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NHS: GP Services

Volume 745: debated on Tuesday 21 May 2013


My Lords, I shall now repeat, as a Statement, the Answer given in another place to an Urgent Question earlier today by my right honourable friend the Secretary of State for Health. The Statement is as follows:

“I have been clear that we have not been satisfied with the performance of A&E over the winter period. On 13 May, I announced to Parliament my intention to launch a new plan for vulnerable older people and publish this in the autumn. As I said in that announcement, there is short-term work under way to address the issues in A&E. However, the plan will look at all aspects of the way we look after those older people most in need of support from the NHS and social care system. In many cases, we could be offering better alternatives outside of hospital. The Primary Care Foundation has estimated that 10% to 30% of A&E cases could be treated elsewhere. The plan is being developed jointly by NHS England and my department, and we will be looking to engage with patient and professional groups over the summer so that the plan can be informed by their views”.

My Lords, that concludes the Statement.

My Lords, first, I refer noble Lords to my health interests as set out in the register. The noble Earl is certainly right about one thing: that the health and social care system is under huge pressure. Hospitals are full to bursting, discharge is becoming ever more difficult, and social care and the voluntary sector are struggling to fulfil the demands being placed upon them. However, from the Statement made by the Secretary of State in the other place, it seems that the Government are seeking to blame everyone but themselves.

For instance, we have heard a lot about the GP contract, but can the noble Earl say why it has taken nine years for that contract to impact on A&E services? These are the very same GPs to whom, only a year ago, the noble Earl was saying we should hand over £80 billion for them to commission services without expertise, experience or inclination. Does he agree that the real causes of the crisis are the government-induced collapse of adult social care, the reduction in nurses, the closure of walk-in centres and ministerial pressure to introduce the NHS 111 service way too soon? Does he accept that all that has happened on the watch of the noble Earl and his ministerial colleagues?

My Lords, we know that A&E departments are under pressure, and the noble Lord is absolutely right to emphasise that. Over 1 million more people are visiting A&E departments compared with three years ago. However, we also know that, on the whole, the NHS is performing well. The latest weekly figures for emergency services show that 96.3% of patients visiting A&E are being seen within four hours and that people are waiting, on average, 55 minutes for treatment. That is a testament to the hard work of many staff throughout the health and care system.

It is not just about the GP contract; it is about making sure that we have a much more joined-up system in which hospitals communicate better with care homes and GP surgeries so that information about a patient’s needs is shared between the professionals who need it. GPs have an important role to play in this, which is why changes were made to the 2013-14 GP contract as a first step. Any future changes to general practice and the contract will of course be made in negotiation with GPs, and it is too early for me to go into detail on what those proposals might be. As regards NHS 111, I do not agree with the noble Lord. I am sure that he will be aware that the pilots we conducted on the NHS 111 service were extremely encouraging and showed a high rate of patient satisfaction.

My Lords, I am sure that the noble Lord, Lord Hunt, would not disagree that the GP contract, although it was some time ago now, was a factor in what has gone wrong with A&E. Does the Minister believe that we can move towards a situation where the responsibility for out-of-hours medicine once again becomes part of what GPs accept as their CCG responsibility? Can he also say whether steps might be taken in the short term to ease the situation in A&E, while in the long term we move towards a more satisfactory answer involving the reintegration of GPs into the care of patients going into A&E situations?

My Lords, I think that the GP contract is but one element of a more complicated picture. It is not the only issue or, indeed, is it the only solution. It is true that access to out-of-hours care in some parts of England is simply not good enough. We are not saying that family doctors should necessarily go back to being on call in the evenings and at weekends. They work hard and have families, and they need a life too, but we must take a serious look at how out-of-hours NHS care is provided. My right honourable friend the Secretary of State will be talking to GP leaders about how we can do that over the coming weeks.

My Lords, the noble Earl has indicated that there is a need to look again at the availability of community-based services. Hospital-based services are available seven days a week but community ones for much less, and that includes social care services. While not wanting staff to work all hours, is it not possible to move towards a situation where the services will be available at all hours while we protect staff working time?

The noble Lord, Lord Laming, has summed up the situation extremely well. I am sure he knows that Sir Bruce Keogh, the NHS medical director, is currently looking at how NHS services across the piece can be provided seven days a week in a much fuller way than they are at the moment. Access to GPs out of hours is part of that wider consideration and NHS England is working with the royal colleges and professional organisations to develop a set of standards that will apply to seven-day services. Some trusts are already thinking about treating patients at weekends for non-urgent operations and procedures. We want to encourage that trend.

My Lords, can I correct a serious misrepresentation and misconception that is constantly made regarding the GPs’ contract, and which has been made in the past few moments? The GPs’ contract for 2003-04 did not remove the requirement of a doctor to work out of hours. That was removed a decade earlier under the previous Conservative Government; indeed, by 2000 a huge percentage of doctors had already opted out. The GPs’ contract was to try to make sure that GPs were not spending part of their normal day bureaucratically chasing up a replacement doctor to take their place. It removed that bureaucratic imperative but it did not remove the right of a doctor to refuse to work out of hours. That was the case with some 70% to 80% by the end of the previous Conservative Government, before the GPs’ contract. That is a very important distinction.

My Lords, I certainly did not mean to mislead the House and if I have done so in any way I apologise. The summary given by the noble Lord is broadly right. Under the old general medical services contract, GPs had a 24-hour responsibility for their patients, although most GPs delegated responsibility to GP co-operatives or commercial providers. At the beginning of 2004, as I recall, only a small proportion of GPs actually provided out-of-hours services themselves. However, 24-hour responsibility continued to be unpopular with GPs as they felt it was discriminatory, which is why the contract was renegotiated at that time. It has brought about a growth in GP co-ops, with more use of telephone triage and more patients offered emergency consultation with a primary care centre. But that has resulted in fewer home visits and I think that point in particular is one that is exercising many people.

My Lords, does my noble friend understand that while he is telling the truth in saying that the contract is only one of a number of aspects that have to be addressed, the problem is that Ministers have said that so frequently from this Dispatch Box and the one in the other Chamber that it is now in danger of being understood as a reason why Ministers will not tackle contract issues? If my noble friend and his colleagues would start by addressing the contract issues, they would be doing us all a great favour. He would thereby be creating a lot more credibility when the other issues, which have to be addressed simultaneously, are turned to.

My Lords, my noble friend makes an extremely important point. He may know that my right honourable friend the Secretary of State is very concerned to look carefully at the current contract to make sure that it does not include too many perverse incentives to tie GPs’ time up too much. If we can work towards a contract with the agreement of the profession that enables GPs to take a more holistic look at their patients’ health and adopt a more preventative approach, which I think everybody agrees is desirable, that is thoroughly to be wished for. However, this is work in progress.