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GP Practice Boundaries

Volume 502: debated on Wednesday 16 December 2009

I am pleased to see you in the Chair, Mr. Cook, presiding over a debate on a subject that is highly important to all our constituents. It is good that the Minister responding to the debate is my right hon. and learned Friend the Member for North Warwickshire (Mr. O'Brien), who is my constituency neighbour to the south-west.

If we look at the Government’s policy on the NHS since 1997, we can see that a welter of statistics confirm the excellent and vital progress that has been made in many areas. For example, we have over 44,000 more doctors and almost 90,000 more nurses, and 3 million more operations are carried out each year than in 1997, with the number of heart operations more than doubling. Net public spending on the NHS has nearly tripled since 1997. Then it was £35 billion; it is now more than £90 billion. Waiting times are at the lowest level in NHS history.

The risk, however, is that the effectiveness and durability of those fantastic achievements may be undermined by an obsession with organisational and administrative reform of the NHS. In the view of many NHS workers, of patients and indeed of Members of Parliament and community representatives, the commercial mantra of choice is being used as a cloak for the marketisation and privatisation of the NHS.

At the Brighton Labour party conference in September, the Secretary of State for Health said:

“I cannot see why families shouldn’t register with the GP practice that suits them best. So, I’ve said we’ll abolish GP practice boundaries within a year.”

That did not exactly come out of the blue, but it caused a great deal of concern among GPs in my constituency and elsewhere. Even those GPs who saw some benefits from that rather rushed reform, such as Dr. Theresa Eynon of the Hugglescote surgery, were quick to express to me their fear that abolishing GP practice boundaries could worsen the plight of those patients most vulnerable to serious long-term health problems.

The Government’s plans provide further proof that the inverse care law is alive and well. As the Minister will know, the idea was first proposed by Julian Tudor Hart in 1971. His law states that the availability of good medical care tends to vary inversely to the need for it in the population that it serves. Put simply, those who need health care services the least use them more, and more effectively, than those with the most need.

That is not to say that there is anything inherently wrong with allowing people to register with a GP practice closer to their workplace, thus enabling easier access to the surgery during the working week. Of course there is nothing wrong with wanting to offer more convenient NHS primary care, although I would quietly suggest that employers could be more flexible in allowing their employees to attend GP appointments; the wheels would not come off the local or national economy if such flexibility were more readily available.

If that was what was being proposed, I would not argue with it, and would not be debating the matter today, but that is not the full story. The Minister said in a speech to the Royal College of General Practitioners conference last month:

“The focus has to be on responding to the needs of patients…Enabling people to choose a different practice near home. Or one near to where they work. Or one with better overall quality scores and patient satisfaction but in a different location altogether.”

That confirms that the Government’s intentions are much more fundamental than an improvement to GP accessibility.

The proposal is more to do with the promotion of competition among GP services, supplemented by initiatives such as NHS Choices that utilise the information gleaned from the quality and outcomes framework to give the public somewhat simplistic statistics on GP practice performance. Given all the academic talk of quality and values, the most crucial issue is the future of the truly local services that GPs provide, particularly the invaluable home visits that they make to the homes of the long-term sick, the immobile and the terminally ill.

In the rush, in the words of the Health Secretary, to turn the NHS from “good to great”, the Government risk ignoring the needs of that most vulnerable group of patients. I note parenthetically that the next debate in this Chamber is about age discrimination in health care. I shall read the Hansard report of that debate with great interest. The proposed reform does not seek to end home visits, but there is a very real risk that the needs of our fellow citizens with the most complex health problems will be put in direct competition with the health-care requirements of the more affluent workers and families. Each will have a QOF score, but there are no prizes for guessing who attracts the most points and, therefore, funding.

I regret to say that the potential of the change to worsen health inequalities goes even deeper than that. Those with the most complex health needs, particularly psychiatric ones, rely on social services that are geographically tied to the local authority. It does not take much imagination to realise that the consequences of abolishing GP practice boundaries may include an increase in the administrative complexity and cost of providing appropriate care packages for all who need them. Dementia patients living at home will be particularly vulnerable to instability and uncertainty.

All Labour Members hope that the Personal Care at Home Bill, which received its Second Reading this week, and the national care service will together ride to the rescue of all those with social care needs, but a period of uncertainty could result from the abolition of GP practice boundaries. I urge the Government and the Minister to think again, on these grounds alone. I should be most grateful if the Minister made a specific response about the impact of the reform on social care provision.

I turn to the intellectual threads of this reform. The spiritual leader of private health care in the NHS and former Health Secretary, my right hon. Friend the Member for Darlington (Mr. Milburn), has rightly stated on numerous occasions that the health gap between rich and poor has grown inexorably since the creation of the NHS. However, that inescapable conclusion has little to do with structural failings within the NHS, as he would be quick to assert; it has more to do with the wealth of a small number of individuals and the private companies that respond to their every ailment, whether cosmetic or chronic.

It goes without saying that widening health inequality is a national concern, and I am pleased that the Government have commissioned Professor Sir Michael Marmot of University College London to consider how we could tackle health inequalities more effectively. We should all look closely at his findings and recommendations, and I hope that we will have an opportunity to debate them in the Chamber.

Men and women in our poorest communities are dying on average a decade or more before those of their generation in the most affluent areas. Putting it at its mildest, that is deeply troubling. However, that is due as much to the increased and inherent politicisation of this totemic institution since the 1980s. That culminated in the Labour Government putting up the money—but rarely the arguments—for maintaining the NHS wholly within the public sector.

With the abolition of practice boundaries, we will undoubtedly increase competition within the NHS. That will be especially so in urban areas, as GP practices have to compete for patients with NHS walk-in centres and one-stop primary care centres—the polyclinics championed in the Darzi review. That will merely distract the NHS from tackling health inequalities, as consistent and lengthy patient records will become more difficult to compile.

As someone with three decades in public sector IT, it would be remiss of me not to acknowledge that computer systems have a role to play in solving the problem, but the less said about the benighted NHS agency Connecting for Health the better. There is little doubt in my mind, however, that we would have had greater success in tackling health inequalities since 1997 if we had trusted and promoted the efficiency of the public sector over that of the private sector and its unseen and unaccountable backers and exploiters.

I mentioned the Darzi review a moment ago. We are all familiar with its aim of putting quality at the heart of the NHS. Who could disagree with that? I certainly would not, although I would question the use of other commercially-loaded terms by a senior Government appointee, who is supposed to be a clinical health specialist and not a management guru. Those phrases are more likely to come out of the mouth of the Chief Secretary to the Treasury, my right hon. Friend the Member for Birmingham, Hodge Hill (Mr. Byrne), than one of our most successful and respected surgeons.

However, when my right hon. Friend the Member for Darlington was Health Secretary, he said in a speech to the Commonwealth Fund in Washington 2002 that

“health care works best…when it harnesses the commitment and knowledge of clinicians to improve care for patients.”

Private health insurer Kaiser Permanente of the US is cited as an example of that health care harmony, but I shall resist the temptation to be lured down that profitable but politically promiscuous avenue.

The Darzi review is the foundation for these troubling proposals in primary care, with a specific quote from Lord Darzi’s summary letter in “High Quality Care for All” establishing the foundation upon which the Secretary of State decided to proceed.

Lord Darzi said:

“Patients will have greater choice of GP practice and better information to help them choose.”

That raises the role of primary care trusts in designing and commissioning local primary care services, as they also have a vital role to play in the democratisation of health care. By that I mean involving patients in the decisions that most affect their health, which is a welcome development. Leicestershire County and Rutland PCT seems to be going out of its way to illustrate to patients the worst excesses of the catchment area system that currently operates. For example, patients registered at Whitwick surgery who lived four miles or so away in Hugglescote were told by the PCT that they would have to leave that practice and re-register at Hugglescote. That was immensely distressing to the patients concerned, particularly pensioners who had built up a good relationship with the GPs at Whitwick over a number of years.

At this point, it is worth quoting Dr. Orest Mulka of the Measham medical unit. He is a highly respected GP at a well-regarded surgery in my constituency, and he said:

“Of course boundaries can be misused...but boundaries aren’t just for the management of GP workload. They are there to allow a practice to identify with a community and see the health of their community as more than just the sum of individual conditions that are brought to them. They allow practices to develop a sense of pride of caring for their patch.”

I repeat:

“They allow practices to develop a sense of pride of caring for their patch.”

He went on to say:

“ In my practice we don’t discriminate—anyone living in our area is accepted on our list.”

I shall use Dr. Mulka’s comments as evidence against the Government’s claim that abolishing practice boundaries will increase local accountability. If a patient is not a member of the local community, their needs may well be at odds and even in competition with those who live closest and who may have greater clinical need.

Whatever the number of patient participation groups, welcome though they are, they cannot hope to replace that local link. That reminds us of the consumer-led nature of the Government’s proposal, which has been described as a move toward a “medical supermarket” where increasing numbers of patients are routinely seen, not by GPs, doctors or nurses, but by “health care professionals” such as “nurse consultants”. We are some way from such dystopian scenarios, but the Government’s obsessive delivery of pro-private policies in the NHS inevitably leads in that direction. Many people see the death knell of a publicly resourced and run NHS in proposals such as abolishing GP practice boundaries; creating polyclinics; making PCTs commissioners rather than providers of health care; encouraging NHS hospitals trusts to apply for foundation status; local improvement finance trusts; and—do not get me going on this—private finance initiatives. Moreover, there are other inappropriate and unnecessary market devices.

Such reforms are the logical conclusion to the brave new world of health care partnerships piloted by my right hon. Friend the Member for Darlington when he was Health Secretary. The frequent speeches made during his tenure in Richmond house seemed intent on sending a chill down the spine of GPs and patients and included such baleful gems as the following examples. He said that

“tax funded health care can only be sustainable if it sits side by side with diversity in provision and choice for patients.”

What he meant is that it is sustainable only when the local commissioning arrangements allow and indeed favour private sector bids for NHS work. He also talked about

“new private sector providers becoming a permanent feature of the NHS landscape.”

Finally, he said:

“The NHS scores well on fairness but is weak on choice.”

Those quotes are all from the same 2002 speech, but seem more akin to a sales pitch than a policy debate. Let us not forget that from 2001 to 2004 our former Prime Minister and right hon. Friend, Tony Blair, was advised on the NHS by Simon Stevens, who promptly joined the US firm UnitedHealth Group, which made $78.85 billion from health care services in 2008, after leaving the Downing street policy unit. By way of a footnote, let me say that at the same time as vehemently opposing President Obama’s modest health care reforms in the US, UnitedHealth, with Simon Stevens on board, is bidding for and winning NHS contracts, and will no doubt regard the abolition of GP practice boundaries as welcome “mood music” at the very least.

To return to the local impact of the Government’s plan, Dr. Eynon has concluded that, once again, the change is one that suits the well, working person. That brings to mind the inverse care law that I cited at the start of my speech. We must not shape our primary care system around the needs of the middle-class, peripatetic, urban elite who go to their local paper and MP every time they cannot get an appointment to treat their squash injury, as we should not normalise or accommodate the social and environmental impact of fundamentally selfish lifestyles.

By 2018, when the NHS reaches its biblical span of three score years and 10, we shall have seen GPs metamorphose from the avuncular community leaders of “Dr. Finlay’s Casebook” to profit-generating assets in a Dr. Foster’s cost centre. The NHS was not created to serve a minority who shout loud enough to see a doctor whenever they want, wherever they are. This proposal is designed to satisfy the few, not the many. To abolish practice boundaries is to hasten the demise of the family doctor.

I congratulate my hon. Friend the Member for North-West Leicestershire (David Taylor), my constituency neighbour, on securing the debate and on his lively and interesting speech.

Although practice boundaries will be the main focus of my remarks, I also want to address the wider issue of competition and choice within the NHS, because my hon. Friend has made his feelings so plain. It will not surprise him to know that I have some sympathy with a few of his points. I, too, am very conscious of the fact that our party founded the NHS. It was a service to be paid for from taxation, free at the point of need and primarily provided through the public service.

However, in respect of some of the comments about marketisation in primary care, we need to bear it in mind that the NHS has always been a deal between the private and public sectors, because most GPs operate independent private businesses that contract with the NHS, and have done since 1948. Therefore, we must be a little careful when we discuss the private sector, because some GPs talk about the private sector as if it were something different from them. Actually, they are in the private sector, but they contract with the public sector.

We have an excellent record in primary care, as confirmed by a report earlier this year from the prestigious Commonwealth Fund, but we should never be satisfied. Although many GP practices are excellent, not all are. I agree with my hon. Friend that the most deprived parts of the country sometimes have the poorest provision of primary care with fewer doctors and greater demand—poorer areas tend to have people with a number of medical conditions that need urgent care.

We cannot simply rely on current general practice to address such problems. That approach has been tried for 60 years and it just has not worked. In some places, patients may be restricted to a single practice. They may wish to move, but find it difficult to do so. That is all very well if their practice is good, but what if it is not? We are now pursuing a different approach, investing in 112 new GP practices delivered by any willing provider with a strong track record on reducing health inequalities.

Choice and competition can drive up access and quality, which is important. We are working to improve the quality of primary care in different areas. One thing that GP-led health centres have done is locate in some of the most deprived areas in the country. We have had great difficulty in getting GPs to work in such areas. They find the work hard and the profits small, because the amount of private work that they get is limited. We have invested huge sums over the past decade in new premises, new technology and many more doctors, nurses and other health care professionals.

Yesterday, I went to Barking where a new family centre has been set up. GPs and dentists were encouraged to locate in a deprived area to ensure that it offered the quality of care that local people needed. As a result of many of those people training in that area—I also visited a centre in the Isle of Dogs—some GPs and dentists have chosen to come back and work there because the facilities are good and the buildings new, and they realise that deprived areas can bring a great deal of job satisfaction.

I am listening very carefully to what the Minister has to say. Does he agree that the bigger polyclinics that are envisaged—where a patient may go and, in a sense, be allocated at random a doctor from a very large panel—will make it very difficult indeed to build a relationship of the type that has been the foundation of our health service since 1948, which is that between a patient and a family doctor?

I think that the NHS and the relationship between patients and GPs have changed since 1948. Some patients want to see the same doctor, particularly if they have a long-term medical condition and they do not want to have to explain their problems all over again to a new doctor. However, some patients are not worried about whether they see the same doctor. If a patient does not have a long-term condition and is, in effect, seeing a GP at random—they might have developed a condition that they just want advice on—they may not be bothered about which GP they see.

There is a tradition of sorts that the relationship between patient and doctor is sanctified. For some people it is, but for others it is not, and we must provide an NHS that enables those people who want to see a particular doctor to see that doctor and those people who are not bothered in the least about which doctor they see not to have to see the same doctor continually. Some people I know do not want to see their allocated doctor at all. They happen to have been allocated to that doctor and end up seeing them. I remember that at some point in the past, although thankfully not at the moment, that was the case for people in my family.

Therefore, we need to ensure that people are able to see the GP who best suits them. My hon. Friend is absolutely right that many people want to see the same GP, but some are not bothered about which GP they see.

We need to provide people with choice, because choice and competition can both make a difference to patients and improve the quality of care. The polyclinics are based in London; we do not have them elsewhere. We have GP-led health centres elsewhere and many are very successful, but the development of polyclinics, which was restricted to the capital, has been enormously successful, particularly in deprived areas. Polyclinics have brought GPs to deprived areas and improved the quality of care in those areas, which we want to continue to work on.

We have pushed power away from Westminster and Whitehall into the hands of primary care trusts, through the world-class commissioning programme, and directly to individual and groups of GPs, through practice-based commissioning. That is all about providing the best possible service for patients—an aspiration that I am sure my hon. Friend shares.

As the Secretary of State has set out, where NHS services are providing excellent quality and performing at the level of the very best, there is no ideological predisposition to look to the market. On the contrary—we want health care provided in the best way that the NHS can possibly provide it. The public service is our preferred provider, but if it is not providing we have to look elsewhere, because the patient comes first.

Where NHS services can deliver, that is good—we want them to deliver—but we are also saying that patients need more power to choose the service that suits them. We in the Labour party created patient choice, precisely because we believe that it should be the interests of patients, rather than those of providers, that determine how health care is provided in this country.

We have already given people far greater choice through the introduction of 90 NHS walk-in centres, which are used by 3 million people every year, and, more recently, through the introduction of GP-led health centres, which enables someone to walk in to see a GP or a nurse while remaining registered at their own GP practice. People can go to the GP-led health centre if they have a random or minor health issue, but if they have a long-term health issue they can still go to see their own GP. They have a choice. Despite fierce opposition to GP-led health centres from some parts of the medical profession and from elsewhere, they have, by and large, proved very popular with patients. Overall, nearly 3 million people have used such a centre already.

Evidence from the UK and from overseas shows that treatments are more effective if patients choose, understand and control their own care. We are putting ever more information about services in the hands of the public. That information will include the waiting times for a particular hospital and the personal comments of patients at a GP practice, so patients can comment on how good their GP practice is.

This process is slowly transforming the traditional doctor-patient relationship, in a way that gives the patient more power. Some GPs do not like it, but it gives patients more power. A more empowered and informed patient can take a more active role in their own care. They can decide, with their own doctor, which hospital to be treated at, and they can take a rational decision about which GP practice is best for them.

The NHS constitution already gives people the right to choose their own GP practice, but for many people that choice is severely limited. Most patients can choose between only a few practices and some patients have no choice at all. That limited choice reduces the competition between practices to attract patients and weakens the incentive for some GP practices to improve quality. Under the constitution, a GP practice must accept a patient’s choice unless there are reasonable grounds for not doing so. At the moment, being outside a practice’s boundary counts as reasonable grounds.

As my hon. Friend said, in September the Secretary of State set out our intention that, within 12 months, people should be able to register wherever they choose. For now, the practice that lies closest to someone’s home may not be the easiest for them to get to.

I ask my hon. Friend to consider his constituents who commute to work and who may find it far simpler to see a GP near their work rather than taking half a day off to see a GP closer to their home. It is all very well to say, as he did, that employers should be more understanding, but some employers just are not so understanding. In addition, many people get paid by the hour, so they would lose money if they had to take more time off work to see a GP.

I also ask my hon. Friend to consider people with children who go to school beyond the boundary of their GP’s practice. Those people may find it easier to register with a GP nearer the school, keeping time off school to a minimum should their child need to see a doctor. Furthermore, some of his constituents may want to change their GP practice because of the better quality of services available at other practices in their area. They may even want to register with the practice closest to their home but cannot do so because it lies just the other side of a line or boundary, or perhaps because of the “closed shop” arrangements that exist in some areas, because a GP practice’s list of patients is full or because lines have been agreed about where the boundary between practices will exist.

The qualities and outcomes framework—the new arrangements to ensure that GPs provide greater health care—has attracted a lot of attention, because money is attached to it. The key thing is that the funding formula is weighted in favour of those people with long-term medical conditions and the elderly. Indeed, there is clear evidence that, since QOF was introduced, health inequalities have narrowed—that is what it is all about. Money follows the patient, so offering people a choice gives practices a strong incentive to improve and attract new patients and retain existing ones.

Similarly, part of the positive impact of the new GP-led health centres has been that they have led other practices to open for longer and to expand their practice boundaries, so that they can compete with new services such as the GP-led health centres. Choice means better access to higher-quality medical care and I cannot see how anyone would want people not to have choice, if that is what choice indeed means.

Of course, given a choice most people will stay exactly where they are; I believe that that is what most people will do. Only a limited number of people want to exercise choice in this regard and, yes, sometimes they are well, middle-class people who just want the choice. Why on earth should they not have it? If they want it, the NHS should be able to provide them with it.

I do not want people to have to go off somewhere and pay privately to get a choice that they really ought to have within the NHS. Frankly, if people are well, young and middle-class, I want them to use the NHS and stay with it. I want them to realise that the NHS will give them a choice, so that later on, when they perhaps really need the NHS for their kids or for themselves when they develop a long-term condition, they will stay with the NHS—those are the people we want too.

However, my hon. Friend is right that we also need to ensure that we care for the people who really need the NHS. They include people from the mining community, such as some of his constituents and some of mine, who have long-term health care conditions. We want to ensure that such people receive the service and the priority that they need.

People with complex long-term medical conditions will want to maintain the continuity of being registered with their local GP, especially when so much of their care will involve other local organisations such as social services, community nursing and diagnostic services.

We want to ensure that where patients want choice, they get it. However, most patients who do not need that choice should not have it forced upon them. In the end, it remains something that patients should choose or not choose for themselves. It is a matter for them.

Sitting suspended.