Family Doctor Services

Speech delivered on Thu 11th Nov 2004

Mr. Paul Burstow (Sutton and Cheam) (LD): As I listened to the exchanges across the Dispatch Box, it occurred to me that the proposition is either GP family services on the Finlay model or primary care services on the "Peak Practice" model, as favoured by the Government. The Minister was a little hard on Dr. Finlay, but perhaps he needed to make those points because the hon. Member for South Cambridgeshire (Mr. Lansley) sounded like an advocate not so much of the consumer of health care, but of producer interests in the health care system. It is essential that the patient be kept at the forefront of our minds and at the heart of our thinking. It was not clear from some of the points about the GP contract whether that was the key consideration.

There can be no doubt that GPs are the backbone of the primary care system. It is right that we are debating the state of family doctor services and their pivotal role. It is also right to acknowledge that there have been improvements. The extra investment is beginning to give us additional capacity. I hasten to add that Liberal Democrats were happy to go through the Lobby in support of that extra investment. Changes such as the new GP contract and the development of practitioners with specialist interests are rightly placing even greater emphasis on the role of primary care in general and GPs in particular. As the Conservative motion and the unselected amendment standing in my name and those of my right hon. and hon. Friends rightly document, areas of concern remain. It is not my job—or any Opposition Member's—to act as cheerleaders for the Government's record. Our role is to analyse, criticise and point out areas of concern, which there are in relation to the development of primary care services in this country.

Mr. Lansley: The hon. Gentleman talked about investment in national health services, but can he clear up a point about which I am slightly confused? The Liberal Democrats appear to be proposing hypothecation to the NHS of the proceeds of national insurance, but the relationship between the two in the coming financial year would result in NHS expenditure having to be reduced by £4 billion if one simply did that hypothecation. I do not understand from where that £4 billion would come if not from national insurance, and it is not hypothecation if money is brought in from elsewhere.

Mr. Burstow: The hon. Gentleman was right to say, "if one simply" hypothecated. I shall happily send him the working paper on which the policy is based, so that he can read it in detail. The paper makes it clear that the hypothecation is spread over an economic cycle, not done one year to the next. That is how the policy would work. It seems an appropriate way to ensure that people see far more clearly how much they pay in taxes for the NHS. I would be surprised if the hon. Gentleman did not want to sign up to that, given that people would understand better how much they were paying into the health service and therefore would be more likely to engage at local level and question whether priorities were correct and whether resources were going to the right areas.

The most recent staffing figures available— I understand that new ones are due to be published fairly soon—suggest that there were 3,435 GP vacancies, a 31 per cent. increase on the previous year. The Minister said that that was no longer the case but did not quote any figure, so I hope that he can tell us today what the most up-to-date survey reveals the number of GP vacancies to be. More telling than the vacancy rate is the fall in each of the last three years for which figures are available in the number of applicants for GP posts. In 2001, there were 6.9 applicants for every vacancy, but that number had more than halved, to 3.3 applicants, by 2003.

Furthermore, the position will worsen before it improves. There is a demographic time bomb ticking away under the NHS work force; the number of GPs who will reach the mandatory retirement age—70— in the next five years will increase rapidly, especially in London and the west midlands. It is clear that there are recruitment and retention issues to be addressed. A change in working patterns has also been noted. Many more GPs are choosing to work part time. As a result, although the headcount of GPs has increased by 4,237 since 1997—a welcome increase—the full-time equivalent has increased by only 2,913.

One of the pressures on the system is the number of people who do not get a choice in which GP they sign up to. Patients in many areas struggle to get easy access to a local GP. Many GPs have lists much larger than the national average, which is about 1,850 per GP; for example, the average Westminster GP is coping with 2,500 patients, and areas such as Barking, Newham and Birmingham also have among the busiest GPs in terms of the number of people on their lists. No wonder many GPs are having to close their lists to new patients and patients are finding it ever harder to register with or change their GP.

Earlier this year, in its "Transforming Primary Care" report, the Audit Commission found that 0.5 per cent. of people every year are assigned to a GP. That might not sound like a large number when described as a percentage, but a significant number of people are affected; about 250,000 people each year are unable to find a GP because of list closures and other difficulties and are assigned to a GP by their primary care trust. The Audit Commission rightly said that this

"can be a significant issue for patients."

Of course it can. People should be able to choose their GP and get care closer to their home; they should not be allocated a GP, which might entail longer journeys away from where they live. Where is the choice for those 250,000 people every year?

Such shortages give cause for concern about how patient choice will work in practice, especially in the "choose and book" programme. I have no problem with patients having more choice and more control over their health care, but I am concerned about the Government's choice agenda being too narrow and its basis being on rather over-optimistic assessments of the capacity available to introduce choice. We believe that patients need to have more control over their health care; they should not just be faced with an array of choices—a choice of five hospitals, say, or—

Mr. Hutton rose—

Mr. Burstow: I give way to the Minister, who seems to have perked up.

Mr. Hutton: I am confused by what the hon. Gentleman just said. He said that our choice agenda is too narrow, but then described it as over-optimistic. Will he explain?

Mr. Burstow: I described as over-optimistic the assessment of the capacity available to make the policy a reality in practice. In my view, patients should be regarded as partners in their care and involved in decision making about their treatment. If that is to become a reality, it must be not be something that is available only to the articulate few. When the NHS improvement plan was published earlier this year, the way in which PCTs and primary care professionals provided support to everyone in their community in exercising choice was left as a matter of local detail, so although the Government have targets for the implementation of the choice programme, there will be variations throughout the country in the support available to make choice a reality for everyone, not just for the articulate few.

The argument about choice between the Government and the Opposition is advanced in terms of, "My choice is bigger than your choice," but Ministers must give serious consideration to the extra time that GPs will have to take to make choice a reality for all patients. I wonder whether Ministers have undertaken any assessment or evaluation of how much additional time GPs will require to support patients in making choices at the point of referral.

It is essential that the best use is made of GPs' time, so the roles of other members of the primary care team will have to be expanded. I do not buy the argument advanced by the hon. Member for South Cambridgeshire, that it is not possible to examine critically the range of tasks for which GPs have historically been responsible and determine whether some might more appropriately be discharged by others in the primary care team. I do not know whether that is his view or whether he was quoting the view of others, but my impression was that it is his own view.

It is estimated that one fifth of GP appointments are made in relation to minor ailments that could be handled by pharmacists. The development of minor ailment services in high street-based community pharmacists could help to ease the pressure on GP surgeries. That is a sensible proposal and one that I think will emerge from the new pharmacy contract. The Liberal Democrats would support such a move.

Mr. Rendel: Is not it the case that not only would the Liberal Democrats support it, but so would most of the best GPs?

Mr. Burstow: I am sure that is so. We need to re-examine the role of the GP and how some of the tasks hitherto undertaken by a GP can be taken on by others who have a great deal to contribute. For many years community pharmacists have felt undermined and undervalued within the system and as though they were not seen as part of the primary care team. There are now opportunities to overcome that.

It is not just the role of pharmacists that can be expanded. There is also scope, for example, to develop the role of therapists, particularly physiotherapists. I was struck by a pilot scheme undertaken in the Forth Valley primary care trust over a 30-month period, which looked at opportunities for self-referral to NHS physiotherapy services in a primary care-led setting. The study found that that had significantly reduced GP workloads. People were choosing to go not to the GP but to the physio, possibly to deal with problems of back pain. That had a marked impact on individuals' quality of life and reduced GPs' workload so that they could concentrate on other tasks, not least issues relating to the management of chronic disease.

Other possibilities such as nurse prescribing, nurse-led practices and therapist-led clinics are providing new career paths for professions that we need to attract into primary care, and are freeing up GP time. These changes in the roles of nurses and therapists are crucial to ensuring that we start to tackle the shortages in these professions.

What is being done with the time that GPs have? The Government's obsession with targets is of real concern to GPs. For example, follow-up appointments are delayed and deferred to ensure that first appointment waiting time targets are hit. Diseases with a target attached take priority over those without a target. GPs end up playing piggy in the middle as frustrated patients turn up at the surgery asking for their appointment with consultants and others to be expedited. It is not just targets in secondary care that need to be scrapped. The 48-hour access target is leading to all sorts of wheezes to game the system.

Sarah Teather (Brent, East) (LD): Despite repeated assurances from my local primary care trust that the 48-hour access target should have no impact on forward-planned appointments, I have had a continuous run of complaints from two groups of patients in particular. The first is those who are chronically ill and find it impossible to book repeat appointments with the same doctor, and the second is those who work and want to book an appointment for, say, next Wednesday, so that they can take a little time off work. They find that the only way they can get an appointment is by starting to jam the phones at 8.30 am, book the whole day off and hope that they can get to see the doctor by the end of the day. That has huge implications for going to see a doctor when the situation is not urgent and people simply want to talk something through.

Mr. Burstow: I thank my hon. Friend for her intervention. Those experiences are reflected in MPs' mailbags. Perhaps the good intentions behind the target are not being translated into reality. My hon. Friend's example of patients not being able to see the same GP at their next appointment raises concerns about the continuity of care, and there are increasing concerns about access to the GP by those who work away from the area where their GP surgery is located and not being able to get an appointment when they want one.

Other wheezes that are being used to game the system have been drawn to my attention by GPs, such as restricting patients to one problem per consultation. I do not know how that works in practice, but it is being tried. Another wheeze involves setting limits on times when patients can call for an appointment and, as my hon. Friend the Member for Brent, East (Sarah Teather) mentioned, rationing access because the telephone is engaged all the time. So many people are phoning in that they cannot get through to book an appointment. The selective release of appointment slots is a further wheeze. Appointments should be booked to meet the patient's need, not to hit an arbitrary target. All too often it seems that the target is shaping the way the system is working.

The motion refers to out-of-hours services. There is still much confusion about how such services will work after 1t January. The Select Committee on Health, whose Chairman intervened earlier, rightly raised concerns about the costs, planning and implementation of a huge change to the provision of family doctor services out of hours. I support the change. [Interruption.] If the Minister would not chunter from a sedentary position, I would be happy to outline my concerns. Hopefully, there will be a response to some of those.

It is evident from my mailbag and that of many other hon. Members that people are worried about the loss of Saturday morning surgeries and the difficulties that that will cause. How did the Government arrive at their estimate of £6,000 per GP to provide out-of-hours and Saturday morning services? According to the results of a survey by the NHS Alliance, PCTs are struggling with the logistics, staffing and finances necessary to deliver out-of-hours services. One in five PCTs say that they will restrict services on the basis of quantity or quality or both. On what basis does the Minister reject the findings of the NHS Alliance's survey? I wonder whether he has looked at it and why he does not consider it an acceptable basis on which to criticise the Government's approach to the provision of out-of-hours services in the new form under the new contract.

Where will all the extra doctors come from to staff the out-of-hours services? How much reliance will PCTs have to place on locum and overseas doctors to fill the gap? Many PCTs plan to use NHS Direct services as the front end of their out-of-hours services. However, that will need to be monitored closely in the light of recent research in the British Medical Journal. A study published on 17 September looked at the effects on consultation workload and costs of off-site triage by NHS Direct compared to on-site nurse triage in general practice. Patients in the NHS Direct group were less likely to have their call resolved by a nurse and were more likely to have an appointment with a general practitioner. In other words, it was costing more to use NHS Direct. Perhaps that explains one of the cost pressures that PCTs are grappling with. Half of PCTs have said that they will contain the extra costs by delaying investment in new services. How long will they delay investment in much-needed new services?

Ministers have said that the recent increases in accident and emergency attendances have nothing to do with the change to out-of-hours services. Certainly some of the figures suggest that the increase predates the changes. I accept that, yet reports from the front line tell another story. The Nursing Times recently quoted an accident and emergency sister at Norfolk and Norwich university hospital as saying that her department had seen a 13 per cent. rise in attendances since January. She is quoted as saying:

"People tell me they are here because it is convenient and because they cannot get an appointment at the GP's."

Perhaps that is another unintended consequence of the 48-hour access target. To what do the Government attribute the increase in accident and emergency attendance?

Mr. Hutton: I have tried to resist intervening on the hon. Gentleman, but it has got too much for me. He has repeatedly attacked the 48-hour target, as did the hon. Member for Brent, East (Sarah Teather). I understand the criticism, but under the hon. Gentleman's proposals, how quickly would one of his constituents be able to get an appointment to see a GP if he scrapped the target?

Mr. Burstow: I am not proposing a target. I am proposing to scrap a target, because it gets in the way of people being treated quickly. The problem is that with the target, people are not getting treatment as quickly as they need because they are unable to get an appointment when they want it. An arbitrary target misses the point. That is my criticism of the Government's target culture.

Mr. Hutton rose—

Mr. Burstow: I will not give way again, if the right hon. Gentleman does not mind. I wish to make some progress and move on to NHS IT procurement, which is mentioned in the motion. Well designed business processes delivered by well implemented systems can save GPs and other primary care professionals time previously spent on administration, but there are real concerns about how the procurement is proceeding and how the end users are being engaged in the process. What control do GPs have over the process?

Mr. Simon: Will the hon. Gentleman give way?

Mr. Burstow: No, I shall make progress, if the hon. Gentleman will forgive me. Without GPs' engagement and without their enthusiastic support, delivering a system that is fit for purpose will be a challenge. It is far from clear who in the national team is responsible for leading on this aspect of the programme's work. How will the full costs of the procurement be met? It has been reported that the total cost of IT procurement could be anything from £18 billion to £30 billion. Most of the extra costs will have to come out of existing budgets, increasing the average spend on IT; yet another cost pressure for PCTs to grapple with.

A further issue not mentioned in the motion but relevant to the working conditions of family doctors and the quality of care that patients receive is the standard of practice premises. According to a written answer that I received there are 700 GP practices operating in sub-standard accommodation; that is, accommodation below the Department's minimum standard, such as surgeries that lack sufficient consultation space, have access difficulties or pose questions about patient confidentiality. What is the timetable for tackling such sub-standard premises?

Many GPs face the serious problem of the affordability of premises, a particular concern in areas with extremely high property prices such as London. In some areas, GPs are retiring and selling their premises at residential rates to recover their investments, and those doctors are not being replaced because prospective GPs cannot afford to set up premises in such areas.

The hon. Member for Leigh (Andy Burnham) mentioned the difficulty of getting doctors to set up in other areas, and I sign up to his view that salaried GPs have a role to play in ensuring good primary care across the whole country.

Sarah Teather: That is a particular problem in Brent, East, where underdeveloped land is scarce and property prices are high. The only way in which doctors can solve the problem is to buy a Victorian property and convert it. However, if one adds the cost of the property to the investment required to convert it, the cost is greater than its overall value, and the PCT will only reimburse GPs up to market value.

Mr. Burstow: My hon. Friend is right to raise that concern, which I know that she has raised with her PCT. GPs often wind up in negative equity as part of acquiring a property, which cannot be sensible. Although NHS LIFT is certainly part of improving existing accommodation and providing new accommodation, PCTs should surely have the freedom and flexibility to find solutions that fit local circumstances.

The motion refers in misty-eyed terms to GP fundholding. Many GPs whom I talk to do not have fond memories of how Conservative proposals on fundholding worked in practice. Fundholding caused a huge equity deficit in the way in which NHS care was accessed; whether one's GP was a fundholder determined how fast one was treated, which was not an acceptable basis on which to provide health care. Serious questions also remain over the cost-effectiveness of the fundholding experiment. Practice-led commissioning must avoid that pitfall, and some of the Minister's comments this afternoon have reassured me on that point. No patient should be left behind in the new system.

A balance must be struck between freeing the frontline to innovate—the reason why I would scrap targets and support practice-led commissioning—and the need to develop and maintain coherent community health services from one part of the country to another. To date, little research has been conducted into the impact of practice-led commissioning, and as that policy is rolled out, I hope that how it works in practice will be carefully evaluated.

I have already said that the Government are obsessed with targets and handing out tick boxes. When it comes to family doctor services and primary care, "Shifting the Balance of Power" has not resulted in a bonfire of targets and red tape.

Mr. Simon: Will the hon. Gentleman give way?

Mr. Burstow: I have already said that I will not give way to the hon. Gentleman.

A PCT executive board member recently told me that after all the spending commitments tied to Government targets, the trust had already allocated 105 per cent. of its budget. That leaves no room for local innovation and no scope to ensure that services are aligned to the health needs of the local population, in which case unmet need remains just that. The NHS needs good local performance management; it does not need poor national political targets.

We carefully examined the Conservative motion, but we cannot support it because it does not offer the right vision of primary care service, while the Government amendment pats the Government on the back, and we will therefore vote against both of them tonight.

GPs are the backbone of the system in this country and are vital to delivering closer-to-home health care, and this debate is an important contribution to that vision. I urge my hon. Friends to vote against both the Government amendment and the Conservative motion, neither of which offers a coherent vision for the future.