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Volume 131: debated on Wednesday 13 April 1988

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'(1) It shall be a duty of the Secretary of State for Scotland to allot to each Health Board, after consultation with that board and with such bodies as appear to him to represent the interest of the public in the area of the Board within the National Health Service, an additional allocation sufficient to meet the cost of allowances paid pursuant to subsection (2).

(2) The Secretary of State shall by order made by Statutory Instruments provide that allowances in addition to any allowances otherwise payable be paid to general medical practitioners satisfying criteria:

  • (a) in respect of the density of the population served in the area served by the practise, or part of such area;
  • (b) in respect of the number of principals and assistants practising therein;
  • (c) in respect of such other considerations as seem to him to be appropriate.
  • (3) A Statutory Instrument under subsection (2) shall be subject to annulment in pursuance of a resolution of either House of Parliament.'.— [Mr. Kirkwood.]

    Brought up. and read the First time.

    I beg to move, That the clause be read a Second time.

    I should explain the purpose of the new clause from the outset because its wording does not make it as clear as it might be. It is an attempt to focus attention briefly on the plight and potential difficulties faced by rural practitioners in Scotland.

    Rural practitioners have problems throughout the length and breadth of the United Kingdom, but I think that the House would accept that, given the geographical disparate nature of large sections of the Scottish mainland, it is appropriate to focus attention specifically on the problems of rural practitioners in Scotland.

    The problems faced by general practitioners in Scotland relate, as much as anything else, to the question of list size. We know that the United Kingdom target is an average list size of 1,700 for general practitioners. In Scotland that is the average list size but the figure is due largely to the number or rural practitioners in the highlands and islands who have extremely small lists because of the nature of the geographical area they cover. In our urban and deprived inner city areas the list sizes remain too high and there is a need for more general practitioners.

    I had an interesting answer to a question that I tabled some time ago. It gave the number of small practices in Scotland. I was told that at 1 October 1986, the latest date for which information was available, there were 779 doctors with a list size of less than 1,000, 982 with a list size of less than 1,200 and 1,316 with a list size of less than 1,500. Therefore, there is a difficulty about the list size in rural practices.

    Having a large number of rural practices—often single-handed practices—with such small lists there are certain peculiar difficulties for the doctors. The proposals contained in the new clause and the thinking behind it seek to redress some of the working conditions they face, particularly the direct reimbursement of local allowances for GPs taking study leave, the introduction of functional group allowances and special assistance to enable doctors to take on a partner. That is the background and provenance of the new clause.

    I was prompted to table the clause, having received a letter from a Dr. Macleod in Inverness, whose permission I sought to advise the House of the contents of the letter he sent earlier this year. He said:
    "We have a relatively small list, so have never expected to make as much money as most of our colleagues. We have, however, time to give to our patients. We cover an area from Smithton to Brodie and Dulcie Bridge to Fort George. Our practice area includes the high risk areas of Dalcross Airport, McDermotts (Scotland)"—
    which is a fabrication and construction yard—
    "and the A96. For the convenience of our patients we operate branch surgeries in Croy and Nairn. We have patients in the local GP hospital and cover there for casualty. We have a Recall System for cervical smears and a Call Up system for immunisations. We provide a Well Woman Clinic and a Well Man Clinic. We undertake some minor surgery. We have a policy of regularly visiting our elderly patients. To avoid the unacceptable delays experienced elsewhere we have not operated an appointments system. We are each available for consultation for an average of 75 hours per week and many more during normal holiday periods. We do not delegate any of our work to deputies. We are a teaching practice.
    We think we run a good practice. Geographically there is no scope for increasing our list size. For whatever reason, the patient demand is increasing well beyond that which one would expect from the pathology exhibited.
    In recognition of all this the proposals on list size in the White Paper will cut our income by something between £4,000 and £11,500."
    During discussions with Dr. Macleod it became clear that the implications for some practices in Scotland, which are small by United Kingdom standards, were severe indeed. I wonder whether the Government understand the full implications of their proposals.

    The new clause aims to make a reality of what the Government claim as being their target in their White Paper, "Promoting Better Health," to try to help rural areas. Far from helping rural areas, cash limiting general practices and plans to increase the size of lists and surgery hours before they qualify for basic practice allowances will have a devastating effect, particularly in Scotland. Under the new clause, the Secretary of State for Scotland would be forced to take into account the large number of rural practices, which are often single-handed practices.

    12.15 am

    GPs who work in isolation, such as Dr. Macleod and his colleagues, must spend more time working for their patients than their urban colleagues because of increased travelling and home visiting. They have little contact with colleagues and experience difficulty in obtaining time off. Rural GPs often play a wider role, as I know from my constituency work, by substituting for other services that are lacking in rural areas.

    The new clause would require an additional allocation to be made, which would include inducement payments to cover the cost of employing high-calibre partners, study leave and improvements to surgery and medical facilities. This would ensure that GPs and their patients in isolated areas do not suffer professionally.

    Rural primary care saves resources by prevention and treatment in the community. The Government do not understand this matter and do not appreciate the needs and difficulties of isolated practices. If the new clause were to be accepted, it would go some way to addressing those problems and to improving health care for people in remote communities.

    I understand that some of these subjects are being discussed and that the Government are still considering what to do to confront the problems. I urge the Minister—a man for whom I have a high regard, even in Scottish matters—to take these matters seriously and to ensure that we get a fair deal and proper allocation for GP services in rural areas.

    I support the new clause, because it relates to a matter about which I have received representations. The Minister should give attention to those representations.

    The matter has been brought to my attention by a single-handed practitioner in my constituency who has been trying to promote the collective development of his practice along with neighbouring single-handed practioners—one in my constituency and two in the constituency of the right hon. Member for Kincardine and Deeside (Mr. Buchanan-Smith). He has been suggesting that it would be much better for individual practices and their patients to join forces to recruit a partner to the four practices to provide cover when the GPs are away on study leave or holiday.

    The obvious advantage is that patients would know the doctor standing in for their normal doctor in a way that they could not know a locum who has been brought in for short-term purposes. I think that the Minister will acknowledge that what tends to happen is that patients suddenly manage to contain their illness when their doctor is away, unless it is desperately urgent. When their doctor returns from study leave or holiday, he has a huge queue of patients who were not willing to see a locum whom they did not know. That is the essence of human nature and I think that the Minister will understand that that is what happens.

    It seems to me that the proposal of that practitioner and his colleagues is sensible and practical. It will help his practice, neighbouring practices and patients. Yet so far he has been unable to get support from the Scottish Office for his suggestion.

    When I first raised the matter with the Scottish Office, officials replied that they were not able to support the proposal because it was likely to be rather more expensive to operate than allowing each individual practitioner to retain his own locum. I then asked the Scottish Office to give an indication of the breakdown of costs, and the officials said that they had analysed the costs and there was no significant difference between supporting the doctors' wishes and simply requiring them to continue with the existing practice of hiring locums as and when they needed them.

    We managed to debunk the argument that it would necessarily cost more, although the new clause states that, even if there is a cost, it should be supported. In spite of having proved that particular point, the Scottish Office continues to resist this practical and constructive suggestion.

    I am sure that the situation is not peculiar to Scotland. There are parts of England to which this suggestion would be relevant and helpful. I have been mystified as to why it has been resisted so far, as indeed have the doctors in question, who feel that they are making a constructive suggestion in the best interests of their own working practices and of their patients.

    I believe that the new clause is sensible and constructive. It will not necessarily lead to enormous costs, and it will ultimately ensure that there is good health provision in thinly populated areas.

    It is not always easy to get dedicated doctors to come to rural areas and operate a single-handed practice. Only a particular type of doctor is willing to take that on. Doctors have come in and have not survived. Within a year or two they have felt unable to sustain the practice. With no disrespect to the doctors who have come to rural areas, it is interesting to note that two of the four practitioners that I mentioned are not British. They are very good doctors, they are very welcome and we are very glad to have them, but that situation is indicative of how difficult it is to attract people into those practices. The new clause would go a long way towards maintaining viable practices, ensuring that practitioners can have some relief from the constant pressure and can work with neighbouring practitioners in a constructive and helpful way.

    I hope that the Minister will take on board this suggestion. If he cannot accept the new clause tonight—we understand that—I hope that he will undertake to consider the thinking behind it and come back at a later stage having considered it. The proposals are constructive and serious and certainly should not be rejected out of hand.

    When I first read the new clause, I was unclear as to its exact intent, but, having heard the explanation, its purpose is now clear to me. I am not sure that the new clause would fulfil all its intentions. Heaven forbid that amateur drafters such as ourselves should always be able to do that. However, the intention is excellent and we should like to record our support of it.

    It is a problem in rural areas, particularly in the highlands and islands and other parts of Scotland, but I am sure that it is also an important issue for some parts of England. A constant problem that affects general practitioners and surgeons who are on continuous 24-hour call for seven days a week is the inability to get away and go to postgraduate meetings. I realise that the new clause applies not to hospital doctors working single-handedly but only to general practitioners, but the principle is extremely important.

    Numerous ways have been considered to give doctors working in such practices time off so that they can keep tip to date with what is happening in medicine and have some relief from being on call for 24 hours. When they go home at night, they never know whether they will have to go out again. There is no respite from the continual ringing of the telephone. Various methods have been tried, and a roving practitioner was used for a while, but that did not really work.

    The purpose behind the new clause is that money should be provided for various things that general practitioners now have to provide for themselves. My hon. Friends and I support the new clause.

    I have to confess that the Government and I collectively face the same difficulty as was experienced by the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith)—that we had not spotted the purpose of the new clause. Most of my brief is therefore scrap paper. I do not think that a carrier pigeon will come to my rescue on this occasion.

    I am encouraged by what has been said about the new clause. We thought that it amounted to a general attack on the system of reimbursing general practitioners that was proposed in the White Paper, but I now understand it to be a perfectly rational suggestion about how the system should be geared to meet the particular problems of particular areas. The suggestion is just as relevant to some parts of England as it is to some parts of Scotland.

    The hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) kindly said that he would understand if I was unable to accept the new clause. I am unable to do so, but I shall ensure that the points that he has made are sympathetically considered. It is not for me to commit the Scottish Office, but I have no doubt that my colleagues there will want to study what has been said, and I undertake to do so in relation to England.

    I hope that it will be encouraging if I point to two quite clear-cut references in the White Paper to our awareness of the problem. I shall not weary the House by reading them at length, but paragraph 3.38, which refers to the possible introduction of a new allowance for areas of deprivation, goes on in the next sentence to say:
    "The effect of these arrangements will be examined and if necessary other changes in the remuneration system will be introduced, for instance to help doctors in sparsely populated areas."
    Paragraph 3.39, which is side-headed "Rural Areas," deals with the extent to which doctors, especially those who practise single-handed in rural areas, can be affected by a number of factors that can contribute to professional and social isolation. The final sentence reads:
    "To take account of the particular pressures on these doctors, the Government will examine, in consultation with the profession, the scope for introducing measures aimed at alleviating their social and professional isolation, for example so that they may have more opportunities to attend post-graduate courses."
    I hope that the spirit of those positive commitments in the White Paper, which are very much in line with the generality of what hon. Members have been urging on me, demonstrates that the Government are willing to look seriously at the points that they have raised.

    We have stumbled on a new tactic. If the Minister is naturally a fairly reasonable chap, the obvious tactic is to table a completely incomprehensible amendment that he has to think through for himself and to which he then, without any help from his civil servants, has to respond. It is a ploy that can be developed and used on future occasions.

    I appreciate what the Minister said, but at the risk of appearing churlish I hope that he will not mind if I press the new clause to a Division. It will demonstrate the importance that we attach to the subject. I understand that conversations are to take place, but a Division may help to concentrate people's minds. I propose therefore to press the new clause to a Division.

    Question put, That the clause be read a Second time:—
    The House divided: Ayes 43, Noes 194.

    Division No. 257]

    [12.30 am


    Ashdown, PaddyLloyd, Tony (Stretford)
    Beith, A. J.McAvoy, Thomas
    Brown, Nicholas (Newcastle E)McFall, John
    Bruce, Malcolm (Gordon)McKay, Allen (Barnsley West)
    Campbell, Menzies (Fife NE)McLeish, Henry
    Campbell, Ron (Blyth Valley)Marshall, Jim (Leicester S)
    Campbell-Savours, D. N.Michie, Mrs Ray (Arg'l & Bute)
    Carlile, Alex (Mont'g)Morgan, Rhodri
    Cook, Robin (Livingston)Morley, Elliott
    Corbyn, JeremyMowlam, Marjorie
    Cummings, JohnPike, Peter L.
    Cunliffe, LawrenceRobertson, George
    Dunnachie, JimmyRooker, Jeff
    Ewing, Mrs Margaret (Moray)Salmond, Alex
    Galbraith, SamSkinner, Dennis
    Graham, ThomasSpearing, Nigel
    Harman, Ms HarrietSteel, Rt Hon David
    Henderson, DougTurner, Dennis
    Hinchliffe, DavidWalley, Joan
    Hogg, N. (C'nauld & Kilsyth)Wareing, Robert N.
    Hood, Jimmy
    Hughes, John (Coventry NE)Tellers for the Ayes:
    Hughes, Simon (Southwark)Mr. Archy Kirkwood and
    Lewis, TerryMr. Ronnie Fearn.


    Allason, RupertArnold, Tom (Hazel Grove)
    Amess, DavidAshby, David
    Amos, AlanAtkinson, David
    Arbuthnot, JamesBaker, Rt Hon K. (Mole Valley)
    Arnold, Jacques (Gravesham)Baldry, Tony

    Batiste, SpencerHughes, Robert G. (Harrow W)
    Bellingham, HenryHunt, David (Wirral W)
    Bennett, Nicholas (Pembroke)Hunt, John (Ravensbourne)
    Body, Sir RichardIrvine, Michael
    Bonsor, Sir NicholasJack, Michael
    Boswell, TimJanman, Tim
    Bowden, Gerald (Dulwich)Jessel, Toby
    Bowis, JohnJones, Gwilym (Cardiff N)
    Brandon-Bravo, MartinJones, Robert B (Herts W)
    Brazier, JulianKing, Roger (B'ham N'thfield)
    Bright, GrahamKirkhope, Timothy
    Brittan, Rt Hon LeonKnapman, Roger
    Brooke, Rt Hon PeterKnight, Greg (Derby North)
    Buck, Sir AntonyKnowles, Michael
    Burns, SimonLatham, Michael
    Burt, AlistairLawrence, Ivan
    Butcher, JohnLee, John (Pendle)
    Butler, ChrisLennox-Boyd, Hon Mark
    Carlisle, Kenneth (Lincoln)Lester, Jim (Broxtowe)
    Carrington, MatthewLightbown, David
    Carttiss, MichaelLilley, Peter
    Cash, WilliamLloyd, Peter (Fareham)
    Chapman, SydneyLord, Michael
    Chope, ChristopherLuce, Rt Hon Richard
    Clarke, Rt Hon K. (Rushcliffe)Lyell, Sir Nicholas
    Colvin, MichaelMaclean, David
    Conway, DerekMcLoughlin, Patrick
    Coombs, Anthony (Wyre F'rest)McNair-Wilson, P. (New Forest)
    Coombs, Simon (Swindon)Madel, David
    Couchman, JamesMalins, Humfrey
    Cran, JamesMans, Keith
    Currie, Mrs EdwinaMarshall, John (Hendon S)
    Curry, DavidMartin, David (Portsmouth S)
    Davis, David (Boothferry)Mates, Michael
    Day, StephenMawhinney, Dr Brian
    Devlin, TimMaxwell-Hyslop, Robin
    Dorrell, StephenMayhew, Rt Hon Sir Patrick
    Douglas-Hamilton, Lord JamesMeyer, Sir Anthony
    Dover, DenMiller, Hal
    Dunn, BobMills, Iain
    Durant, TonyMitchell, Andrew (Gediing)
    Dykes, HughMitchell, David (Hants NW)
    Eggar, TimMonro, Sir Hector
    Evans, David (Welwyn Hatf'd)Moore, Rt Hon John
    Fallon, MichaelMorrison, Hon Sir Charles
    Favell, TonyMoss, Malcolm
    Forman, NigelNeubert, Michael
    Forsyth, Michael (Stirling)Newton, Rt Hon Tony
    Forth, EricNicholls, Patrick
    Fox, Sir MarcusNicholson, David (Taunton)
    Franks, CecilNicholson, Emma (Devon West)
    Freeman, RogerOnslow, Rt Hon Cranley
    Gale, RogerPage, Richard
    Gill, ChristopherPaice, James
    Goodhart, Sir PhilipParkinson, Rt Hon Cecil
    Goodson-Wickes, Dr CharlesPatnick, Irvine
    Gorman, Mrs TeresaPatten, John (Oxford W)
    Gorst, JohnPattie, Rt Hon Sir Geoffrey
    Gow, IanPeacock, Mrs Elizabeth
    Greenway, John (Ryedale)Portillo, Michael
    Gregory, ConalPrice, Sir David
    Griffiths, Peter (Portsmouth N)Rattan, Keith
    Grist, IanRathbone, Tim
    Ground, PatrickRedwood, John
    Gummer, Rt Hon John SelwynRiddick, Graham
    Hamilton, Hon Archie (Epsom)Roberts, Wyn (Conwy)
    Hampson, Dr KeithRoe, Mrs Marion
    Hanley, JeremyRyder, Richard
    Hargreaves, A. (B'ham H'll Gr')Sainsbury, Hon Tim
    Hargreaves, Ken (Hyndburn)Sayeed, Jonathan
    Harris, DavidShaw, David (Dover)
    Haselhurst, AlanShephard, Mrs G. (Norfolk SW)
    Hayes, JerrySims, Roger
    Heddle, JohnSmith, Sir Dudley (Warwick)
    Hind, KennethSmith, Tim (Beaconsfield)
    Holt, RichardSpicer, Sir Jim (Dorset W)
    Howard, MichaelStanbrook, Ivor
    Howarth, Alan (Strat'd-on-A)Stanley, Rt Hon John
    Howarth, G. (Cannock & B'wd)Stern, Michael
    Howell, Ralph (North Norfolk)Stevens, Lewis

    Summerson, HugoWard, John
    Taylor, Ian (Esher)Warren, Kenneth
    Thompson, D. (Calder Valley)Wells, Bowen
    Thompson, Patrick (Norwich-N)Wheeler, John
    Thurnham, PeterWhitney, Ray
    Townsend, Cyril D. (B'heath)Widdecombe, Ann
    Tredinnick, DavidWilshire, David
    Trippier, DavidWinterton, Mrs Ann
    Trotter, NevilleWinterton, Nicholas
    Twinn, Dr IanWood, Timothy
    Vaughan, Sir Gerard
    Waddington, Rt Hon DavidTellers for the Noes:
    Wakeham, Rt Hon JohnMr. Robert Boscawen and
    Walden, GeorgeMr. Tristan Garel-Jones.

    Question accordingly nagatived