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Primary Care

Volume 480: debated on Thursday 16 October 2008

I beg to move,

That this House has considered the matter of access to primary care.

Even before the NHS was born 60 years ago, Nye Bevan recognised that, for it to stay relevant and to retain public support, it had constantly to change and improve. Primary care, as the gateway to the NHS and the upholder of its values, is in the vanguard of that change. I would like to share with the House the ways in which the Government are reshaping primary care for the 21st century: how we are listening to patients and letting them lead the way; how we are pushing power down to local level to primary care trusts, giving them the freedom, finance and support to transform primary care; and how we are doing more than any previous Government to improve access to primary care so that the hard-working men and women who pay for the NHS through their taxes can benefit from it at a time and place convenient to them.

In the 11 years since this Government came to power we have put unprecedented investment into primary care, supporting a massive increase in new staff and modern premises and improved services. Funding has more than doubled. Investment in GP services has increased from just £3 billion in 1997-98 to £7.86 billion in 2006-07. There are 5,300 more GPs and 4,500 more practice nurses. The average length of a GP consultation has risen by 50 per cent., from 8 to 12 minutes, and outcomes for patients have improved, and patient satisfaction in England with GP services has risen. In 1997, fewer than half of all patients could expect to see a GP within two days of asking for an appointment; now, more than 87 per cent. of patients say they see their GP within 48 hours.

Appointments are an important issue because they are the first point of access between doctor and patient. In most circumstances, it is sensible for a person to make a phone call, and they will then get an appointment for that day or the following day. However, patients who telephone are increasingly finding that they are placed behind others who make appointments through the internet. As a consequence, elderly people who do not have a computer are at a disadvantage in getting appointments. Is the Minister aware of this, and what can be done about it?

I am certainly aware that some GP practices are introducing the option to book appointments electronically, and I welcome that as it provides a greater range of means by which people can make appointments; the complaint has often been made in the past that is rather difficult at some surgeries to make appointments via the telephone. However, the hon. Gentleman is right to highlight the potential danger of people who do not have access to the internet, or who do not use e-mail and rely on the telephone, being disadvantaged. I hope that GP surgeries and primary care trusts will do what they can to ensure that that does not happen.

Can the Minister explain why the GP-patient survey said that 87 per cent. of those asked whether they were able to get through to their surgery on the phone said yes, but in a report published by the Healthcare Commission just a couple of months ago on urgent care, the patient experience survey found that 55 per cent. of people always or sometimes had a problem getting through to their GP practice or health centre on the telephone. Why is there a discrepancy between those two results?

If the hon. Gentleman will bear with me, I will come on to deal with the discrepancies that have emerged between those two surveys and the Healthcare Commission report.

In some parts of the country there is still access to GP surgeries via 0844 numbers, and I consider that to be an unfair tax on those patients who have to pay a higher charge to get through to their GP—and where the GP effectively revenue-shares with the phone company, perhaps through how they pay for the phone system. This practice damages access, and I would like to learn what the Government might do to stop it, as it disadvantages patients, particularly in poorer areas.

I can reassure my hon. Friend that we are looking closely at this. We have repeated on a number of occasions that the public should not be charged more than the cost of a local call for contacting their GP surgery. Some surgeries have introduced these more expensive phone systems, but we are looking at whether we can introduce a system where that would not be the case without disadvantaging surgeries.

I wrote to the Minister’s Department on the following matter in the summer. We are all keen for access to primary care to be encouraged and promoted, and we are also keen to encourage people to go to their GPs. However, a pharmacy White Paper is currently out for consultation, and for an area such as my constituency unless the first option outlined in it is adopted, which is the option of no change, it will be less likely that people will go to their GPs and more difficult, particularly for elderly people, to obtain the prescriptions they get at present from their dispensing doctors. Will the Minister take into account the fact that if we are serious about encouraging better access to primary care, moving in a direction other than that proposed in the first option will severely damage that aim?

I reassure the right hon. and learned Gentleman that we are listening very carefully to the representations that he and other Members have made on dispensing GPs. No decisions have been made yet, but we recognise the value in their work that he describes. At the same time, we want pharmacies and pharmacists to play a greater role in the provision of primary care and we need to address some of the distortions that have been in the market for rather too long.

Many of the improvements that I described a moment ago have resulted from the much, and unfairly, maligned new GP contract. The contract was vital to prevent the haemorrhaging of GPs from the service, but that does not mean that it cannot be improved. Since its inception we have been improving it in relation to the quality of service from GPs and value for money for the taxpayer.

The UK’s almost unique system of family doctors is envied throughout the world. Most of us need and expect our GPs to be there for us when we need them, but in repeated patient and other public surveys the public have told us that they do not always find it as easy as it should be to see a GP quickly or make an appointment in advance and at a time that suits them. That is why the Prime Minister, when he took over just over a year ago, said that he wanted at least half of GP surgeries opening in the evenings and at weekends. Earlier this week we announced that that target had been met three months early.

If my hon. Friend examines the matter carefully, he will see that Gloucestershire sits alongside two other authorities in not having negotiated any improvements in GP access so far. I am assured by my primary care trust that that is historical data and that a lot of practices have now come on board, but will he ensure that there is not a huge disparity across GP practices? They should all offer some out-of-hours provision. Although many do so, the problem is how it has been reported. It was a bit of a shock to see that not one practice in Gloucestershire could qualify as part of the long-awaited improvement.

My hon. Friend is absolutely right to draw attention to PCTs’ so far variable performance in delivering on the target that more than 50 per cent. of GP practices should offer evening or weekend openings. It must be frustrating for him, as a Gloucestershire Member of Parliament, to note that his is one of the areas that still has some catching up to do. I am confident that Gloucestershire will catch up and that every strategic health authority in the country will hit the target by December.

Of course, the more GP surgeries that offer extended hours, and the more patients decide they like them and vote with their feet, the more likely it is that there will be a snowball effect. In that case, probably far more than 50 per cent. of surgeries in most areas will end up offering extended hours.

Despite the Minister’s words, does he not understand the cynicism that many general practitioners will have about the policy of getting rid of the minimum practice income guarantee? Some will feel that that means a move towards a capitation-based, quantitative approach to family primary care rather than a quality-based approach. The real effect will be to close many small surgeries up and down the country.

No, I do not accept that. I think that the minimum practice income guarantee is one area of consensus in the House, and I shall say a little more about it in a moment. I welcome the fact that the British Medical Association has now signed up in principle to phasing it out, and we want to work with the BMA to ensure that we do that in a way that does not have the impact that the hon. Gentleman describes. The very problem with the guarantee is that it does not reward performance and quality. It makes a significant proportion of payments based on what has historically been paid, and I do not believe that anybody in 2008 thinks that that is the right way forward.

The Minister will no doubt have seen that last week GP magazine reported the Department’s director of the GP access programme as saying that one option that the Department was considering was to replace the directed enhanced service for extended opening hours with a local enhanced service. Can he confirm that that is one of the options that the Department is considering, and that in effect it would bring us to the situation that should have obtained under the contract introduced in 2004?

No, I cannot comment on those remarks. I can say that we would not want to do anything that was in danger of reversing the marked and welcome progress that has been made on extended hours over recent months.

The Minister says that he cannot comment, but is he saying that the report is not true? Do we face another change, on top of the one that was introduced earlier this year?

If it would help the hon. Gentleman and the hon. Member for South Cambridgeshire (Mr. Lansley), I shall write to them with clarification on the matter.

The Minister has been extremely gracious in accepting so many interventions. Before he leaves the issue of getting access to a GP within 48 hours, I want to ask him about something that happened in my constituency. A rather poorly elderly lady went early in the morning to get an appointment at the doctor’s surgery, only to be told that it was full for that day. When she asked whether she could have an appointment for the next day, she was told, “No, you have to come back and try again tomorrow.” Presumably that did not register as her not being able to get an appointment within 48 hours, and surely that cannot be the way in which the Government want GP access to operate.

No, that would not comply with the standard that someone should be able to see a GP within 48 hours. Some surgeries operate a walk-in, non-appointment service, whereas others offer appointments only. However, if someone is not able to see their GP within 48 hours, that would not comply with the current standards. That lady would, therefore, have every right, aided by her able Member of Parliament, I am sure, to complain to the practice concerned and to the primary care trust.

The people who are taking advantage of these new extended hours are not the people whom the Leader of the Opposition recently described, so disparagingly, as executives who

“need some jabs for a business trip to India”.

Neither are they the people whom some doctors’ leaders have described as the “worried well”. They are the hard-working people who pay for the national health service, and they welcome the fact that they do not have to take time off work any more, in some cases losing wages as a result, just to see a doctor. The new evening and weekend opening hours are proving extremely popular with the public and with the doctors, nurses and other practice staff who are implementing them. I hope that the Conservative party will soon perform another U-turn and abandon its pledge to reverse evening and weekend opening—perhaps the hon. Member for South Cambridgeshire will assure us now that it will abandon its pledge to reverse extended opening.

The Minister will doubtless be aware that I will have an opportunity to say something after he has finished, but may I ask him a question now? Has he seen the report on extending opening in this week’s Pulse? It says that its survey of 398 GPs found that

“only 37 per cent. of those attending are working professionals”.

So, the hours are not necessarily being used by people who are in work, and that is what one would have expected. He must know from his own patients survey that the people who most wanted to be able to attend on a Saturday morning were the elderly, not those who are in work. Of course we can respond to patient choice, and to do so is Conservative policy, but we need to be aware who is seeking this system.

That was exactly the point that I was making. I was citing the suggestion by the right hon. Member for Witney (Mr. Cameron) that the only people who would use extended hours were yuppies getting their jabs before going to Asia, and making the point that a cross-section of patients are benefiting from these hours. This week, I visited a surgery in west London that has introduced extended opening, where I was told that the patient profile of the people using the service was almost exactly the same as the surgery’s overall patient profile. It included not only people who welcomed the fact that they could attend before or after work on a week day, but elderly people, who liked the fact that the surgery was quieter, and parents, particularly mothers, who found that they could use the evening opening—their child care arrangements were looked after because their partner, husband or spouse was already home. We should not be sniffy about the fact that extended opening is being used and welcomed by a cross-section of patients, because that is exactly why the Government introduced it. I hope that the Opposition will abandon their pledge to reserve it.

Helping patients to fit a doctor’s appointment into their busy lives does not just mean making available evening or weekend appointments; it also means patients being able to be seen quickly and to book appointments ahead. Some of the media today have said that the Healthcare Commission’s report shows that just 31 per cent. of primary care trusts are giving patients an appointment within 48 hours. That is not correct. The Healthcare Commission’s own patient survey and the much larger national GP patient survey, which questions 5 million patients, both show the same thing: last year, 87 per cent. of patients said that they could see their GP within two working days of asking for an appointment. That is a further improvement on the year before.

The Healthcare Commission has its own separate measurement to judge how effectively primary care trusts are performing. It is that far more stringent measurement that has led to some of today’s misleading headlines. While 87 per cent. is good, it is not good enough. Every patient should be able to see their GP within 48 hours. If any of the hon. Members present, or their constituents, think that local GPs are not providing that service, they should take the matter up with their local primary care trust.

The Minister referred to the fact that the assessment by the Healthcare Commission is much more stringent, and I have read the relevant section of the report. None the less, the results are alarming, suggesting that patients often cannot get an appointment within the defined period. When the surveys do their mystery shopping, they make three calls, because in real life people often cannot make specific times, especially if they are working. The commission report should therefore give rise to considerable concern and demonstrates how much further we still have to go.

I agree, and I wish to put on record my admiration and respect for the work of the Healthcare Commission. We established that independent health watchdog and its work has helped us to drive up standards across the NHS. It is also right to highlight in its report the relatively weak performance at primary care trust level. There has been significant improvement across the NHS, as Sir Ian Kennedy, the chairman of the commission acknowledged, both in his foreword to the report and in his media interviews, but acute hospital trusts are performing much more strongly than primary care trusts. That is partly because primary care trusts were massively reorganised only two or three years ago and have been settling down since. There has been improvement, but the Healthcare Commission is right to focus the criticisms in its report towards primary care trusts, and especially their management of GPs.

It is important to be clear about what the Healthcare Commission is saying. Will the Minister therefore agree that it was unhelpful for the Secretary of State to wander around studios this morning insinuating—and sometimes even stating—that there was a difference between the commission’s survey and the Department’s, because the latter asked about the chance of seeing “a” doctor within 48 hours, and the former asked about the chance of seeing “your” doctor? That is irrelevant. In fact, the Healthcare Commission incorporated the result of the GP patient survey fully into the measure that it has published. In that sense, what the Minister has said is true, and not what the Secretary of State said.

It would be unwise for me to comment on media interviews that I did not hear or see. I do not think that there is any difference between us and the Healthcare Commission on the surveys. Indeed, the commission used our survey as part of its report. The difference, as the commission acknowledged, comes in its interpretation of some of the data, which has led to headlines claiming that two thirds of people cannot see a GP within 48 hours, so millions of people are deprived of access to GPs—to misquote the splash in The Daily Telegraph today. That is not the case, and the Healthcare Commission has been happy to put it on record that that is not its view.

What the report actually said was that two thirds of primary care trusts were failing to get everyone in their area seen within 48 hours. If that is the case, it is quite a failure to meet the Government’s target.

It is not a target, but a standard; let us get our terminology right. The hon. Gentleman is right, but it would be wrong to imply from that information that millions of people were being deprived of access to a GP—that is not the case—or to give the impression that the vast majority of people in both surveys were unable to do so: 86 or 87 per cent. said that they could get to see their GP within 48 hours.

I am sorry to intervene again, but if we are in the business of clarifying we should clarify properly. There are two surveys, one of which is the primary care access survey conducted by the Department through primary care trusts. The other is the GP-patient survey conducted by Ipsos MORI. That survey says that 87 per cent. of patients say that they can access a doctor within 48 hours. The national primary care access survey says that 98.93 per cent. of patients can access a doctor within 48 hours. Part of the issue is how the Healthcare Commission has constructed its measure. It has done so partly to incentivise improvement on the patient access survey, and partly to penalise the gap between the two surveys, which on average across the country is approaching 12 per cent. The measure has taken some PCTs below 80 per cent. overall achievement—below a mark of 80—which means that they are held not to have achieved the level. I know that that is complicated, but it does not mean that it is true that the two surveys deliver the same result.

We are dancing on the head of a pin. I agree completely with what the hon. Gentleman just said, and I am not quite sure what point he was trying to make.

One way in which we have achieved the improvement in GP access is using incentives in the new contract. An ever-increasing proportion of the payments made to GPs is based on a patient’s ability to get an appointment within 48 hours and to book appointments ahead. More than £38 million is now available through the quality and outcomes framework to award those practices whose patients are highly satisfied with the speed and efficiency of the appointments system.

Providing incentives for practices to open for longer, and making it easier to see a GP quickly and to book appointments ahead, are only part of the story. We are also expanding primary care through new and additional GP practices. We have already replaced and refurbished nearly 3,000 GP premises and built more than 650 one-stop primary care centres. We have invested nearly £1.5 billion in primary and community care facilities since 2003 under the LIFT—local improvement finance trust—initiative.

In order further to improve access to GP services and to tackle some of the persistent health inequalities, we need to do more. We are investing £500 million over the next three years to provide a new GP-led health centre in every primary care trust in the country. Any member of the public, regardless of which local GP practice they are registered at, will be able to walk in and use those services or book an appointment in advance. Every centre will be open from 8 o’clock in the morning to 8 o’clock in the evening, seven days a week, 52 weeks a year.

The Minister has talked about carrots and incentives for GPs to improve access, and I am sure that we all welcome that, as it is good news. However, there is one thing that I am at a complete loss to understand. In the whole area covered by the Oxfordshire PCT there will be just one Darzi centre in one bit of the county, so how will that help everyone else all over the rest of Oxfordshire? Would it not be better to put the money that will go into that Darzi centre into the general pot of incentives and carrots to help all GPs improve their services? Effectively, what will happen is that one Darzi centre in one bit of the county will be competing with the GP practices there, while the rest of the county will not benefit at all from the centre. I do not understand the public policy imperative of all that. It is very confusing.

What happens in Oxfordshire is a matter for Oxfordshire PCT. The hon. Gentleman might want to make representations to the PCT. If he does not want the new walk-in centre in his constituency, in Banbury, perhaps the trust would be better off putting it in Oxford, where students could benefit from it.

As I said earlier, one thing that has come top of the public’s concerns on the further improvements that they want in the health service is the ability to see a GP at a time that is more convenient to them. As we have discussed already, more than half of GP surgeries now offer appointments in the evenings and at weekends, but it may be that only half or 60 per cent. of GPs in Oxfordshire do so. It is right that a service should be provided so that people whose surgeries are not open in the evenings or at weekends, or at a time that is more convenient for them, can make use of them on a Saturday or Sunday or a weekday evening. I must tell the hon. Gentleman that those facilities that are already up and running are incredibly popular.

Earlier this year, the proposals were subject to a campaign of opposition led by the British Medical Association. I am afraid that that campaign was supported by both the Conservatives and Liberal Democrats. The claim was that the proposals posed a threat to existing GP services and would lead to the wholesale closure of GP practices. I believe that both Opposition parties are pledged to scrap them, and that is another area in which I confidently predict U-turns by them.

What we opposed was the central imposition on every PCT. The Minister responded to the intervention from the hon. Member for Banbury (Tony Baldry) by saying that the decision was up to each PCT, but that is not the case. It was imposed from Whitehall. Will he confirm that every PCT had no choice but to go along with the decision, and also that the time scale was very tight?

I do not know whether the hon. Gentleman has misinterpreted my remarks accidentally or deliberately, but I said that the decision on the location was entirely up to Oxfordshire PCT. He is entirely right to say that we are insisting that every PCT in England establishes one of the new facilities, but I have never met anyone who is 100 per cent. satisfied as to the current level of access to general practice in their area. The new facilities will be a big improvement, and as I said, the ones that have been set up already are extremely popular.

One big concern in the opposition to the proposals was the cost per patient visit of the new centres. My own GP, Dr. John Fitton of the Dryland surgery in Kettering, has produced evidence that that cost in his surgery is far less than in the new Darzi centre that might be established in the town. Will the Minister satisfy the House that the cost per patient visit in the new centres will not be far larger than in current GP surgeries?

I shall be happy to look at the figures if the hon. Gentleman would like to provide them, but it will be the responsibility of his local PCT to ensure that the services are provided effectively and efficiently, and that they represent good value for the taxpayer.

The Minister is being very generous, but is he aware of the survey done last month by the company CACI, which helps big commercial organisations with mapping their retail operations across the country? It found that a significant number of PCTs do not have suitable sites for Darzi centres, and many PCTs were quoted as saying that the centres would lead to an “inefficient and overlapping network” of services. The lack of a major centre plan from the centre means that a lot of public money would surely be wasted if the Darzi centres were imposed on PCTs.

One moment we are criticised for having too much of a strategic plan from the centre, and the next for not having one at all. By referring to Darzi centres, the hon. Gentleman is confusing his terminology in the same way that the hon. Member for Banbury did. He may be thinking of the polyclinic model, which is certainly part of the likely emerging health landscape in London but which I suspect is not something that most areas of the country will pursue.

The new centres will give people the flexibility to visit a doctor at almost any time of the week, at a time that is convenient to them, while remaining registered with their own GP. The benefits will be immense, especially for people who commute or spend long periods away from home, for students who want to remain registered with their doctor at home but who want access to health care where they are studying, or simply for people whose own GP does not open in the evenings or at weekends.

As well as the new GP-led health centres in every area, and in order to help tackle further health inequalities, the NHS is establishing 112 new GP practices in the areas of greatest need and where there are fewest GPs per head of population. The Jubilee line heads from here in Westminster to Canning Town in east London, and the average life expectancy of people whose homes pass overhead along the line falls by a year for each of the seven stops along the way. The ratio of GPs to population also falls dramatically. Based in the community, the GP’s surgery is in the front line in improving health and tackling inequalities.

Increasing the number of primary care clinicians in an area can therefore be the single most cost-effective way of improving the health of that population. Yet the most deprived areas—those most affected by poverty, an ageing population and rising levels of obesity—are usually the very ones that have the fewest GPs, so funding new practices in the areas of greatest need will have a decisive impact. They will help remove long-standing inequities in health provision in England and improve health outcomes for the local population. More practices will also mean greater choice for local people.

I mentioned earlier that we were always looking for ways of improving GP services. One of the aspects of the existing contract that has come in for criticism, in my view justifiably, has been the minimum practice income guarantee. It has protected the historic income of GP practices that would otherwise have lost out when the new contract was introduced in 2004. It was right for that time, but as GP pay and conditions have improved, we believe that it has outlived its purpose. It reduces the incentives for popular GPs to take on more patients, thus constraining real patient choice, and it is not closely enough related to GP performance.

We are very pleased that earlier this week the British Medical Association agreed that the time had come to end GPs’ reliance on that source of income. On Tuesday we announced that in 2009-10 we would take the first step towards abolishing the MPIG.

I will just finish the point. As we take those steps, practices will be able to offer improved services to their patients. This includes better access to those services. I give way to the right hon. Gentleman.

Well, sometimes right, sometimes honourable.

We have discussed the MPIG in the past. As the Minister says, it was always intended that it would disappear over time as the award to GPs was focused on the quality and outcomes framework and weighted capitation. Given that we are moving in that direction, does it not also make sense to ensure that as GP practices lose income guarantees, so the GP-led health centres that he is talking about should not have income guarantees built into their contracts? Then at least whoever wishes to provide a new practice in the form that he describes does so on the same basis as existing GPs.

I certainly agree with the hon. Gentleman that there should be a level playing field throughout primary care. That is what the phasing out of the MPIG will at long last help us deliver.

The reform of the MPIG will, as I have already said, help improve patient choice. Everyone in England can now choose which hospital to go to for their operation. We want people to have the same level of choice when it comes to their GP. The NHS Choices website provides patients with ever-more detailed information about their local GP practice, the services that it provides and its opening hours, and even what fellow patients think of the practice. With these important reforms and with people exercising choice, GPs will be more accurately rewarded for providing top-quality services, and that will help drive up standards even further.

The quality and outcomes framework, which links GPs’ pay to the health outcomes that they deliver, has also brought major benefits for patients. It has significantly improved the way in which GP practices record risk factors such as high blood pressure or smoking. This focuses attention not just on helping the sick to get well but on how to help people lead a more healthy lifestyle. This week we also agreed improvements with the BMA to the quality and outcomes framework. The new agreement will see £80 million relocated to reward practices delivering a range of new services for their patients, including helping to prevent cardiovascular disease in people with high blood pressure, improving advice and choice on contraception, a new indicator for depression to make sure that treatment is not stopped too soon, improvements for chronic kidney diseases, diabetes and chronic lung disease and improved drug treatment for people with heart failure.

In its report a week ago, the Public Accounts Committee indicated that there was not yet much evidence of any significant improvement in health inequalities as a result of the use of the QOF. When does the Minister think that evidence will be available that will demonstrate that the QOF is working to create a healthier population?

Given the time lag in terms of the impacts on health outcomes, it is inevitable that the evidence will take some time to come through, but the hon. Gentleman might note the advances we are already making on mortality rates for some of the long-term conditions and killer diseases that have disproportionately affected people from the lower socio-economic groups. We are already making progress in that regard and GPs are firmly convinced that the QOF has helped. The more we change and reform the framework in the way I have just outlined, the more we will tackle the inequalities that he and I and all Members want tackled.

The new agreement also introduces valuable improvements to the framework. It recognises and rewards high-quality patient care and has a stronger focus on health outcomes. As well as rewarding and providing incentives for good clinical outcomes, we want to ensure that patients feel they have been treated with courtesy and respect. That is why, earlier this year, we announced in the next stage review that a greater proportion of the incentive payments made to GPs in the future will be based on how good the public feel the service provided was, based on our comprehensive annual patient survey. The 2008-09 patient survey will provide even more information about whether practices are getting the basics right. Do patients have the option of a telephone consultation? Are they listened to and treated with respect? What is their experience of out-of-hours services? What GPs are paid will directly reflect the standard of accessibility and convenience that they offer.

The Government are overseeing the greatest expansion in primary care since the creation of the health service 60 years ago. We are investing in new practices and new services. We are putting patients at the centre of health care planning. We are giving patients a greater choice of when and how they see a GP. That is not an alternative to existing primary care provision, and it will not undermine GP practices; it is an addition to existing services. Patients now enjoy an unprecedented quality of service. Their views are translated into local action and their desire for a more convenient and accessible high-quality NHS is being brought to life.

Primary care is the cornerstone of the national health service. It is where we all turn first when we or our families need help. I am pleased to report that in its 60th year primary care is in excellent health. With continued investment and reform under this Government, it will get better still.

I am glad that the Government have chosen to discuss access to primary care this afternoon. It was timely given that the Healthcare Commission reported this morning, although from the Government’s point of view they might have checked what the commission said before choosing to hold a debate on the day it reported. However, from our point of view we are pleased that they did.

The debate follows two debates in Opposition time during this Session—on family doctor services and on the Government’s polyclinic plans—both of which gave us substantial opportunities to set out how we feel about general practice’s central contribution to health care, how we value general practice and how we hope to support and develop it in the future. I shall not take up as much time as the Minister, and will try to limit my speech, as this was the chance for him to set out some things in detail.

I did not mean to be critical. The Minister took many interventions, which allows me to avoid having to say some things I would otherwise have had to say.

The hon. Lady is in the hands of the Chair, who determines matters such as the timing of debates. If the Chair felt that I were being excessive in the use of time, I have no doubt that he would stop me.

I have never seen a better description of the central role of primary care than that offered by Barbara Starfield, professor of health care management at Johns Hopkins university in America. In one way, it is surprising that an American academic can understand it, but I suspect that she can see it, not least because there is often a lack of such primary care infrastructure in America compared with the UK, and there is envy of our primary care system, particularly our family community physician service. She said:

“Primary care deals with most health problems for most people most of the time. Its priorities are to be accessible as health needs arise; to focus on individuals over the long term; to offer comprehensive care for all common problems; and to coordinate services when care from elsewhere is needed.

There is lots of evidence that a good relationship with a freely chosen primary-care doctor, preferably over several years, is associated with better care, more appropriate care, better health, and much lower health costs.”

All those things are true, but as hon. Members will recall from previous debates, defining primary care in those terms also helps us to identify some of the central problems of the Government’s approach to primary care.

Primary and secondary care are too often separated from each other. Family doctors—community physicians—have too little control over care. They do not have enough ability to manage the care for their patients, so the thing we are all looking for—more integrated care, focused on the needs of patients—cannot be delivered.

People’s relationship with their GP is being undermined by the Government’s Martini strategy—“Any time, any place, anywhere”. From the Government’s point of view, it is good enough that the patient is seen by somebody, whereas from the public’s point of view, it often matters a great deal who one is seen by. Awareness of that seems to have disappeared. The atomisation of primary care in the Government’s hands is one of the central problems. It is not that the Government think primary care access unimportant, but the way they are going about it is undermining one of the most important aspects of primary care.

The Minister raised a number of subjects, and I shall mention one at the outset. He said at the start that he would illustrate how, in primary care, the patient voice was being listened to, but I did not detect that in anything that he subsequently said. Apart from the fact that a lot of the Government’s thinking seems to have been dictated by some of the results from the GP patient survey, the patient voice as such, in any qualitative sense, seems to have disappeared from primary care. Patients are supposed to be able to exercise choice. If the Minister really wants to know what we most want to achieve, we want to achieve a situation where patients have choice and voice, which has not happened.

I have been at this Dispatch Box talking about health for my party long enough to recall responding to a statement by the Secretary of State in January 2006 on the community White Paper called “Our health, our care, our say”. One of the things in that document, which we supported, was the intention that patients should be able to exercise greater choice about their general practitioner; but it has not happened.

For example, where is the incentive to take on new patients? This week, the Minister said for the first time that the announcement about increasing the global sum in relation to the correction factor means that there should be a greater incentive to take on new patients, but it has taken nearly three years to get to that point. In January 2006, it was stated that we could expect something on the expanding practice allowance, but it has not happened. The same promise was repeated in the next stages review published in June 2008, as though two and a half years had just passed by and nothing had been done inside Government.

The Government promised, in January 2006, that they would stop general practices being “open but full”. It did not happen. What happened? The promise was repeated in the next stages review: “We are going to do it now”. Well, two and half years have gone by.

The Government said, in January 2006, that walk-in centres would be reviewed. I was listening out for walk-in centres. They were not mentioned. If you had asked me, Mr. Deputy Speaker, before the Government went down the route of polyclinics, “What actually should Government be doing?” this is what we would have said—I think that the Liberal Democrats probably agree with this. First, encourage and incentivise more practices in under-doctored areas, and make sure that practices working in the most deprived communities have genuine incentives, rather than perverse incentives, to do so. Across the country, ensure that people can maintain their registration with the practice of their choice—and that they have greater choice. There is a need and a wish for patients to be able to access care on a more discretionary basis, not always having to go to their own practice. Actually, that was what walk-in centres were all about.

The logical thing to do is not to set up new polyclinics, the purpose of which is not to be open from 8 am to 8 pm seven days a week, but to look at the walk-in centre pilots and ask how we can make walk-in centres do that job in the places where they are necessary. My hon. Friend the Member for Banbury (Tony Baldry) has left the Chamber, but he made a good point. The Government have told primary care trusts to do it, and they are doing so in places, mostly of their choosing, that do not necessarily relate to that need.

There may well be a need for a walk-in centre in Oxford—perhaps there is such a centre—but in that city as, for my part, in Cambridge, where there are lots of tourists, students and people who, because they are commuters, sometimes find it difficult to access their local GP, the idea of a walk-in centre is a perfectly reasonable one. In 2006, the Government said that they would review walk-in centres and create the right incentives across primary care to look after unregistered patients, but they did not conduct such a review. They said that they would allow people to register near their work, rather than their home, but they have not done so. I am afraid that the things that the Government said that they would do have not been done, so the House will forgive us if we are less than confident about the Government’s intentions.

None of this has allowed patient choice to occur, but neither has patient voice had an impact on primary care. Community health councils have been abolished in England. Patients forums have been abolished in England, and it is very difficult to establish what is happening on local involvement networks in many places. The people who are most able and willing to support serious qualitative input by the public and patients who wish to engage with the quality of their health care have found that their contribution has been so disparaged and undermined by constant Government changes that they have walked away. We have to change that.

I hope that the hon. Lady will say that she will support Conservative proposals for an independent, empowered health watch in every part of the country, including a national consumer voice in health care.

Is my right, or not, hon. Friend—[Hon. Members: “He is not the hon. Lady’s friend.”] Is the hon. Gentleman stating that his party’s manifesto will reintroduce all those quangos?

Just a few weeks ago, I published a summary of our health care policies, and it is clear that LINks should be converted to health watch locally. Local authorities, such as Kent county council, have set out to create precisely that kind of powerful consumer voice in England, embracing health and social care. A previous Secretary of State commissioned a review of regulation in the health care sector from Lord Currie of Marylebone, who as the hon. Lady will know, was previously a Labour Member in the House of Lords. He recommended to the Government that there should be a national consumer voice in health care, but the Government have effectively abolished that voice, and it has disappeared.

Instead of talking about patients very much, the Minister talked about the GP survey, which led Ministers to the conclusion that, because just less than 10 per cent. of respondents were dissatisfied with their surgery’s opening hours, because their surgery did not open in the evening or on Saturday, they needed to tell GPs what to do. The Minister keeps asking whether we are going to reverse his policy, and the answer is yes, we are going to do so. We are not going to tell GPs what to do. We are going to make them far more accountable to patients, and to give patients much greater power. We are going to hold GPs to account for the quality and outcomes that they deliver. There is something utterly perverse about the Government’s belief that quality and outcomes are the basis on which GPs should be measured and rewarded, but then try to dictate in detail—sometimes in absurd detail—how GPs should go about their processes, rather than measuring their performance and rewarding them on the quality and outcomes of what they do.

How would the hon. Gentleman give this new power to patients, when both he and the right hon. Member for Witney (Mr. Cameron) have said that they would give the BMA a veto over opening hours?

Those words have never passed my lips or those of my right hon. Friend. The focus is on patient choice. There is something absurd about the entire argument. The negotiation of the GP contract in 2004 was the moment when GPs said, “If we offered Saturday morning surgeries up to now, we will stop doing so. If the primary care trust wants us to do Saturday morning surgeries, the contract states that the PCT will commission that as a local enhanced service.” Most PCTs did not do so.

We discussed the matter in February this year. The Secretary of State and the Minister were in a stand-up row with the BMA about it, quite unnecessarily. The Secretary of State admitted that he did not know how many primary care trusts commission, through their local enhanced service, extended GP opening hours. The Minister will not say whether that is happening or not, but we will probably end up going back to a local enhanced service in order to do it on a locally determined basis, which is precisely where PCTs should have been in the first place. The present situation is outrageous. The relationship between Government and general practitioners has been damaged to a remarkable and deeply unwelcome degree.

There is much in the GP patient survey that the Government seem to have ignored by focusing on extended opening hours and nothing else. Look, for example, at patients wanting to book ahead. The fact that almost 10 per cent. of patients in the survey wanted extended opening hours was the basis upon which the Government created a raft of policy. We know that almost exactly the same number, just under 10 per cent. of those in the survey, wanted to be able to book ahead for their appointments but were unable to do so. Why? That is a consequence of the Government having introduced their 48-hour target, rather than GPs being able to manage their appointments system in the way in which they want.

So we have ended up with the Government creating unhappy patients, in large measure, by introducing a target. Another part of the survey revealed unhappy patients as a consequence of the Government’s own contract. They ignore one and blame GPs for the other, when clearly it was the Government’s fault. It is an outrageous abuse of the Government’s position to blame GPs, as they have done. I do not have to be a friend of the BMA to defend GPs against the way in which the Government have behaved towards them.

The Minister said that changes are needed to the quality and outcomes framework. There are benefits in shifting GP remuneration towards the global sum and the quality and outcomes framework instead of the correction factor. It is important that the QOF responds to evidence about what is likely to deliver quality. When the Minister responds, perhaps he can explain this. The Darzi review in June stated:

“We will introduce a new strategy for developing the Quality and Outcomes Framework which will include an independent and transparent process for developing and reviewing indicators.”

The expert panel for 2008-09 recommended that there should be a new indicator for osteoporosis and for peripheral arterial disease. The Government did not do that in 2008-09, because they wanted to focus all the points on their extended opening hours—directed enhanced services. For 2009-10, the opportunity existed to introduce a new indicator and the expert panel had told them to do it, but it is not among the clinical indicators that have been added. Effort and money were spent on delivering expert advice on the QOF, and the Government have ignored it. Perhaps the Minister will explain that.

GP commissioning is central to our policy, although I will not explain at length why it is central. When the Minister spoke about devolving decisions, he talked about devolving decisions to primary care trusts. Devolving decisions to GPs has disappeared from the lexicon of Ministers, as it has from most of the next stage reviews that were published over the summer. We know from the Audit Commission’s work that was published in June that practice-based commissioning has stalled. Most GPs feel that their primary care trust does not support it, that they do not receive any management support for it and that they do not have the opportunity to do anything. As a consequence, very few GPs have been able to commission any new services.

I know where we stand—we want to create proper, powerful GP commissioning as a basis. The integral strength of primary care, in being able to manage the care of patients by someone with whom they have a relationship, points directly to that conclusion. Ministers used to talk about practice-based commissioning—when Tony Blair talked about reform of the national health service, practice-based commissioning was one of his key reforms—but it has disappeared. If the Minister is going to talk about primary care when he replies, perhaps he will tell us whether practice-based commissioning is still the Government’s policy, because I think that it is disappearing.

May I commend to the hon. Gentleman a Liberal Democrat survey of GPs in Norfolk that asked about practice-based commissioning? In answer to the question whether GPs thought practice-based commissioning had improved patient care, just 11 per cent. felt that it had, with only 6 per cent. saying that it had had a considerable impact on their practice. In Norfolk, therefore, practice-based commissioning is simply not happening in most practices, and that is very depressing.

Yes, it is depressing. Indeed, what the hon. Gentleman describes is consistent with what the Audit Commission said in its document earlier this year. It said, understandably, that the few practices where GPs had grabbed hold of practice-based commissioning and were using it creatively tended to be the same ones that had substantial experience of fundholding, so they are responding only now, 11 years later.

I do not want to go back to fundholding. I want to develop GP commissioning that is relevant and applicable to every GP practice, so that they can all use the kind of freedoms that came with fundholding. More to the point, however, I want to do that within a better accountability framework, in which the PCT’s role is that of strategic commissioner, if necessary policing the boundary between commissioning and provision, and in which patients exercise greater choice than under fundholding.

We are talking about access to primary care, but the Minister did not mention dentistry, as though dentistry in primary care did not exist. If my hon. Friend the Member for Hemel Hempstead (Mike Penning) catches your eye, Mr. Deputy Speaker, I hope that he will have time to say something about dentistry. The Minister did not talk at all about the process of accessing urgent care. However, for many patients, one of the central issues is how they can get hold of somebody. That obviously includes the out-of-hours service, which is, at least in theory, an extension of general practice, out of hours. However, that has not been true of the out-of-hours service since the introduction of the new contract, because the service has been taken away from GPs.

We know that in many places GPs continue to manage out-of-hours services through co-operatives. My personal experience is that where that happens, GPs and patients locally find that the service still meets more of their objectives. Indeed, I am surprised that the Minister did not speak positively about the benefits of that, since Devon Docs, which operates out of his constituency and which I had the privilege of visiting earlier in the year in Marsh Barton.

Yes, I did. Devon Docs provides a service not only in Devon, but under contract in parts of the north-west, such as St. Helens and Warrington, if my memory serves me correctly.

What would the hon. Gentleman do, given the fact that his party destroyed dentistry by privatising it?

I am sorry; I should not have given way. My hon. Friend the Member for Hemel Hempstead will say something about primary care access to dentistry later. I will leave that to him, because I know that he feels strongly about it.

I do not want to go on about the out-of-hours service in detail, but it is just not good enough for Ministers to treat access between 8 am and 8 pm, five days a week—or even including the weekend—as a sufficient answer to the issues that the public have raised. The GP patient survey does not touch on out-of-hours services to find out what patients’ experiences are. We need to ensure that GPs feel that the out-of-hours service properly integrates with the service that they provide during the week, and we need to ensure that it is more accessible from the patients’ point of view.

This is all part of an urgent care approach. Interestingly, the Next Stages review documents all over the country are saying that we need to reform access to urgent care, but no one is doing anything about it. My hon. Friend the Member for Hemel Hempstead might add to this later. It is clear that we need to think hard about how people first approach the NHS. If they want to go to a walk-in centre, that is fine. But if they want to pick up the telephone, they often find themselves not really knowing whether to ring NHS Direct, their local GP, a different number for the out-of-hours service, another number for a dental service or 999. They are not sure about any of these things, even in an emergency. In fact, the figures demonstrate that large numbers of people end up ringing 999 when there is not an emergency.

We need to arrive at a position in which there are just two numbers. If there is an emergency, people should ring 999. If there is not, they should ring another number. Clearly there is work to be done regarding that other number, because I understand, having spoken to Ofcom, that the numbers that we could use are being progressively taken by others across Europe. We have to do this on a Europe-wide basis, and others across Europe are taking the relevant 116 numbers. If we do not get our skates on, the proverbial beach towels will have been laid across all the numbers—and we can guess who is doing that.

Access to primary care is not confined to GP practices. It also includes health visitors. I suppose we all choose to cite numbers selectively to serve our purpose, but it is astonishing that, although the Minister can get up and tell us how many additional practice nurses there are, he will not tell us how many health visitors there are. Health visitors are also instrumental in the process of delivering better health care. Their numbers have been declining: we have seen a 10 per cent. decline in the past three years. We saw 800 health visitors leave the profession in 2006, while only 330 were being trained, even though there were nearly 800 applicants for such posts.

We need to restore a more universal health visiting service. We, at least, have made it clear that we will make a start by making the resources that were to be used for outreach workers at Sure Start centres available for health visitors who would see mothers when they came home shortly after their babies had been born and see them through those first few weeks. That would be instrumental in delivering an improvement.

The Minister said that he wanted to improve access to pharmacy. I will not go on at length about pharmacy, but pharmacists are constantly being led up the hill. They were led up the hill over the pharmacy contract. They were told that, instead of the old scheme, they would have a new scheme in which their payment would increasingly be geared to the commissioning of additional services, particularly in the area of public health, such as screening. They are now being told the same thing again, three years after the previous pharmacy contract. That did not happen before, and all their expectations were frustrated. They believe that it will happen again now. At the moment, however, I see no evidence that primary care trusts are launching into this process—indeed, quite the opposite.

If we look at the way in which the Government are approaching the cardiovascular risk assessment programme—this was part of the quality and outcomes framework announcement in relation to the GP contract—we see that it is being geared to be delivered through GP practices. There is good evidence, however, that we do not have the risk-assessment tool available to see what the Government are planning to do, still less the cost-benefit evaluation that supports it. At least, there ought to be an opportunity for pharmacists and pharmacy chains to offer the same service on the same basis. As far as I can see, the information that triggers the risk assessment can be gained in a pharmacy as readily as in a GP practice. If we are talking, as we often are, about men in their 40s and 50s who probably have no reason to be visiting their GP, but find themselves in pharmacies from time to time, this may well be a more convenient and acceptable way for them to access pharmaceutical services.

Let me move on to polyclinics. The Minister behaves as if these are somehow an accomplished fact. In many places across the country, we are just beginning to realise what the evidence shows—my hon. Friend the Member for Banbury made clear what was happening in his area and it is occurring elsewhere—which is that the choices made by the primary care trusts, entirely at the behest of the Government who told them to have a polyclinic in every area, are entirely inappropriate in the view not only of local GPs, but of local populations.

Is not part of the problem the fact that this is being imposed on the basis of such a tight time scale? I am told that, in Norfolk, the estate review for the whole county had not been completed before the instruction came to just get on with producing a polyclinic or a GP-led health centre. That took away the capacity properly to commission and to determine priorities within the county.

I entirely agree. Some GP practices had plans to get together to create more accessible physical accommodation, but because those plans could not be accommodated within the Government’s mandatory timetable, they were not able to adapt the polyclinic plan to their particular local circumstances. Yet that is what they should be doing. This is not rocket science; it is very straightforward. If we want more access to outpatient clinics in the community, more access to diagnostic services and to therapists in the community—all of which we do—and if the Government want to make £1 million available to a primary care trust to achieve that, the PCT should have that money and be able to decide on the best way of implementing those objectives.

It is interesting to note what is happening in London. Having had the benefit of Boris’s election campaign, which put wind in our sails, we have been campaigning, but it is quite clear that NHS London does not want to do what the Government have told it to do. The Prime Minister said from the Dispatch Box last year that London would have 150 polyclinics and the subsequently published document said that each polyclinic would be a large building with 25 GPs in it and all the rest of that stuff. Now, however, NHS London has arrived at the point where most of what it wants across London is the so-called hub-and-spoke model, which means that most GP practices stay where they are and do what they were doing before. Put into the so-called hub are outpatient clinics, diagnostics and therapists—all perfectly okay from my point of view, but that is not what the Government told London to do. It just shows the poverty of the ideas in the Government’s original proposals.

The hon. Gentleman is confusing two different things, as a GP-led health centre is not the same as a polyclinic—[Interruption.] Well, let me tell the hon. Gentleman about London, which is a subject that he raised. My PCT is going to be in the first wave of polyclinics. It told me and other MPs in the area very clearly and simply that a polyclinic is not the same thing as a GP-led health centre. Indeed, the GP-led health centre is a completely separate proposition from the hub-and-spoke polyclinic that is being introduced. I do wish that the hon. Gentleman had talked to some people in London before telling us what he thinks is actually happening there.

Well, I do talk to people in London. Indeed, I talked to the chair of the joint health overview and scrutiny committee in London—and Mary told me exactly what was happening. I do not have them with me now, but I have received written answers from the Minister on the definition of a polyclinic and a GP-led health centre—and they are virtually the same, in the Minister’s own words.

My point is that the Darzi report said that there would be 150 polyclinics in London. I hope that we will end up with a small number of polyclinics in places where it makes sense locally, and with a large number of investments—again where it makes sense locally—in GP or primary access to diagnostics, therapists and other services that might otherwise be provided in a hospital context. If that happens, it means, frankly, that we have won the argument to the benefit of London. Everywhere else in the country, however, it seems that people are still being told to do something on the basis that it is the same as what is recommended in the Darzi report which was published in London, and even London now appears to be abandoning that. The collapse of the Government’s policy seems to be nearly complete.

I hope that people working in general practice and primary care understand that we value what they do, and that we want to re-empower them by doing away with some of the top-down targets that the Minister spent all his time talking about. We want to give them the support that they need in order to deliver the best possible care for patients. We will make the accountability less to the bureaucracy and less to what the Minister wants them to do, and much more to patients, and we will build that accountability throughout the country.

I have been in the House for 16 years, and if I had to identify a service that I believed to have been transformed during that time, it would be the health service. In fact, that transformation has happened over the last 11 years.

I remember what primary care in east London was like in the mid-1990s. It was characterised by single-handed GPs working in totally inadequate premises, often houses that had been converted into surgeries. It was characterised by the frequency with which people found it impossible to register with a GP, because virtually none of the GPs had open lists. It was characterised by the fact that both GPs and patients were in absolute despair at what happened when GPs tried to refer patients to secondary care. The patients had to wait months and months for treatments or diagnoses.

I saw the difference myself earlier this year. I have visited my GP five or six times in the past year, which is more often than I had visited a GP in the previous 20 years. I saw how quickly my GP was able to secure for me the diagnostic test that I needed. The position of 10, 11 or 12 years ago had been completely transformed.

As for patient choice, in those days there was no choice. People waited. If there was a choice, it was this: they waited or they paid. That is the choice that faced people 10 or 12 years ago. I remember seeing people who were desperate to get treatment. They would say to me, “I do not agree with private medicine. I do not like private medicine. What should I do?” The alternative was to wait and wait and wait. Now, as a result of the local improvement finance trust programme, I am seeing new health centres with groups of GPs operating in them, and GPs being encouraged to invest.

A few weeks ago I visited a practice very near my home, where GPs demonstrated the investment that they had been encouraged to make in their premises to deliver better access and better services. They talked to me about the extended hours as well. I am very pleased that 39 of the 47 practices in my local PCT area are now offering those extended hours. I cannot understand for the life of me why anyone should think there was something wrong with that. Certainly none of the GPs to whom I have spoken think that there is anything wrong with it.

As the hon. Gentleman is extolling larger practices and the benefits of extended opening hours and increased access for patients, can he explain why the GP patient survey shows that on all five measures—satisfaction with telephone access, 48-hour access to GPs, advance booking, appointment with a specific GP and satisfaction with opening times—the performance of small practices with fewer than 2,000 patients was better than the performance of large practices with more than 15,000 patients?

All I can say is that I observe what has happened on the ground. What I observe is that people are able to see their GPs more quickly, that they are seeing them in better premises, and that where GPs are grouped together, they frequently offer better access to patients than single-handed practices. That is not to say that single-handed practices cannot work—I can think of examples that work well—but I remember what it was like when we were almost entirely dependent on such practices.

For people who have jobs where they are paid hourly, taking time off during the week is not a trivial thing to do. It costs them money. Many people in permanent full-time jobs may be able to have a half-day holiday, but if an hourly paid worker takes half a day off, it costs them half a day's pay.

There are some issues about extended opening. GPs still have some issues with that. They need to sort them out and they need help with that. Obviously, if they are going to have extended opening hours, they will have to have receptionists and support staff there for longer. That is not always easy, particularly in smaller practices. Extended opening hours benefits patients. It certainly benefits local hospitals as it keeps people from attending accident and emergency when that is not appropriate.

We still have too many people who are not registered with GPs. In an area such as mine, that is partly because of the nature of the population. There are significant numbers of people there who come from cultures where primary care does not exist, or does not exist in a form that would be recognisable to them.

Non-registration used to happen because of closed lists and because people found it impossible to find a GP they could register with. Now, with the new GP contracts, the vast majority of my local GPs are opening their lists up and trying to attract patients. It is possible now for everyone to find a GP and to get to see them.

I am listening carefully to the hon. Gentleman. Does he agree that it could be different in different parts of the country? In my area, which is fast expanding, it is difficult to get on to a GP’s list? One has to refer them to the primary care trust to force them on to a particular doctor's list, so I do not think that what he says is necessarily repeated across the country.

That may well be the case. However, what the hon. Gentleman has just described is what I was seeing until relatively recently. Until relatively recently, I would have had to ask the PCT to step in and to ensure that someone got on to a list. However, over the past year or two, I have seen a significant shift on that and many more practices are offering open lists.

I understand the points that have been raised about people wanting to see their own GP and forming a relationship with them. Of course that is true, but what is also important to many people is that they are able to be seen when they need to be seen. They value that as well as having a relationship.

There are still issues about appointment systems. I see great variation between one GP practice and another. Some run systems where they meet 48-hour targets and are able to deal with advance bookings. Others do not have systems in place that allow them to do that. A lot of that is about simple administration, getting better administration and getting the practices that are not delivering a proper appointment system to learn from the ones that are.

I am listening to the hon. Gentleman's comments with great care. Obviously, he comes from the perspective of an inner-London constituency. Why is it, if things are so great, that it is only in the 12th year of a Labour Government that the Minister is promising to look at the quality and outcomes framework? If polyclinics or GP-led health centres are such a good idea, why has not the Department of Health decided to have consensus by piloting them in some areas and seeing whether they work first?

There are a number of issues there that I was not talking about, but I will come to the question of polyclinics in a moment. I want to finish my points about the appointments issue. One of the problems is that, when a practice does not have decent systems, is not delivering on appointments and could do so if it improved its administrative systems, PCTs are relatively powerless to do anything about it. They cannot impose systems on GPs. Therefore, when things go wrong, it can sometimes be difficult for the PCT to deal with that. However, we measure the targets on appointments across the whole PCT, even though it does not have direct responsibility for that.

I agree with some of what the hon. Member for South Cambridgeshire (Mr. Lansley) said about patient involvement, and I think it was a mistake to get rid of the community health councils, but we must be careful about the ways in which patients are involved and the ways in which we listen to patient opinions. In the past few years, I have come across examples where the PCT—and in one case the General Medical Council—was taking action against a GP and patients were protesting and signing petitions and coming to me and saying that that person was being extremely badly treated. In my opinion, the truth was that they were familiar with the standard of treatment they had been getting so they did not realise how appalling it actually was; they thought the GP was a nice person, and he might well have been, but he was not actually delivering much for them. However, just because of that familiarity, they assumed things were okay.

In terms of polyclinics, I would be absolutely against developments that led to existing GP practices being closed, as we want that relationship between GPs and patients to remain, but I also firmly believe that many tasks that have traditionally been done in hospitals can be moved out and be done efficiently elsewhere, and that one of the models through which that can be achieved is the polyclinic. My PCT will be among the first in London to have a polyclinic. That will be implemented on a hub-and-spoke model and discussions are already taking place as to how that might operate. GPs want to be involved, and it is perfectly possible that there will be a bid to operate that polyclinic from a consortium of local GPs. I would welcome that; I hope it happens, and if it does, I hope that it succeeds. It does primacy care services no good to set up an artificial argument between polyclinic and GP.

I want to raise a couple of specific points on access to primary care, the first of which relates to the quality and outcomes framework. A number of Members were approached on this by the National Osteoporosis Society, which was disappointed that osteoporosis was not included within that framework. I can understand that; whatever we include, there will always be other people who are disappointed that their particular interest is not there. One issue the society raised, however, was that there should be a new system for reform of the quality and outcomes framework involving the National Institute for Health and Clinical Excellence and patient groups, and that a consultation had been promised in autumn of this year. It was keen to know when that might take place, because it and other interest groups might want to have some input into it. Therefore, I would be grateful if the Minister could give us some information on that.

In May 2004, the Department of Health launched the consultation, “Proposals to Exclude Overseas Visitors from Eligibility to free NHS Primary Medical Services”. That consultation exercise had a number of aims, including getting the rules on eligibility for access to primary and secondary care matched and ensuring that failed asylum seekers and unauthorised migrants did not have routine access to NHS primary care. I recognise that this is a complicated and sensitive issue, and that we cannot simply say that anybody can come here as a visitor and have whatever costly treatment they want—although I suspect that the most costly treatment would result from visitors accessing secondary rather than primary care, and I also suspect that some of the really costly stuff would result not from failed asylum seekers or unauthorised migrants, but from relatives of people who are already settled here. My concern, and I think that of a lot of health professionals, is the potential effects of denying access to primary care to vulnerable people. It could be argued that a failed asylum seeker should not get medical treatment, but if they have not been removed, it is an immigration problem and should be dealt with by the Home Office, not through the denial of access to medical care.

No decision on the consultation has been announced, even though it has been promised a number of times. Neither has there yet been even a report on the consultation results. The Department was asked by the Global Health Advocacy Project, under freedom of information legislation, for the results of the submissions that were made to the consultation and a list of those who made them. It released the list but refused to release the actual submissions. Some arguments about that are currently being made to the Information Commissioner, but I shall not pursue them now. On the basis of the list, a lot of the respondents were contacted, so we know what many of them said. It was clear from the responses that health professionals were concerned about the possible consequences of the denial of care.

Médecins du Monde UK, which runs a UK clinic, has produced a report pointing out that although GPs themselves might understand the current regulations, administrative staff do not necessarily. That has led to people who should have been treated, such as citizens of other European economic area countries or asylum seekers whose claims had not been determined, being denied treatment. Médecins du Monde’s evidence suggested that service users coming to its clinic had been in the UK for an average of three years, which does not suggest health tourism. It also stated that the vast majority of the visits to the clinic were to do with primary care such as antenatal services rather than expensive, specialist care.

The real issue is the public health effects of denying access to treatment. People might have infectious diseases or conditions that are cheap to treat if they are caught early and treated by the GP, but if they are left will end up requiring emergency hospital admissions costing far more. If people are barred from access to GPs, they will end up in hard-pressed accident and emergency services.

As I said, we have not seen the results of the consultation. I hope that the report in The Observer last Sunday suggesting that the Government would not go ahead with barring access to primary care was right. I fully understand that we cannot have an NHS that provides expensive care free to the rest of the world, but if there is an immigration problem, we should deal with it as such through the Home Office, not by pressurising people to remove themselves by denying them access to medical care, particularly if the consequences are health risks to other people.

There have been huge improvements in primary care in east London in the past 10 to 12 years. There have been improvement in facilities, in people’s ability to access them and in the secondary care that follows on. Referrals to secondary care happen very quickly now so that people can be treated. I do not want that to be marred by a wrong decision about vulnerable people. While they are here in the UK, we should allow them to receive primary care.

It is good to follow the hon. Member for Walthamstow (Mr. Gerrard). I agreed with much, but not all, of what he said. He made some important points about key public health concerns and on the basics of decency and humanity towards people who are in this country. I shall be interested to hear the Minister’s response.

I also agreed with the hon. Member for Walthamstow that we must not allow ourselves to drift back to the access to diagnostics and treatment of the 1990s. The Conservatives will not be pleased to hear me say that their judgment that we should remove all targets and have no other mechanism to guarantee access to diagnosis and treatment is dangerous, and could easily lead to waiting times drifting back towards the lengths that we experienced in the 1990s.

I thought it was Liberal Democrat policy to oppose top-down process targets, but the hon. Gentleman seems suddenly to have shifted. My view on patient choice and contracts is that where something is wanted, the primary care trust or the relevant commissioners contract for it to be provided; they do not have a Government target to make it happen.

I am grateful to the hon. Gentleman for giving me the opportunity to expand on Liberal Democrat policy. Our policy, which is based on how the system works in Denmark, is to give a personal entitlement to treatment within a defined period of time, which depends on the condition, and where someone does not receive their treatment within that defined period, it is paid for privately. That guarantees access for every citizen, irrespective of their income or wealth. Health economists tell us that in Denmark the approach has resulted in a radical improvement in the efficiency of state hospitals, and not in a great leakage to the private sector. I commend that approach to him—perhaps he should re-examine it. [Interruption.] It is not the patient passport at all, because the treatment is paid for in its entirety. Without any mechanism—either a target or an entitlement to access treatment—the great danger is that we will drift back towards having much longer waiting times.

This debate is timely, coming, as it does, on the day when the Healthcare Commission’s annual health check report is published. It is worth repeating that we in this country have an immensely valuable network of primary care that we should cherish and build on, and, although each of us has concerns about various aspects of primary care and access to it, many other countries envy enormously our network of primary care.

The debate is timely, because the Healthcare Commission’s chairman, Sir Ian Kennedy, pointed out that one of the key areas highlighted in the report was the need for improvement on GP access. He said:

“Primary care trusts must redouble their efforts in areas such as access to GPs and the provision of choice.”

The reports refers specifically to

“poor performance clustered around major cities”.

The report shows that the worst areas in London, where there has been a complete failure to meet the target, are the inner-city ones, where the need for access is perhaps at its greatest. The performance map for the whole country again shows that the areas of weakness and of failure are almost entirely clustered around the inner cities, where the need is at its greatest. Of particular concern is the situation in north-west and north-east England.

The report also refers to very “significant regional variation”, beyond the concentration of failure in cities. It states:

“Six of the eight PCTs in the South East Coast SHA area achieve the access to a GP indicator, compared to only one of the 31 PCTs in the London SHA area”.

There is massive variation in performance. The results are hardly surprising. As Lord Darzi said recently:

“Sadly it turns out that our current GP system has actually led to a larger inequality in the distribution of GPs across the country over the past two decades even as the overall number of GPs has increased.”

The situation is still deteriorating. A Department of Health report earlier this year confirmed that two thirds of the most deprived fifth of PCTs are more than 10 per cent. below the English average for the number of GPs per 100,000 of the population, which is worse than the figures for 2002. In a period that has seen massive increases in investment in the health service, inequality of access to GPs—in relation to the number of GPs operating in an area—has worsened. For example, Barking and Dagenham, which is one of the poorest boroughs in the country, has 48.3 GPs per 100,000 of the population, but Devon has 81—or nearly double. In areas where need is greatest, access is worst.

What are the Government doing to redress that imbalance, which is bound to have an effect on health inequalities? Everyone signs up to the need to reduce the inequalities, but some of the things that have happened in the past 10 years are bound to have worsened the problem. That is why I described the Government’s record as complacent: they have allowed this situation to continue for so long.

Although the hon. Member for Walthamstow sought to define the difference between polyclinics and GP-led health centres, the latter—at the very least—give the appearance of being embryonic polyclinics. They have many of the hallmarks of a polyclinic and many people struggle to distinguish between the two. The Minister confirmed earlier that the Government are committed to introducing one GP-led health centre for every primary care trust, so what assessment have the Government made of whether that initiative will do anything to combat inequality of access? As the hon. Member for Banbury (Tony Baldry) said, if a polyclinic or GP-led health centre is placed in the centre of a city in a particular primary care trust area, it may do nothing to improve access for low-income communities that are some distance away. How well will that policy target resources at the actual problem?

The Minister also referred to the other initiative to introduce 112 new GP practices in some of the poorest communities. The announcement was made a year ago, at the time of the interim Darzi report. What progress has been made? The Minister said that it was happening, but when is it happening? What is the time scale for introducing the new practices, and what is the mechanism for ensuring their arrival? Is it ultimately down to the discretion of the primary care trust? How will the Minister ensure that he delivers that commitment?

I am pleased to hear about the start of the demise of the minimum practice income guarantee. As I have been saying for some time, that reform is welcome. However, the Minister said that it would be phased out, and reports of the agreement with the BMA also mentioned phasing out. What is the time scale for that? Can the Minister give a target date by which we will be rid of that mechanism for funding GPs, which he has agreed has nothing to do with quality or the extent of the challenge faced by GPs, and everything to do with historic payment mechanisms?

Let me move on to QOF—the quality and outcomes framework—which is the basis for incentivising GPs to engage in preventive health care and so on. In a booklet on inequalities of health care, the NHS Confederation specifically considered that subject. It described how the mechanism for rewarding GPs under QOF ends up giving more money to GPs in the wealthy areas—the leafy suburbs—than to those in the poorest areas.

It seems bizarre that a system that is presumably designed to help reduce inequalities and to improve the health of the nation should end up paying doctors more where the problem is least. It does so for two reasons. First, it is easier to hit targets if a patient base is middle class and everybody is informed, educated and understands the importance of preventive health care. They will go along for their screenings and so on. In a community where people are harder to reach, it might be much tougher to hit the targets and to earn the income under the QOF system.

The NHS Confederation also makes the point that the QOF formula remunerates practices with high disease prevalence at a lower rate than practices with a low disease prevalence. It states:

“The greater the prevalence of a disease, the less money the practice receives per patient.”

The confederation concludes that the structure of the QOF payment disadvantages practices in deprived communities. I have raised the subject before. What are the Minister and the Government doing to remove that ridiculous distortion, which provides a disincentive to doctors to work in the poorest communities? Surely it should be precisely the other way around.

When will the Government consider ways of really incentivising GPs to work in the toughest, hardest to reach communities? It seems to me that the money should, as far as possible, be attached to the patient so as to encourage GP practices to take on more patients, and that there should be a premium attached for serving individuals from deprived communities—a sort of patient premium to incentivise GPs to work in those communities.

Next, I want to deal with the exclusion of osteoporosis from QOF. The subject has been mentioned by a couple of speakers. The independent expert panel made the case for osteoporosis to be included, and I disagree with the hon. Member for Walthamstow, who said that that was one more group arguing its particular interest. It is more than that. It is an independent panel that is designed to give dispassionate objective advice to the Government about what conditions should be addressed through the incentive scheme. The Government chose to ignore it.

I want to make it clear to the hon. Gentleman that I am not in any way disparaging what the panel is saying. It sounded as though he was suggesting that I was doing that. My point was that, inevitably, when decisions are made about what is and what is not included, various interest groups will always believe that their interest has somehow been ignored. The panel is making a perfectly valid point.

I am grateful for that clarification; we are clearly in agreement.

Let me quote the National Osteoporosis Society, which states:

“It is very concerning that this QOF review”—

the one that has just taken place—

“has not been subject to independent review and has been negotiated behind closed doors between NHS Employers and the GPC.”

Why is that important? Why should osteoporosis be included in the QOF process? The answer is that the process offers crucial preventive healthcare: there are 300,000 osteoporosis fractures every year, and independent evidence suggests that it should be possible to cut that total by about 50 per cent. through the early identification of a problem and treatment to strengthen bones.

We have an extraordinary opportunity to reduce substantially the prevalence of osteoporosis fractures. The cost to the NHS and social care of treating fractures is some £2 billion a year, and fractures among people over 60 result in 2 million hospital bed days in England alone. Investing in preventive health care upfront could have a massive impact on the cost to the NHS, and it would also be critical in preventing the crisis undergone by patients who have to be admitted to hospital because of a fracture. When old people suffer a fracture, the result can be a permanent deterioration in health, as I am sure the hon. Member for Dartford (Dr. Stoate) can confirm.

The hon. Gentleman nods in agreement. I therefore urge the Minister to look at ways of introducing osteoporosis into the QOF system, given the potentially massive benefits that could be achieved.

I want to ask the Minister about progress on extending hours. I have always believed that there is a benefit to be achieved by extending hours within primary care, and my opposition to the Government’s proposals had to do with the way that they sought to impose them. The announcement earlier this week suggested that virtually no progress has been made in some areas, with just 1 per cent. of practices in Liverpool going for extended hours. I should be grateful if the Minister said why he thinks there is such enormous variation.

The pharmacy White Paper floats the idea that the current rules for GP practices with dispensaries should be changed. Such practices primarily serve rural areas but, taken together, the White Paper and the impact assessment appear to suggest that a GP practice could be forced to close its dispensary if there is a pharmacy within 1 km of it.

I want the Minister to understand just how strongly people in rural areas feel about that. The current service is remarkably attractive, as it means that elderly people with a GP appointment in the early evening can walk out of the building with their medicines and take them straight away. It is an immensely valuable service, and losing it could force an elderly person to make a separate journey, perhaps of some distance. That seems utterly crazy to me, as the impact assessment suggests that the change could result in 700 dispensaries closing, affecting 2 million patients nationwide.

Of great concern also is the possibility, which has been brought to my attention by local dispensing practices, that the change could undermine the viability of the range of medical services that such practices provide. Again, that would be to the detriment of people living in rural areas, and I urge the Minister to reject any change that would result in such closures. It would be a massively retrograde step.

I want to say a word about practice-based commissioning. The Government lauded that as an initiative with enormous potential to develop services in the community. They said that it would provide convenience for patients because often they would not have to travel a long distance to an acute hospital. Lower-cost care closer to home was claimed to be the great potential benefit that could be achieved. Yet when we talk to GPs around the country, we discover that the scheme has largely stalled. It has suffered in part as a result of the reorganisation of primary care trusts. PCTs have been inward looking for the past two years, with people worrying about their own jobs. So many GPs tell me that when they try to engage with their local PCT to get something moving on practice-based commissioning, they get no practical interest or engagement from them. If practice-based commissioning is to achieve the potential that all of us see for it, something has to change to allow it to grow from the bottom up.

The Conservative spokesman, the hon. Member for South Cambridgeshire (Mr. Lansley), referred to NHS dentistry. It is important to touch on that service. I shall confine my remarks to simply asking the Minister a question. When will there be a full and proper assessment of the impact of the new contract on access and on inequality of access? Great claims were made for the new contract and what it could achieve. The claims have not been met in reality. In many parts of the country, people on a low income and people who struggle to travel considerable distances have real difficulty in accessing an NHS dentist because there simply are not any available locally. There is an incredibly powerful case for revisiting the issue to make sure that the money available for dentistry within the NHS is deployed to the best possible effect and in particular to ensure access for those who do not have the luxury to be able to afford to go to a dentist privately.

If the Government’s intention for today’s debate was to crow about their record on access to primary care, it has fallen rather flat because the record is not good. The Healthcare Commission today has identified access to primary care as one of the big challenges that we face. Confidence among GPs is at an all-time low. I commended a survey undertaken by Norfolk Liberal Democrats to the Conservative spokesman. I will send him a copy later. When we asked GPs in Norfolk their view of the Government’s stewardship of the NHS, 0 per cent. said that they were positive.

Does the hon. Gentleman realise that if I were to move to Norfolk there would be an infinite percentage increase in the number of GPs satisfied? That would be something of a Government target hit.

I accept the point. It is much needed by the Government because at the moment the percentage could not get lower.

Confidence in the Government’s stewardship of the NHS, especially with regard to primary care, is at an all-time low. The record is not good. The Public Accounts Committee reported last week on the cost of the GP contract. The impact on productivity and the change in out-of-hours arrangements have also led to massive problems with access and anxiety among patients about how to access care. That has led, many reports conclude, to a mushrooming in visits to accident and emergency departments at enormous cost to the NHS—again, a counter-productive move.

Access to good-quality primary care, avoiding admissions to expensive acute hospitals, must have high priority. It is time that the rhetoric was matched by measures that will have practical effect and really change things rather than the Government just claiming that they want to achieve change.

As the House is well aware, I am still a practising GP, so it gives me great pleasure to have caught your eye, Madam Deputy Speaker, in this important debate. I am sorry that more Members could not find time to be here.

Every Member who has spoken so far has mentioned quality and outcomes and has commented on the variability of services, which is where I want to concentrate my remarks. There is quite wide variability of services, and I want to look at why that is, what we can do about it and what is at the heart of that thorny question.

I do not want to rehearse all the figures and statistics released by the Healthcare Commission today. Members are aware of them and many of them have been mentioned already. However, one figure from a survey published by the commission in July 2008, based on interviews with 69,000 people in England, showed the variability that I am talking about. One of the things found by the survey was that the overall proportion of respondents who had waited two working days or more for their most recent appointment with a doctor had risen from 74 to 75 per cent. this year, which was a modest change. However, in the highest scoring trust, 89 per cent. of respondents said they were seen by a GP within two working days, yet in the lowest scoring trust only 43 per cent. of people had been seen within two days. That is a far more worrying statistic than any of the others I have heard this afternoon. Furthermore, 23 per cent. of patients who made an appointment felt that they should have been seen sooner.

Those findings have been picked up by the Patients Association, which said:

“The Patients Association continues to monitor access to GP services and Out-of-Hours care very carefully. We regularly hear of patients experiencing difficulties in obtaining a GP appointment or a poor service when trying to access out-of-hours care. We call on both GPs and Primary Care Trusts to ensure they are providing the highest level of care possible to their patients.”

I am sure that plenty of colleagues in the House this afternoon will have been presented with examples from constituents of people waiting longer than they should to see a GP. The scenario where a patient rings their practice for an appointment and is told that nothing is available for the next three, four or five days, not just with their GP but with any GP, is one that I hear far too often for my liking.

We can argue about the Healthcare Commission figures. Only yesterday, I had a meeting with Anna Walker at which we tried to pick to pieces why there was such a variation in the figures and why it looked as though only 31 per cent. of trusts were able to achieve the GP access target. The answer seems to hinge to a large extent on whether we say to a patient, “Are you able to achieve an appointment in 48 hours?” or “Did you manage to actually get an appointment within 48 hours?” That is when there is a much lower response. The figures need more examination, although that is probably beyond the scope of the debate.

I hear the possible explanation of the difference, but does the hon. Gentleman accept none the less that the greatest problem, whatever the measure, is in poorer, inner-city areas?

I entirely accept that point, which is important and worthy of closer examination, and I want to develop it in more detail.

Many patients—often vulnerable ones—tend to accept what they are told. If they are told, “There’s no appointment, come back tomorrow morning and you might be able to get one”, they often do so. They are thus less likely to appear in the figures as missed 48-hour appointments. Other patients who may understand the system better and say, “I know I’m entitled to an appointment within 48 hours” are more likely to be given one. That explains to some extent why people in more disadvantaged areas are more likely to accept what they are told and less likely to demand their rights than those in areas with more vociferous and middle class patients.

It is entirely possible for practices, perhaps unwittingly, to deflect patients for 48 hours, and such patients would not be picked up by the surveys. It would thus appear that they were performing better. I find it difficult to accept that situation. Why can many practices—it is probably even the majority—provide a perfectly good service? They have no difficulty whatever in combining 48-hour access with appointments booked two weeks in advance. Why do so many patients and practices have no problems, whereas others seem to run into difficulty time and time again?

We need to go back a long way and look at the origins of primary care in the health service in 1948, when, as Members know, independent contractor status was conferred on GPs. The system has served the UK remarkably well. It has managed to ensure that because GPs are independent contractors—in effect, private businesses working on a profit and loss account—their only payment mechanism is the bottom line of their practice profits. Those profits are the GPs’ income, because there are no shareholders; the GPs share the profits as directors of the company. That has had an enormously beneficial effect on British general practice, and it explains why it is still one of the envies of the world. It is fantastically cost-effective. GPs are focused on what they do very well indeed and the system is extremely cheap, which is one of the things I want to consider. Our system, which is cheap, cost-effective and has served us well, has also allowed quite marked variations of practice and circumstances to build up. Let me suggest one explanation for that.

Remarkably, over that time no Government have seriously challenged independent contractor status, and no Government have seriously looked behind it at exactly what it means. In fact, what it boils down to is that GP practices have been taken for granted. It has just been assumed that GPs are professionals, do a good job, look after their patients, do what they need to do and produce reasonably good outcomes. No one has ever looked beyond that.

On the one hand, depending on which side of the fence one is sitting, one might say that that is a huge vote of confidence in the British general practice system, which has served us well. Others might say that it is mind-bogglingly complacent, because no one has ever looked very closely behind it. It is hardly surprising, therefore, that quite a variable quality has been built into the system.

Under the old red book system, GPs were remunerated in a way that was purely beancounting. They were paid according to the number of patients and of services provided. One added them up on paper and sent the piece of paper off to what was then the family health services authority, and it sent back a cheque each month. That was that.

The 1990 contract, introduced by the Conservative Government, extended that arrangement a bit by producing 27 outcome measures. GPs fulfilled those measures: they sent their pieces of paper off; they got paid. They were process measures, not output measures. They looked at how many patients had their blood pressure checked, how many had a new patient examination and how many had been given advice for obesity. Not once were GPs to produce any evidence that they had done any good by that method.

All Members in the Chamber this afternoon have spoken about quality and outcome, yet the words “quality” and “outcome” effectively did not exist until 2004, with the new GP contract that this Government introduced. For the first time, GPs were measured on the quality and the outcome of what they were doing. The indicators in the QOF are all evidence-based. They are all carefully thought through by a panel of independent experts; agreed between the profession and the NHS Confederation as being the right indicators; and carefully monitored. The question is not how many patients’ blood pressure has been measured, but what percentage of those patients have blood pressure within a certain range—what percentage of diabetics, for example, have cholesterol levels below 4, not how many people’s cholesterol levels have been checked. The intention is to measure the number of patients whose measures have been improved, thereby leading to improved patient outcome on an evidence-based system. Ironically, although all hon. Members on both sides of the Chamber bang on about the need to improve the QOF, before 2004 it had never even been properly considered. This Government deserve a huge vote of confidence for doing that.

I should like to take issue with my GP colleagues, but not only with them. There is variable quality, and some of it is down to GP practice; sometimes GP practices could, should and must do better. I intervened on the Minister to draw attention to the problem of 0844 numbers, which is an example of where GPs have not been very friendly to their patients. He needs to look at that. It is obvious to me that some GPs could and should do more, and I believe that with a bit of incentive they probably will be able to sort that out. The fact is, however, that we have allowed the variability to continue for too long.

The hon. Gentleman is very generous in giving way. The undertaking that he is asking for from the Government, and particularly from the Minister, to abolish the use of 0844 numbers was given by the Under-Secretary of State for International Development, the hon. Member for Bury, South (Mr. Lewis), some time ago, when he was a Health Minister, and nothing has happened.

I accept that. I also accept the Minister’s assurance that the matter is being looked into by the Government. I await, as does the hon. Gentleman, the outcome of the Government’s deliberations, and I hope that this will be sorted out quickly. I think I have explained why there is so much variability, why practices have such different approaches, and why some provide services that are not up to the standard that we would like to see, whereas others motor ahead and produce everything that the Government want.

The Minister mentioned the MPIG or minimum practice income guarantee. He is right to say that it was an historical device to ensure that when the new GP contract was brought in, no practice would suffer huge financial loss as a consequence—at least for the first three years, until its practice income had taken off and it had managed to produce income from elsewhere. However, I would counsel caution. We must not simply dump on GPs more and more of the work that they are currently unable to do, because it simply will not work if the Government expect GPs to work even harder to recoup income that will be removed from them when the MPIG goes.

Let us consider the average working day for the average doctor. It is a sobering thought, and I want to share it because I think it is important. The average GP sees 35 to 40 patients a day. At 12 minutes or so per appointment, that is six or seven hours of consulting time. On top of that, they make home visits, of which there may be an unlimited number. They also have to undertake medical examinations for people requiring HGV or taxi-cab licences; write referrals to hospital consultants if a patient needs to be referred; and read and action all the letters that come in during the day to the practice from consultants who are treating their patients in hospital. They have to action pathology reports and electrocardiogram reports that come into the practice on a frequent basis, and they have a sea of repeat prescriptions to write for people who remain on medication. On top of that, the majority of GPs run clinics for child health surveillance, minor surgery, maternity care, diabetes, dermatology and joint injections. The majority of GPs are involved in teaching or training the next generation of GPs, and on top of that, they are expected to keep abreast of recent developments and ensure that they are up to date with the best possible medical practice and the latest Government missives. That is a pretty daunting work load. If we embrace the idea that a GP can simply do more because the incentives and QOFs have changed, the MPIG is going and there is a lot more work from extending their hours into the evenings and weekends, we have to be careful lest we kill the golden goose simply by putting more and more on to already hard-pressed practitioners.

I should like to say a word or two about the Government’s relationship with GPs. I have been critical, with good reason, of some aspects of GP performance, but the opprobrium that has been heaped on GPs in recent months by the media and other groups is undeserved and counter-productive. GPs are well rewarded under the terms of the new contract, and there are justifiable questions about how the profession has been allowed to dispense with out-of-hours services so lightly and with so little penalty. However, it was the Government who signed off on the deal, and much of the responsibility for the shortcomings in the contract must lie in their hands.

Blaming the profession for having the temerity to make a good deal and then looking for ways to recoup the money that was spent on the contract is not a tenable long-term position for the Government to take. In a letter sent to me after a recent meeting, a group of GPs in my local area commented:

“You expressed the view that the Department of Health had a high regard for general practice, and saw GPs as a key component in the redesign and modernisation of the health service. The general feeling from my colleagues was that the Department of Health had a very strange way of demonstrating their regard for general practice, as demonstrated by their public pronouncements and attitude.”

That group of GPs is not a recalcitrant minority that is anti-reform and dismissive of the need to change—quite the reverse, in fact. They are progressive practitioners who are doing their level best to work with the Government to improve access and delivery of services.

I completely agree with the analysis that the hon. Gentleman has offered. Does he think that that sort of thing has led to this extraordinary loss of confidence among general practitioners in the Government’s stewardship of the NHS, which I am sure he accepts has taken place?

Well, that has been hyped as well, because personally, I do not see the complete loss of confidence that the hon. Gentleman mentioned with regard to his area of Norfolk. I obviously cannot comment on his local GPs, but my local GPs have not completely lost confidence, and neither have the GPs with whom I work closely up and down the country, those who write or phone me, or those with whom I work on many groups on medical matters. However, I accept that GPs’ thoughts about the way in which things are going has taken a knock. I should like the Minister to clarify the Government’s position and make the case that they are not anti-GP; they are not trying to bash the system, but simply trying to get better care for patients.

I have given the House examples of cases in which GPs have felt undervalued and taken for granted. I do not think that the Government are going to win any friends among GPs unless we try to redress that important issue. During these difficult financial times, Ministers may believe that GPs will not win any friends by complaining about their pay and conditions. That is a fair point, but a damaged relationship between Government and GPs will have long-term consequences. We have seen examples of imported, privately contracted “para-GPs” who work 9-to-5 shifts with a half-hour break, providing GP services for patients in areas where there is a shortage of GPs. Their turnover rate is impressive and at one level they provide good value for money. They get a good throughput of patients, but whether patients are satisfied with that type of medicine and consultation is another matter. I do not believe that that is the way to proceed. Asking GPs to do more all the time without appropriate resources will not only alienate GPs; ultimately it will damage patient care and prevent GPs from being able to rely on the prevention and early detection of disease, which it is important that they do.

I am in favour of the GP-led health centre model, as I have said on a number of occasions. A group of GPs in my local area has just been awarded a contract from a company to provide an out-of-hours centre and a GP-led health centre in Ebbsfleet, which is a fast growing area of my constituency. Those are the very GPs who are keen to progress, work with the Government and see the Government’s model pursued.

I am interested in the point that the hon. Gentleman makes. The centre that he describes seems similar to something in my area. Was that group of doctors engaged in that activity before the Government imposed their target for one such health centre in each PCT? Does it pre-date that target?

No. It was a response to the Government wanting to put a GP-led health centre into my area. The GPs have taken up the idea with a vengeance. They have seen that there is a gap in provision in the area. There is a new development around Ebbsfleet International station in my constituency, which will see many thousands of new houses and businesses moving into the area, and they recognise that there will be a need for new health facilities in the area. My local hospital has also looked forward to the expansion of its services as the population rises. That is entirely natural.

What is important is that the GPs feel themselves to be supported, properly resourced and adequately advised by the primary care trust to make sure that the scheme is a success, because they want it to be a success. My point to the Minister is that if we are to make sure that GPs are willing to pick up the baton and run with it and produce extra services, we must send out a message that we are supporting them in the same way as we expect them to support their patients. I have heard from Members in all parts of the House that currently there is a real gap between the thinking of GPs who want to get on with the scheme and their perception of how the Government see them. That leaves something to be desired. I hope that my hon. Friend will look into that.

The hon. Member for North Norfolk (Norman Lamb) mentioned the Dispensing Doctors Association and the view that we should be careful about how we handle dispensing practices. I am pleased that the consultation leaves four options open, and that the Government do not yet have a preferred view on how dispensing practice is dealt with. It is possible that when the consultation is finished, things will stay as they are. I emphasise that dispensing practices are a useful resource in some rural areas and provide a very good service to patients. I would like to make sure that that is not damaged.

The other side of the coin is to ensure that pharmacy also has good access to patients. As has been mentioned in the debate, pharmacists can and already do provide a range of services that is expanding all the time and can be an important part of primary care delivery in the front line. I am pleased to see them expand those services. I am pleased, too, that the Government took seriously the report on the future of pharmacy from the all-party pharmacy group, which I chair. The report has received favourable comments from Ministers and I am pleased that they have examined closely some of our suggestions on how pharmacy might be progressed. That is a positive development.

GP patient access is fundamental to how people see the health service. General practice is the front line of the health service. Ninety per cent. of all care takes place in a primary care setting. The majority of people see their GP or their GP practice three, four or five times every year. If we can ensure that we build on general practice, not only can we improve patient outcomes and patient well-being, but we can keep hospitals free of cases that are less serious and ensure that they can get on with the heavy duty and high-tech cases that only they are equipped to deal with. If we get that right, we will have a health service that we can be proud of and continue to be proud of into the future. I am sure that that is what everyone in the House wants and what Ministers want.

It is a delight to follow the hon. Member for Walthamstow (Mr. Gerrard). Having trained in London rather a long time ago, I know what the standard of general practice was then, and I am very pleased to hear that it is so much better.

I am delighted to follow the hon. Member for Dartford (Dr. Stoate), because he has removed the need for some of what I had intended to say. I had intended to stand up for GPs, because their morale is incredibly low. Indeed, after I talked to my GP he sent me a few thoughts:

“Why are we under attack when we are efficient, good value for money and valued by our patients?”

His practice spends precisely 2 per cent. on management, because the doctors do most of the management. This is his perception:

“Government has no idea of what we do and what we achieve. The fiasco of out of hours shows this. As did our over performance in QOF. Which should be a thing of celebration not criticism.

Consultations are now highly complex. Minor illness is dealt with by nurse practitioners. We are dealing with complex cases inadequately supported by the acute trust”.

My GP’s description supports what the hon. Gentleman said about timings in the day almost to the minute. GPs start work at about 7:30 am and finish at 6:30 pm. Six hours and 40 minutes are taken up in consultations, with 34 patients seen, but GPs are also engaged in making telephone calls, writing referrals, looking at reports, making home visits and so on. They therefore fully justify their pay. I hope that the Minister will acknowledge that to make GPs feel a little less disregarded and insufficiently appreciated.

I know that our time is limited, so I will focus the rest of my speech on out-of-hours care, which is crucial. Access to out-of-hours care, which is not the function of A and E departments, is what has really brought the Healthcare Commission ratings on emergency care down. Years ago, GPs provided out-of-hours care, which meant that they were working night and day, which was not very good. As a patient, one felt guilty about ringing up a GP in the middle of the night, knowing that they had been working all day. Then we had the local co-operatives, which were excellent. They were a conglomeration of the local GPs working together in a rota to cover the nights, so that they did not have to work in the day as well.

Unfortunately, we lost the co-operatives when the contract was introduced. It was amazing that GPs were no longer expected to work at weekends, which meant that PCTs had to provide out-of-hours care. However, in my area and many others that has not been a success. I am pleased to say that the PCT in my area realised that it had to reform the service, which was put out to competitive tender. Rather to my surprise, a conglomerate of GPs from Suffolk has taken over the provision of out-of-hours care in the whole of Worcestershire.

I am so far very pleased with the intentions of that firm, although I am going to follow its progress closely. There is a bit of a flaw in the contract, which was short sighted but understandable, in that the firm covers only the patients of GPs registered in Worcestershire. Unfortunately, the rest of my hospital covers the area right on the Shropshire border, so when patients from Shropshire, from as little as three or four miles away, turn up in the middle of the night with something rather nasty, the firm says that it cannot take them, because the contract is not with the Shropshire GPs. I am looking into the matter, because it is in the firm’s interests to take more people, because it will get the money for doing so. That was a difficulty with the contract when it was first written, but I am optimistic that it will be improved.

The one thing that would most helpfully improve out-of-hours care has been mentioned, which is a single telephone number. If people are really desperate, 999 is fine, but we want another number. As I have said before in similar debates, people do not know whether to contact out-of-hours care or go the minor injuries unit, the A and E department or the walk-in centre. They do not know who to ring, so we want one number. In previous debates with the Minister, he has said that he is looking into the supply of a single number.

An organisation called NHS Pathways operates a brilliant triage system that has been trialled in various parts of the country, and those trials have been successful. I have here the minutes of the AGM of the North East Ambulance Service NHS Trust, where NHS Pathways was trialled:

“The year also saw confirmation that the clinically-based assessment system—NHS Pathways—was a safe and efficient method of call handling…The clinical evidence-base underpinning it means NEAS is in a position to assess calls from a much wider range of patients, not only those who have chosen to access the ‘999’ number, and to use alternative pathways of care that can be referred to from the system that is most appropriate for the patient’s needs.”

The trust has already noted areas of “significant improvement”, including a “considerable reduction” in the number of patients going to A and E departments unnecessarily.

NHS Pathways is a marvellous triage system, and if it—or something similar—could be accessed from a single phone number, it would be a huge help, particularly for out-of-hours care. I should very much like to find out from the Minister whether he will push NHS Pathways as a useful form of access, and whether we can aim to have a single number.

It is a pleasure to follow the hon. Member for Wyre Forest (Dr. Taylor), who, as usual, has made some powerful and important points about the health service. I start by thanking GPs across the country for what they do. I know that we are discussing access to primary care, and that we have totally ignored dentists, whom I would like to mention briefly. GPs are valued by my constituents, and not least by me and my wife, as one of them effectively saved my wife’s life. It was an advantage in that situation that the GP knew her, because she had been a patient for a number of years. Many of the GPs in my area are concerned that, if we were to introduce GP-led health centres, that continuity might not continue.

Age Concern is also worried about that. That matter has not really been touched on in the debate so far. Age Concern states:

“Many older people value the continuing relationship they have with their GP—that must be retained in any reform of the system. We would therefore want a commitment that the personal GP patient relationship would be protected.”

That is extremely important. Another point that Age Concern makes is rather the reverse of the Minister’s wish to make more time available to patients in the evenings and at weekends, so that people who go out to work can have access. Age Concern makes the very fair point that it wants to ensure the same amount of weekday availability for the people whom it represents, because that is when older people want to go to see their doctor.

The hon. Members for Dartford (Dr. Stoate) and for Wyre Forest are both GPs, and they have made the point that GPs work exceptionally hard. If we ask GPs to work in the evenings, they will take time off in the daytime to compensate for that—it has to be that way. A local GP from Finedon in my constituency came to see me and told me that the new system was absolutely nuts. He has a surgery during the day and anyone can come along. He sees patients during the day, but now he has to open his surgery one night a week and sit there with his practice manager while nobody comes to see him. It is a pointless exercise.

If I have learned one thing from this debate, it is that there is a huge difference around the country and that one idea or size does not fit all. When I grew up, if I needed to see a doctor, I saw one whom I knew. We could ring up, make an appointment and we would get seen. If I needed to go to the dentist, I would make an NHS dentist appointment, and I would be seen. If I needed to go to hospital, it would be arranged through my local doctor. If I was ill in the evening, the local doctor would come out. I remember that I once needed to see a doctor on Christmas day, and the senior partner in the practice came out to see me. All that was under what many Labour Members like to portray as the wicked old days of the Tories, but it seemed to me to work well. What we should do is build on a system like that rather than apply top-down approaches. I understand that the Minister has adopted those approaches for the very best motives, but I just do not believe that they will work. Why not let existing GP practices expand and develop services that are relevant to their areas?

As I have said, the answer to the question is that there is great variation. The good practices will no doubt pick up the baton and provide everything that the Government could possibly dream of. However, the hon. Member for North Norfolk (Norman Lamb) has pointed out on the basis of surveys in his area that there are far too few practices—sometimes as few as 1 per cent.—able or willing to do that. We must try to reduce the variation.

I am grateful for that intervention, which adds to my point that there are big differences around the country. My argument is that imposing one GP-led health centre in every PCT is not right.

This morning, three hon. Members who are currently in their places were sitting in the Health Committee. We heard that the Government have found £250 million of taxpayers’ money to inject into primary care. However, £150 million is going into a minimum of one health care centre per PCT, and we do not know how the other £100 million will be divided up. I was trying to understand the best way of allocating that money so that it was focused on the areas that needed it most, and I suggested a very simple system.

The Government devote a lot of time, concern and expense to working out—on the basis of deprivation, growth and other factors—what each and every PCT needs as a minimum, but they do not fund every PCT to that level. Because some areas are overfunded, others are underfunded. My Northamptonshire PCT happens to be the worst funded in the country, so I declare a certain interest in finding a solution. Surely it would be better to take this £250 million and give it to the PCTs that are underfunded according to the Government’s own criteria, and then let them develop local solutions to their problems.

I have another idea for raising some extra money to put into the pot. Why not get rid of the strategic health authorities? I cannot see that they do anything other than push pieces of paper about and tick boxes. The only criterion that an SHA takes into account as making for a good PCT is ticking all the boxes; it does not take local need or local decision making into account. What we should do is get rid of all those pen pushers, take this money and put it into primary access.

Towards the end of this morning’s Health Committee meeting, we were all convinced of the value of SHAs, because they carried out the consultation for Lord Darzi’s review and canvassed the views of patients, citizens and staff. I changed my mind about the SHAs at the end of that meeting.

I certainly did not. My opinion was the same at the end of the meeting as it had been at the beginning. The witnesses confirmed all my thoughts about bureaucrats wasting time and money.

Talking of surveys, I run a tracking survey in my constituency. It is called the listening survey. One of the questions is “What concerns you most?” Health is always one of the two top issues. There are so many other issues—council tax, pensions, education, immigration, which is a huge issue in my area, and overdevelopment—but health is always first or second.

Does my hon. Friend think that if he asked his constituents whom they respected most, GPs would be quite high on the list—higher than Ministers or Members of Parliament in general?

I should hate to include that question in my survey. If I asked “Do you value your GP or me?”, it would be like the election return in an African republic: 100 per cent. would value the GP and none would value me. So, with all respect to my hon. Friend, I do not think that I shall include that question.

The question “Why do people put health first or second?” leads to another question. A number of Members have said that many people make their local hospital their first call, because they can obtain primary care in the accident and emergency department, and they are not sure where they should go or cannot see their GP. I only wish that we had that option in my area. We do not have a hospital, although an area of that size should obviously have one, and if my PCT were funded correctly, it would have one.

As for access to GPs, Wellingborough has one of the worst GP-patient ratios in the country. Because the town is expanding, people coming into it cannot get on to GPs’ lists. They have to be forced on to them through the PCT. Again, the position varies considerably around the country. I feel that rather than there being all these plans and targets, money should be found to provide more GPs. We are lagging behind the rest of Europe when it comes to GP numbers. We are asking GPs to do more—to work longer hours, or to work at weekends and take time off during the week to compensate—which is not at all helpful.

On average, a GP sees 34 patients a day. Goodness me! I shall sit down at 9.30 tomorrow morning, and after I have seen 12 of my constituents, I shall be completely worn out. The fact that our GPs see 34 people who are really ill in a single day is an extraordinary testament to them.

Out-of-hours access is never an issue in my constituency. The doctors—or the doctors and the PCT—have worked it out. Many surgeries stay open in the evenings, but, as was mentioned earlier, there are doctors’ co-operatives running night-time services. I have a seven-year-old. He was ill one night—not ill enough for us to dial 999 and take him to a hospital, but ill enough for us to ring NHS Direct, which told us that we should use the out-of-hours service. When we went to the out-of-hours service, we were seen very quickly and it was a first-class service. In my area, there is no demand for polyclinics or GP-led health centres, but the Northamptonshire PCT had planned to put three in the county. Sense has prevailed and that has been knocked back to one, which no one seems to want.

The hon. Member for Dartford made a strong case about how GPs in his area were embracing the scheme and bringing it forward. That is the way in which it should happen. If people want to do it, they should do it. In my constituency, there was a doctor’s surgery that was already planning to move to a bigger location and to add services. That is the sort of thing that is evolving and should be encouraged, but local doctors are concerned about funding.

The Minister will probably pull me up on this, as I will not use the right terminology, but, as I understand it, if there is a polyclinic or a GP-led health centre in the town, it will attract people because of the out-of-hours service and the seven-days-a-week service. People will register with that centre, which is how it will be funded in due course, and move away from existing surgeries. It is rather like cherry-picking. The people who tend to be healthier will go to the GP-led health centre and my surgeries will be left with the more difficult cases—namely, the elderly and the young. Those surgeries have to spend more time on them, but because it is a per capita funded system, their income will go down. Therefore, they will spend longer with the patient for less money and not be able to develop their services. That cannot be what the Government planned. If I have that totally wrong, I would like the Minister to tell me in his winding-up speech. That issue really concerns local doctors in the area.

I want to move away from GPs, because, in many respects, the problem is not as serious in my area as it is elsewhere. What is fundamentally wrong and driving people up the wall is NHS dentistry, or should I say non-NHS dentistry? Like thousands and thousands of people in Northamptonshire, I have had to take out private insurance to continue to see my dentist. When I talk to my dentist, he makes a powerful case. Admittedly, he is standing over me with a drill at the time, but he makes the case strongly that the Government have forced him to do what he has done. Here am I and thousands and thousands of others paying through taxes for an NHS dentist, yet there are no NHS dentists in the area and I am paying £48 a month extra for insurance. That cannot be right. That cannot be how NHS dentistry should work.

The Minister said nothing about dentistry in his opening remarks. I am sure that that was not an oversight. I think that he wanted to avoid a hugely embarrassing situation. The one thing that I can say with certainty is that NHS dentistry is worse now under this Labour Government than it was under Margaret Thatcher.

Many things may have improved in the health service—if funding for the health service is increased in real terms by 82 per cent., things should improve. The fact that most of that money has been wasted and that we have seen only a 23 per cent. increase in outcomes is down to the Government's inefficiency. The fact that the median waiting time is still longer under Labour than it was under the Conservatives is a minor point when we are talking about access, but the Minister has to answer this question: why is it that my constituents and others in Northamptonshire cannot see an NHS dentist? If one rings up and says, “I must see an NHS dentist,” the reply is, “If you do not mind going out of the county, you can see one.” That is the reality of NHS access in my county.

It is a pleasure both to wind up on behalf of Her Majesty’s Opposition in this important debate, and to follow three members of the Health Committee. Having left the Committee myself only just over a year ago, I know how diligently they work. The Health Committee is one of the great Committees in this House, and I do not hold back in my praise of it—although I wonder whether the Minister might drag himself away from his notes for five seconds and listen to a contribution this afternoon? [Interruption.] I may tease him a bit more, as I have now got his attention.

Interestingly, the Minister was, I think, referring to spin when he complained about the coverage of the Healthcare Commission report in this morning’s press. That is astonishing coming from a member of a Government who have welcomed back into their ranks Lord Mandelson, a man who got his reputation from practising the black arts of spin in the 1990s.

Perhaps I can tease the Minister a little more? On page 68 of that report, reference is made to an access to a GP indicator. The report is not as definitive as it might have been because some areas refused to return any data. One such area was Devon, which is run by the Minister’s own primary care trust. It is a shocking indictment of the Minister that he cannot even control his own PCT by getting it to give data back to the commission, let alone understand what is going on. The Healthcare Commission report is timely—although I am sure the Government were not expecting it to be published at this time when they timetabled this debate for this afternoon.

I will try not to go over the points raised by the shadow Secretary of State, my hon. Friend the Member for South Cambridgeshire (Mr. Lansley), but instead I shall cover some areas I have a personal interest in and some responsibility for. I will come on to urgent care and dentistry, which my hon. Friend the Member for Wellingborough (Mr. Bone) referred to, and polyclinics.

However, I must first highlight something. If Ministers come before the House and make commitments to Members and to the country that they will address certain matters, the public have the right to expect that to happen. Therefore, given that the former Health Minister, the Under-Secretary of State for International Development, the hon. Member for Bury, South (Mr. Lewis), came to this House and promised he would address the 0844 number issue—which is leading to our constituents being ripped off when they phone their GP surgeries—and that that practice would stop, it is astonishing and unbelievable that, in this later debate, Labour and Opposition Members have highlighted the problem of patients still paying these charges.

We must also address the fact that the Government have gone to war with the GPs. I do not understand why, as the Government brought in the new contract in 2004. It was not written by the GPs or the Opposition; it was a Government contract for better health care in GPs’ surgeries. The GPs took it and delivered it to their patients, but then the Government started to attack GPs throughout the country. The hon. Member for Dartford (Dr. Stoate) was absolutely right: morale is not great. For the first time since I have been involved in politics, all the GPs in my constituency have come together with the community to complain about what is going on in health care.

We should briefly address the polyclinics issue—although I know the Government do not like to call them that. The Prime Minister stood at the Dispatch Box and said there will be 150 polyclinics in London. The Darzi report said that, and the Prime Minister said it would be imposed in London. Rightly, London is revolting against that, and areas of London say they are not going to have them. In some areas in London and the country a polyclinic might be a good thing. I listened to the comments of the hon. Member for Dartford; if he has an expanded area and there is no existing provision in it, a polyclinic might well be a good way forward in that part of his constituency. However, it is clear from other Members’ comments that in the other parts of the country where they are being imposed, it is not right that they will be plonked down in the middle of an area regardless of whether there is a need.

I am sure the Minister is aware that I will raise the issue of the polyclinic that is being imposed in the middle of Hemel Hempstead town centre. Every GP surgery has signed an open letter to the PCT, along with myself and the patient groups in the town, saying, “Please do not impose this on us.”

Not one GP surgery in that part of my constituency has a full list. The other evening, I purposely made a 7.30 pm appointment with my GP at one of those surgeries, just to see what demand there was. I could have gone at another time of day, but I booked online and went at 7.30 pm. How lonely I was. I got there five minutes early and was seen five minutes early, because there had been no patients in for the previous half an hour. There was no one booked in after me either. There were two receptionists on duty—quite rightly, because they should not be left alone in that situation at that time of night. The pharmacy attached to the surgery was open, and my GP was there. I saw my GP, and we then left and had a conversation about a lot of other things. The demand is not there. If it were, the surgery would be open at that time day in, day out. The polyclinic is to be only 200 yd to 300 yd away from there.

There are parts of Hertfordshire, in the same PCT area, that might well need such a clinic in future. Some 80,000 homes are being imposed on Hertfordshire, not least 18,000 in my constituency. If those homes are to be built, a polyclinic might well be the right vehicle for delivering primary care to my constituents, but to say that one size fits all around the country is wrong.

I was interested to hear the hon. Member for Dartford, who brings his expertise to the subject, say that GPs have got together to run clinics, but in most parts of the country they are being prevented from doing so. Two of the GP surgeries in my constituency would probably like to join together to run a clinic rather than compete, but they are being prevented from doing so.

I shall touch on a couple of points that hon. Members have made before turning finally to dentistry. The hon. Member for Walthamstow (Mr. Gerrard)—I know that part of the world well, having grown up there—rightly said that there are good GP surgeries and bad, and that some offer more services than others. I am sure that he is aware that because of how the funding formula works within PCTs, some GP surgeries get double the money that others get.

I was interested by the Minister’s saying that one reason for the problems in delivering primary care was the reconfiguration that had taken place around the country. There may be an argument for that, although I have not heard that one before, but in London there was no reconfiguration. The PCTs were left in situ as they were before, so that argument does not stack up.

I agreed enormously with the hon. Member for North Norfolk (Norman Lamb), the Liberal Democrat spokesman, when he talked about his own surveys. We are all doing that type of survey—I am sure that it is not just a Liberal Democrat thing. We all try to make contact with our constituents and find out their concerns. GPs are not happy, and they feel as though they are being persecuted even though they are delivering front-line services to our constituents in a most professional way. Where there are problems, they are for the PCTs to address in their commissioning. That is their role in life.

I was slightly concerned when the hon. Gentleman talked about the Liberal Democrats’ policy that if patients are not treated in a timely fashion, they should be able to go off to the private sector. I would like to see the costings for that, if the Liberal Democrats would like to publish them. It sounds as though they must be quite phenomenal.

I mentioned earlier that that policy was based on the Danish system. The evidence from Denmark is that it has massively increased efficiency in the state sector, thereby saving money.

We examined the methods in other countries in the Health Committee, but a completely different type of health care is provided in Denmark, Sweden and other countries.

As always, it was a pleasure to listen to my friend the hon. Member for Wyre Forest (Dr. Taylor). He is renowned in the House, and particularly in the Health Committee, for his expertise. It is very important that we all understand the type of care that our constituents want. They do not want to go and meet a stranger, or see a different GP every time they need some care. They want the relationship provided by years of work together, often down the family line. Although GPs in Worcestershire were pressed, it is a crying shame that GPs from other parts of the country are coming down to Worcestershire, because Worcestershire GPs probably understand the hon. Gentleman’s constituents much better and would represent the way forward.

We are pressed for time, but I want to make a couple more comments. The hon. Member for Wyre Forest alluded to the fact that we must address the out-of-hours urgent care system. So many people are frightened and need help, and they do not know the myriad numbers involved. I know that NHS Direct has tried desperately to get its number into the public’s perception, but people still do not know it. The branded number that people know, 999, is sadly being abused on a daily basis. We must get another number branded quickly, before these numbers disappear—the European Union is progressing with these 116 numbers as we speak. He also mentioned the important NHS pathways software, and I have seen it working brilliantly in the north-east.

My final point is about dentistry, which is the part of primary care missing from the Minister’s speech. It is crucial that this Government address the mess that they have created by imposing the dentists’ contract on this country. So many people cannot see an NHS dentist, but they deserve to do so, because that is what they pay their taxes for, and so it is about time that this Government scrapped their ludicrous contract.

I shall endeavour to respond to as many of the points made in this good and constructive debate as I can in the short time that has been left to me. I hope that hon. Members will understand if I am not able to respond to their points, and I shall endeavour to write to them where that is the case. [Interruption.] The hon. Member for Hemel Hempstead (Mike Penning) said from a sedentary position that I should not have spoken for so long earlier, but he may recall that I was extremely generous in taking interventions. That was why my introductory comments took so long. I should warn him that, as a result, I do not intend to take any interventions in my summing up.

My hon. Friend the Member for Walthamstow (Mr. Gerrard) made an interesting speech about the transformation of the health service that he has witnessed in his area over the past few years. He made a specific point about osteoporosis and the quality and outcomes framework—QOF. It might help if I were to inform him that general practitioners are rewarded for improving particular clinical services, including those in connection with osteoporosis, by not only the QOF, but the enhanced services. This year, the enhanced services have already been rewarding GPs for the work that they done on osteoporosis. The rewarding has been to the tune of £50 million on five clinical directly enhanced services including osteoporosis. Thus, some of the progress that he would like to see has already been made. He also asked when the National Institute for Health and Clinical Excellence consultation on the changes to the QOF process would be published, and I am advised that we intend to publish that by the end of October.

The hon. Member for Banbury (Tony Baldry), who is no longer in his place, asked why there was a reason to have a health centre in his area—we dealt with that in some detail at the time—and why Oxfordshire’s primary care trust did not seek to have more centres. It is perfectly within its rights to seek to have more centres.

In contradiction to what was said by the hon. Member for Wellingborough (Mr. Bone), I am informed that Northamptonshire’s authority still intends to procure four new GP-led health centres—one before Christmas, another before March next year and two more thereafter. We have stressed all along that primary care trusts are perfectly free to decide the pattern of health care provision in their areas.

My hon. Friend the Member for Stroud (Mr. Drew) highlighted the fact that Gloucestershire PCT was one of a small number of PCTs that, according to the latest figures, had not yet progressed very well, if at all, on extended hours. I am happy to be able to inform him, again via Hansard, because he is no longer in his place, that Gloucestershire has rapidly caught up, that 34 out of its 84 practices have extended opening hours and that the PCT is confident that it will achieve the 50 per cent. target next month—two months ahead of schedule.

My hon. Friend the Member for Dartford (Dr. Stoate) and the hon. Member for Wyre Forest (Dr. Taylor) both did a sterling job of standing up for GPs. In every speech that the Secretary of State and I make, we emphasise the incredibly valuable work that GPs do and the contribution that they make. I have defended today, as I do regularly, the contract that we brought in. I said in my opening remarks that it was vital that GPs were rewarded properly, because they had not been in the past, which was why we had such a problem with recruitment and retention. That is not to say that we will not have disagreements and, earlier this year, we had such a disagreement about the introduction of GP-led health centres with the BMA leadership. My hon. Friend was on our side of that disagreement and, as he rightly said, had discussions with his local GPs who are now involved in the delivery of one of those health centres in his area. We will praise primary care and the work of GPs when that praise is due. The vast majority of GPs do a fantastic job, but it is also the role of Government to try to improve things and to get better value for money out of the contract on behalf of the taxpayer.

In response to the questions that the hon. Member for Wyre Forest posed about urgent and out-of-hours care, I welcome—as he does—the changes in his area. Just because the service is being provided by a Suffolk co-operative does not mean that it will necessarily be substandard. The hon. Member for South Cambridgeshire praised Devon Doctors, a doctors’ co-operative from my area that happily and successfully runs the out-of-hours service in Devon and has expanded its tentacles all over the place. I hope that the new service will be an improvement on the last one in the constituency of the hon. Member for Wyre Forest. As I am sure he will have noticed, we said in the next stage review that we will

“consider options to improve and simplify access for the public to urgent healthcare by exploring the introduction of a single three-digit number in addition to the emergency services number 999.”

We expect to publish further details on that work later in the autumn.

The hon. Member for North Norfolk (Norman Lamb) asked why there was such a variation in the performance on extended hours so far. We are not sure, but there may be several reasons for that. Some PCTs may have been a bit slow off the mark. In some areas where local medical committees are more powerful, they may be holding out for a better deal. It may be some time before they hit the target. In the case of Liverpool, the low offering is due to practices not meeting the core DES criteria. The PCT in Liverpool is working hard to achieve compliance and some practices were working for DES before signing up. The PCT says that it is confident of achieving at least 50 per cent. by the end of the year, which is what the Government expect of it.

The hon. Gentleman also asked me about comments in Pulse. I apologise if I am not such an avid reader of the GP press as Opposition spokesmen, but I am informed that the quotation to which he referred was a misquotation. The official concerned actually said that PCTs have a choice in contracting with their practices through a local contract or by using the national direct enhanced service. However, PCTs must ensure that local contracts meet core minimum standards. They can then build on those to expand and enhance the services.

The hon. Gentleman asked what role QOF was playing in reducing health inequalities. Research by the national primary care research centre in Manchester shows that the performance of practices in deprived and disadvantaged areas has significantly improved since the introduction of QOF, and that practices in those areas achieve as well as other practices. I agree with the hon. Gentleman that more can be done, which is exactly why the agreement this year will end the prevalence adjustment that disadvantages practices with the highest number of patients with certain diseases. That adjustment will end completely in 2010, when practices will be rewarded on true prevalence, not adjusted prevalence.

The hon. Gentleman also asked how long it would take to phase out the minimum practice income guarantee. That depends on what level of uplift the Doctors and Dentists Review Body, the independent pay review body, recommends for primary care. For argument’s sake, if it recommended a 2 per cent. uplift this year, and that was repeated in subsequent years, it would take five years to phase out the MPIG completely, apart from a small rump of practices that would need some level of protection. I am also informed that if there were a 2 per cent. uplift this year, it should reduce the amount of protection moneys paid by about 50 per cent. nationally in the first year, so that would be a big step forward. We will continue to work with the BMA to secure year-on-year progress.

The hon. Gentleman also asked what role GP-led health centres will play in helping to address health inequalities. They will play a role through the additional and enhanced services that many of them will offer and the community-based services with which they will be co-located. His own, in Norwich, will be providing sexual health services, and I am sure that that is something that he will welcome.

In response to a point made by the hon. Member for Hemel Hempstead, the latest information is that about 40 per cent. of all those invited to tender for the new health centres are GPs themselves.

It being Six o’clock, the motion lapsed without Question put.