GP Fundholding (Hansard, 16 July 1997)

§ Baroness Jay of Paddington
My Lords, with the leave of the House, I shall now repeat in the form of a Statement the Answer to a Private Notice Question which 1014 is being asked in another place on GP fundholding. My right honourable friend the Secretary of State for Health said: "My announcement today of fair waiting lists for the patients of all GPs is an attack on unfairness. It is not an attack on GP fundholding.
"The previous government introduced the internal market into the National Health Service. This created a two tier system where patient was set against patient and GP was set against GP. That was unfair to patients, repugnant to the doctors and nurses who had to apply it and cost a fortune in extra paper-work.
"At the general election we promised to restore fairness to the health service, end the two tier system and ensure that access to treatment is based on need and need alone. We pledged to change the system so that no patients and no GP practices suffered any longer from the unfairness introduced by the Conservatives.
"We are keeping that election promise. All NHS trusts must operate a fair waiting list for urgent admissions regardless of who is commissioning the care. With effect from April next year, when current contracts run out, all health authorities must establish common waiting time standards for all the people living in their area. From the same date, health trusts must not offer preferential treatment to any particular group of patients from a health authority whether those of GP fundholders or not. Faster treatment must be provided only on accepted clinical or social grounds. This change will be fair for every patient and will be more comfortable and acceptable for doctors and nurses to operate.
"My announcement has been welcomed by the British Medical Association, the Royal College of Nursing and the NHS Confederation. The National Association of Fundholding Practices has made it clear that it fully accepts the principle and that if properly implemented the new policy will benefit all patients.
"In two thirds of all health authorities the patients of non-fundholding practices have to wait longer for hospital treatment. What is not so well known is that in the other one third, it is the patients of GP fundholders who lose out.
"We are determined to have a National Health Service which is fair to all patients. That fairness will be achieved through co-operation, in place of the competition and division of recent years. That fairness will be achieved by levelling up towards the best that is already being achieved and not by levelling down.
"In our general election manifesto we recognised that the development of fundholding has brought advantages as well as disadvantages. We promised to remove the disadvantages. A month ago we set out to bring fairness into the financing of non-fundholder practices. Today we are bringing fairness for their patients.
"We are now consulting the professions and patient organisations on how best to develop a new primary care system in which doctors and nurses can play a leading part in planning local health services more effectively for all the patients in their area.
1015 "In this way we hope to reconcile the better aspects of fundholding with fairness for all patients and all the professionals involved. We are discussing this with them and will test out our new proposals through pilot schemes in different parts of the country.
"The new system will be based on the principle that access to health care will be based on need and need alone. That is the principle of quality and equality on which the Labour Party founded the health service. That is the principle on which we will run the National Health Service—so that it is fair to every patient. And who can possibly quarrel with that?".
My Lords, that concludes the Statement.

§ Lord McColl of Dulwich
My Lords, the Statement says that this is not an attack on GP fundholding; it is an attack on unfairness. This new Labour policy is an attack on freedom. The Labour Party simply cannot bear to give people the freedom to choose. Fifty-four per cent. of GPs chose to be fundholders, and, of the remainder, half want to be fundholders.
The late Brian Abel-Smith, that highly intelligent socialist who advised the Labour Party for many years on the NHS, strongly recommended that all GPs should become fundholders. If the Labour Government were really interested in fairness, they would encourage all GPs to be fundholders. Then, the so-called two-tier system would disappear.
This new Labour policy will have two effects. First, waiting times and waiting lists will inevitably increase. What the Labour Government have failed to understand is that fundholding gave GPs much more influence over hospitals. It was a shift of power. It enabled them to goad the hospitals into providing a better service. The GP fundholders were made into better advocates on the patients' behalf.
The second effect of this new Labour policy is one that the Labour Government have completely failed to understand; that is, it will completely deprive many patients of operations altogether. Some health authorities have stopped treating varicose veins, lumps and bumps, lipomas and so on. But patients of GP fundholders were able to have those operations. Now they will not. I should like to know what the Minister has to say about that. This is old Labour again. It is a fatal mistake for many people.

§ Baroness Robson of Kiddington
My Lords, unlike the noble Lord on the main Opposition Benches, I welcome the Statement that has just been made in another place because it will create a fairer system. It will not solve the problems of the NHS. It might mean that patients of GP fundholders will have to wait slightly longer for treatment. But it will make very little difference to the length of time that all patients have to wait. That will be solved only when the Government agree that the NHS needs more funding—and only the Liberal Democrats have costed plans for increasing that funding. I know what the Minister will say about extra funding. The proposal will not come into effect until next year. What are the Government doing about it in the meantime?
1016 I am pleased that the Minister in another place referred to the fact that fundholding has also brought advantages to the health service. One is that the fundholding GPs were much more closely involved in the planning of hospital services through their influence because they had money behind them. I hope that any change will ensure that all the GPs in a health area will have an increased input into the planning of services. They are the people on the ground who know what the general public need in the way of health services; they see them every day in their surgeries.
I also welcome the fact that we are not about to rush into some wonderful new system. The Minister says that he is discussing with all the professions involved what should happen, and that they should test out the new proposals and pilot schemes in different parts of the country. I welcome that.

§ Baroness Jay of Paddington
My Lords, I am grateful to the noble Baroness for her welcome for the Statement, which certainly accords with that of the professional bodies outside this House, which responded so favourably to what my right honourable friend said.
I confess to being slightly surprised at the tone of the response from the noble Lord, Lord McColl. He seemed to suggest that what I had described, in repeating the Statement in answer to a Private Notice Question in another place, was that the Government were about to abolish GP fundholding. That was certainly not included in the Statement, and it was certainly not the intention of my right honourable friend. The noble Lord may be interested to know that changes are already in hand to examine the next wave of fundholding—the eighth wave—which, as the noble Lord will know, was suspended at the beginning of May in order to free up some much-needed immediate resources for our plans for this year. The NHS Executive is even now working on guidance on budget setting for 1998–99. That will reflect the advantages that we have discovered in some of the aspects of fundholding referred to in the Statement and indeed in our general election manifesto.
As the noble Baroness, Lady Robson, said, the object of the Statement and of the policy decisions reached by the Government today are to establish a fairer system of waiting lists. As she said, they reflect a determination to approach the matter on a long-term basis. That is why I am satisfied, even though the noble Baroness suggested that she was not, with the additional funding mentioned by my right honourable friend the Chancellor of the Exchequer in his Budget Statement, which will enable us (over a longer period) to deal with the long-term problems which the waiting list division has created. I remind the House that the problem at the moment is that not only do we have a whole series of local trusts, created under the internal market—under the unfair system that we are seeking to redress—a record number of local trusts at a record level of debt, but there are also record numbers of people on the waiting lists. This initiative today is, as the Statement said, designed to return equality of treatment based on need to all those people who are waiting.

§ Lord McColl of Dulwich
My Lords, will the Minister answer my question? As some health authorities have withdrawn treatment for operations for varicose veins, lipomas, lumps and bumps and so on, GP fundholders were able, under the old regime, to request that the hospitals carried out those operations, and they did so. If that part of the system is abolished, what will happen to the patients who cannot have those operations? At the moment they are having to use the private sector. Is that what the Government want?

§ Baroness Jay of Paddington
My Lords, with respect, I think that the noble Lord has perhaps not understood the basic purpose of the Statement; namely, to create a common waiting list for all patients waiting for elective care. Under the previous system it was indeed the case that GP fundholders could, if there was excess capacity within a hospital trust to carry out operations, etc., use that time to "fast-track" people who were their patients. Under the new system everyone will be treated equally on the basis of clinical need.

§ Baroness Carnegy of Lour
My Lords, might I ask the Minister a rather simple question? If the noble Baroness, Lady Robson, is right about the comparative effect on the length of the waiting list for the growing number of patients of hospital trusts, and the reduction in time for other patients, what does the Minister believe will be the effect on the average waiting list for patients? A growing number will come from hospital trusts, and they will have to wait longer. What will be the overall effect?

§ Baroness Jay of Paddington
My Lords, perhaps the noble Baroness has misunderstood when she said that patients would come from NHS trusts. Does she mean that they will come from non GP fundholders? I do not understand the question.

§ Baroness Carnegy of Lour
My Lords, I beg the Minister's pardon, I am not entirely familiar with the subject and get my phraseology wrong. However, it seems to me from what the noble Baroness, Lady Robson, said, that the overall time that patients will have to wait under the new Labour plan where everyone is treated exactly the same but where GP fundholders have less power over the hospitals, is longer. The overall effect will be that the waiting lists will be longer. Is that correct?

§ Baroness Jay of Paddington
My Lords, I do not believe that that is what the noble Baroness, Lady Robson, said. However, perhaps I could try to unwind this immensely complicated NHS jargon—and I share the noble Baroness's problems with it. My point is that what will happen under the system is the following. At the moment all NHS trusts must admit every kind of emergency that comes for treatment on the basis of need. Anyone who comes to the hospital trust with an emergency must be treated on the basis of their arrival time or whatever may be appropriate, whether or not that person comes from a GP fundholder practice. The system that will be developed from 1018 next April is that everyone will be treated on the same basis for elective treatment. That is, for ailments which are not emergency admissions, such as the varicose veins to which the noble Lord, Lord McColl, referred. So it does not matter whether you are on a GP fundholder's list or a non GP fundholder's list, you will be treated on the basis of your referral and your clinical need.
I cannot see that that would lead to a lengthening of the waiting lists. It will mean that, for example, as I described in repeating the Statement, people who come from GP fundholders' lists—and at the moment in two-thirds of health authorities they have an advantage—will be treated in the same way as others. As I also mentioned, in one-third of health authorities, people from GP fundholders' lists are disadvantaged. They are the ones who tend to go to the back of the queue.
Thus the object of the exercise is to achieve equality on the basis of clinical need, as is already done for emergency treatment. If the noble Baroness, Lady Robson, is saying something different, then I am sure she will intervene.

§ Baroness Robson of Kiddington
My Lords, I was not saying anything different. I was just saying that the GP fundholder's patients may have to wait longer. The patients of other GPs would perhaps have a slightly shorter wait, but it would not be much shorter.

§ Baroness Carnegy of Lour
My Lords, I am sorry to pursue this but, having confused the issue at the beginning, I wish to get it quite clear. Will the effect of what the Minister has just said be that the average length of time that all patients will have to wait will be longer, shorter or the same?

§ Baroness Jay of Paddington
My Lords, I cannot imagine why it should be longer. We are talking about finite resources and a finite number of patients. There is one set of hospital theatres and one set patients waiting for treatment. Presumably, if you divide those resources between the two sets of patients there is no reason why the average wait for a combined set of patients should be any different from the average wait at the moment. I am sorry, I am not putting that very clearly. You are dividing like and like; you are not making a preference towards one group of people. That is the object of the exercise.

§ Lord McColl of Dulwich
My Lords, I am sorry to go on about it, but I should like the matter cleared up. Some purchasing authorities have stopped purchasing certain types of operations from hospitals. If the patient happens to be under the care of a GP fundholder, he can purchase them.
I should like to know what will happen to those people. Will they be able to get their operations on the NHS? In other words, will the Minister instruct the 1019 purchasing authorities to purchase the treatment for people with varicose veins, lipomas and lumps and bumps?

§ Baroness Jay of Paddington
My Lords, we seem to have the same problem as we did on the previous question. Perhaps I may try to make the matter clearer. If there are X number of slots for treatment of varicose veins, for example, and you are a health authority purchasing on behalf of a hospital X number of varicose vein treatments, then you continue to do that. The point is that the people who come from GP fundholders do not gain an advantage in getting the treatment. They will not get their treatment if there is no slot for them to be treated anywhere.

§ Lord McColl of Dulwich
My Lords, I am sorry but the Minister fails to understand what I am talking about and it is an important issue. Very many patients are worried about it. At the moment there are patients who cannot have those operations. What I want to know is whether the Minister will instruct the purchasing authorities to start purchasing the operations for the patients who have been deprived of them.

§ Baroness Jay of Paddington
My Lords, we shall ask the purchasing authorities—we shall not instruct anyone—to admit all patients, whether they are for elective surgery such as varicose veins or for emergency surgery, as is the present system, on the basis of clinical need. No one will be disadvantaged by the process and some people will be advantaged.