General Practitioners: Appointments

Lord Prior of Brampton Excerpts

Thursday 17th March 2016 Grand Committee

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, I also thank my noble friend for raising this issue. General practice has been a golden thread running through the NHS since 1948. It is worth reminding ourselves that although the situation may be dire in some parts of the country, as the noble Lord, Lord Turnberg, mentioned, the NHS is still almost unquestionably the most efficient, highest-value healthcare system in the world. Not long ago, I was with some people from the Mayo Clinic who made that point—we are very self-critical. It is right that we should be but also right that we should remember that much of what we do in the NHS is absolutely world class and we do it with very little resource. My noble friend Lord Bridgeman and other noble Lords made the point that the NHS is, in their own individual experience, absolutely first class. If you read the newspapers every day you might think that everything is going to hell in a handbasket but most people’s individual experience of the NHS is extremely good. I have not seen the Commonwealth Fund report to which the noble Lord, Lord Hunt, referred but I would like to.

We should be extremely concerned if confidence in primary care is diminishing. I will write to the noble Lord, Lord Turnberg, about research. I could answer his question if it was directed at specialist research, but I am not sure how much money or resource is going into research into primary care. The noble Lord, Lord Rennard, raised the issue of hypothecated tax. The argument for hypothecating tax for health is no stronger or weaker than doing so for education or overseas aid, or other areas. He will know, as well as I do, that the Treasury has wrestled with and discussed this issue for many years. Any decision will be made in the Treasury, not by me. I could argue both sides of the case with equal conviction and sincerity, so I cannot give the noble Lord the answer he might want to elicit from me.

The noble Lord, Lord Rennard, and my noble friend Lord Bridgeman raised the issue of variation. We have got thousands of GP practices and there will inevitably be variation. The question is how we reduce that variation and shift the curve to the right in terms of getting a great general practice. I happen to believe that one way of doing that is through networks and federations. The noble Lord, Lord Hunt, referred to Vitality in Birmingham. Unquestionably, it will spread best practice within that group. The good CCGs are measuring the performance of GPs in their area much more intelligently than they used to. My noble friend Lord Bridgeman mentioned that his practice has very low referral rates. That is exactly the kind of information that should be measured on a GP-practice basis across all GP practices in CCG areas. For example, I have seen the metrics that the CCG in Camden looks at. You can see very clearly what the referral rates are from practices. The outliers can be seen and you can manage that down. They have had some very good results. If noble Lords would like to look at the atlas of variation, or at the Right Care model that NHS England is using to try to identify variation on a disease on a population basis to drive down that level of variation, I can well recommend that they do that.

I have come to the view—it is almost a statement of the bleeding obvious—that of all the tools that we have in our toolkit to try to secure improvement, be it in clinical outcomes, performance of trusts or in general practice, the best is identifying variation. The crucial thing about variation is that you have good-quality data. The first thing when you shine a light on clinical practice, for example, is that the clinicians will dispute the data—often rightly—so you have to demonstrate that the data are good. If you can prove the data, GPs, psychiatrists, acute physicians, surgeons and the like will take that as a challenge, because they tend to be competitive individuals. They like their own practice to be better than anybody else’s. Variation based on good-quality data is essential.

I will take away the comments made by my noble friend Lord Bridgeman on PMS. NHS England is committed over the five years to increasing spend on primary care by some 25% in real terms, whereas in the rest of the NHS it will be more like 15%. There will be more resource relative to other parts of the NHS going into primary care. They will want to be sure that they are getting real value out of any premium payments made under the PMS contract, but I will take that away if I can and write to my noble friend on that matter.

Governance is an extremely important issue. I had not thought about it in terms of where a network of general practice is almost the same size as the underlying CCG, which raises another issue about governance. We thought about it in terms of conflict of interest and the award of contracts, but that is a very serious point. NHS England is looking at these governance issues. I will bring this aspect to its attention.

I turn to what I had pre-prepared. My noble friend Lord Attlee is quite right that people should receive the right care from the right professional at a time convenient for them. However, we know that there is variation in people’s ability to access a GP and that those in full-time employment report lower levels of satisfaction with surgery opening hours than other groups. This is one of the reasons why, by 2020, everyone will be able to access routine GP appointments at evenings and weekends as part of our commitment to a seven-day NHS. That does not mean that every practice will be open seven days a week. We hope that by 2020 most general practices will be part of a network or federation and they will be able to offer that kind of service across the federation.

As I am sure my noble friend will understand, it is not possible to make a direct comparison between accessing GPs and other professionals such as solicitors, but he is, of course, right that people should be able to access a GP appointment when they need it. This is why the Government have already invested £175 million in the Prime Minister’s access fund to test improved and innovative access to GP services. I know that it is very spotty across the country still, but there is a growing understanding that the traditional model of GP practice—lots of small practices with two or three partners, as described by the noble Lord, Lord Turnberg —is not a viable model of delivering primary care for the future.

The traditional model is going to change. We will have networks and much bigger practices with 10 to 20 salaried partners supported by a much larger team of skilled people—pharmacists, physios, OTs, physician associates, prescribing nurses and the like. As well as providing extended hours, schemes are also looking at other ways of improving access for patients, including better use of telecare and health apps. This is an issue that noble Lords raised in the debate today. Not only will we see much more use of the telephone but, for example, the Hurley Group has an e-consultant system, and more people will use other ways of accessing primary care rather than being seen by the GP. This has a lot of legs, if you like. Apps such as Babylon, with which noble Lords will be familiar, and many other apps will make a face-to-face consultation with a GP less critical than it has been in the past.

My noble friend also asked about competition between surgeries. Here, I will point to what we are doing to increase choice for patients. In particular, my noble friend raised a concern about having to move from one practice to another when he moved house. I was pleased to hear that he is now aware of the steps that have been taken to make it easier for patients to exercise choice over which practice they are registered with. The GP contract for 2014-15 brought in a measure allowing GP practices to register new patients from outside their traditional boundaries, but without a duty to provide home visits for such patients, which seems reasonable in the circumstances. This measure is designed to increase flexibility in the system and the freedom that patients have to choose a GP practice that suits them. For example, commuters may wish to register with a practice close to their work as opposed to where they live or a patient who moves house may wish for continuity.

I return to the technology point about booking systems raised by the noble Lord, Lord Hunt. Take-up may be low at the moment—I think that 6.5% of bookings are done online—but I have no doubt that it will grow. If you look at the number of people now ordering basic food from supermarkets online, that is the direction of travel and it will speed up as time goes by.

The noble Lord raised the issue of reducing pressure on A&Es. In January, there was an increase of 10% in A&E attendances on the previous year. This is putting huge pressure on hospitals because if the front end of the hospital is being flooded, it makes it increasingly difficult for it to meet its waiting times on elective surgery, for example. Delivering more care to people outside hospital will not only lower the cost but provide better care because going into A&E with a fairly minor problem is not a great way of delivering care.

The noble Earl raised an issue about blood tests. Examples of improved access to diagnostic tests can be seen in both the vanguard sites which NHS England is developing. They are part of the new models of care programme and access fund schemes. For example, a vanguard in Birmingham offers consultant-led outpatient clinics and diagnostic facilities, such as X-rays. We often talk about integrating social care with healthcare, but integrating healthcare is also not a bad way to go. We have talked in the past about collocating GPs in A&Es or just outside them, but there are also many specialist outpatient clinics that can be delivered in primary care settings, so long as the facilities are there. We hope that the £1 billion infrastructure fund that we have announced will deliver better facilities closer to where people live.

We have a lot to be proud of but we are inclined to dwell on areas where we are failing and forget sometimes where we are achieving great success. The workforce is a serious issue. We are committed to finding 10,000 new GPs or GP equivalents in general practice by 2020 and we have increased the number of training places by 3,500 from this year and going forwards. To be honest, there is a risk around whether we will be able to get that number of people into general practice. However, without that kind of workforce commitment it will be difficult to deliver our ambitions.

So, it is a combination of technology, workforce and infrastructure. The five-year forward view is behind the thrust of the comments made by noble Lords and, if I am still here in 2021, I hope that I will be able to say that we have spread the best practice that exists in large parts of the country on a much wider basis. However, I am afraid that we will not have eliminated all variation.