On a point of order, Mr. Speaker. On Monday, the House heard a savage attack on Mr. Mohamed al-Fayed, made under parliamentary privilege. Can you tell me whether any redress at all exists for people who are traduced, even under parliamentary privilege?

Order. Privilege is absolute. [Interruption.] Order. I am not going to pursue the matter; I have given a ruling. Will hon. Members who are leaving the Chamber do so quietly?

I inform the House that I have selected the amendment in the name of the Prime Minister in both of today’s debates.

I beg to move,

That this House supports the family doctor service, and recognises that it is the first point of contact for the majority of patients; further recognises the invaluable role that GPs have in the NHS; regrets the undermining and undervaluing of GPs by the Government; is concerned about the lack of empirical and clinical evidence for the establishment of polyclinics in every primary care trust; opposes the central imposition of polyclinics against local health needs and requirements; is further concerned about the delay in publishing evidence on the cost-effectiveness of walk-in centres; believes that patients should be able to choose the most convenient GP practice, whether close to home or work; calls for GPs to be given real budgets, incentives to make savings, the freedom to re-invest for their patients and the ability to innovate in contracts with healthcare providers; supports rewarding GPs who choose to provide services in deprived areas or areas of expanding population; and further supports the incorporation of patient-reported outcome measures into the Quality and Outcomes framework and the development of structures and services in general practice that are designed by GPs and primary care providers in response to patients’ needs and choice.

The purpose of the motion is straightforward. Through the new contract with general practitioners, the Government had a major opportunity to revive general practice in this country, and to rebase the NHS in patient-centred care and primary care-led services. They failed to do that; by contrast, they have entered into a conflict with general practitioners that will undermine the service. The Government are taking an approach to the reconfiguration of primary care services that matches the dangers of the approach that they took to reconfiguration of secondary care. The progressive centralisation of services, the progressive undermining of access to care, the progressive undermining of the ability of clinicians across the NHS to determine what is best for their patients—those are the tragic consequences of the Government’s failure to negotiate the GP contract successfully. Their mean-minded approach is not to negotiate in partnership with general practitioners, but to try to arrive at a solution that cuts costs and centralises services, while undermining the independence and clinical effectiveness of general practice.

Does my hon. Friend agree that perhaps the single most popular feature of the national health service is the trust that patients have in their family practitioner, but that the Government are absolutely determined to prove that they do not trust family doctors any more? We have to rebuild that trust.

My hon. Friend is right. I have heard exactly that from GPs in his constituency, who fear that a polyclinic will be established in or near Salisbury, the effect of which will be to force the closure of other GP practices and undermine the relationship with patients.

Let me remind the House what the evidence tells us about the benefits of a strong primary care system. In the context of examining why the American health care system did not deliver successfully for Americans, which is an interesting subject, given the nature of the current debate on health care in the United States, Barbara Starfield, who is the professor of health care management at Johns Hopkins university in America, concluded:

“There is no single or simple answer, but a large part of the story—and a part that is commonly overlooked—is precisely the predominance of specialist care over primary care.”

She went on to say, and this is a good definition of primary care:

“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.”

She continued:

“There is lots of evidence”—

indeed, there is international 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.”

In light of that evidence, which demonstrates how successful primary care can be, I find it utterly astonishing that today, when we tabled a motion whose purpose is to support general practice and the family doctor service and to stress the importance of the relationship between patients and their doctor and the importance of continuity of care, which is so lacking in other parts of the health care system, the Government’s amendment fails to support the family doctor service and focuses on their current ideological fixation in favour of large polyclinics, and in the process undermines precisely the continuity of care and the relationship between doctor and patient that the evidence suggests is so integral to the successful delivery of services.

Does my hon. Friend share my concern that the Government’s proposals represent a national template to be imposed on primary care trusts, with no thought given to social inequalities and need at the local level, or to the need to open more GP surgeries in areas of deprivation in our constituencies, rather than the Government’s one-size-fits-all approach?

My hon. Friend raises an important point. In the course of the GP contract negotiations, the move towards a quality and outcomes framework had real potential, but as the National Audit Office report published earlier this year set out starkly, in order to try to secure agreement with general practitioners the Government took a large amount of that money out of the pot and put it into the minimum practice income guarantee. Over the intervening years, the system of remuneration for GPs has not impacted on list size and need as it should have done, which would have helped the most deprived areas; nor has it incentivised more doctors to come into those areas.

The Government’s and everyone else’s purpose in starting to negotiate the new GP contract back in 2002 was to deal with problems of recruitment and retention. Recruitment in deprived areas was most difficult and it remains difficult. The Government’s response should have been to deal with that problem, not to try to impose a solution everywhere else. By encouraging PCTs to offer new practices in under-doctored areas, the Government are saying now the same thing as they said in 2006 in the community White Paper, which we supported throughout. However, it is wholly wrong for them to seek to impose a polyclinic system in London and across the country, including in the most under-doctored areas, which would deprive many people of access to GP surgeries in their local neighbourhood.

Does my hon. Friend agree that there is a danger that if patients do not have a named doctor—an individual doctor to whom they can relate—they may not report illnesses as soon as they should, which will add to the burden of costs to the health service?

My hon. Friend is right. In an article in the British Medical Journal on 22 March 2008, Martin Roland, professor of health care at the university of Manchester and director of the National Primary Care Research and Development Centre, said:

“The UK system of universal registration with a single general practice promotes equity, provides a ‘medical home’ for coordinating care, and is an effective mechanism for holding providers to account for the quality of care provided.”

That is where my hon. Friend is coming from. That relationship between patients and their doctor is instrumental in delivering effective care, but the Government are determined to undermine it. [Interruption.] The Secretary of State says “Rubbish,” but he should look at what his own PCT is proposing in Hull. In a document, which I have seen, the purpose of which it acknowledges is to reconfigure GP care in the area, it says that its objective is to have fewer GP sites—by which I think it means practices—and to put polyclinics down in Hull. Hull is an under-doctored area, as the Secretary of State knows perfectly well. Of course there is a case for additional practices, but the consequence of the polyclinic plan will be that some of the existing practices will be shut down, and that will not enable services to be delivered more effectively in the area.

My constituency is in a rural area outside Hull, and it is rural areas that are particularly concerned about the proposals. They suffered when the Government tinkered with dentistry and my constituency has seen a major loss of dentistry services. The idea that the Secretary of State and the Government will now be tinkering with GP services horrifies my constituents.

I agree with my hon. Friend. The impact on rural areas is one of the most significant and worrying aspects of the way in which the Government are going about this. I have been to many places throughout the country. Not so long ago I was talking to GPs in Worcester and to the local medical committee in Cornwall. One can imagine the situation: there are practices throughout Cornwall and the Department of Health tells the local PCT that it must have a polyclinic, but there is no obvious place for it, so it is just popped down next to a GP practice somewhere and practices in many neighbouring areas close down as a consequence.

There are different models of care in different parts of the country. Interestingly, the south-west has some of the largest practices in the country—for example, I went to Frome—for the simple reason that sometimes a network system between a large GP practice and satellites is one of the most effective ways of ensuring access to neighbouring villages. But scrapping all that and not having an organic system that is developed by GPs themselves, in favour of the polyclinic system where GPs do not have independent contractor status and can no longer design services for their area’s needs, will undermine access in rural areas at precisely the moment that towns and villages throughout the country are losing their post offices, shops, pubs and public services. Their GP surgery is one of the critical elements that they now perceive is under threat.

They are also losing their dispensaries. Is my hon. Friend aware that 8.5 million patients are in GP practices that dispense drugs? Under the Government’s White Paper on the future of pharmacy services it will be almost impossible for GPs to dispense drugs in the future. Why on earth remove patient choice in this way? This is yet another service that will be lost in villages in my constituency and colleagues’ constituencies.

Yes, I am interested in what my hon. Friend says because in one particular respect the effect of the pharmacy White Paper, which was published during the recess, may well be to undermine dispensing by dispensing doctors, and it may all be part of a common process by the Government. The polyclinics are expensive beasts; they cost about £800,000 each, so money has to be raised for them. I suspect that in many cases the Government intend to ensure that they have a large pharmacy, which will take the pharmacy profits, and the dispensing doctors in local surgeries will lose out and shut down as a consequence.

I caution the hon. Gentleman to go a little further down the line of variation around the country. Wolverhampton is one of the most deprived cities in the country. We have the excellent Phoenix medical centre, which might be termed a polyclinic, which is expanding its hours because it is so popular, and many of the services that it offers have been taken from the acute hospital, not from GPs. Correspondingly, the Castlecroft medical centre, with which I am registered, is building a brand new GPs’ surgery, and the Mayfields medical centre, which opened recently, has a pharmacy alongside. The configuration in different parts of the country is different, and in Wolverhampton we will have three new GP practices from the Government, which are welcome because we are under-doctored.

The hon. Gentleman has not been listening carefully, and he cannot have read the speech by my right hon. Friend the Member for Witney (Mr. Cameron) to the King’s Fund on Monday. My right hon. Friend made it clear that we do not oppose change in general practice, but it must be driven by GPs themselves. [Hon. Members: “Why?] It must be driven by GPs in response to the needs of patients—it would be useful if the Secretary of State were to read the Opposition motion. The Government amendment does not provide any evidence that the Secretary of State sees any role for GPs or clinicians in interpreting the needs of patients, so I do not know how he thinks that patients’ needs will be met.

For the PCT to contract with additional practices to provide additional services in under-doctored areas is fine—we have always said that, and there is no reason why it should not go ahead. There is no reason why services that can be delivered more effectively in the community should not be delivered in the community, and there is no reason why GPs should not be able to commission services from a hospital or a community provider transferring services into the community. Sometimes, the hospital itself can provide those services, which certainly can involve diagnostic and treatment services. There will even be places where GP practices conclude that their premises are so poor that they need to come together in larger practices and premises. None of that causes me any problem at all.

As the hon. Member for Wolverhampton, South-West (Rob Marris) represents a constituency in Wolverhampton, perhaps he has not carefully examined the Darzi plan in London and what is being rolled out in every PCT across the country in a one-size-fits-all fashion: the creation of polyclinics. The Darzi plan in London makes it clear that a polyclinic is 25 GPs occupying 16,000 sq ft costing £800,000 a year with all the services in that place. Where are those polyclinics being put? Last week, I was in Bexley, where a polyclinic is being located on the site of Queen Mary’s hospital, Sidcup. In Epsom, a polyclinic has been proposed for the site of St. Helier hospital. That is not taking care closer to home; that is centralising primary care, which will take it further away from the people whom it is meant to serve.

The hon. Gentleman seems to regard GPs as being at the centre of the infrastructure. How can we ensure that the best interests of patients are represented? What assessment has he made of the fact that GPs are most likely to commission services from themselves in areas in which they have a specialist interest? Is there not a conflict of interest, and where is the scrutiny when we discuss the best use of taxpayers’ money?

Last October, we published our document, “The patient will see you now doctor”, which the hon. Lady has probably read. In that document, we made it clear that there must be a mechanism by which, beyond the boundary of the primary medical services contract, GPs can commission services from connected providers or providers that they control only in circumstances in which there has been a tendering process controlled by the PCT, which would prevent them from handing business to themselves. That is one of the problems with GP fundholding that needed to be sorted out. The Government have not sorted it out because the same problem is occurring in places where there has been any progress on practice-based commissioning.

The hon. Lady also raised the issue of a voice for patients. We have repeatedly made it clear in this House that we need a strong voice for patients. We need “health watch” locally and nationally to make that happen, but where general practitioners are concerned, we also need the exercise of patient choice. Again, it is interesting to quote Martin Roland from Manchester:

“The NHS goal of providing patient choice in primary care is not realised in many parts of the country where patients have little real choice of practice. Increased patient choice requires more high quality practices, not the small number of large practices that some polyclinic models suggest. We know that patients in small practices rate their care more highly in terms of both access and continuity. Indeed, although small practices show more variation in quality, on average, they achieved slightly higher levels of clinical quality than larger practices in the quality and outcomes framework.”

So having more high-quality practices, which include many smaller practices, is the route down which to go. Our patient choice proposals are similar to some that the Government made in the community White Paper of 2006. They are about making sure that when patients move from one practice to another, proper capitation follows them and to ensure that practices with open lists cannot be declared full when there is no justification for that.

Those proposals are precisely the mechanisms to make sure that general practice, although integral to service delivery and commissioning, is none the less increasingly accountable to patients. At the moment, the Government seem to be moving to a world in which the only customer to matter is the primary care trust. To whom is the primary care trust accountable? The experience of everybody—including, I suspect, most of my hon. Friends across the country—is that primary care trusts are accountable only to the Department of Health and Ministers, who are the only people they ever listen to. At the moment, patients get no look in at all.

rose—

My hon. Friend has had plenty of experience of that in Wiltshire.

I am most grateful to my hon. Friend for giving way; he is being very generous. What he describes has particular resonance in Wiltshire, where the PCT seems to be giving GPs incentives to move towards a polyclinic system. For example, a polyclinic is being proposed for halfway between the town of Corsham and the nearby village of Box. That would be convenient for neither place, but the PCT appears to be giving GPs in both places financial incentives to move towards it, even if that is not in patients’ best interests.

That is interesting. I understand exactly what my hon. Friend has said. If there were a rationale behind the measure, the many GPs whom I have met in many places across the country would be supporting it. If it was going to provide better services for their patients, they would understand that. In some places, better services are being provided. Macclesfield is an example. My hon. Friend the Member for Macclesfield (Sir Nicholas Winterton) is not here, but if he were, he would ask us to consider what happened in his constituency. General practices there wanted to come together and create a single premises for the whole town. They have done that, and the services are there. What is happening now? The Government say that there must be a polyclinic in every primary care trust, so the GPs in Macclesfield are threatened by the fact that the PCT wants to create another polyclinic in the PCT area. That would undermine those GPs’ situation. Frankly, that is not acceptable.

The Government made a complete mess of the GP contract. To give a simple measure of that, they paid £1.76 billion more than they were planning to. The National Audit Office reported that the Government said that under the new contract they were expecting a productivity gain in primary care of 1.5 per cent. a year. In fact, there was a drop in productivity of 2.5 per cent. in each of the first two years. The Government got the precise opposite of what they were hoping for—and we know the whole story of what happened to out-of-hours services across the country.

Interestingly, local primary care trusts that cared about open access and extended opening hours for patients—they now claim that they do—had opportunities in the contract to provide them. Local enhanced services could have commissioned Saturday morning surgeries or extended opening hours on weekdays. I find it utterly astonishing that back in February, in the midst of a conflict with the British Medical Association, I could ask the Secretary of State whether he knew whether primary care trusts had commissioned local enhanced services for extended opening hours and get the answer that he did not even know. Having not used the contract for the purpose for which it was intended, the Government now blame GPs for the costs and consequences of a contract that they negotiated and pressed GPs to accept.

rose—

rose—

I talked about Cornwall, so I shall give way to the hon. Member for St. Ives (Andrew George).

The hon. Gentleman mentioned Cornwall, where there is concern that, as a result of the proposed package, we will end up with a private sector solution. That issue concerns me. I note the hon. Gentleman’s analysis: that the Secretary of State appears to be contradicting himself and imposing a top-down, centrally controlled solution in many areas. The Opposition motion talks about innovating in contracts with health care providers. To what extent does the hon. Gentleman believe that those contracts should include, or predominantly be, private sector contracts?

I am talking about contracts between GPs as commissioners and the whole range of health care providers. Overwhelmingly, the contracts will be with NHS providers, although they will include private sector providers. I see absolutely no reason why there should not be an “any willing provider” policy in respect of both community provision and secondary provision.

The hon. Member for St. Ives makes an important point; in the midst of what he was asking was the question of what the consequence of the shift to large polyclinics will be. In the past couple of days, we have seen on the Department’s website evidence of how it is guiding primary care trusts to go about not only developing polyclinics but reconfiguring the whole of general practitioner services. It is clear that it wants to do that on the basis of a small number of contracts with large providers. That is true not only for this first polyclinic, but pretty much across the board.

For a long time, the Department has wanted to get rid of the independent contractor status of GPs and turn them into salaried employees; Ministers seem now to have embraced that absurdity. Presumably, the Department is thinking that it can save a third of the cost of a GP, because a salaried GP costs only two thirds of what a principal in general practice costs. That is a dangerous route, because if practitioners lose their independent contractor status, they will find it impossible to take the position of GP budget holders or practice-based commissioners.

In November 2004, we had a debate on family doctor services in the Opposition’s time. The Government’s response then was to say, “Look how useful practice-based commissioning will be for the future.” Now we have another debate, and what is the Government’s response? It is, “Look how useful polyclinics will be in future.” Practice-based commissioning has disappeared. It has stalled across the country; more than half of primary care trusts are not giving it management support and the information to support it is not available to general practices. The proposed measure is a weak substitute for fundholding in the sense that it does not give real budgets or real incentives to save and reinvest for patients and it does not give the opportunity to innovate in contracts with health care providers.

The Government’s approach is a shameful abdication of the Government’s existing policy, which two years ago Tony Blair said was absolutely central to health care reforms. He said that there should be practice-based commissioning, but that has disappeared and is off the lexicon; instead, the Government are reverting to type and going towards a centralised, top-down, one-size-fits-all approach.

The hon. Gentleman may not have seen the briefing e-mailed in the past hour to Members by the NHS Confederation, the independent organisation representing NHS bodies. It cites the National Audit Office, which has said how successful the GP contract has been. It says that £500 million-worth of savings on the back of the contract have been fed back into new services and how for the first time the contract relates patient outcomes and curing diseases to funding. All those things are improvements brought about by the GP contract and have been cited by the NHS Confederation. They fly in the face of what the hon. Gentleman is saying.

The NHS Confederation is “independent”, is it? It is the body that negotiated the contract and is responsible, with the Department, for the outcome. It is hardly independent. The National Audit Office is independent, and its conclusions on the contract need to be read. The contract was principally about delivering GP services where they were weakest; let me quote paragraph 4.13 of the NAO report:

“Elements of the new contract have not necessarily supported practices in deprived areas. The development of a new, needs-based funding formula was the key element of the new contract aimed at reducing inequality of provision. However, the introduction of the Minimum Practice Income Guarantee significantly reduced the redistributive impact of the formula”.

The contract has undermined the tackling of health inequalities, which were at the heart of what it was trying to deliver. I will not go on about some of the other things, but if the hon. Gentleman wants another independent view about polyclinics, I refer him to the Patients Association, which understandably sees things entirely from the patient’s point of view. Dr. Halperin, its chairman, said:

“What I believe patients want is to see their own GP, to have a regular relationship with a GP, and when they require further or more specialist treatment, to go to a hospital…what you”—

that is, the Government—

“are now doing is interposing a third layer of a polyclinic and I really don't see any advantage for it.”

The hon. Member for High Peak (Tom Levitt) cited the NAO and the NHS Confederation report, and he quoted selectively. Does my hon. Friend recall the NAO pointing out that the GP contract was overspent to the tune of £1.76 billion? Who does the NAO think might be to blame for that?

We know exactly who is to blame for that—the Government. To be fair to NHS employers and the NHS Confederation, when it came down to it they were overawed by the Government, who put in their own interpretation of their estimate of the QOF—quality and outcomes framework—points that were going to be gathered by GPs. The British Medical Association, to be fair, said pretty clearly that it thought that it would be a higher figure. The difference on the QOF was about 16 per cent.—that is about 160 points, and there is £125 a point, so that is about £20,000 per GP. The Government have therefore ended up spending millions more than they ever intended. That was not simply because they got more out of the contract but because they did not put into their negotiations a proper understanding of the existing practice of GPs before they started to negotiate it.

Will my hon. Friend give way?

No, if my hon. Friend will forgive me, because I need to make this clear.

The purpose of this debate is not only to criticise polyclinics and how the Government are going about this but to make it clear that the House should express its support for the family doctor service and for the future of general practice, which needs to develop in future. We need to have GP commissioning; GPs must be responsible for real budgets. There is clearly an opportunity for GPs to manage care on behalf of their patients so that the relationships and continuity that they already have can be turned into something that delivers integrated care for patients and so that where services are provided they are in the best interests of patients. GPs should not be immune from competition. There should be a role for alternative providers and different models of care, but it should not be a one-size, top-down kind of care. We need patient choice of the kind that I described. Patients should be able to exercise not only choice in secondary care but choice in who is their primary care provider. We should ensure that the remuneration of GPs not only incentivises them to be in socially and economically deprived areas looking after the patients who are most in need of their primary care services but is geared towards quality and outcomes, including patient-reported outcomes, not just the process measures that are in the QOF at the moment.

We know that primary care is highly effective—the international evidence shows that—and primary care in this country is in many respects the envy of many other countries. Primary care is instrumental to the delivery not only of high-quality care but of cost-controlled care. We can see, in this country and in others, what happens when the people making clinical decisions are not also responsible for the resource consequences. GPs can be those people. They will be well rewarded, as they are and should be, but they should have the responsibility that goes with it. They should not be treated, as the Government have treated them, as production line drones who behave only as the Government direct.

We need a future for general practice that responds to the needs of patients and to GPs’ own clinical evidence about what is in the best interests of the patients and the service. The Government use the excuse of patients wanting longer opening hours, although only 4 per cent. of patients expressed a desire for longer weekday openings. Most GPs to whom I have spoken would be happy to respond to that and would have no difficulty in doing so. Earlier this week, I spoke to a GP in Camden who said that when she went to the primary care trust and said that she wanted to open at 7 o’clock in the morning because all the patients who wanted extended hours wanted them at that time, she was told, “No, that is not good enough because the Government have told us that you’ve got to open until 8 o’clock in the evening.” She does not have any patients who want to go there at 8 o’clock in the evening—they want to arrive at 7 o’clock in the morning—but the PCT is now in such a top-down system that it will not even listen to GPs and patients.

Will the hon. Gentleman give way?

No, I am sorry—I am about to conclude.

Using the excuse of the row with the BMA and the fact that GPs’ salaries appear to have increased—although we do not have the last two years’ data, when GP remuneration will have been at a static level—the Government are embarking on the destruction of the family doctor service as we know it. Access to primary care in local neighbourhoods will be lost, and rural areas will see a decline in further access to services. In many neighbourhoods in the most deprived areas, local pharmacies and local GP surgeries are among the public services that people most value and are some of the few things that really work at the moment, yet they too will disappear, as we can see from the example in the Secretary of State’s own constituency. The relationships between patients and GPs will be lost, continuity of care will be lost, and the independence of GPs will be lost and, as a consequence, the ability of primary care-led commissioning directly responsive to patients’ needs will also be lost.

rose—

I cannot resist my hon. Friend.

There is one danger that my hon. Friend has omitted in talking about the push for polyclinics—the impact that they may have on the delivery of local services in, for example, cottage hospitals and smaller district general hospitals if the PCT commissions more services that can be delivered in polyclinics. As I am sure that my hon. Friend knows, my hon. Friend the Member for Macclesfield (Sir Nicholas Winterton) supported the first getting together of GPs on condition that that arrangement did not in any way challenge the services provided by Macclesfield district general hospital, which is also valuable to my constituency.

I am grateful to my hon. Friend. She may have heard me refer to the GPs coming together in Macclesfield, which demonstrates what is possible if they are given the opportunity to commission services. We are not saying that there should not be change, but that it must be driven by the needs of an area. That is why we make it absolutely clear in our motion that we are opposed to a one-size-fits-all, top-down system that is not responsive to local health needs and circumstances. My hon. Friend and her very hon. Friend fight hard for the needs of their area, as can be seen in the way that they have fought not only for the GPs there but for Macclesfield district general hospital when it was threatened with reconfigurations.

The Government’s polyclinic plan will be the triumph of the one-size-fits-all approach and bureaucracy in place of clinical evidence and professionally-led—clinician-led—services. I am sorry that Government Front Benchers, in their amendment to our motion, cannot even bring themselves to support the family doctor service. They removed that from the motion where they could have left it in. In their amendment, they propagate the fallacy that the interests of GPs and patients are opposed, but they are not—GPs and patients have common interests, and patients trust GPs. There is an overwhelming sense of trust in GPs, while 97 per cent. of GPs have now reached the point where they have no confidence in the Government. That is, I am afraid, a message that the Government really should have listened to. They cannot even bring themselves to mention in their amendment the benefit of practice-based commissioning, which two years ago was a key health reform.

I am afraid that ignorance and ideology make a fatal combination. The Secretary of State has picked up the ideology of centralisation and combined it with an ignorance of general practice. When I asked about two months ago how many GP practices the Secretary of State had visited, the Minister of State, the hon. Member for Exeter (Mr. Bradshaw), told me that the Secretary of State had visited one GP practice—[Interruption.] I am told that it is now two.

Is he better now?

Not in a personal capacity—in a professional capacity.

It is entirely typical of this Government that a new Secretary of State comes in, knows absolutely nothing about health, would prefer to be doing something different, visits one GP practice in Kingston that happens to extend its opening hours to 8 pm because it is in an area that has a lot of commuters, and draws the conclusion that every GP practice all over the country should do exactly the same thing. It is ignorance and ideology in the most absurd combination.

The Labour Government appear no longer able to understand primary care. They do not appear to value it but are none the less determined to interfere with it in the most high-handed and ideological fashion. Our motion sets out a framework for general practice. It sets out a framework of values that we are now going to encourage GPs and patients across the country to sign up to—a framework where the value of general practice is not only understood but enhanced through developing GP budget-holding and patient choice. That would be in the real interests of patients and of the NHS. I commend the motion to the House.

I beg to move, To leave out from “House” to the end of the Question, and to add instead thereof:

“welcomes the fact that the Government is providing £250 million, in addition to existing GP services, for 152 new state-of-the-art GP-led health centres open from 8 a.m. to 8 p.m., seven days a week; notes that these will offer a wide range of health services including prebookable GP appointments and walk-in services; further notes that where patients previously had trouble seeing their GP or had to make numerous visits to a variety of health professionals, they will now be able to see a doctor more quickly, collect their prescriptions, get their eyes tested, have a variety of diagnostic tests or see a physiotherapist in the same building and at times convenient to the patient; further welcomes the additional centrally funded 100 GP practices to be located in the most deprived areas which will have a strong focus on promoting health and reducing inequalities; acknowledges the landmark agreement with GPs to extend surgery hours in evenings and on Saturdays and agrees that extended access will benefit hardworking families; further welcomes the extension of the role of pharmacies to be able to prescribe for and deal with minor ailments on the NHS, as well as promoting good health, supporting those with long-term conditions and preventing illnesses through additional screening and advice; recognises that the Government is on the side of patients; and agrees that extending access to GP services through extended hours and new GP health centres can have a real impact on health inequalities.”

I am delighted that the Conservatives have used this Opposition day debate to allow us to highlight the investment that we are making in primary care and the measures that we are taking to give the public better access to the improved services that they require. Also, it is very good of the Conservatives to commemorate the 60th anniversary of the NHS by seeking to recreate the historical position of the Conservative party in 1948—opposed to better services for patients, defending instead the narrow vested interests of the more reactionary elements of the profession. I guess we could call it a sort of parliamentary version of the television programme, “Casualty 1907”.

Making sure that every citizen has access, free of charge, to a local GP if they are sick or worried about their health was the major premise on which the NHS was established, by a Labour Government in the face of fierce opposition from the Conservative party and its allies in the profession 60 years ago—it is really good to commemorate that in this anniversary year. We continue to support that premise. The role of the general practitioner as provider and commissioner of care, and as a strong advocate for their patients’ health and well-being, is central to everything that we are doing. It is why we have made an unparalleled investment in GP services, from £3 billion in 1997 to £8 billion today. It is why there are now 5,318 more GPs and 4,471 more practice nurses than there were in 1997. It is why GPs now spend, on average, 50 per cent. more time with each patient than they did in the 1990s. And it is why we have increased the pay and reduced the hours of GPs, thus resolving a serious recruitment problem, while introducing a quality and outcomes framework regarded with admiration around the world, which helps to make GPs central to the care of people with long-term conditions, achieving documented improvements in health outcomes for conditions such as asthma and diabetes. The Tory motion describes all of that as “undermining and undervaluing…GPs”. I can think of lots of professions that would love to be undermined and undervalued in such a way.

Given what the Secretary of State has just said, does he agree that GPs represent one of the most cost-effective and efficient aspects of health care in the UK?

I believe that absolutely. GPs are fundamentally important to everything that happens in the NHS, and we have world-class primary care. That is why we have introduced those measures over the past 10 years—to bring in more investment and to attract more GPs, while ensuring that they are better rewarded and can spend more time with their patients.

Let me deal with the rather pathetic attempt by the hon. Member for South Cambridgeshire (Mr. Lansley) to misrepresent our position. There is no national policy for replacing traditional GP surgeries with health centres or, indeed, polyclinics. There are no plans to herd GPs against their will, or the will of patients, into super-surgeries. We are not seeking to reduce the number of GP practices. I quote from the interim report of my noble Friend Lord Darzi—this also answers the intervention made by the hon. Member for Mid-Bedfordshire (Mrs. Dorries)— who said:

“More than 80 per cent of NHS patient care takes place in primary care... Our registered GP list system is renowned internationally. Our primary care system co-ordinates care for patients in a way few other countries match. There are strong bonds between staff and their patients, families and carers.”

One always knows that the Labour party’s arguments on health are vacuous when it is shroud-waving about the events of 60 years ago. In the week when the Government’s own Back Benchers are revolting—even more than normal—over the abolition of the 10p tax band, is it not ironic that these proposals will potentially have the most significant impact on the oldest, the poorest, the sickest and those with the least voice in Government and policy making? That is from a Labour Government of 11 years’ standing.

The hon. Gentleman will have to do better or I will not allow him to intervene again.

What are we doing? What is the destructive policy against which the Conservative party has decided to take up arms? Of what crime against humanity are we guilty? What devastating blow are we dealing to communities throughout the country? We plead guilty to investing an additional £250 million to enable the local NHS to develop more than 150 GP-led health centres in every part of the country, open seven days a week from 8 am to 8 pm, and more than 100 new GP practices in some of the most deprived areas of the country—deprived not just in terms of poverty but in terms of people’s inability to access primary care because they live in so-called under-doctored areas. A clear correlation is seen in the areas with the lowest life expectancy and the fewest GPs per head of population.

What is the Conservative party’s policy for dealing with under-doctored areas? We see it in the rather vacuous petition—“anodyne”, as one GP described it—that they have launched. It says that GPs should be free to determine where they practise. That is the situation now and, by and large, they do not choose to practise in deprived areas in sufficient numbers. If they are to do so, under the Conservatives’ primary care policy, it must be for more pay. In the words of the petition, they must be

“rewarded for working in socio-economically deprived areas.”

The Opposition motion asks right hon. and hon. Members to support

“rewarding GPs who choose to provide services in deprived areas”,

but the inequalities of access have existed for 60 years. By and large, GPs have chosen not to locate in such areas, which is why we have taken the decisive step of investing new money in new health centres to provide extra services—not to replace existing services. Those health centres will have a strong focus on the promotion of health and the prevention of health inequalities. Most will provide physiotherapy, pharmacies, district nursing and minor surgery services.

A moment ago, the Secretary of State said that he pleaded guilty to making a major investment in primary care, and without question the extra money is welcome. However, he is not pleading guilty to contradicting his welcome words of 4 July last year, when he said that he would give the NHS a

“sustained period of organisational and financial stability”

and that

“there will be no further centrally dictated, top-down restructuring”.— [Official Report, 4 July 2007; Vol. 462, c. 962.]

If he wants to realise those aims, why does he not allow local communities to decide how best to achieve the objectives, which he rightly identifies, that will meet the needs of deprived communities, instead of having this centrally dictated, top-down restructuring, which could produce the same sort of ridiculous results as the independent treatment centres that have wasted millions of pounds in Cornwall?

I announced last July that there would be no more structural reorganisation in the NHS—no more changes to strategic health authorities and no more merging of PCTs—and we have kept to that. As I hope the hon. Gentleman will accept when I come to the gist of my speech, we are not imposing a top-down measure. We are providing £250 million for investment in the expansion of the primary care service, mostly to take services away from hospitals and bring them into local communities. That is the major reason for the investment.

Does my right hon. Friend agree that in areas such as mine, which is a heavily and densely populated one, with narrow streets and little car parking, many GPs have welcomed the chance to move into modern premises with car parking for ambulances and patients’ cars, and the ability to expand their services and share support staff?

Indeed, and that is the experience throughout the country. It is the experience of my constituency, which the constituency of the hon. Member for South Cambridgeshire is a long way away from. In Hull, there has been a revolution in primary care services, which is happening in cities and communities throughout the country.

Further to my right hon. Friend’s point, I am grateful for the assurances that he has given about structural change and GP practices. Has it not been the case over the years that GPs have, by and large, migrated from single-handed practices into common practices precisely because they can deliver more and better services on the spot? Will he ensure that there is no ban on single-handed practices, while acknowledging that the pattern may well be for such practices to refer patients on to multiple-handed practices so that people can receive their care locally?

My hon. Friend makes an important point. We can take the example of London, where polyclinics are a specific proposition. A review of health services in London, carried out by NHS London and involving London clinicians, pointed out that for 40 years people have been trying to revamp, reorganise and update services there. In London, 54 per cent. of GP practices are single-handed, compared with an average of 40 per cent. throughout the country, and 97 per cent. of patients have to go to hospital for out-patient appointments. That figure stands at 90 per cent. in the rest of the country, which is still too high. The vast majority of people want to access such services in the community. In London, we have the worst problem of people going to A and E and clogging it up when they should go to primary care. That is why Lord Ara Darzi, working with clinicians in London, has devised a specific model for London, which is not a blueprint for the rest of the country.

The Secretary of State said that the policy was not centralised or imposed. If a primary care trust told the Department that it did not want to provide a polyclinic, but preferred to use the resources in another way, would he allow it to do that?

There would be no problem with that, given that we are not specifying polyclinics as any part of the exercise. The crucial point is that the local NHS will develop services in ways that best meet the needs of the local population by engaging members of the public and local doctors, nurses and other health care professionals. That is the way to implement the proposal.

The Secretary of State referred to the extra investment in new practices in under-doctored areas, and I fully support that. Does he agree that it would be ludicrous if the operation of the GP contract results in financial incentives being greater for practices in the leafy suburbs than for those in disadvantaged areas? Practices in disadvantaged areas receive less pay on average than those in wealthier areas.

That is an important point for our health inequalities strategy, which we will publish soon. As Lord Ara Darzi pointed out in his interim report, it is also a major issue for his continuing work.

I welcome my right hon. Friend’s remarks. May I urge him not to give in to the calls for a free-for-all for GPs? It has not worked in cities such as Wolverhampton. As a bit of an old Labourite—I know that he is, too—I want a bit of planning. I want a bit of planning from the excellent Wolverhampton primary care trust, engaging with local people. However, I also want some accountability on the part of the PCT, because it is not as accountable as it should be. Even though it does an excellent job, we need more accountability by primary care trusts.

I am tempted to say that, if a bedpan falls on the floor in a Wolverhampton hospital, I expect it to echo around Whitehall, to paraphrase Nye Bevan’s famous centralising edict. My hon. Friend and the hon. Member for South Cambridgeshire make a fair point about PCT accountability. As part of the review and our attempts to construct a constitution for the NHS’s 60th birthday, we need to introduce greater accountability, especially as we distribute to PCTs a far greater proportion of the central pot than we have ever done.

I am grateful for my right hon. Friend’s reassurance about polyclinics. When I first heard the word, I thought that a polyclinic was for treating people who were as sick as a parrot; clearly, I was wrong. Will my right hon. Friend clarify exactly how, in principle, a polyclinic is different from, for example, the three GP practices in Buxton, where five, six or more GPs, practice nurses and other health professionals work in one area in a system that has evolved over the years to provide better health care for people locally?

Those definitions of a polyclinic and a health centre—

It would be useful to know.

The hon. Gentleman says that it is useful to know. In the London context, we are considering including services that were previously perceived as secondary in primary care services, thus providing an integrated service, whereby patients can access a far wider range of services than they could traditionally. However, I must say that we have had such services in Hull for years and never called them polyclinics. The chief executive of the NHS said that he went to a place recently and was told that it did not want a polyclinic. He was speaking in a community hospital, which was, to all intents and purposes, a polyclinic. There is, therefore, a problem with definitions.

The Secretary of State began to discuss public engagement, and engagement with stakeholders is important, but will he reassure us that there will be no more ridiculous, sham consultations on reorganising primary and intermediate health care? Such consultations happened in Wiltshire, where three of the four community hospitals closed, much against local people’s wishes.

The Minister of State, Department of Health, my hon. Friend the Member for Exeter (Mr. Bradshaw), tells me that that horrendous action was supported by the Conservative-run overview and scrutiny committee. However, I accept the tenor of the hon. Gentleman’s points. In the big reconfiguration in Greater Manchester, there was an absence of proper involvement and engagement by the public in the early stages. When the proper engagement took place, we reached an acceptable solution, which everyone supported locally.

There has been a move towards group practices, but that has been driven by GPs as a way to improve services for their patients. In my constituency, single-handed practices are increasingly moving into fabulous new health centres, with an investment of £14.8 million in new facilities, rising to nearly £30 million by 2009 under the local improvement finance trust programme, which is transforming primary health care in our city. However, what works for Kingston upon Hull will not necessarily be right for Kingston upon Thames. It does not mean the end for single-handed practices, many of which provide an excellent service to patients across the country; they will continue where they are right for patients.

As the Secretary of State knows, I campaigned in my constituency for an urgent care centre as part of the effort to ensure that hospital reconfiguration in the area did not leave my constituents short of services. My constituents want the reassurance of an urgent care centre, but they also want GP practices where there is a familiar, friendly face. Can the Secretary of State give an assurance that people will have a family doctor, who comes out on visits and is there for them?

Of course I can. Two central fallacies underpin the Tory party position. The first is that we are imposing a system of polyclinics throughout the country. We are not. The second is that, if an area has a group practice or a health centre, or if GPs decide to move into much better facilities where several practices operate together, people can no longer see their own GP. That is nonsense. It is wrong to suggest that the proposals signal the death of the important patient-GP relationship; they do not.

Individual, single-handed GP practices will continue to operate where they are right for patients. When we talk about developing health centres, or what some local parts of the health service describe as polyclinics, we are not considering a single, fixed model of care. Those terms describe flexible models for bringing primary care together with a range of other services, be they diagnostic services, specialist care for patients with long-term conditions such as diabetes, or adult social care. It is hardly a novel idea. Health centres featured in the earliest descriptions of the national health service in 1948. Examples abound of GPs, nurses, specialists and other health care professionals coming together to provide integrated care for patients. With advances in new technology and medical science, we can and should do that to a greater extent in much more imaginative ways.

We are also guilty as charged of expanding access both through the new health centres and the new arrangements that we are introducing for extending opening times at GP surgeries in the evenings and on Saturday mornings. The Conservative party appears to have adopted wholesale the distorted view expressed in some quarters of the BMA and articulated by the right hon. Member for Witney (Mr. Cameron), who believes that the cash-rich, time-poor professionals—I paraphrase from his speech on Monday—who need to get their back problem fixed, as well as some jabs for a business trip to India, will be the main beneficiaries. One has only to visit practices that are already open for longer in the evenings and weekends to find that it is not, as so often claimed, a service for the worried well. Those who are most likely to benefit from extended hours are manual workers worried about taking time off, parents balancing child care responsibilities, certain ethnic minorities who are most dissatisfied with current access arrangements, and those very pensioners and mothers with young children, who are said by opponents of extended hours to want only a Monday to Friday service, with a half day on Wednesday.

I am grateful to the Secretary of State for giving way. When we had a debate on the issue three and a half years ago, the precise point made by the right hon. Member for Barrow and Furness (Mr. Hutton), then a Health Minister, was that the Government were planning a new system of what were called walk-in centres, which would give patients greater access and enable them to receive medical care in the evening and at weekends. What has happened to walk-in centres? The Minister here today promised to publish a review of walk-in centres last summer. It has not been published, but simply dropped in some distant part of the Department. Are walk-in centres not the mechanism that the Government said should be used?

Bristol university has already conducted an assessment of walk-in centres. It said that they were good on quality and accessibility, but that more work needed to be done on their finances. That work is ongoing and forms part of the Darzi review.

May I tell the Secretary of State about a new health centre in Wigan called Boston house, which has been open for three or four years? Taking some of the services and moving them there has transformed the lives of many patients living in the area that I represent. We are talking about a health centre outside a general hospital that provides renal services. People in Wigan have always had to go to Bolton, Salford and other places nearby for renal dialysis. Now we have that in Wigan, located in primary rather than secondary care. Is that not what health centres are all about—transforming the lives of people by taking things out of secondary care and into primary care?

That is a perfect example of why we should thank the Conservative party for allowing us to have this Opposition day debate, when we can highlight the important improvements being made throughout the country. We offer better access and improved facilities. What do the Tories offer? They offer a petition for GPs pronouncing on their absolute right to put their own interests before those of the public.

Nonsense.

So says one of the architects of that petition. It is clear what the petition is about. I have heard the arguments from various quarters. In that petition we hear the hallowed cry of those who ask why they should have to open on Saturday, when their accountant, working in a similar profession, is not open on a Saturday. As one GP down in the west country put it to me in wonderful terms the other week, “If the public are seriously worried about their health, they should be prepared to take time off during the week to come to my surgeries”—at times that suited him, obviously. What we have in the Opposition’s petition is the articulation of all that. It says that GPs should be

“rewarded for working in socio-economically deprived areas,”

and continues:

“We also believe we should be free to determine the opening hours, size and locations of our practices”.

That is a petition for GPs to sign telling us how important it is to look after their interests rather than those of the patients. That is the position that the Opposition have put them in.

Does the Secretary of State accept that in some parts of the country GPs have already got together to provide perfectly satisfactory out-of-hours services that nobody wants changed?

The common problem among those on the Conservative Benches is that they do not understand the difference between extended hours and out-of-hours services, to which I shall come in a second.

The Opposition offer a return to the bad old days, when GPs were effectively responsible for their patients 24 hours a day, 365 days a year. The Royal College of Physicians is among the many organisations that have pointed to the international evidence of the risk to patient safety that long hours pose. How could we ever have supported a system in which tired GPs called out in the middle of the night had to attend patients the next morning, and it was common to wait weeks instead of days for an appointment that would often be little more than cursory, because of the pressures that GPs faced?

The new arrangements for extended hours will mean that the average-sized practice, run by three to four GPs, will open for an extra three hours a week. Those arrangements offer a fair deal for both doctor and patient, and I am pleased that the British Medical Association has given its agreement, following a ballot of its members in which 92 per cent. voted in favour.

The Opposition claim that they support the traditional family practice, but what does this mean—restricted opening hours, problems getting appointments, tired GPs and under-doctored areas? Yes, small family practices can work well and are popular with many patients; but we should not support this fixed model of primary care any more than we should support any other fixed model, particularly at the expense of improving access to primary care in areas of most acute need. Patients should be able to see a GP or a practice nurse at a time and location that is convenient to them. That should be a defining feature of a world-class primary care system, but it will not be for politicians to determine nationally what will work best locally.

The next stage review, led by the noble Lord Darzi of Denham, is a bottom-up process, with 2,000 clinicians engaged with the public, unions and patient groups in determining how clinical care can be improved in every part of the country. That will be another stage in the exciting journey that commenced with the NHS plan and that has seen greater investment, improved resources, new hospitals and better clinical outcomes—a journey to an NHS that is world class in all aspects, instead of world class in just some.

Will my right hon. Friend give way?

No, I am coming to the end of my speech.

Although the Conservative party professes to have joined us in supporting the NHS, it has proved by its approach to primary care that it remains stuck in the past—conservative in every respect and willing to put vested interests before better service to the public. I commend the amendment to the House.

This is an opportune time for us to discuss the Government’s record and their plans for family doctors. The debate gives us Liberal Democrats an opportunity to reaffirm our opposition to central control of local health services.

I was fascinated when the Secretary of State again tantalisingly indicated his recognition of the lack of accountability among primary care trusts to the communities that they serve, while the Conservatives rejected any change to the accountability of primary care trusts. May I commend to the Secretary of State the Liberal Democrats’ proposals to democratise the commissioning of health care? Primary care trust boards should be elected, not appointed nationally. Ultimately, the Conservatives want to retain the central model of control of the NHS. The Secretary of State suggested that he recognised the case that we had made, but will he go the whole way and provide proper accountability to the communities that trusts serve? We wait to see what his announcement amounts to.

I want to talk about the morale of general practice. It is important to recognise that the network of family doctors in this country is the bedrock of health care and the NHS. As others have said, that network is the envy of the world. We should not, however, be complacent or take the view that the service is never capable of improvement to meet modern needs. We should always be prepared to accept the case for evidence-based reform. The Government must recognise that they damage the service, which is so widely supported among the general public, at their peril, because it is such an important part of our health service.

Whatever the Secretary of State says about how fortunate GPs are, given the way in which the Government have treated them, he must recognise that morale among GPs is very low. I am sure that he talks to GPs throughout the country, so I am sure that he recognises that they feel demoralised. Indeed, one Norfolk GP said to me recently, “We’re well paid—we recognise that—but we feel that some of our professionalism has been taken away from us, because we’re dictated to so much from up above”—that is, from Whitehall. When GPs try to develop practice-based commissioning, those who make the decisions often do not listen. When they try to refer patients for services such as those for teenagers with mental health problems and discover that services are inadequate or simply non-existent in rural Norfolk, they cannot feel much pride in their job, despite the fact that they are being well paid. The Secretary of State should recognise the real concerns among general practitioners, who take pride in their work, which they undertake for the very best of motives. Their concerns should not simply be dismissed as unfair attacks on the Government.

I have spoken to a number of GPs in the past fortnight. They raised several issues with me, the first of which was the GP contract, and I shall come back to that in a moment. The second issue was the state of practice-based commissioning and where it is going. The Conservative spokesman rightly referred to the fact that it appeared to have completely stalled, certainly in many parts of the country. The third issue is the central imposition of what we must now call health centres, rather than polyclinics. I shall return to that issue later as well.

Are those concerns justified? Doctors feel that they are taking the blame for a contract that was ultimately the Government’s contract. It was forced through three years ago, and GP leaders at the time warned the Government of the effect it would have. The National Audit Office reports that there has been a £1.76 billion overspend on the contract since its introduction. Remarkably, the contract frustrates GPs while failing to be consistent with some of the Government’s key objectives, particularly in regard to preventive care, despite the potential of the quality and outcomes framework—QOF— system. I fully recognise that the introduction of that system could do much to incentivise preventive care. The contract also fails to be consistent with the Government’s stated objectives on reducing inequalities.

Is my hon. Friend aware that the NAO report states quite explicitly that there has been no productivity increase in GP practices?

My hon. Friend is absolutely right to highlight that. We should acknowledge, however, that measures of productivity can sometimes be misleading. If GPs are spending more time with their patients, that could be a good thing. This is certainly an issue that has been highlighted by the NAO, however.

I want to deal specifically with the QOF system—the system that encourages GPs to do all sorts of things with preventive care. When the QOF system is reviewed, there is an evidence-gathering process to determine what should be incentivised in the reviewed system. On this occasion, a lot of work was done to develop ideas for addressing osteoporosis, including testing those who are most at risk, especially after the first fracture. A lot of work was also done on peripheral arterial disease and on heart failure. But what happened then? The thing that particularly frustrated GPs and many others is that the entire objective evidence-gathering process came to nothing because, at the last minute, the Government decided that the political imperative was to force through a one-size-fits-all extension of hours. That is the reality.

An NHS Confederation briefing yesterday confirmed that the political imperative had involved increased hours and that all the evidence-based work—especially the work on osteoporosis—had gone out of the window. That is what frustrates clinicians who care about their patients more than anything. A one-size-fits-all extension of hours has now been forced through. I fully support the case for extending hours and for making access more flexible. I am sure that everyone in this Chamber finds it difficult to see their GP—because of the hours we work and the fact that we work away from home—quite apart from those on low incomes who feel anxious about taking time off work and who would like to see a GP outside normal working hours.

I agree with my hon. Friend about the one-size-fits-all solution. One of my local surgeries deals with a lot of commuters, and it has devised a scheme whereby people can e-mail their doctor and get a response on a certain day. Often, it is not a case of needing to see a doctor so much as needing to ask a question and getting reassurance, which might not be available from someone who does not know the patient. Would my hon. Friend support more such schemes being developed in the future?

Absolutely. All sorts of innovative things are being developed. In many practices, there is a commitment to speak to a patient by telephone on the same day, if an appointment cannot be arranged. Often, a telephone consultation is just what the patient needs. We should certainly support the use of e-mail and telephone consultations. Surely it should be for local commissioners to drive through decisions on increasing hours and making access more flexible in order to meet their local needs, rather than having a one-size-fits-all solution imposed from the centre.

I want to return briefly to the question of osteoporosis. When I asked about the loss of that valuable work at the NHS Confederation briefing yesterday, I was given an indication that there would be an announcement shortly on ways—outside the QOF system—of encouraging GPs to test for osteoporosis. I understand that there was a written statement yesterday, although I have not seen it. I would welcome an intervention from the Secretary of State to tell us what might be about to happen. We understand that an announcement is imminent. Will he tell us, either now or through the Minister of State, the hon. Member for Exeter (Mr. Bradshaw), at the end of the debate, what is proposed? A lot of people who care a lot about this matter want that work to be incentivised, because it involves good, preventive health care.

In an earlier intervention, I challenged the Secretary of State about the fact that the GP contract often ends up paying more to GPs in the leafy suburbs than it does to those in the most deprived communities. I want first to look at the minimum practice income guarantee. The Health Service Journal has highlighted huge variations in payment to practices, regardless of the number of patients they serve or the needs of those patients. The article highlights two practices in Westminster, one of which happens to be based at Buckingham palace. That practice gets twice as much money as it ought to, because of the minimum practice income guarantee. The article states:

“Under the allocation formula, the Buckingham Palace practice was due to get just £14,657 this year. But the guarantee added another £16,505. That left the practice with payments of £113 for each of its 276 needs-weighted patients, compared with the sample average of £63.”

How on earth can the Government justify that system? They are paying more money to practices—often in the more affluent communities—that do not need it. As the Health Service Journal and many others have said, that money ought surely to be used to address health inequalities.

Another issue highlighted by the Health Service Journal is practices excluding patients under the QOF system. I hope that the Minister will be able to respond to this when he winds up the debate. Massive variations have been highlighted, with some practices excluding 10 times more patients than the national average. As I understand it, if patients can be excluded from the QOF target, it is easier to hit the target and to get the money. There is no evidence, however, that the problem is most serious in practices that genuinely find it difficult to approach patients because they are in hard-to-reach communities. For example, Tower Hamlets and the Heart of Birmingham primary care trusts have among the lowest levels of exclusions in the country. The point made by the Health Service Journal is that this is a misapplication of millions of pounds of public money that ought to be going towards reducing health inequalities in some of the most deprived communities.

Overall, the highest payments under the QOF system of incentivising GPs to undertake preventive health care, which is so important to reducing health care inequalities, go to practices in leafy suburbs. How on earth can the Government justify that system? My fear about the Conservative perspective is that if we simply give all the responsibility and power to GPs, that will ultimately do nothing to change such inequalities. Ultimately, if we are to ensure that money and funding is directed to the most disadvantaged communities, there is an essential role for strong commissioning.

I am grateful to the hon. Gentleman for his thoughtful speech. I think that he puts his finger on a difficulty that, if we are honest, all political parties have with these issues: on the one hand, we seem to have the shibboleth of local control and local accountability; on the other hand, we have things such as health inequalities, which we would like to address with different mechanisms. Perforce, such mechanisms are often seen as top-down control—and it seems to be another shibboleth that we should decry that sort of control. Will the hon. Gentleman explain how one does that balancing act? It is difficult for any of the three main parties to balance in their policies the top-down element, which, unlike local control, we think we do not like, bearing in mind some of the results that flow from local control—most notably displayed in the phrase “postcode lottery”.

The hon. Gentleman makes a thoughtful intervention. There is, of course, the potential for conflict. Ultimately, however, our highly centrally controlled system has failed to deliver in reducing health inequalities; and all the evidence suggests, particularly if we reflect on what happens overseas, that real engagement at the local level and integrating services for health and social care with housing, community regeneration and so forth is the best way to address those underlying inequalities. Change to that extent cannot be delivered from Whitehall; it simply does not work. All the evidence from centrally controlled systems demonstrates that point. For me, then, we are more likely to achieve success if we provide genuine accountability to the communities that are served.

The evidence that I have picked up from talking to GPs in many different parts of the country—it was reflected in what the hon. Member for South Cambridgeshire (Mr. Lansley) said earlier—suggests that practice-based commissioning is dead in the water. There is a growing frustration among GPs that all their efforts to try to make something of it and put forward innovative ideas about services that could be delivered in a community setting close to people’s homes—perhaps avoiding the need for a long journey to an acute hospital—are falling on stony ground. They feel that there is no longer any political drive behind it, which has resulted in GPs becoming completely disillusioned with the concept, increasingly believing that it is going nowhere.

Over the past few weeks, I met a group of GPs in Dorset. I noticed that the Conservative spokesman was in Poole, so I was about 10 miles up the road from there. I met another group of GPs in Norfolk last week and heard how frustrated they were about putting forward their ideas on how to develop services to the primary care trusts, yet getting no reaction at all.

The hon. Gentleman is making an intelligent point, but I have to say that I disagree with him on a number of issues. Certainly in my area, the availability of alternative community-based clinics has made a radical difference to GP referral patterns—hugely to the benefit of patients and patient satisfaction. In my practice, we do regular surveys of patient satisfaction and we have seen significant increased satisfaction as a result of patients being able to see medical people much closer to their homes and much more focused on their GP practice. In many cases, they receive care and treatment from people they personally know, which has to be an advantage. I accept that in other areas it might not be working as well, but the model itself seems to work very well.

I am encouraged to hear what the hon. Gentleman says—despite his very recent arrival in the Chamber, which I welcome. I have to say that in many parts of the country—[Interruption.] I hear a suggestion from a sedentary position that the hon. Gentleman has been saving lives, but I suspect that he was just having his lunch—[Hon. Members: “Ooh.”] I do not know how much the hon. Gentleman talks to his GP colleagues around the country, but what he referred to is simply not happening in many parts of the country, where many GPs are becoming very disillusioned as a result.

I want to say a few words about the Conservatives’ over-reliance on the GP to ensure that that whole health system works effectively and in the patient’s interests. The Conservative spokesman acknowledged, in response to an earlier intervention, the importance of recognising the potential for conflicts of interest, but that is absent from the Conservative motion and from most of their pronouncements. There are real concerns, including among many GPs, about potential conflicts of interest, and it cannot be said that GPs will always act in the patient’s interests. One example can be seen in what I said earlier about exclusions under the QOF system. In my view, it is a dangerous game simply to believe that GPs can run the whole system. They are absolutely central to it, but their role has to be combined with strong, effective commissioning.

This afternoon’s discussion on the difference between a polyclinic and a health centre was interesting. As I said at the NHS Confederation briefing yesterday, the honest truth is that the difference amounts only to a rebadging. The Government were calling these bodies polyclinics, but they got such a bad name through what GPs and others said about them that we now call them something else. When I asked what a GP-led health centre was all about, all the things that I was told they would contain sounded very much like a polyclinic. These are, at the very least, embryonic polyclinics.

There is a lack of semantic clarity about the issue, as we have already seen in our debate, but one would expect the Government to know where polyclinics were. When I asked the Secretary of State

“how many NHS polyclinics there are in England; and where each is situated”,

I received the reply:

“The Department does not collect information about services commissioned locally by primary care trusts”.—[Official Report, 29 February 2008; Vol. 472, c. 1982W.]

That was news to all of us; as well as not knowing what they are, it seems that we do not know where they are.

It is a state of total confusion—[Interruption.] The hon. Member for Wolverhampton, South-West (Rob Marris) talks from a sedentary position about denying centralisation, but we know that there is a central imposition of a GP-led health centre in every primary care trust. There is no option; all trusts have to introduce them. I had discussions with the East of England strategic health authority, which made it clear that every PCT must have such a centre. In the case of Norfolk, for example, I was told by the GPs I met last week that the PCT has not yet even completed its review of its estate—the buildings it owns—to ensure that it makes the most effective use of that estate. Suddenly, however, because the Government told the trust to do so, it has stopped doing that work and is now having to focus on the introduction of a polyclinic—sorry, a health centre—in Norwich.

Introducing a centre of that sort in Norwich does nothing for rural disadvantaged people who have no access to a car and have poor public transport. It also does nothing for the greatly disadvantaged community in Thetford, which has a low income level and has a great need to improve primary care services. The imposition from Whitehall of a GP-led health centre in the centre of Norwich will do absolutely nothing for those people. That is what frustrates so many.

Amid the usual slurry in the Opposition motion is one nugget of gold that is worthy of note: the reference to a

“lack of empirical and clinical evidence for… polyclinics”.

That lack is undeniable, and I raised it in Prime Minister’s Question Time only a week or two ago.

Does the hon. Gentleman hope, as I do, that the Minister who replies will provide more substantial evidence of where the concept has worked? Countries in eastern Europe and elsewhere that have used it are retreating rapidly towards our own model in order to retain doctor-patient relationships and put a distance between doctors and specialists, and to deal with other issues on which polyclinics have foundered.

The hon. Gentleman makes a good point. I believe that policy should be based on evidence. The hon. Gentleman, who is familiar with north Norfolk, will know about rural disadvantage. In disadvantaged parts of Norfolk, a polyclinic—or health centre, or whatever it is called—in Norwich will have no impact at all. As the hon. Gentleman says, we should also try to learn the lessons of experiences overseas.

I am grateful to the hon. Gentleman for giving way for a second and, I hope, final time.

Although this policy may be a partial solution in London and other major cities, I do not think it will translate to rural areas and suburbia in anything like the way that the Government imagine. The same has been true of policies on, for example, housing and trust schools.

The hon. Gentleman makes another good point. I want to say more about the concept of the health centre, or polyclinic. It seems to me that such schemes should be piloted to establish how they work in given settings, so that the lessons can be learned. I think that there is something in the concept for certain communities.

Last summer I visited the Arches centre, in a very disadvantaged part of Belfast. People in the Province have the benefit of health and social care trusts, which the Liberal Democrats support. That health centre combines various services. It brings together health and social care, and makes available to the community services that would normally be in a more remote acute hospital. That is a very attractive model. Surely we should let these centres develop and grow, and then analyse their successes and, in some cases, their failures empirically before rolling them out across the country. What I find both extraordinary and frustrating is that, without such empirical evidence-gathering, the system is being imposed throughout the country on a ludicrously tight time scale. The Government should be condemned for that.

I thank the hon. Gentleman for giving way to me again. He is being very generous with his time. Perhaps I can help him. I have a letter from the commissioning lead for one of the primary care trust consortiums in my constituency, who says precisely the same about the need for piloting. He writes:

“The intentions of the bids are to encourage a range of pilots that will explore the potential and flexibility of the concept.”

Pilots could, he says, be

“existing health facilities which could be adapted or expanded… on-going developments”

or any other combination that local people decided was good for their area.

I do not understand where the hon. Gentleman is coming from when he says that there is no flexibility and no ability to pilot. That letter makes it entirely clear that the flexibility exists. [Interruption.]

As my hon. Friend the Member for Southport (Dr. Pugh) observes from a sedentary position, everyone is compelled to pilot. I do not consider it a pilot approach to tell every primary care trust that it must introduce a GP-led health centre.

Where does the hon. Gentleman get the evidence?

The NHS Confederation confirmed yesterday that every PCT had been so instructed, and we see the same in all the evidence. The strategic health authorities have confirmed it as well.

Perhaps I could assist the hon. Gentleman. It was set out in a press release accompanying the Labour party’s local election campaign that the Secretary of State and the Minister launched in Exeter about 10 days ago.

I am grateful to the Conservative spokesman for that information. It is of some concern that the Chair of the Select Committee on Health does not appear to know what the Government policy is.

There seems to be a conflict in the Government’s approach to the NHS. They talk of empowering patients and responding to what they really want, but when it comes to the crunch they always opt for a model imposed from the centre.