patients than can be provided in acute hospitals. Those could be very interesting and beneficial developments.

Therefore, particularly on those grounds, I regret that the red herring of the contract has been imposed on this much more important debate, particularly as I believe that it is going to require revision in the light of experience.

There are parts of the regulations that we can all welcome. The noble Baroness, Lady Robson, has referred to some. However, it would have been better to have left the contentious parts unchanged for the time being in order to get professional support for an expanded primary care and preventive role and to give time for doctors to settle into the system. The Government have rather clumsily elected not to do so, and to fight the profession on two fronts. That is a bad tactic, to say the least. Ultimately the Government have to depend on the profession to implement the reforms in the interests of patients. They simply cannot get round that aspect.

I very much hope to hear from the noble Baroness this evening that the Government do not regard these arrangements as set in concrete for all time. If I hear that from her lips, I for one shall come to the debates on the Bill in a very much better frame of mind.

7.41 p.m.

Lord Butterfield

My Lords, I came prepared to speak in the debate about the support that I should like to offer for many of the matters in the document which is the subject of this Prayer. I should like the noble Lord, Lord Ennals, to know that I was very proud to serve under him when he was Secretary of State; I was always very well received by him. I had not realised that this debate would be more on what I shall call the party political side of general practice than on the principles that lie in the regulations. Noble Lords must therefore forgive me if I concern myself with the principles that are incorporated in the regulations and offer praise where I think it is due.

In order to give the Minister a little succour, I ought to record that one can find quite a lot of general practitioners who are not so distressed about the proposals and the new contract as might be supposed from reading Hansard. Since the White Paper has been mentioned, I ought to put forward my views on it. The health service has changed in two respects since 1948. We must therefore not be surprised that more management is coming in. I understand the point of the noble Lord, Lord Ennals, about the Secretary of State's performance in the cockpit of politics, and with the BMA. As I am sure he must have found when he was Secretary of State, we now have two factors that did not exist in the past. No longer do we use British pharmacopoeia remedies; no longer do doctors send their apothecaries to the physic garden. The health service has an enormous international pharmaceutical industry with which it has to deal through a price regulating scheme. So far as I can make out, the scheme is working. However, it will undoubtedly need a good deal of scrupulous surveillance through close management.

We have to admit that the medical profession and the other professions involved in the health service have become better organised, more unionised, than in 1948. I sense that, if we wish to obtain more money from the hard-headed men in the Treasury, it may be wise to make it clear that there has been a period of careful scrutiny, better management and the clearing away of wasteful practices such as the use of expensive medicines or procedures which may not be so good as the users might like to think.

Having said that, I agree with the noble Baroness, Lady Robson, that we are very fortunate with our general practitioner force in this country. I shall not speak for much longer because I shall be followed by the noble Lord, Lord Rea, who is a general practitioner. Noble Lords may ask why I, as a hospital professor, should be involved with such a document. My excuse is that at Guy's I became very interested in trying to organise an integration of community service and general practitioner service arrangements in the new town of Thamesmead. The noble Lord, Lord Kilmarnock, will be pleased to know that there we were very keen to use the ancillary people as best we could. Professor Peter Higgins, who ran the show, has told me that he is in favour of the kind of developments that are looming up for general practice. He thinks that they will present an opportunity for better organisation of general practice in the future. We can only hope that all the noble intentions in this document will succeed.

I wish to make a few remarks about the regulations. I find many people who are very cross about the contract have not read the schedules very carefully. In Schedule 1, paragraph 5, it states; the services which a doctor is required by sub-paragraph (1) to render shall include the following:— (a) giving advice, where appropriate, to a patient in connection with the patient's general health, and in particular about the significance of diet, exercise, the use of tobacco, the consumption of alcohol and the misuse of drugs and solvents". It is good to see the idea of health promotion and health education enshrined in this document. I am very interested in health promotion through the work of the Health Promotion Research Trust, on which I serve. The health promotion field will undoubtedly expand very rapidly as a source of interest and research. Some of our young research workers in Scotland have come up with pretty firm evidence, despite what people may have been reading, that a pregnant woman is highly unlikely to cause any harm to the foetus that she is bearing if she keeps herself down to one standard drink a day. That is information which those general practitioners giving advice to their patients will need. More work is going on to show the tolerance limits about which the population can be advised.

I thought that the recommendations about the elderly were very good. The noble Baroness, Lady Robson, also liked that part of the regulations. The possibility that general practitioners would make a domiciliary visit, would be concerned about the sensory functions and mobility and preventing accidents in the home were logical and splendid steps forward. I know that many general practitioners do so, but that this is now becoming part of the standard arrangements in general practice appeals to me immensely.

I was also intrigued by Schedule 5 to the regulations. It concerns minor surgery procedures, such as intra-articular and periarticular injections, the treatment of varicose veins and so on. I am very pleased that it is included because people abroad have often thought that our general practitioners were primarily concerned with psychosomatic medicine. It is nice to see that the other part of the medical school curriculum is coming through in this way.

I merely give these observations as a general practitioner watcher. I am relieved to know that the noble Lord, Lord Ennals, will not push this to a vote. I hope that the Government will receive credit for bringing to the forefront matters such as those I have picked out from the document. I hope that they will not be lost in the party political conflagration that appears to be going on in this field at the moment.

7.50 p.m.

Lord Rea

My Lords, in supporting my noble friend's Motion, I feel that I can claim to represent both general practitioners and their patients. Everyone is a patient at some time. The subject therefore concerns everyone. I ask first whether these regulations will improve the well-being of patients; and, secondly, whether they will help the professions which are involved in working towards that end. Although the changes are intended to benefit patients, the overall package may prove to be very unpopular.

Last month Which? magazine showed that adequate time with their GP is what consumers value most of all. I am afraid that these regulations and the proposed changes to the basic practice allowance and capitation element will have the opposite effect. Doctors are to be encouraged to look after more patients and more of their efforts are to be diverted to checking and screening. That may be to the detriment of good clinical care which is the time-consuming part of medicine. If carried out properly it may lead to rational prescribing and rational referral practices using the hospital service.

At present people in large numbers seek alternative medicine because they do not have sufficient time with their GP who perforce must have his mind on the clock. Private medicine is popular largely because people can buy professional time. I am afraid that the proposals will give patients less time to talk to their GP about problems which really worry them.

As a GP I can only echo the deep disquiet with which the regulations are viewed by my colleagues. That is not so much about some of the new services which are to be encouraged but about the way in which consultation with the profession was handled and the unnecessarily directive, bureaucratic and possibly unworkable nature of the regulations.

Almost every week the medical press contains well-thought-out descriptions of the difficulties that will occur if the Government press ahead with the new contract on the present timetable. I am aware that every National Health Service GP originally agreed to provide services according to the terms of service for the time being in force. They have changed from time to time but changes are supposed to be preceded by consultation, with advice from the professions' representatives.

The noble and leaned Lord, Lord Denning, recently expressed a view in a letter to a GP, Dr. John Cormack of Essex. He stated that the new terms may be so different from the existing contract as to constitute a completely new contract which each and every GP should sign individually. I understand that a legal challenge to the new contract is being considered, despite the BMA's original advice that they must accept the contract as it was imposed upon them.

The major change in the new contract is the diminution of the basic practice allowance, the abolition of seniority payments and group practice allowances and the augmentation of the capitation element. I know of no medical voice which has welcomed that. It goes totally against the trend which my noble friend Lord Ennals and the noble Baroness, Lady Robson, have mentioned; namely, the trend to encourage small, manageable lists of just under 2,000.

Formerly when changes have been made to the terms of service to further government policy, additional payments have been offered. In this contract, income is first taken away. New services must then be provided in order for the GP to break even. Some doctors, giving good service (but not in rural or deprived areas thus attracting an extra payment) with lists of about 1,500 —which we believe to be the optimum size —will lose up to £.10,000 of income per year if they do not provide minor surgery, health promotion and child health surveillance and achieve targets in cervical screening and childhood immunisation.

I do not suggest that such things are bad. I suggest that it is unfair to require a doctor possibly approaching retirement, probably well liked by his patients, giving good and caring service, suddenly to have to alter his mode of practice which was until then perfectly acceptable in order not to lose income and to comply with the new regulations. Surely new procedures should attract new money. The basic practice allowance should not be reduced so drastically, possibly never, but certainly not initially.

I make a plea to the Minister that if the changes in pay structure are to be introduced this should be done in stages; that the carrot rather than the stick should be used. Many of the doctors who will lose do not deserve to be penalised.

I should like to raise a few points of detail. As the noble Baroness, Lady Robson, mentioned, there is much concern about the inaccuracy of doctors' lists in inner cities. Therefore, the achievement of targets will be difficult. The population is so mobile that it is difficult to keep track of individual patients. Perhaps the Minister is aware of a recent study carried out by a team at St. Mary's Hospital into cervical screening in north Kensington. It found that in 52 per cent. Of the records of patients on GPs' lists the addresses were inaccurate. It has been said that it is the responsibility of GPs to update their records but that is almost impossible without much additional expense. Can the Minister say how that problem will be addressed?

Many GPs believe that the regulations are too detailed and venture into areas which should be left to professional discretion. How many noble Lords and noble Baronesses over the age of 75 will welcome annual inquiries into their powers of urinary continence? How will each family practitioner committee monitor whether each GP records the 13 items of clinical information required for each new registration before receipt of payment?

All this adds weight to my suggestion to phase the programme slowly and drop items which are unworkable. I suggest that if that is done the profession is much more likely to assist.

7.56 p.m.

Baroness Masham of Ilton

My Lords, perhaps I should declare an interest on three counts. First, I have the honour to be an honourary fellow of the Royal College of General Practitioners. Secondly, like many people throughout the country, I have a chronic, long-term disability and I am dependent on the National Health Service. Thirdly, I live in a rural area.

I should like to bring to your Lordships' notice some of the concerns and wishes of patients. It is a great pity that more diplomacy was not used when introducing the contract to doctors. On the whole, people are suspicious of change and if the Government had discussed their aims with the Royal College of General Practitioners and the Royal College of Physicians perhaps there would not have been so much fury. It has not helped the general practitioners, the Government or the patients. Many patients feel frustrated and worried.

As in all professions and groups of people, a percentage will be laggards. Perhaps the Government set out to try to call the lagging doctors to order and get them to fulfil their obligations. But I have heard that the contract may not achieve that aim. It has infuriated many of the good and hard-working doctors, who feel that good practice has not been appreciated.

In October 1989 Which? magazine carried out a survey into patients' wishes. Among the top five in the "What I want from my family doctor" list are: "More time explaining about my illness"; "More time explaining about the drugs"; and "More time listening to me". More than eight out of 10 people said that it was important to them to have more information about the specialist to whom their GP was referring them. More than seven out of 10 people said that it was important to have a choice of hospitals to attend.

Shorter waiting lists at the surgery and more helpful receptionists were rated as important possible changes by eight out of 10 people. A nicer waiting area was only considered important by just over half. I should like to ask the Minister whether she can explain how doctors will be able to spend adequate time with their patients if they are being encouraged by the new contract to have more patients on their lists and to spend more time checking well patients when ill patients may be neglected.

Can the Minister give an assurance that patients with long-term disabilities such as kidney disease, diabetes, paralysis, cystic fibrosis, epilepsy and all the other disabling conditions will be well looked after and receive the drugs which they need to maintain a good quality of life? There is concern that no serious thought seems to have been given to those patients who feel that they may become the unpopular unwanted patients when trying to get on a doctor's list.

I give your Lordships an example of how difficult it can be for a disabled person to get on a doctor's list. One afternoon I telephoned the general practitioners committee here in the Riverside Health District to see how many practices were available for a disabled person who uses a wheelchair. The list I was given included several practices which I was told had accessible facilities. That turned out to be untrue when I telephoned. Most of the practices had steps and the ones with access said that they could not take any more patients on their lists. I am sure that they were the popular practices.

With more pressure put on the practices to take more patients, what are disabled people to do if they have no safeguards? I ask for an assurance from the Minister that the money will follow the patient and not the patient follow the money when the patient goes to hospital.

I live in a rural area when in Yorkshire. Many of the GP practices will not be budget holders. Will the general practitioners still have total freedom to refer a patient to the consultant or hospital which the doctor and patient choose? There is fear that if districts take block bookings of beds the family doctor may lose that vital choice. If a doctor has to send the patient to a consultant chosen by the district and that consultant is not considered the most suitable for the patient, all trust among patient, doctor and district will break down. If the Minister can make a statement about that this evening she will help many doctors and patients who have genuine concern about that matter.

In rural areas it is vital that there should be no curtailing of cross-boundary flows. The doctor knows which consultants do good work and sees the good and the bad results when the patients return from hospital. There is very great fear that the districts will hold the purse strings and may dictate where the patients are sent. That would be a passport for the bad family practitioners to sit back and let that happen while the good GPs would become more and more frustrated.

It would be quite unfair if a financial or any other type of penalty were imposed upon practices which opt not to be budget holders. Some GPs have over-prescribed tranquillisers with dreadful results and that should be corrected. However, no GP should be penalised in any way for exceeding indicative drug budgets so long as treatment is being given in a responsible and reasonable manner.

I hope that the Government will reconsider the contract for women GPs to make it more flexible. Women GPs can be of great value in a practice when women patients may desire to see a woman doctor.

I thank the noble Lord, Lord Ennals, for giving us the chance to bring to your Lordships a few points of concern this evening. It would be a serious state of affairs if the conflict between general practitioners and the Government continues. For the sake of patients, I hope that there will be a happy ending and that all people involved will swallow their pride and put the real needs of patients first.

8.5 p.m.

Lord Pitt of Hampstead

My Lords, I must apologise for coming in at this stage. However, earlier this week I went to the Chief Whip's Office to put my name down for this debate and was told that there was not a list. That is why I am not on the list this evening.

I speak this evening in sorrow rather than anger because I believe that the Secretary of State missed an opportunity. He is like a general who was in a way in a position to win a battle and proceeded to take the necessary steps to lose it.

If the White Paper suggests that we shall have certain changes in the National Health Service, those changes are predicated on the co-operation of general medical practitioners. I cannot see how the Minister can start by placing practitioners in the position where they are utterly opposed to him, not only on the new arrangements but on the basic arrangements. Therefore, I am sorry not only about that but I am sorry that we shall not divide the House this evening. The Minister should be made to go back and negotiate and try to improve the situation.

I say that because as the debate within the profession has crystallised it is apparent that there are about three issues on which the profession is very much up in arms. The first is the increased capitation fee and the fear that there will be large lists and less time. There was a suggestion by the negotiators that the Minister should reduce the upper limit, which is now 3,500, to 2,500. He may not wish to be as drastic as that. However, after the profession had voted against the contract, the Minister should have seen the negotiators again and tried to see in what way the Government could meet the profession. My view is that a reduction in the upper limit would have been a gesture suggesting that the Government are as concerned as the profession about large list sizes and are prepared to see that that does not happen. I think the Minister missed an opportunity.

We know something about large list sizes. I started in practice in 1950. In 1961 when I went on the LCC I had 3,500 patients and I was specialising in midwifery. When I could not actively serve on the LCC doing that, I gave up the midwifery and I gradually reduced the practice to 2,000. When I first reduced the practice I had financial difficulties until there was the charter. The charter, which gave me seniority allowances and matters like that, made life much more tolerable for people like me. I believe that 2,000 patients is a good list. You can handle that number.

I am quite amazed at all this talk about the days and hours that doctors work. I worked six days a week from 1950 until 1983 but I gave up working on Saturdays in 1983 because my wife had been badgering me to do so. I did that when I was 70 years old. I confess that I was sorry I did not give up Mondays instead of Saturdays because Saturday was my best practice day from the point of view of the patients. This idea of suggesting the number of hours that doctors give patients is nonsense. Doctors give full time to their practices and the Government should react accordingly.

The other way the Minister shot himself in the foot is on the question of targets. Targeting is sensible, but it is clear from all the information that there will be areas where targeting will be very difficult. The Minister ought to have kept the item of service fee at a lower level than it is now and have the target as a bonus. What will happen as a consequence of merely paying the bonus is that the best will be made the enemy of the good.

If you are in an inner city practice and you know, because of the changes, that you are never going to reach your target, there is no incentive to go out of your way to carry out immunisations, and so on. On the other hand, if there was an item of service payment there would be some incentive to go out of your way to add to your practice income.

These are two ways, therefore, that the Minister could have met the profession and where, as a result of discussions, the negotiators could have said, "We have had concessions from the Minister which improve the contract. We suggest that our first proposal should be signed. We have improved it even more than before. Will you now agree to it?" The Minister would probably have carried the profession if he had taken that attitude. Therefore, I should like to hear the Minister say that she will inform her right honourable friend that it will be wiser for him to try to meet the profession half-way. Unless he does that we are going to have more problems than we need.

I give another example. The suggestion in the White Paper is that we should have family practitioner committees with only one doctor on them. The FPCs on this contract are given many powers. It reduces opposition from the profession if doctors are well represented on the FPCs. The Government ought to be thinking along those lines in a positive and not a negative way.

There is a large government majority in the Commons and it is easy to impose the will of the Secretary of State by using that majority, but that is not sensible. I know the Minister cannot make such promises this evening, but I hope she can agree to inform her right honourable friend that he should, so to speak, step back a little and give more thought to how to bridge the gap that at present exists between the Government and the profession.

8.14 p.m.

Earl Russell

My Lords, listening to this debate I am increasingly being drawn to the suspicion that the Secretary of State has brought on himself a great deal more obloquy than he needed. It is not only my noble friend Lady Robson, with whom I agree entirely, who believes this contract contains some good points. That view is quite widely held around the House, but it has not produced a good reaction.

Listening to the Secretary of State talking about doctors I am led to reflect, first, that there may be worse things than to have the Parliamentary Under-Secretary of State for Education and Science in charge. Secondly, this Government rave not been very fortunate in their relations with the professions. Indeed, when they complain about their experience with the professions or with public service workers it sometimes reminds me of King Henry VIII in a state of hurt bewilderment lamenting h is misfortune in meeting with such ill-conditioned wives. Henry genuinely wanted to know the answer to that question. It was a rather risky thing answering King Henry's questions. I hope our situation is a little safer than that.

The problem we are suffering from here is one of philosophy. The Secretary of State in his speech to the Tory Reform Group avowed that he had a philosophy and that it was the same as this Government were bringing to all the public service professions. A philosophy in politics is a little like hypertension. We can mostly live with it, but it needs controlling by a daily dosage of real life. It is this controlling by the daily dosage on which the Minister is possibly getting a little short.

I have been re-reading the Minister's speech to the Tory Reform Group. He insists on three points regarding this philosophy, all of which are relevant to why he has got into so much trouble tonight. First, he insists on shifting power from producers to consumers. The Liberal Democrats are all in favour of consumers, but if a noble Lord who, for the sake of argument, runs a bank were to hear an academic at present on this side of the House coming to the Dispatch Box and insisting that banks should be rearranged to increase the power of pupils against tutors, he might feel a certain amount of bewilderment. You cannot transfer models from one place to another like that. Circumstances vary.

Secondly, the Secretary of State insists on competition. Again, on these Benches we have nothing against competition, but the Secretary of State was once described —I think it was in the Sunday Times—as a person whose instinct, faced with a problem, was to throw competition at it. That is the problem. In the thinking of the Secretary of State, so far as I can follow, the increase in the element of capitation fees represents the element of competition. GPs are being encouraged to compete with each other in order to increase their list sizes. The object of competition, as the Secretary of State understands it, is to increase what he understands by efficiency.

I have attempted previously to draw attention in this House to the inadequacy of this Government's understanding of the word "efficiency". It would be an exaggeration to say that they use it simply as synonymous with "cheapness", but it would be rather less of an exaggeration than I would wish to see. In this philosophy there seems to be a real conflict with professional standards. It is where these two languages meet that there appears to be a misunderstanding between the Government and the professions because this leaves out two professional standards. One —the concern with quality —gives many professionals a definition of efficiency entirely the opposite of the Government's definition. The other is a concern with standards of service.

Where there is such a conflict of language there has to be give and take; there has to be dialogue. The language of professionals has in some cases perhaps been too indifferent to the issue of cost. Some correction is taking place in that regard, and I believe that it is needed.

However, adjustment has to take place on both sides if dialogue is to come in. The capitation fee seems to have been the overwhelming centre of criticism today. It is the area of competition which encourages the building up of bigger lists and gives bigger rewards to those who do so. It has been pointed out many times that it will encourage GPs to spend less time with patients. That is the opposite of what we mean by efficiency. It sounds a little like James Bond's recipe for running a whorehouse. You need a quick through-put like a casino.

I shall mention a few cases where I believe this situation will be liable to cause particular trouble, one of which has not been mentioned so far tonight. That is the case of academic medicine, which is of considerable concern to a number of my colleagues. I know that there is provision in regulations for those doctors who also have a teaching commitment. I must declare an interest because my own doctor is one of them. But there is an adamant insistence that they must be available in their surgeries four days a week. People who try to do two jobs know that there is a constant struggle for adjustment. One cannot absolutely guarantee that there will not be an emergency at the other end of the line and that one will not have to reorganise because, for example, a colleague is ill.

There is not enough flexibility in the arrangements for GPs who are also engaged in teaching. That is a pity. Speaking from experience, I believe that it adds something to a GP's ability to understand and communicate with his patients. I agree with everything that my noble friend Lady Robson said concerning women doctors, and that is the only reason I am not going to say it all again. I do not think I could say it better.

Like the noble Baroness, Lady Masham, I am concerned about rural practices. I know that negotiation is still continuing on that matter. I hope that negotiation will be conducted with a little less philosophy. I also agree with what the noble Lord, Lord Rea, said about records. I once had the experience of canvassing in an area close to the one he has described on a brand new electoral register which was already 20 per cent. out of date. You cannot do any better than that.

What is going to happen when the pressure to increase list sizes has been in operation for some time? Are we to get a great number of bigger lists and therefore fewer doctors? Is this in fact a covert drive for saving by reducing the number of doctors? I think that is probably not the case. On the other hand, if it is not that, then it is a procedure for the weakest to go to the wall in order to encourage those who can build up big lists and drive out those who cannot.

The Secretary of State believes that this will be competition inducing the success of the best. What many of us wonder is whether it may be competition leading to the success—as we would see it —of the worst.

8.23 p.m.

Baroness Hooper

My Lords, I begin by thanking noble Lords on all sides of the House for their contributions, many of which have been made with the benefit of practical experience. I say to the noble Lord, Lord Ennals, that the preliminary point he raised with me as regards errors in drafting took me by surprise. I certainly have not received notice of his question and I am not aware of any such errors. However, I shall look into the matter.

In the course of our debate this evening we have ranged widely over the field and perhaps in one or two cases, outside it. However, the debate has been both interesting and instructive: interesting because we have had a useful examination of those parts of the new contract which have proved controversial; and instructive because I now appreciate more than ever the extent to which there is a continuing misunderstanding and misrepresentation of many of the Government's objectives.

In launching the public information campaign about changes in the family doctor service, my right honourable friend the Secretary of State made clear his support for the general practitioners' service. In these GP contracts we are setting a framework to take the service into the 1990s. With these changes we want to see a family doctor service where all GPs reach the standards of the best and provide a wider range of quality services to patients. I believe that we are all united in that aim.

After the most thorough review of primary health care involving three years of consultation and debate with the public and the profession, we are finally moving towards improved services on the ground. Informing the public is an important part of that process. It is no good changing the GPs' contract to introduce more and improved services and greater patient choice unless the public knows about it. For that reason the Govenment produced a public information leaflet setting out the main changes that we are introducing backed up by advertisements in national and local newspapers.

We have started the campaign now because we want the public to have as much notice as possible of what to look for from their family doctor. Some practices already provide all the new services, but unfortunately not all of them. General practitioners in the latter category will be reviewing their position in the light of the new contract. It will do no harm if their patients are better informed and bring a little pressure to bear to encourage an improvement in services.

The noble Lord, Lord Ennals, criticised the way in which my right honourable friend the Secretary of State has conducted consultations concerning the new contract. The noble Lord said that it would worsen services to patients. And he expressed regret that the contract is being "imposed", as he put it. The new contract will improve services to patients. It will do so by raising the quality and increasing the range of services available; for example, by introducing new payments for child health surveillance and minor surgery. The contract would also help patients by increasing the information available about the services that general practitioners provide and by making it easier to change doctor if the patient is dissatisfied.

We on these Benches regret that it has been impossible to reach agreement on the new contract. It is not for want of trying by the Secretary of State. Since the White Paper promoting better health was published in November 1987, there have been over 100 hours of face-to-face discussions with the profession's representatives. Indeed, agreement was reached with those representatives on 4th May. In those circumstances my right honourable friend had no choice but to proceed with implemention. I was relieved to hear from the noble Lord, Lord Butterfield, that many GPs support the contract. That has also been my experience.

It is interesting to note that the contract agreed with the GPs' leaders is now being refuted. The same leaders are the ones who were re-elected after the rejection or refuting of the contract. The Government are convinced that this is the best deal for both patients and GPs. We believe that they will come to recognise the benefits once the new contract is in operation.

We do not believe that an increase in capitation will lead to an increase in the average list size. With a static population an increase in GP numbers of over 400 every year and with plenty of applicants for practice vacancies, the average list size must continue to decline. Some GPs may wish to build up larger lists to increase their income, but patients will not join or remain on the list of a GP who takes on so many patients that he or she can no longer provide good quality services. That is our interpretation of competition.

Perhaps it is only fair to quote that the last survey of GPs' workload which took place in 1985–86 showed that the average family doctor worked 38 hours a week in general practice, including the calls answered while on call. The average doctor was on call for a further 31 hours but not actually called out. Nearly a quarter worked fewer than 30 hours a week in general practice. A Kent University study showed that only part of the extra time released by falling lists is spent on patients. The rest is spent on increased leisure. The number of practice staff, nurses and receptionists has increased by more than 70 per cent. since 1977.

Taking all these factors together, it is difficult to see how the new contract will add to the individual GP's workload. Indeed most of the new duties required by the new contract can be carried out by professional practice staff, such as nurses. In this connection one of the major features of the new contract is the removal of restrictions on the recruitment of practice staff and the increased investment in this resource. All the trends which I have described illustrate how we now have an important opportunity to improve general practice. The resources are there. There are more doctors and more practice staff. The contract provides the impetus.

In areas of high mobility, GP's lists and family practitioner committees' records do not perhaps match as well as in other areas. The noble Lord, Lord Rea, suggested that records were inaccurate. The computerisation of FPCs is already improving matters. The new contract will be an added impetus to get and keep records up to date. In the case of the new target payments which rely on good records, there will be time for the information that is needed to be made available to both GPs and family practitioner committees.

It was suggested that some GPs will lose money no matter how hard they work. The new contract will provide opportunities for all GPs to generate income from providing new services such as minor surgery and health promotion clinics. The great majority of GPs who provide the services that patients need will not lose from this contract. Indeed those who already provide these services will be financially better off under the new contract without increasing their workload. There are a few who in spite of providing comprehensive services could experience a drop in income.

To give these GPs time to adjust, we shall introduce a transitional payments scheme to help bridge the gap between old and new income for a period of two years. This will allow time for two things to happen; first, for the rural practice payments scheme to be revised to target the money better at the truly rural practices, some of which have small lists which they cannot increase; and, secondly, for the GPs in question to develop other health care activities such as hospital work which provide additional income. Perhaps the academic GPs might also come into this category. It must be remembered that small list GPs —those with a list size of 1,000 to 1,300 —are not working full time; yet under the present scheme they earn the same amount of basic practice allowance, group practice allowance and seniority payment as GPs with a full list of 2,000 or more.

Only the fund for practice staff and premises improvements is to be cash limited. The Government have undertaken to increase investment in these areas. There will be more money and it will be better targeted. Under present arrangements, FPCs have little control over where the money goes. The Government want to improve services in areas of greatest need such as inner cities. The new arrangements will enable that to happen.

On the subject of inner cities, I was grateful to the noble Baroness, Lady Robson, for drawing to my attention the studies about coverage rates for childhood immunisation. She admitted, however, that these studies must be used with caution. I know of one study by the Public Health Laboratory Service which showed that high coverage levels can be reached in areas of deprivation. It may be helpful if I make clear that we have introduced a lower target coverage level of 70 per cent. for childhood immunisation. This, we believe, is within the reach of all GPs, because national uptake rates for the childhood vaccines are all currently above that level. We are, however, aware of the difficulties faced by doctors in deprived areas. That is why we are introducing a deprived areas allowance specifically to recognise those difficulties.

I turn now from inner cities to rural areas. Clearly, practice in truly rural areas has features which should be recognised in the remuneration system. We and the professions' leaders agree on the need for support for such practices. This support should be better targeted than at present. That is why we will ask the Central Advisory Committee on Rural Practice Payments to revise the present system. In the meantime the current scheme will continue.

A number of noble Lords referred to women doctors. I am happy to confirm our strong belief that women doctors are an asset to partnerships. A number of patients prefer to see women doctors. In fact the number of women doctors in practice has increased by more than 75 per cent. since 1977. Women now form more than 40 per cent. of all trainee GPs. The trend is clearly towards more women doctors. The new contract will support and encourage that trend; first, by making it easier for women doctors to take up part-time contracts; and secondly, by making it easier for them to employ a locum when on maternity leave. I find hard to understand the suggestion that women doctors will be worse off as a result of the new contract.

We must acknowledge a limit to what the Government can do for women doctors. After all, GPs are independent contractors. Women doctors must continue to fight their corner for satisfactory partnership agreements. It is not for the Government to interfere in such matters but we believe that we have made it easier for women doctors to play a greater part in general practice.

I listened carefully to the point made by the noble Baroness, Lady Masham, about budget holders and the worries of patients in rural areas. The regulations do not address the question of practice budgets. They are in fact outside the provisions of this statutory instrument. Perhaps I may write to her on the matter shortly. However, in relation to her question about services for the disabled, I can say that all the changes to the GPs' contract will benefit disabled patients. In particular we are making easy access for wheelchairs a requirement in practice premises in future. In addition, there will be annual check-ups for elderly patients who want them, but these may take place in their own homes.

It was suggested that the contract would introduce increased bureaucracy. I must point out that more than £1 billion is spent on the family doctor service. That is taxpayers' money and the doctors must be accountable for how it is spent. That accountability will be achieved in a number of ways, none of which is particularly burdensome. In the first place, GPs must agree their surgery hours with the FPC. By that means we shall ensure that surgery hours are convenient to patients rather than to the doctor. Secondly, FPCs are to receive annual reports from the doctors about their lists. That will enable FPCs to judge how well services are provided and to identify areas where improvements are needed. Lastly, there is the doctors' remuneration.

No one can object to a system whereby the FPC satisfies itself as to the services provided before payments are made. That means that GPs must make claims for certain payments. The bureaucracy involved is the minimum consistent with the proper stewardship of expenditure. I can assure noble Lords who fear that the contract is set in concrete that this is not so. We shall of course monitor its effectiveness in delivering more health promotion and disease prevention. If further improvements are necessary we shall, of course, be happy to introduce them.

Perhaps before finishing my response I should refer to the Which? report which was mentioned by several speakers in the debate. The report suggested that patients want more time with their GPs. The new contract will achieve that aim. As I said before, there will be more practice nurses and counsellors and this will enable the whole practice to extend its listening time. Indeed, many of the problems which patients brińg to their doctor may well be better dealt with by a nurse or a counsellor. Moreover, as the family doctor service becomes more competitive, so doctors will recognise the importance of ensuring that their practices have the time to listen to patients—otherwise patients will vote with their feet because it will now be easier to change one's doctor.

Perhaps I should reiterate that consultation has been going on for 18 months with well over 100 hours of discussion taking place, including meetings with Ministers. All aspects of the revision to the GPs' terms of service have been the subject of detailed correspondence with the GMSC.

The noble Lord, Lord Ennals, suggested that the legality of these changes brought the regulations into question. I should say that this is an observation which does not apply to the relationship between general practitioners and the National Health Service. That relationship is a statutory arrangement resulting in the main from the application of the National Health Service Act 1977 and the National Health Service (General and Pharmaceutical Services) Regulations 1974, as amended. Therefore the relationship is not governed by the private law of contract and the Government are quite satisfied that the form of the amended arrangements is perfectly lawful.

I have taken some time to go through the many interesting points which were raised in order to remove, I hope, many of the misunderstandings about our proposals. Once people understand what the new contract would mean for them, and what it would mean for doctors in that they will be able to provide an up-to-date efficient service to their patients, many of the reactions which were initially based on misleading propaganda will, I believe, disappear.

It is no exaggeration to say that the new contract represents the most significant change in the family doctors' services since the National Health Service was set up. I believe that it will benefit patients and doctors alike. I therefore urge the House to support the regulations before us.

8.42 p.m.

Lord Ennals

My Lords, in conclusion perhaps I may thank all noble Lords who have taken part in the debate. I should also like to express my thanks to the noble Baroness for her reply. I shall make but three brief comments. First, it is noticeable that except for the noble and loyal Baroness, Lady Elliot, there has been no presence on the Back Benches to support the Minister. That is a sad situation. She must have felt very lonely. And it is, perhaps, a precursor of the debates which will follow in the next few months. However, I know and understand that the noble Baroness feels happy with her Front Bench support.

I should like to make a further point to the Minister. She said that what is proposed will improve general practice and that once people understand it they will realise that the Government were right. Of course GPs do understand this; indeed, they probably understand it better than the Minister or myself or anyone else in this House, except for the two GPs who have spoken in the debate.

Can the Minister explain why, having analysed the matter and having been involved with the representatives in negotiation, there is still a three-to-one ratio of GPs who reject what is proposed at the end of the day? In my view the question as to whether their judgment is right is worth further thought.

The noble Lord, Lord Butterfield, referred to a party political commitment. This is only a party political issue because the Secretary of State, in my view, decided that he was not seeking consensus. If he had been able to achieve agreement, the issue would not have arisen in the way that it has. I must stress that the criticisms which I mentioned this evening have all been pressed upon me by general practitioners. In no sense have I accepted a party brief in speaking this evening. The Minister and her right honourable friend the Secretary of State should consider whether they are right in assuming that after all these months of negotiation they have it right and that everyone else has got it wrong.

As I said at the beginning of the debate, it is not my intention to press the matter to a Division. Therefore, I beg leave to withdraw the Motion.

Motion, by leave, withdrawn.