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GP Services (Tower Hamlets)

Volume 580: debated on Tuesday 13 May 2014

It is a pleasure to see you in the Chair this afternoon, Mr Streeter. I am grateful to Mr Speaker for affording me the opportunity to hold this debate, to the Minister for being here to listen and respond and to my parliamentary neighbour, my hon. Friend the Member for Bethnal Green and Bow (Rushanara Ali), for taking an interest and supporting the debate.

My remarks are designed to defend Tower Hamlets GP services. I am a great admirer of all that they have achieved, especially over the past 15 years. I called for this debate for three reasons. The first is to find out more about the nature of the problem facing GP services in Tower Hamlets. The second is to determine whether the Government accept that there is a problem. The third is, hopefully, to identify a solution.

The picture is confused and many aspects must be considered, but the real concern is that primary care budgets are being cut, and not only in Tower Hamlets. In response to my written question about average annual changes to GP income in Tower Hamlets, the Minister stated that there would be

“a decrease of £184,000 spread across 21 GMS practices.”—[Official Report, 6 May 2014; Vol. 580, c. 126W.]

However, The Guardian has reported that the Jubilee Street practice alone

“will be down £77,263 by the end of 2014-15”

and that it had “already lost £30,000 QOF”—quality and outcomes framework—

“income last year and will lose its £219,508 a year MPIG allocation incrementally over the next seven years—the accumulated loss due to MPIG alone amounting to over £903,000.”

The figures do not add up.

As well as the Jubilee Street surgery, four other practices in Tower Hamlets are reported to be part of the 98 surgeries facing closure, but we do not know where they are. Will the Minister commit to publish a list of those surgeries and to place that list in the House of Commons Library?

I am grateful to my hon. Friend for asking the Minister that question and look forward to his response.

The Jubilee Street and St Katharine Docks practices are the two main affected surgeries in my constituency. They are professional, efficient and well-loved and respected by patients. Jubilee Street says that if its proposals to solve the dilemma are not addressed and no agreement is reached, it will have to give notice of closure by October this year.

Today, I accompanied my right hon. Friend the Member for Leigh (Andy Burnham) and my hon. Friend the Member for Leicester West (Liz Kendall), my colleagues in the shadow health team, on a visit to Jubilee Street to see first hand the problem. At the same time, we launched Labour’s NHS pledge on GP appointments within 48 hours, which I am sure the Minister has noted. What is causing the problem? I will be grateful for the Minister’s views. Is it the shift from deprivation indices to age in the new allocation funding formula from 2012? Is it the elimination of a percentage of the QOF indicators? Is it the seven-year phase out of the minimum income practice guarantee?

Sitting suspended for a Division in the House.

On resuming—

I had just asked the Minister three questions relating to what he thinks might be causing the problems confronting our GP practices. The fourth is whether it is because of the range of different contracts negotiated over the past decade, awarding different levels of funding for numbers of patients to different practices; and the fifth is whether it is because there is a shift of funding away from primary care, and, if so, where the money is going. Some 90% of NHS contact with patients is through primary care, but it receives less than 10% of the NHS spend, a point I will come back to later.

I would also be grateful if the Minister indicated who makes the decisions. Practices, in discussion with the local clinical commissioning group and NHS England, have been unable to identify exactly who determines the funding levels. Obviously, it is NHS England that implements ministerial policy, which is why I have an outstanding request to speak to the Minister responsible, who I understand is the noble Earl Howe. I have briefly mentioned that request to the Minister, who kindly said that he would pass on the message and reinforce the request that we have made directly to his office. I would like to have that meeting, and would be accompanied by clinicians and practice managers from Tower Hamlets to put the case.

Tower Hamlets primary care has much to be proud of in the past 15 years; at one point it was the fastest improving primary care trust in the UK. Practices such as Jubilee Street have cupboards full of awards. When I was first elected in 1997, complaints about NHS services and GP practices were numerous and regular, but they disappeared due to the investment by the Labour Government over many years and the dedication and professionalism of clinicians and staff in primary and secondary care.

My own GP practice in Ettrick street on the Aberfeldy estate in E14 is a great example of that first-class service and improvement; I thought that I had better mention it, because if the staff there knew that I was complimenting other practices but left out Dr Phillip Bennett-Richards, Dr Sarah Pitkanen and their colleagues, they would be mightily disappointed.

The local worry is that all that is about to change. Not only have Labour stalwarts such as London assembly member John Biggs—our mayoral candidate—and Councillor Rachael Saunders been on the issue, but local Conservative councillors have been expressing concerns, so the issue is not party political in that sense. I attended a meeting last week at the Mile End hospital with nearly 100 people and many GPs in attendance. I have had numerous e-mails from constituents concerned about what is going on, and I know that my hon. Friend the Member for Bethnal Green and Bow has, too. There are petitions with hundreds and hundreds of signatures springing up all over Tower Hamlets.

All that is against the background of increased pressure. The British Medical Association has said:

“It is estimated that 340 million consultations are undertaken every year. This is up 40 million since 2008.”

As I mentioned, it also said:

“Over 90% of all contacts with the NHS occur in general practice.”

The then-chair of the Royal College of General Practitioners, Dr Clare Gerada, called for

“an urgent increase in general practice’s share of the NHS budget from 9% to 10% so that 10,000 more GPs could be hired, in order to make GPs’ work loads sustainable.”

Does my hon. Friend agree that, in a borough such as Tower Hamlets, with high levels of health inequalities, the fact that people cannot get GP appointments for days on end is scandalous? It will devastate people’s lives further and actually cost more, particularly by putting pressure on accident and emergency services while we are having an A and E crisis.

I agree entirely with my hon. Friend, and I am sure that the Minister also agrees that if we can treat people in general practice and prevent them from going to A and E, that is a much more efficient use of NHS resources. Her point is valid.

The House of Commons Library has produced for me a table of data on GP funding, which

“shows a shift on the share of funding for general practice from 10% in 2005-06 to 8.3% in 2012-13. The real terms change in spending over the past three years shows a fall of £432 million”.

At the same time, there has been an equivalent

“annual percentage decrease of 2.1% per year”

in GPs’ salaries through the same period.

So there we have it. There has been a 40 million increase in appointments but cuts in the share of the NHS budget; a significant real-terms fall in salaries; huge variation in funding at local level; and crises affecting many local practices in my constituency—some looking at closure, which would be a disaster for some of the most vulnerable people in our country.

I want not just to return to the Jubilee Street practice but to take the issue wider. The NHS deputy head of primary care for north central and east London, Rylla Baker, recently wrote:

“The situation has, unfortunately, developed further and we met with the Jubilee street practice earlier this week. Although the situation with the loss of MPIG”—

the minimum practice income guarantee—

“is, for most practices manageable, when the practices take into account other changes in funding that impact on them, the cumulative impact is significantly greater and practices such as Jubilee Street have said that if there is no mitigation against the loss the practice will not be viable… I have copied in Neil Roberts, Head of Primary Care for North Central and East London and Jane Milligan from the CCG as discussions are ongoing about the best way forward. It is also relevant to point out that this is an issue that is not limited to Tower Hamlets.”

We are hearing of numbers of practices in Hackney and Newham, two other impoverished boroughs, that are facing similar problems.

The Royal College of General Practitioners has said:

“In total, the phasing out of a key NHS funding stream called the Minimum Practice Income Guarantee…could affect a total 1,700 practices with the care of 12.2 m patients potentially under serious threat.”

I know that the Minister is deputising for his colleague Earl Howe—that is why I would like a face-to-face meeting with Earl Howe, or indeed with the Secretary of State—but I am keen to hear his response to the points I have raised. I am sure he has some information and data for us.

In Tower Hamlets, we have some of the poorest and most vulnerable people in the United Kingdom. There is the lowest life expectancy, on average, of anywhere in the UK. It is estimated that between 10% and 12% of residents are not registered on GP lists. Now, this crisis is coming to a head. I look forward to the Minister’s response, but I look forward more to a proper meeting with Earl Howe or with the Secretary of State, and I look forward most to arriving at a solution for the patients, the staff and the clinicians, so that we can protect and continue to provide first-class primary care services in Tower Hamlets.

It is a pleasure to serve under your chairmanship, Mr Streeter, for what I believe is now the third time, and to respond to this debate. I congratulate the hon. Member for Poplar and Limehouse (Jim Fitzpatrick) not only on securing the debate but on his advocacy on behalf of local patients. We have discussed that before during meetings in my office in the Department on other issues. I am sure that my noble Friend Earl Howe will be happy to meet him, and I extend that invitation on my noble Friend’s behalf.

I apologise for intervening so early, but I do not remember having any meetings with the Minister in his office on any subject. I would not want to mislead the House, or for people to think that we had held meetings in which I had not raised this issue.

A congregation of MPs from London came to see me and I believed that the hon. Gentleman had been there, but I am obviously mistaken. I apologise for that mistake, but I can recall similar conversations in the past during meetings with other MPs from other parts of the country, in which we talked about not just GP services but other local health care services of a similar nature. During those meetings there was advocacy of similar strength to that which we have heard today.

Indeed, a previous debate in Westminster Hall, led by my hon. Friend the Member for Westmorland and Lonsdale (Tim Farron), focused on the impact of the minimum practice income guarantee changes on more rural practices in his constituency. The topic has come to the fore for many hon. Members, who I know will wish to discuss it further with the relevant Minister. I therefore want to put on record a formal invitation to come and see my noble Friend Earl Howe to discuss the subject further at some point after this debate.

It may be helpful if I outline why the minimum practice income guarantee was set up in the first place and why it is important to change the payment structure for general practice. The minimum practice income guarantee is a top-up payment to some general medical services—GMS—practices. It was introduced as part of the 2004 GP contract to smooth transition to what were then new funding arrangements, so it is now 10 years out of date. Last year, we announced that the minimum practice income guarantee will start to be phased out from April 2014. We consider minimum practice income guarantee payments to be inequitable because under the system, two surgeries in the same area serving similar populations may be paid different amounts of money per registered patient.

The MPIG will be phased out over a seven-year period, as the hon. Member for Poplar and Limehouse will know. We are phasing it out to make sure that there is more equity between what different practices in comparable areas receive per patient, and that funding follows the patient more accurately, rather than the practice. I am sure we can all sign up to that in principle. The payments will be phased out gradually with the overall intention that the funding for GP practices will be properly matched to the number of patients they serve and the health needs of the local population.

The money released by phasing out the MPIG will be reinvested in the basic payments made to all general medical services practices. Those payments are based on numbers of patients and key determinants of practice work load such as patients’ ages and health needs—deprivation is of course a driver of patients’ health needs. We are committed to making sure that patients have access to high-quality GP services wherever they live and ensuring that in the same geographical area similar practices receive effectively the same amount of funding for each patient they look after.

It is also worth highlighting the overall impact for practices, both in the country more generally and in London in particular. NHS England has undertaken analysis regarding the withdrawal of the MPIG. Inevitably, a small number of practices will lose funding, and NHS England has considered the very small number of significant outlier practices for which alternative arrangements may need to be made to ensure appropriate services are maintained for local people.

We appreciate that this is a matter of concern for some practices, including some in the hon. Gentleman’s constituency that he has mentioned today. That is why we have decided to use the next seven years to implement the changes to the MPIG, introducing them gradually through a phased transition to a new funding arrangement, rather than taking a big bang approach. Phasing the changes in over that seven-year period will allow the minority of practices that lose funding to adjust more gradually to the reduction in payments.

As the hon. Gentleman highlighted in his remarks, the changes cannot be seen in isolation but should be looked at together with the changes to the quality and outcomes framework payments for GP practices; those changes need to be set alongside the global sum paid to GMS practices. When all those factors are put together, I understand that practices in London with a GMS contract, of which there are 721, will see an overall funding increase of £731,000 resulting from the net effect of all the changes. I will write to the hon. Gentleman to outline that in detail ahead of his meeting with my noble Friend Earl Howe.

When we have that meeting with Lord Howe, it would be useful if NHS England could provide the Minister and his officials with an accurate breakdown of figures for the practices in Tower Hamlets. Given the order of deprivation, the chronic ailments and conditions, the age profiles of very elderly and very young people, and the language problems, even NHS England, as I quoted, is saying that the combination of changes to the minimum practice income guarantee and the quality and outcomes framework reductions is creating specific difficulties in Tower Hamlets that are not generally replicated across the rest of London.

I am happy to write to the hon. Gentleman after the debate to outline the more general points, and I am sure that we can ensure that more specific details are available for him to discuss in his meeting with my noble Friend Earl Howe. NHS England has made it clear that it has been looking carefully at how it can support the practices that are most affected, through its area teams, and I am sure that it will be happy to continue a dialogue with local practices and with the hon. Gentleman to work out how further local support could be given if some practices are struggling as a result of the changes. That offer has been made to those practices that have already been identified as most affected, but NHS England is continually reviewing the matter as a pathway process for phasing in the changes.

NHS England has also suggested that those practices with very small lists, which may be particularly affected, could collaborate through federating, networking or merging with other practices nearby to provide more cost-effective services. It also suggested that it would be possible to identify other ways in which practices might improve cost efficiency, such as reviewing staffing structures and other commissioning or contracting options—for example, how some patient care services are offered in the area by collaboration. Sometimes, back office costs and inefficiencies can be reduced to free up more money for patient care. We must remember that, on the whole, GP practices are small businesses in their own right. We expect NHS England to work with GPs to support best practice and technology, and to encourage general practices to collaborate and work together, and it is happy to do so. It is expected that general practices will do what they can to help themselves, and that NHS England will work with them to facilitate that for them as small business owners.

I recognise that there is some logic in the Minister’s suggestion about smaller practices. The Jubilee Street practice has 13,000 patients. It is a big practice and is multi-handed with clinicians and staffing, and is considered to be extremely efficiently run.

Indeed. I will talk in more detail about Tower Hamlets, but the hon. Gentleman is right to say that it has a long history of collaboration, efficiently run practices and good working between GPs and other community health services to support some of the most vulnerable people in our society and to address specific issues of health care and equality. The hon. Gentleman outlined that in his speech and local GPs should be proud of what they have done and their work and efforts in many cases to help deliver greater efficiencies. Nevertheless, the offer is there from NHS England to engage with area teams to see what more support can be provided. It is keen to ensure that if particular practices believe they are disadvantaged, the teams will do what they can to work with the practices to mitigate that.

It is worth talking briefly about the changes in the quality and outcomes framework. In addition to the minimum practice income guarantee from April this year, we have also made changes to QOF and reduced it by more than a third to free up space and time for GPs to provide more proactive and personalised care for their patients, particularly the frail elderly. One of the great frustrations that we are all aware of—medical staff, health care staff and particularly GPs—has been the amount of bureaucracy that GPs are sometimes required to undertake, which has got in the way of their being able to deliver front-line patient care and spend time with patients. The changes to QOF were welcomed by the British Medical Association and GPs because they will help reduce the bureaucratic burden and allow GPs to spend more time with patients and focus more on personalised care and more vulnerable patient groups. I think we all believe that to be a good thing and a great achievement from those GP contract negotiations.

As part of the QOF changes, we have retired indicators when they were either duplicating other incentives in the health care system, or were of low clinical value and use—for example, if they were just process measures rather than measures linked directly to patient care. We are ensuring that the payment system is strongly linked to delivering better care and improving care for patients rather than to process measures. That has sometimes been a criticism of QOF payments in the past, not least by GPs. Removal of these indicators will help to reduce bureaucracy, unnecessary patient testing and unnecessary frequency of patient recall and recording.

The money released from the changes to QOF will be reinvested in the basic payments made to all general medical services practices, to which I alluded earlier. The global sum will be reinvested through the GP contract and I understand that practices in London with a general medical services contract will overall be net beneficiaries to the tune of roughly £700,000. We welcome that, and I will give the exact figures in my letter to the hon. Gentleman, but I believe that what I have said in this debate is an accurate reflection of the situation.

I turn to Tower Hamlets and will address some of the concerns that have been raised in the debate today. We understand that some practices have particular concerns about the changes to the minimum practice income guarantee and to QOF funding. I assure the hon. Gentleman and his constituents that the Government and NHS England are committed to ensuring that good, high quality primary care for local people, such as his constituents, is a priority. I understand that despite being one of the most deprived boroughs in London, Tower Hamlets has developed some outstanding general practices often as a result of the hard work and dedication of the GPs who want to address health care needs, to look after vulnerable people in society, and to ensure that the health care inequalities that we have discussed are properly addressed. His local GPs and all health care staff delivering care on the ground should be proud of that.

As the hon. Gentleman outlined, Tower Hamlets is top in the country for blood pressure and cholesterol control for patients with diabetes, resulting in reduced complications of diabetes and reduced admissions for heart attacks. It is also top in London for MMR vaccination and for flu vaccination for the over 65s. That is an example of how, even in one of the most deprived areas with some of the greatest health care needs, local GPs, local primary care and local community care are delivering very good results for patients. It is also one of the 14 national pioneers for integrated care, a programme in which primary care will play an increasingly important role. We want to keep people out of hospital and it is vital that they are supported in their own homes and communities. Integrating primary care with community care and effective adult social services care from the local authority will be key in delivering that.

I understand that NHS England’s area team has set up a task and finish group to look at the support that might be offered to practices with membership drawn from local medical committees and the London office of the clinical commissioning group’s chief officers and the local area primary care commissioning team. I understand that NHS England’s area team in London has been in regular contact with individual practices in Tower Hamlets to offer them ongoing support regarding these changes. I am sure that after this debate, that important input and dialogue will intensify to recognise some of the issues that the hon. Gentleman raised.

We also recognise some of the challenges facing small practices in delivering the increasingly wide range of primary care services as more services move from hospital settings into the community. All health services, hospital trusts, community and mental health care providers, as well as GPs, are facing the challenge of meeting increasing demand with small increases in funding. That demand is coming from an ageing population with increasing levels of long-term conditions as well as the costs of new drugs, and patients’ expectations. Those issues are faced throughout the health service, but they are acute in Tower Hamlets. Local GPs recognise the need for flexibility in the way in which future services are provided and we need to support practices to work together to demonstrate how best to use their resources for the benefit of all their patients.

We have announced that NHS England is supporting practices as they phase in the changes to the minimum practice income guarantee and to QOF payments. There is an offer to meet my noble Friend Lord Howe and I know that NHS England will continue to do what it can to support local practices in Tower Hamlets.

Again, I put on the record my congratulations to the hon. Gentleman on securing this debate and to the local GPs who deliver some of the best health care outcomes in England for the patients they look after.

Question put and agreed to.

Sitting adjourned.