HL Deb 05 February 2004 vol 656 cc833-49

1.25 p.m.

Baroness Gardner of Parkes rose to ask Her Majesty's Government how the changes in National Health Service funding have affected the provision of general medical services for students, in particular the effect on general practitioners' surgeries on university sites.

The noble Baroness said: My Lords, to begin, I would ask the Minister whether he is agreeable to amending the wording of the Question to the future tense, as it is not the past that I wish to discuss. The Question would then read: to ask the Government how the changes in National Health Service funding will affect the provision of general medical services for students, in particular the effect on general practitioners' surgeries on university sites".

The new NHS contract for general practitioners will come into force on 1 April. Seventy-nine per cent of GPs voted in favour of this new contract and 21 per cent were opposed; that is, one in five GPs. Most patients will be completely unaware of any change in their access to medical treatment, and indeed some practices will have a real opportunity to benefit from the new contract. Today I wish to bring to the attention of the House the particular and difficult situation in which some GPs—those in practices where the patients consist mainly or entirely of students— will find themselves. The Imperial College Health Centre has about 4,500 students and 500 local residents. I declare an interest as one of the 500.

The main problem for these practices is that the new GP contract changes the way in which GPs are paid from being remunerated for each patient and each service, to receiving a global sum for each practice. The Carr-Hill formula—a linchpin of the new contract— has been used as part of the calculation for the global sum. This formula assumes a certain profile for "normal" practices in that their workload will include caring for children, pregnancies, chronic diseases such as coronary heart disease and diabetes, and the elderly. I shall in general throughout this debate use the word university but I intend this to include those in higher education generally.

Most university practices have few such patients with chronic illnesses. Some dedicated student health services do not have any. Nevertheless, the demands on the health services by young adults, often away from home for the first time, are many. Their needs comprise not only of the usual health problems and anxieties, but also stem from increasing stresses and pressures, academic, financial and social. Student health services have invested a great deal of human and financial resources to provide the expertise necessary for the additional services that are essential for students. Services such as comprehensive mental health provision and sports medicine are not recognised by the new contract.

The Quality and Outcomes Framework—quoted as "one of the major new sources of income for practices"—is intended to provide opportunities for practices to earn more money. This framework does not recognise the high quality work, which includes comprehensive in-house services such as mental health, and sports medicine, done by university health services. By providing minor injury clinics the need for hospital referral or casualty attendance is replaced and it is better for students to be treated quickly and locally—and of course it saves the hospital costs.

The paradox is that at a time when the Government are seeking to widen access to university—and charge fees, thus increasing the burden of student debt and stress—they are simultaneously creating a primary care financial climate wherein many student health services will not be viable and provision of the essential services to care for and keep students in higher education will cease. In others, there will be insufficient funding to ensure continued investment and development leading to great difficulties in the recruitment of staff, including nurses and doctors.

Students cannot afford to lose time from their studies and coursework either academically or financially. Therefore, health services geared to their needs try to avoid the long waits associated with hospital referral, particularly in the field of mental health. Ironically, although this good practice is one of the goals of the new contract, because of the anomalous population in student health, it will not be funded under the current scheme.

There are two areas of development where university practices might be able to obtain extra funding—sexual health services and depression. I shall not go into detail, but there are particular difficulties in providing these services and remuneration is not commensurate. Primary care trusts are under no obligation to commission these services, and many university practices report that their PCTs are not commissioning special services of any description due to insufficient funds.

Persuading primary care trusts to fund student health centres as locally enhanced special services would be another possible area of extra funding. That would involve making a business case, including patient data, evidence of need, evidence of quality and hospital cost savings. There is not enough time for that data to be collected before April. The BMA is keen for the Minister to support that as an ongoing process.

In April the new GP contract will no longer pay for each patient and each service that a practice provides. Each practice will be given a global sum which assumes that basic services are being provided to a practice with a profile of patients of all ages and needs. In replies to questions asked in the House by the noble Lord, Lord Butler, and myself, the Minister has relied on the fact that if the global sum to be paid to a practice under the formula is below the current practice income, the contract will allocate a "minimum practice income guarantee"—MPIG. It will be based on practice data gathered over three-quarters of a year. That three-quarters includes the summer months. That would give a very false result, as NHS students leaving at the end of their courses come off the list in July and the replacement students do not arrive until the autumn. That means that the statistics of the number of patients of the practice being used for calculating the global sum will be distorted and will result in an inappropriate under-funding of those GPs. A practice must keep its staff and continue to operate throughout the whole year.

The MPIG is a combination of a practice's global sum, calculated on a quarterly basis, using the formula and a correction factor calculated on a once-and-for-all basis in April 2004. It is that correction factor that I would draw to the Minister's attention. The information that I have is that the PCT will decide the correction factor for each practice. PCTs should have been collecting information from practices to identify the amount of their funding allocation. Information from all of the practices in the area then goes from the PCT to the Department of Health which will in turn give PCTs their allocations.

The funding streams to PCTs have not yet happened. PCTs will soon send practices an indicative allocation. There will still be time for practices to speak to PCTs about adjustments to that allocation as the final allocation will not be made until after April 2004. The delay is that the final allocation is based on figures from the quarter ending March 2004. Global sums will be adjusted quarterly once the system is up and running. As well as talking about the correction factor, I urge the Minister to ensure that PCTs take account of the fluctuating quarterly patient lists so that university practices are not penalised. A university practice's global sum income will vary according to the annual "peaks" and "troughs" in university practice populations and list sizes. There will be a particular disadvantage in relation to the July to September quarter.

I am sure that the Minister is aware of the recent furore over the local government situation, where the official census figures differed widely from the local authorities' own records. We should try to avoid a similar discrepancy and its consequent recriminations occurring in the health service. Will the Minister ensure that PCTs are conscious of the particular situation of student health services and encourage them to use that correction factor to make some adjustment to offset the under-valuing of the numbers on the student health centre GP lists?

In any case, MPIG was not designed for university practices, but for those practices not in a position to make money under the new contract, primarily because of poor organisation. The assumption was that as those practices became better organised their income would increase with quality points. That will not work for university practices as their patient profile will work against them. University practices deal with young National Health Service patients. They are young adults who are as entitled to health care tailored to their needs in the same way as other groups of patients, such as children and the elderly.

The National Union of Students is running a health and welfare campaign this year, which aims to increase access to decent healthcare for students and to educate and inform students about ways to improve their overall levels of health. I quote: NUS is concerned that funding for sexual health services is falling. GPs' surgeries are unable to cope with the demand for sexual health screening and treatment with waiting lists often exceeding four or five weeks".

The BMA believe that the new general practitioners' contract will improve GPs' quality of care. But the BMA says: Compared to other practices, university practices may be financially disadvantaged under the new GP contract". The BMA has met representatives from university practices, including representatives of the British Association of Health Services in Higher Education, and is keen to ensure that the valuable services provided to students remain at their present high level. The Royal College of Psychiatrists is concerned that there has been a progressive increase in the number of students seeking help for mental health problems.

There is no time to say more but can the Minister assure me of two things: first, that he will encourage PCTs to look at the correction factor in connection with the special situation of those practices; secondly, perhaps even more importantly, ensure that PCTs are aware of the fact that numbers of patients on university practice lists will not be consistent throughout the year, but will vary between quarters. If the Minister can do that, I will be hopeful that there will be better introduction of the new GP contract in those practices.

1.36 p.m.

Baroness Finlay of Llandaff

My Lords, I am grateful to the noble Baroness, Lady Gardner of Parkes, for having raised an important debate and raised her questions. I must declare an interest as vice-dean at the University of Wales College of Medicine and I have dealings with, and responsibility for, large numbers of students.

Student health is important and there are some specific issues for general practitioners providing general medical services to students that must be considered as the nature of the GP contract changes. First, there is of course the fluctuating workload for a practice, although that presents an opportunity for a practice to take in a term-time working partner or assistant—a position that might be ideal for a working parent of small children.

Students are by their nature concentrated in the 18 to 25 age bracket. Specific problems are psychologically and psychiatrically related, sexually related and infection linked. In that cohort of intelligent young people, the males have a particularly high incidence of schizophrenia and it is in that age-group that it manifests itself. Drug-related psychoses are prevalent in that population and, of course, acute psychiatric emergencies correlate closely with drug abuse. It has been estimated that about 40 per cent of those presenting as psychiatric emergencies are drug abuse-related overall.

I am not implying that students are drug abusers, but they are in that young, vulnerable age group. Another drug used by many students is alcohol. High risk drinking behaviour needs to be identified early and intervention focussed to detect the early alcoholic. Debt incurred from alcohol often compounds their problems.

Sexual activity in the age group makes them frequent users of post-coital contraception—the "morning after pill"—and at risk of sexually transmitted diseases. It has been estimated that one in eight of that sexually active population will be found to be chlamydia positive on testing. The long term implications are great, with the associated risks of pelvic inflammatory disease, ectopic pregnancy and infertility. There is a case for introducing rapid molecular diagnostic techniques in that population as a screening tool. Sweden introduced screening 25 years ago and has recently reported a decrease in prevalence of chlamydial disease and of ectopic pregnancy rates. That runs counter to the international and UK trends, where no screening programmes are in place.

Depression is also prevalent in that age group and with it the tragedy of suicide and parasuicide. Previously undisclosed abuse presents as a variety of symptoms, not only depression. The student may have felt unable to disclose to the GP at home, who is also the family doctor, but will disclose once they are away at university. Other manifestations of distress that are prevalent include anorexia and other eating disorders and those who self-harm. People who harm themselves do so as a way of release from their overwhelming distress. They can benefit from specialised intervention, but the management of self-harming is often outside the experience of the ordinary GP and local general psychiatric services may not have anyone with a particular interest in these complex cases.

But there is a much more complex issue in trying to improve health in this population. The time frame for intervention is short. They are a mobile population who are poor attendees for planned appointments but often need acute short interventions. They have a very low incidence of chronic conditions, clearly outlined by the noble Baroness, although of course a few will have conditions such as diabetes or physical disabilities requiring general medical input. They present with a variety of acute sports and other injuries related to lifestyle. They need to be seen there and then.

They tend to drop in to student health services in a panic, seeking rapid intervention. Peaks and troughs in demand coincide with terms and vacations although many are slow to register with the GP when they first arrive at university. So the practice does not have the benefit of the well non-attendee on its list as calculated for in the new ordinary remuneration rates: students present and register when they have a problem and need help.

Students coming from abroad and those travelling in vacation or as part of their course may bring with them infections that are less frequent in this country. Tuberculosis is on the increase in all parts of the world. Immunisation affords only partial protection, but many have never even had a BCG immunisation.

Loneliness is a major problem for some students, away from home and facing fear of failure. Acute isolation, debt and poor living conditions conspire against such a student to drive him further down the road of despair. He may feel fearful of seeking help and stigmatised by mental health problems.

Confidentiality is a major worry for some. They do not want to encounter their friends in the waiting room, so effective services will do all they can to ensure strictly that the reception staff are sensitive to the students. The acute emergency of meningitis is a time when the practice must suddenly alter its work pattern to work with public health to contain any outbreak. Students live close to each other and it is in this group that meningitis strikes and fatalities occur.

This Government have done much in the new GP contract to ensure that the true workload for general practitioners is reflected in remuneration. However, the additional services provided from those practices with a large student population will be in mental health and in public health particularly in relation to sexual activity.

The minimum practice income guarantee should mitigate against penalising existing practices, but there is little incentive in the contract for a practice to move into the area of student health. I hope that the Minister can give some assurance that primary care organisations will be asked to monitor the commissioning of student services from university practices and set standards for these to ensure that they are run by those with a particular interest in the health concerns of young adults.

The ability of the primary care organisations to commission enhanced services for those running student health services provides an excellent opportunity for the specific needs of this group to be met and to impact on sexual health, unwanted pregnancy rates and avoid, it is to be hoped, the awful incidence of suicide.

I also ask the Minister whether consideration is being given to the cost efficacy of a screening programme in under 25 year-old, non-pregnant, sexually active women to detect chlamydia. Student health services could be an ideal starting point for such an evaluation.

1.43 p.m.

Lord Butler of Brockwell

My Lords, I, too, thank the noble Baroness, Lady Gardner of Parkes, for tabling the Question and giving us a further opportunity to debate the issue. It is a problem about which I feel most concerned as a head of a college at Oxford University. In that respect, I declare an interest. I declare a further interest because I am on the list of one of the practices involved as part of the college.

The Minister was kind enough to answer a Question from me a few weeks ago and I do not want to go over the ground I mentioned then. However, there have been further developments to which I want to refer. I want to underline some of the points that have been made so competently by the noble Baronesses, Lady Gardner and Lady Finlay.

As has been said, the new GP contract is recognised as a considerable advance. It reflects the different needs of various sectors of the population, and the Carr-Hill formula is surely right in recognising that some sectors of the population have greater needs than others. I am advised that the rate under the formula for, for example, elderly women is six times that for young males. It makes sense, and those of us who are elderly will agree, that elderly members of the population should carry greater weight in the capitation rates for general practice. However, I am advised, and the Minister may wish to comment on this, that the similar formula in Scotland allows three times the weighting for elderly women compared with young males. Compared with the rate south of the Border, there appears to be a discrepancy.

Even if the relative weighting is right, as the noble Baronesses, Lady Gardner and Lady Finlay, have said, there are particular problems for students living away from home compared with those in a similar age group who are living at home with their families. And the statistics show that the consultation rate among students living away from home is much higher than for young people of similar age who are living with their parents.

The reasons for that are not difficult to see. Many such young people will be living away from home for the first time. They are exposed to experiences and risks to which others in more sheltered circumstances will not be exposed. Many are foreign students and the strain on them is particularly heavy. But even those who are in a familiar context are prone and vulnerable to mental stress, to the temptations which come from sexual experiences and to exposure to drugs.

Again, the Government have taken some excellent preventive initiatives in these areas and in my experience GPs dealing with such young people strongly support them. But they need funding. The preventive measures—the health education that is highly desirable and encouraged—need to be allowed for. The present formula does not allow adequately for it.

When I asked my previous Question, the Minister put a good deal of weight on the ability of the primary care trusts to provide extra funds for this purpose. Indeed, the noble Baroness, Lady Gardner, referred to that today. The question is whether the primary care trusts will have the funds and will be willing to recognise this particular need and to provide adequately for it. That is the unknown aspect that is creating great uncertainty in practices dealing with students.

Since I asked my previous Question, there has been a meeting between the British Association of Health Services in Higher Education and the BMA. At that meeting, the BMA recognised the problem and told the association that it had been making representations to the Government on its behalf.

The difficulty is that, as I understand it, the Carr-Hill formula will not be reviewed until 2006. By that time, a great deal of damage may have been done. The Government are saying, as the Minister said to me previously, that the formula is widely supported by the medical profession and that they are unwilling to reopen it. So there is a great deal of weight on the primary care trusts. If a solution is to be found, the first recourse must be there.

The danger I see is that it may be one of those situations where everyone acknowledges a problem and recognises a need but will be tempted to leave it to another body to solve it, so that it will not be solved. The noble Baroness, Lady Gardner, made some very practical suggestions of ways in which primary care trusts might be urged to take cognisance of the problem and provide for it. I warmly support her in urging those measures on the Minister and hope that he will be able to tell us that the department will encourage primary care trusts to take them seriously.

1.51 p.m.

Lord Addington

My Lords, the noble Baroness, Lady Gardner of Parkes, has put her finger on a specific problem in this debate. The new run-of-the-mill way of allocating funds for health services does not serve a particular group in a particular set of circumstances—that is, students. As has been said by all those who have spoken in the debate, things such as chronic disease, heart conditions and so on will not manifest themselves in that group. However, it then becomes apparent that that group has potentially much higher needs in other areas. Thus, there is a lack of funding and specific needs go unmet.

Other speakers have called on the Government to try to address that by changing the way in which funds are allocated. The enhanced services being introduced by primary care organisations appear to be a way forward. I ask the Government for an assurance that encouragement will be given to ensure that those enhanced services are provided. The noble Baroness, Lady Finlay, listed what students will generally need. I am surprised that that was not taken into account. It is another example of how joined-up government does not really work.

Experimenting with drugs and alcohol, what is often the start of an active sex life, and sports injuries have been there as long as students have been around—let us face facts. The myths about those activities and in which combination they strike have also been universal, but let us not go into that. Everyone who has been to university since universities began would probably say the same.

The Government should ask why that was not factored in. No one has been talking to anyone; but everyone knows what goes on. The majority—indeed, the overwhelming majority—of civil servants are graduates, after all, so that is a big miss, to be perfectly honest.

Let us consider the benefits of taking those factors into account. The traditional gripe that I have against GPs concerning injuries, especially sports injuries, was that they would say, "Rest for three weeks". The noble Baroness, Lady Finlay, shakes her head; I agree that this is probably an historical problem, but it did happen. I remember saying, "Doesn't that mean that I will weaken the muscle, which means that when I start playing again I will stand a greater chance of getting a worse injury that may be permanent?". A look of panic spread across the doctor's face, and he said, "Rest for four weeks". That degree of ignorance existed; it is not as bad now, but elements of it remain. The fact is that doctors are not the best people to deal with that problem; we need physiotherapists or other specialists in the field.

What tends to happen with the young is that they are fit enough to patch over the injury but there is a profound weakness that means that the health service ends up paying for a lot more treatment later. If that type of injury is dealt with in a centre of excellence, there is a facility that others can use as well. The same applies to work-based injuries of the young and not so young doing manual work. Those centres will be better organised to provide such services. That point is unanswerable. The Government should be ensuring that within their structures encouragement is given to creating such services. People will be better able to use them and, in the long term, there will be savings.

Other points were raised about depression and the temptation to experiment with drugs or binge drinking, which it is currently fashionable to discuss. As a young rugby player, I fear that the origins of that were there among young and not so young rugby players-it was encouraged. Once again, with preventive healthcare in place and now that people, we hope, have more open minds, we can establish patterns of behaviour that will benefit us in future.

It is worth bearing in mind that it is proposed to increase student numbers and to put increased pressure on those students by making them pay more to go to university. The mental health implications of that must be obvious. With the best will in the world on the Government's part, even if their policy is correct—I do not think it is; but that is neither here nor there—they must take into account that there will be greater pressure on students. As a greater percentage of the population will go through university, intervening early on will save resources in the long run.

The noble Baroness, Lady Gardner of Parkes, has raised a real problem that must be dealt with. The waiting system must be addressed quickly. If we get it wrong, we are just saving up cost implications for later. I hope that the Government will tell us today that they are encouraging the health service and those in charge of it to ensure that specialist services are available. In the long term, that will benefit all those in society and save resources. The noble Baroness is correct: the Government should act.

1.57 p.m.

Earl Howe

My Lords, I have the distinct feeling that everything worth saying in this debate has already been said, so I do not propose to speak for long. Nevertheless, not for the first time, my noble friend has raised a topic of considerable interest and importance. In preparing for the debate, I re-read the debates in Hansard on the two Starred Questions of 8 May and 15 January that related to the subject of this debate. I cannot say that I am surprised that my noble friend wanted to take a third bite of this sizeable cherry. We always receive well informed answers from the Minister, but last time, we were all left with the feeling that the issue was far from settled.

I start, as have others, with a statement of the obvious: with university students we are dealing with a vulnerable population group. They may not be vulnerable in the normal sense of that word, but they are vulnerable none the less as young adults who, as the noble Lord, Lord Butler, said, are spreading their wings away from home, often for the first time. There are a great many of them: 2.1 million at the last count; a figure that is growing every year.

Although they are not like the frail elderly, the health requirements of students can often be more acute than those of other age groups. One has only to glance at a BMA publication from last December entitled Adolescent Health to be reminded how many undesirable conditions affect young people in the 16 to 24 age range, above all other age ranges: alcohol use and binge drinking, drug use, depression, self-harm and sexually transmitted diseases.

The BMA laid great emphasis in its report on the need for early intervention in all areas of adolescent health to help to prevent problems escalating. It rightly made the point that young people need information and support in order to be able to access health services on their own. Once they access those services, the facilities must be there. In an area such as sexual health, we are all well aware—even apart from the context of this debate—how overstretched those services already are. A condition such as chlamydia is insidious because it can be asymptomatic, so screening facilities must be accessible to those at risk.

When we reflect on what the noble Baroness, Lady Finlay of Llandaff, said about students suffering from mental health difficulties—as many unfortunately do—we need to think in terms of providing services that are equipped to deal with substance abuse, which can often lie at the root of those mental health problems. The role of health education is also especially important here. It is not sufficient to have skeleton medical services on university campuses. The services must be there when they are required, and they must be of a particular kind if they are to meet the needs of the local population. It is against that backdrop that my noble friend's concerns about the new GP contract should be viewed.

I have taken the opportunity to do some fairly thorough reading-up of the GP contract; and in doing so I have been considerably assisted by a briefing paper published the day before yesterday by the BMA. It leaves me in no doubt that the GP contract, for all its merits, is highly likely to put the student population at risk of inadequate medical cover. First, there is the global sum payment. This is the payment that each practice will receive for the basic services that they provide to patients, and it is expected to make up at least half of most practices' incomes. The global sum payment will be calculated by reference to a weighted capitation formula.

There are two main reasons why this formula will disadvantage university practices in comparison with others. Because the practice population is classified as young and relatively healthy, the associated multiplier in the formula in respect of patient need, workload and costs will be smaller than it would be in a practice in which the age range of patients is more spread.

The way in which populations and list sizes are calculated in university practices will produce peaks and troughs. As my noble friend said, list sizes are reported on a quarterly basis for the purposes of calculating the global sum payment. If students who graduate in a particular year are removed from the practice's registered population by 1 July, the July to September quarter's figures will reflect that. If, as may happen, new students have not registered by 1 October, the October to December quarter's figures will also be depressed. The Minister said that practices that keep their practice lists up to date should not be disadvantaged. Frankly, I do not understand how he can say that, particularly when one bears in mind that practices have precious little control over when students choose to register and deregister.

If we look at other elements of the GP contract, there is little for our comfort in them. Practices can earn points in the quality and outcomes framework, QOF, but the value of those points depends on the prevalence of given chronic diseases, such as coronary heart disease, in the patient population. Because student practices have a low prevalence of these chronic diseases, payments based on QOF points will be less than they would be if the calculation of points was based solely on list size.

The Minister has laid considerable emphasis on the minimum practice income guarantee. The purpose of the MPIG is to prevent destabilisation and to protect practice income. The problem is that the MPIG is itself partly dependent on a practice's global sum calculated on the normal quarterly basis using the formula. It also includes a once and for all correction factor, to be calculated in April 2004. Like my noble friend, I would be interested to hear whether that correction factor could be specially tailored in respect of university practices.

The BMA said that, despite the MPIG, it is likely that the finances of university practices will fall relative to their colleagues elsewhere and that important enhanced services such as health promotion, treatment of sports injuries, and services for patients with eating disorders and depression are likely to suffer. These are services provided over and above the range of so-called "essential" and "additional" services. It might be thought—and the Minister has previously suggested this—that university practices will be in a good position to tender for these sorts of enhanced services, but if we look at what is actually happening on the ground, there is precious little evidence that they are being resourced in this way by the commissioning PCTs.

It is somewhat sobering to read this week's statement from the BMA calling on primary care organisations to ensure, that they commission an appropriate range of enhanced services for students". There is absolutely nothing to ensure that primary care organisations will do so, and I am afraid that the BMA knows it. It is not only the BMA that is exercised. The British Association of Health Services in Higher Education have also expressed grave disquiet, as the noble Lord, Lord Butler of Brockwell, said.

Last time we debated these issues, I detected signs of a dry stone wall being erected on the other side of the Dispatch Box, so I hope that this time the Minister will be a little more forthcoming and will acknowledge, in the light of what has been said, that there is a real risk of university practices suffering cuts in staff or becoming unviable. We know that the whole situation will be reviewed after six months of operation, but can the Minister say whether in the mean time strategic health authorities will be performance-managing PCTs on this aspect of their activities? Can he also say whether in due course PMS contracts might be the answer on university campuses where doctor numbers become insufficient?

From what the BMA is now saying it is clear—at least to me—that GP practices on university campuses were simply overlooked when the GMS contract was being negotiated. That is an alarming state of affairs, and if there are unintended and detrimental consequences flowing from the contract, there is only one direction in which we can look for these to be rectified; that is, to Richmond House.

2.8 p.m.

Lord Warner

My Lords, I am grateful to the noble Baroness, Lady Gardner of Parkes, for raising her concerns on this important issue. It provides me with an opportunity to set out the new approach to contracting for primary care services that the Government are undertaking. The noble Baroness has great knowledge, experience and commitment to the NHS, and I always pay careful attention to her observations. As a parent who has had four children go through this experience, I am well aware of the needs and vulnerabilities of students. I do not need a lot of tuition in the problems that can arise. I reassure the noble Earl that if he had ever seen any of my dry stone walls, he would not be too worried about what is being erected here.

In responding to the concerns of the noble Baroness, Lady Gardner of Parkes, and others, I begin by placing the GMS contract in its proper context of higher investment in primary care. Across the UK, investment is increasing by about £1.9 billion. There is a 33 per cent increase in funding. There are more GPs in the National Health Service than ever before. Between September 1999 and June 2003, the number of GPs increased by more than 1,500, bringing the numbers in post to more than 30,000. That is the context in which the changes are taking place.

Much new equipment and facilities have been coming on stream. Up to 3,000 GP premises will be improved or replaced and 500 one-stop centres established by 2004. All that means improved access and quality of services for patients. Some of the concerns raised about resources for PCTs do not seem well founded. I will discuss that later.

With that level of increased investment, it is essential that reforms are made to how we deliver primary care so that it becomes more patient-centred with more individualised care and more choice. Alongside that, decision-making is being devolved from the centre to local areas so that the NHS can respond better to the specific needs of local communities, including those with high student populations. The new GMS contract is part of that approach. Some of the concerns expressed derive from an anxiety about how devolution of decision-making on priorities at local level will work in practice. It is important that as Ministers we resist the temptation to second-guess every set of decisions taken in this area where there is a difference of view at local level about priorities. We do not want to return to a world in which Richmond House intervenes at every instance of local unrest.

Under the new contract, the income that a practice receives to provide basic GMS services is termed the global sum. Funding for the global sum is determined by the needs of the local patients. The formula has been designed so that practices with more needy patients and that face higher costs are fairly rewarded. That is intentionally redistributive, and some practices—for example, those in affluent areas, or those with atypical populations—may see a reduction in their global sum compared to their previous income for equivalent items.

I must make it clear again that the new contract has not been imposed on an unwilling profession. It is the result of 18 months' negotiation between the general practice committee of the BMA and the NHS Confederation. In a ballot of GPs, nearly 80 per cent voted for acceptance of the new contract.

The noble Lord, Lord Butler, raised contract comparison issues with Scotland. I will look into the point that he raised and write to him. However, I gently mention to him that health is a devolved function, and if the Scots wish to pursue a different agenda in this area they have a right to do so. They must exercise their judgment on what they think fit and suitable for the people of Scotland in their health service.

It has always been clear that the new contract will pose some transitional problems. That is why the minimum practice income guarantee has been devised with the profession to ensure that practices that might otherwise lose through the global sum will be protected. It ensures that no practice, wherever it is sited and whatever the make-up of its list, will receive less under the global sum than it did under previous equivalent funding mechanisms. There is a permanent commitment to the principle of that guarantee.

The baseline spend data on which the minimum practice income guarantee is based are collected over the 12 months from July 2002 to June 2003. That recognises the changing levels of a student population and ensures that there will be no distorting effect on the calculation of the minimum practice income guarantee that university practices are eligible to receive. The minimum practice income guarantee is designed to protect fairly all practices whose global sum funding is reduced under the new funding arrangements. That means that when the new arrangements come into operation in April there will be no drop in income for any practice.

It is also worth bearing in mind that the factors influencing funding allocations include increased funding to reflect list turnover, which will benefit university practices. That recognises the extra workload caused by higher levels of demand for services that patients, including students, usually make in their first year of registration. Many payments, including those made under the quality and outcomes framework, will be adjusted by list size quarterly to reflect the demands of a changing population throughout the year.

It is also important to recognise that the new GMS contract is being introduced in a context in which primary care trusts are responsible for ensuring that primary care services meet the needs of their local communities. That is to help the NHS become a more personal health service where meeting the needs of individual patients is paramount. PCTs will have more operational and financial freedoms, and new opportunities to develop locally based services that meet local community needs. They can, therefore, let practice-based contracts for specialised services geared to local circumstances.

For practices, there will thus be new opportunities to offer enhanced services to cover the specific needs of university students, for example, and to address those problems more prevalent in student populations. Where appropriate, it will be open for PCTs to commission, for example, services for sports injuries— I am sorry to hear of the previous experiences of the noble Lord, Lord Addington, in that area—stress-related health problems, sexual health services or substance abuse, if those were considered appropriate and necessary for a university population. The noble Baroness, Lady Finlay, outlined very authoritatively, as is her manner, some of the important health needs of some students. It is important to mention that it is only some students. We should not generalise about students and assume that they all need such specialised services.

Practices sited on university campuses may already provide those more specialised services, and the new contracting arrangements ensure that they can get paid properly for that work. They will be well placed to develop new enhanced services and thus increase their income. Several noble Lords have referred to the BMA briefing for the debate. I wish to quote one part of it: university practices should be in a good position to tender for some national enhanced services such as the more specialised care of patients with depression and more specialised sexual health services, as well as local enhanced services such as sports injury service or a service for the provision of prophylactic care following a meningitis outbreak". That is from the BMA circular; it is not government-speak.

The noble Baroness, Lady Gardner of Parks, mentioned the Westminster PCT in both the earlier Question and this debate. I have looked into that. The professional executive committee of Westminster decides what services to commission within that PCT. It met in December to decide on the range of services that it would commission as enhanced services. The provision of services was determined there locally by prioritisation, and sexual health services were not deemed a high priority for enhanced funding. But that was because local people made that decision on the basis of their understanding of what services were already available in that area.

The increased investment in primary care that I have mentioned will enable PCTs to commission those more bespoke local services. After all, NHS expenditure is increasing by an unprecedented 7 per cent in real terms a year over a five-year period, and PCTs now have at their disposal 75 per cent of NHS expenditure for commissioning services. But the Government have gone a little further—this will respond to some of the concerns expressed. They have identified specific and rising sums of money for enhanced services. Those are: £315 million in 2003–04, £385 million in 2004–05 and £460 million in 2005–06. Each PCT will be advised of its local floor—I emphasise, floor—for enhanced services below which it is not expected to spend. It is then down to it to decide how, when and from whom it commissions enhanced services. Local primary care practices must then convince the PCT of the local need and their capacity to respond to that need. I hope that that reassures several noble Lords who have spoken in the debate. There is very specific, rising provision for enhanced services.

I thought the noble Baroness, Lady Gardner, described well the iterative nature of settling PCT and practice budgetary allocations. I certainly would not wish to quarrel with what she said. PCTs do take account of the varying nature of quarterly list sizes. I am sure that in taking forward the new contract PCTs will look at the correction factor and the fluctuating list of practices with high numbers of students.

In conclusion, let me emphasise again that the British Medical Association welcomes the new contract that it negotiated and which the profession has overwhelmingly voted for. Its briefing for this debate is consistent with what I have said. The minimum practice income guarantee will prevent any immediate drop in income for all practices. We have also agreed with the profession that the funding allocation formula will be kept under review. This review will begin in October 2004 and any changes to the formula are unlikely to lead to a different resource distribution before 2006–07. Even then, the commitment that practices will not be destabilised will remain. It is down to local primary care organisations to use the growing volume of resources for enhanced services to meet local needs and to university medical practices to demonstrate locally the value of their local services. This is not a matter to be settled centrally. I am sure PCTs will study the concerns expressed in this debate.

The noble Earl, Lord Howe, is quite right. The SHAs do have a responsibility to monitor performance in their areas and respond to any concerns. It is open to other people on GMS contracts to move to PMS contracts—a salaried service, if you like—if they think that meets their particular circumstances. This could be a helpful way to respond to a local situation. This contract constitutes an essential reform to match this Government's unprecedented financial investment in the NHS. It will provide new, more autonomous, local service delivery geared to local circumstances that better meets the needs of patients and with the support of the great majority of GPs.

Encouraged by my noble friend to my left, I shall keep going. This will give me an opportunity to respond to a particular point raised by the noble Baroness, Lady Finlay of Llandaff. The cavalry is at hand, by the looks of it. Her point related to screening for sexual health services. We believe that an additional service will be set up to target women from the age of 25 to 64 for cervical cytology screening. But I will write to her in more detail to set out some of the thinking taking place in this area. I am grateful to my noble friend for his arrival. That ends my contribution to this debate.

Baroness Andrews

My Lords, I beg to move that the House do now adjourn during pleasure until 2.25 p.m.

Moved accordingly, and, on Question, Motion agreed to.

[The Sifting was suspended from 2.23 to 2.25 p.m.]