QUEEN'S SPEECH: HEALTH CARE
26th November 1998
Mr. Michael Fabricant (Lichfield): I do not know whether doctors in Bedford feel the same as doctors in Lichfield, but there is no enthusiasm whatever for primary care groups among general practitioners in Lichfield. I shall quote later from GPs in my constituency who have e-mailed me on that matter in the past 24 hours.
First, I want to address the Queen's Speech. The Prime Minister and the No. 10 Downing street policy unit seem to have difficulty in determining exactly what the third way is--or the "troisieme voie", as the Prime Minister put it at the Assemblee Nationale in Paris recently. The third way, or the middle road, as the Prime Minister puts it, sounds suspiciously like the caring capitalism of my right hon. Friend the Member for Henley (Mr. Heseltine). Privatising the Queen's flight, air traffic control and other organisations is following in Margaret Thatcher's footsteps, not Attlee's. While we should welcome the Prime Minister's apparent conversion, I think that he sees that this is no road to posterity. The Prime Minister, like others before him, wants to be remembered. He realises that following a well-trodden path is no road to posterity.
As we know, the Labour party is heavily into marketing so, to use a marketing term, the Prime Minister has to product differentiate the Labour Government from previous Conservative Governments. Therefore, the Prime Minister has decided to tinker, without thinking through the consequences. His big idea is to tinker with the constitution and, as we shall see later, to tinker with the NHS.
The Prime Minister will tinker with devolution, even though it may mean the Labour party in Wales and in Scotland splitting away from new Labour. That is a real possibility for the Labour party. Conservative Members will be watching that space with considerable interest when it comes to the elections for the Scottish Parliament and if, as we all believe at the moment, the Scottish National party wins.
The Prime Minister will tinker with the other place, although a Chamber of placemen is even less democratic than the status quo. Why cannot he wait for the royal commission on the other place to report back first?
The Prime Minister will tinker with our voting system, even though Israel, New Zealand and Italy all seek to adopt a first-past-the-post system--the very system that the Prime Minister is now trying to abolish.
As I said just now, not happy with tinkering with the constitution, the Prime Minister now wants to tinker with the health service. This Government of soundbites maintain that the internal market is somehow destructive. We have heard that from the hon. Member for Bedford (Mr. Hall) and from other Labour Members. They criticise the internal market, but it benefits patients. Let us remember what it was like before the internal market.
In 1990, the King's Fund centre published "Health Care UK", its annual review of health care policy. The paper addressed the lack of efficiency within the NHS compared with other Government Departments. The centre, a neutral body, asked: "Why should so little have been achieved within the NHS not just during the 1980s, but in the previous decades?"
Mr. Stephen Hesford (Wirral, West): Will the hon. Gentleman confirm that the 1990 review was carried out after 11 years of a Tory Government and that that is why there was no progress in the NHS? It was under your Government. It was your tinkering--
Mr. Deputy Speaker: Order. The hon. Gentleman must distinguish between his second and third person.
Mr. Hesford: It was the hon. Gentleman's Government after 11 years.
Mr. Fabricant: The hon. Gentleman spat it out eventually. Unfortunately, he was preparing his intervention before he had heard the full quote. I repeat: "Why should so little have been achieved within the NHS not just during the 1980s, but in the previous decades?" I said that, but the hon. Gentleman was not listening.
The report describes the huge leviathan of the NHS, the biggest single employer in the United Kingdom since 1948, as being incapable of efficiency with "simultaneous centralising and decentralising tendencies interfering with the thorough-going implementation of either." That could not have been a Conservative party report because there is no way that such a report would use a ghastly phrase such as "thorough-going" with a hyphen.
The report went on to detail how cumbersome the NHS was. Its efficiency was almost as bad as that of the BBC, yet just four years later, after the introduction of the internal market, the same King's Fund centre was writing a different story. In a paper entitled "Evaluating the NHS Reforms", it stated: "In many areas of hospital operations, trusts had significantly lower costs than non-trusts, particularly in ward unit costs and in areas associated with administration and management."
Let us be absolutely clear about this history lesson. The money saved is money that can be spent on patients and beds instead of on waste. In 1989, a report in The Guardian -- hon. Members know that it is my favourite newspaper -- gave an example of the waste and bad management that existed. It stated: "Health authority beds have patched fences, walking sticks have been spotted in vegetable plots smothered in runner beans, and bed hoists have been seen raising engines from cars. Sheepskins have moved from beneath the bedridden elderly to the pride of place in front of fireplaces. Equipment is haemorrhaging at a cost of £1,000 a week." That is in one health district. The paper also stated: "Officials calculate that a quarter of their £56,000 of home-care equipment goes over the garden fence each year."
In 1988, the same paper, The Guardian, citing an example of waste, before our reforms and the introduction of the so-called evil internal market--which, incidentally, the Government are not getting rid of, simply giving it a different name--stated: "Responsibility for equipment is split between health, social services, and the artificial limbs and wheelchair authorities. Supply is a muddle: social services fit one type of hoist, the health authority another . . . Multiple sources for some items, the lack of others, and informal rationing which means long waits, all create confusion for disabled people and their carers. They often have to accept what's on offer, instead of choosing the equipment that would best suit their needs. . . Research shows that up to 50 per cent. of equipment can go unused."
Dr. Whitehead: The hon. Gentleman is being a little selective in his trip down memory lane. In 1983, the Conservative Government introduced the Griffiths reforms to introduce general management into hospitals to solve precisely the problem that he has just described. Is he not therefore describing the failure of the Conservative Government to get to grips with the NHS?
Mr. Fabricant: The hon. Gentleman raises a perfectly reasonable point. Policies evolve -- after all, who would have thought that the Labour party would be into privatisation? The Labour party has evolved. In 1983, we tried to do something with the leviathan -- and yes, you are right, it did not work. That is why we brought in the internal market. That works, and that is why the Labour party is not getting rid of it. Don't believe your pager--
Mr. Deputy Speaker: Order. It is the hon. Gentleman who is now forgetting his second and third persons.
Mr. Fabricant: You are absolutely right, Mr. Deputy Speaker. That goes to show how important it is to have debates and interventions. It shows also that one can get emotionally concerned -- as I am -- about the welfare of people of this country, and not about spin-doctoring. Who are the Government kidding? Does the Under-Secretary of State for Social Security, the hon. Member for East Ham (Mr. Timms), want to return us to the old shambles? The Minister -- whom I know from the previous Parliament -- is a sensible man and does not want that. Let us hear no more soundbites about the internal market setting nurses against doctors, and all the other claptrap that we have heard over the past hour or two.
The latest proposals from the Government involve tinkering with the GP fundholding practices, and that is what I want to concentrate on now. The proposed changes have serious consequences for my constituents in Lichfield. Every GP in Lichfield has chosen to be a fundholder; not one has shown any enthusiasm for the Government's proposals. That is not because Lichfield doctors -- or any other fundholding doctors in the UK -- are greedy, as the Government try to make out in an attempt to demonise them. It is because my local doctors firmly believe that GP fundholding practices benefit their patients. As a local doctor said to me last night, "Fundholding had its faults but at least GPs were in the driving seat of improving patient care."
He believes that primary care groups will worsen the treatment of patients. While PCGs give GPs the responsibility for looking after their patients' interests -- in theory, at least -- they will lack the power to have any significant impact.
The Government will point to the higher tiers of the new system, culminating in level 4, where the primary care trust will be responsible for all services to patients -- like the health maintenance organisations in the United States, which the Government are attempting to copy. On paper -- like all soundbites -- it seems like a good idea, but not for Lichfield, and not for the rest of the country. Let me explain why.
Leaving aside the high management costs of HMOs, GPs will be locked into underfunding. Let us cast our minds back to the introduction of fundholding. This history lesson puts things in context. Hospital consultants were using the media time and again to say that the NHS was not providing a service to individual patients. The then Prime Minister, Margaret Thatcher, personally announced on television a review of hospital services, out of which grew the purchaser- provider split to generate efficiencies for the benefit of patients. Until then, hospital consultants had huge power at health authority level, and the authority was responsible for providing hospital services. As community services did not have the power to influence health authorities, proper development of community services, with a fair share of resources, did not happen. However, the purchaser-provider split could be killed at birth, as the consultants and health authority executives were the same people. Why would a hospital become a self-governing trust and take all the risks when paying lip service to the reforms was all that was required? Many hospitals would have remained under health authority control, so there would be no purchaser-provider split. From this, GP fundholding was born.
Let me give the House a local perspective. In the main, patients from Lichfield are sent to three main hospitals--Good Hope in Sutton Coldfield, Burton hospital and Stafford hospital. Lichfield doctors tell me that the services provided by Good Hope hospital used to be "atrocious"--their word. GP representatives on teams and authorities were merely tolerated, and were usually ignored. Fundholding empowered their voices. By good fortune, and through the skill of the family health services authority--then chaired by a good friend of mine, Philip Jones--seven local practices were selected in the first wave of fundholders in the UK. Suddenly, local GPs controlled half of Good Hope hospital's budget for elective services. A marked improvement occurred at Good Hope for the benefit of patients as a direct result of the introduction of fundholding practices. At Burton hospital, where the service was adequate prior to fundholding, most of the business came from Burton and south Derbyshire. With little impact from fundholders, the consultants retained their power. Only when a consortium of practices around Burton formed the Burton fundholding group did change for the better occur--change driven by doctors, caring for their patients at community level. These successes have been duplicated up and down the land.
Mr. Patrick Hall: What the hon. Gentleman has just described--which applied to small parts of the country, and certainly not to the whole country, under GP fundholding--can now apply to the whole country. That is the difference between the Government's proposal and the Opposition's proposal. Why does not he want the benefits that he has just described, regarding the balance of power, to apply to the whole country for all patients?
Mr. Fabricant: A sensible question, if I may say so, from the hon. Gentleman. On paper, it would seem to be a good idea--make fundholding compulsory, give it a different name and take away one or two of the powers. However, it will not work like that. If it did, I would be voting with him--but it ain't going to work like that. The Government--and the hon. Member for Bedford--have recognised that fundholding has been a success, but they argue that it is a two-tier system with the patients of fundholding GPs benefiting because they have more money. The Government argue that the system is fine for fundholding patients, but not for ordinary patients. As the hon. Gentleman says, the Government have said, "Let us change the name to primary care groups and make membership compulsory. There will be a single tier and everybody will be happy."
That is not the case. Two fatal flaws in Labour's logic are dogging the Government--just as they have dogged previous Labour Governments. First, the Government ignore the fact that some GP practices are more skilled than others in management. It is not a question of whether they have more money or not--it is a question of whether they have the inclination to be involved in the management of practices. The second mistake in Labour's logic--a mistake that has been a common thread since 1948--is that the Labour party persists in the belief that dragging down to an equality of mediocrity is better than allowing excellence. We have seen that with the Government's aim to abolish the remaining grammar schools--we are now seeing it with fundholding.
I shall now be more specific. Primary care groups are not the same as fundholding practices--despite what the hon. Member for Bedford might think.
All partners in first-wave fundholding practices had to agree to enter the scheme. One veto from one doctor in the practice blocked their joining the fundholding scheme. With PCGs, every GP is compulsorily a member of the PCG. The boundaries of the group are arbitrary. For example, in Lichfield--I am sure that this will be duplicated in other parts of the country--if practices had a choice, they would join with certain practices in Tamworth, where there are like-minded GPs with whom they have worked for years. Instead, they have been bundled in with Burntwood. However, that is not the main point. In fundholding, each practice was responsible for funds for its own patients. With PCGs, the budget is for all practices in the group, with the implication that every GP has corporate responsibility for the spending of GPs in other practices. In fundholding, the budget was set for planned procedures--this is the most important point, which has not been picked up yet--with the budget for emergency procedures remaining with the health authority. The new PCG scheme will result in practices having to fund unpredictable emergency treatment.
Will the doctors in the House be so pleased with the changes if we have a bad winter and more people go to accident and emergency departments, and their budgets are cut accordingly? I suspect not.
The budget for first-wave fundholders was set according to the hospital, drug and staff expenditure in the year before anyone had even coined the idea of fundholders.
A Lichfield GP wrote to me. He said: "Will I be able to convince the Chancellor that my practice needs extra funding for winter pressures or waiting list monies to reduce the number of my patients on waiting lists? I am sure you know the answer to that question, and you will understand the attraction to the Government of PCGs. South Staffs Health Authority is about 13 per cent. underfunded so the playing field is not level; hence a multi tier NHS. Where you live may still determine the service you get. In addition to the 13 per cent. underfunding inherent in the budget calculations, there is also the thorny question of how to deal with overspends run up by health authorities by the end of this financial year. Will the Treasury write off these debts or will PCGs be forced to take on board these debts as a first charge on next year's funds?"
I do not know whether the Minister will be able to answer that question, but it would be helpful to receive a letter from the Department. The letter from the GP continues: "Unlike fundholding if it goes wrong we cannot pull out."
What about the management skills needed by GPs? First-wave fundholders had to demonstrate management skills to be accepted on the scheme, but PCGs are compulsory. There has been no assessment of whether the skills are available countrywide. Are the Government aware that management skills are not part of GP training? Perhaps the Government feel that management skills are not needed because of the appointment of general managers, but the overall sum available for the manager and his team, for reimbursing GPs for the cost of locums in their absence on PCG business and for an honorarium for GP advisers is a measly £3 a year per patient registered with the practices in the PCG. The formula is obviously insufficient for Lichfield, Tamworth and Burton and for other areas.
Will the Lichfield team be able to deal fairly when Tamworth GPs will want to protect their Sir Robert Peel hospital? Could the Victoria hospital in Lichfield be threatened in such a scenario? As development at the Victoria has involved portakabins for several years, I would like to know whether Premier Health now favours Sir Robert Peel over the Victoria?
With fundholding, savings made by practices could be carried forward for up to four years, so GPs did not have to waste money by rapidly spending any surplus in the last month of the financial year. Savings had to be accounted for and the spending of savings had to be approved by the health authority. Improvement in care or facilities for patients was paramount. It was prudent to keep a reserve for future years' hospital care, as a practice could have an unusual imbalance of expensive procedures. The Government have said nothing about what is to happen to PCG savings. If savings are not carried forward, where is the buffer for extraordinary years? The question is especially pertinent now, as for the very first time, the Government are making GP budgets pay for unpredictable, emergency work. It is a fundamental question: if the weather is bad, will GPs have their budgets slashed? The Government should tell the truth.
Mr. Nicholas Winterton: My hon. Friend reflects the concern of GPs throughout the country. I spoke earlier of the benefits brought by GP fundholding, but admitted that there had been abuses. My hon. Friend is outlining some of the problems with the Government's proposals, but how would he amend GP fundholding to reduce the abuses and the problems that were created for some hospitals and hospital trusts, while preserving the many benefits that it brought for patients, putting as it did the GPs on an equal footing with the hospital consultants, who had hitherto dominated the health service?
Mr. Fabricant: I would like to extend fundholding. I would not make it compulsory and I would provide better training so that all GPs would have the ability and the financial wherewithal to manage their own practices, as happens with the 55 per cent. of practices that are currently fundholding. Eventually, by voluntary choice and ability, all practices in England and Wales would be GP fundholding practices. We should certainly not say, as the Government do, that the extraordinary budget--for emergencies, for illnesses in winter and cardiac arrests--should come out of the GPs' budgets.
The measures will not help community care. They are all about party dogma. I end not with my words, but with those of my Lichfield doctor. In an e-mail that he sent to me last night, he said: "Like the 'new' arrangements for the House of Lords,"-- I will have to sign this doctor up to the Conservative party if, as I believe, he is not already a member; his words provide a better ending than any that I could possibly write. He said--I repeat his opening words-- "Like the 'new' arrangements for the House of Lords, the new NHS seems to be words with no substance. Sorry, that is unfair; circulars describing the new NHS arrive almost every day. The comparison is only valid as nobody seems to know how either will work!!"
