General Practices (Coventry)

Geoffrey Robinson Excerpts

Thursday 30th October 2014 Commons Chamber

[Mr Geoffrey Robinson (Coventry North West) (Lab)]

This debate might not be as lively as the debate on post offices in May, when we also had the pleasure and privilege to have you presiding over us, Madam Deputy Speaker. Nevertheless, we have an important topic to debate and I am pleased that the Under-Secretary of State for Health, the hon. Member for Central Suffolk and North Ipswich (Dr Poulter) is ready to respond, because we have one or two questions for him. I thank Mr Speaker for granting the debate. My hon. Friend the Member for Coventry South (Mr Cunningham) would like to take part and he has my willing acquiescence. I do not intend to detain the Minister or the House for long this evening, but I wish to put to him a point that was made to me in a precise and graphic way by the local medical committee for Coventry—it is also for Rugby, but in this debate I am principally speaking as the Member of Parliament for Coventry North West.

The situation has been described as a “crisis”. A letter, almost a cri de coeur, went out from the local medical committee on behalf of GPs, issued in the name of the chairman of Coventry local medical committee, Dr Peter Whidborne. He said that,

“due to increasing workload, and decreasing resources, general practice has now reached crisis point.”

That is what triggered my interest in this matter and my concern as the local MP, and it was reinforced by many anecdotal and personal encounters with residents in my constituency—I am sure my hon. Friend will confirm the same thing for Coventry South—who said that they cannot get appointments with GPs. Patients are finding the situation increasingly frustrating, and an assiduous campaign has been waged by certain elements of the popular press against the 2004 GPs contract and all the weaknesses that we know it contained, yet there is also the reality of the pressures under which GPs operate.

The public’s general impression is that the previous Government granted GPs all too easy a deal but that GPs have not responded in kind, and that despite the general improvement in their terms and conditions, rather than improving services they have in fact responded with a decrease in the level of service provided. Many would agree that there has been such a decrease, but they would disagree that that is due entirely, or even mainly, to the 2004 contract changes. In fact, it is a reflection of the general unease throughout the whole health care service. Such unease is reflected in, among other things, reliable figures produced by the Deloitte Centre for Health Solutions, which I will refer to in a moment. On access to GPs, as with other areas of the health service such as A and E departments in the acute hospitals or services for elderly people who suffer from a chronic condition, people are finding it increasingly difficult to get the level of care required, and the resources needed to provide it, because of the stretching of health service provision at a time when resources are relatively stagnant.

Let me cite some figures that I think graphically illustrate the situation we are facing. In Coventry, the number of people emigrating from other countries is increasing and the number of GPs is decreasing—the figure from the Deloitte study is something like a 2.5% decrease in the total number of GPs over the last five years, at a time of increasing demands on them in terms of visits and patients to be seen. Let us remember that 90% of all patients are first seen in a primary practice by GPs before they access any other services offered by the NHS, including the general hospital, and that figure is increasing every year. For the first time in the NHS’s history, however, the number of GPs is shrinking. We must deal with that basic fact at a time when numbers should be increasing.

I am pleased that the Labour party has pledged—this is not a party political point—to increase the number of GPs by 8,000, and to raise the money for that and for wider £2.5 billion spending on the health service through a mansion tax and a tax on tobacco companies. I am sure that in so far as such measures have success—I have some experience of that with the windfall tax that some Members may remember—the latter idea will find widespread support throughout the House. If at the end of the day the mansion tax does not prove successful for whatever reason, the Government will have to look elsewhere, but the need for additional resources can no longer be denied.

Shortly before coming to the Chamber for the debate, I heard on the news that the Secretary of State has said that the reconfiguration involves not only integration of care for the elderly and social care with the mainstream health care services. That is important, but it also involves dealing with the divisions between the acute hospitals, which take the bulk of the spend, and GPs. The reconfiguration must mean that more is done by GPs when services can be sensibly provided by them, and that less is done in hospitals. I believe I am correct that that idea was first mooted by Lord Darzi in around 2008-09. The word used at the time was “polyclinics”, which require a lot of investment. In the interview on television news, the Secretary of State said words to the effect that we need more GPs and 15,000 more community workers in GP practice to make it a success, both of which clearly require more money.

Somehow or other, the Government must face up to the fact that, when it comes to claims for money, services to patients in Coventry and cities throughout the country must be increased. Otherwise, we will have more closures of local management committees and GP practices. Some 518 UK practices have closed in the past five years. Others have expanded, but in Coventry alone, eight major practices have closed. We have shrinkage of capacity and an increase in demand. By the definition of those two statements, we have a crisis, which is the subject of our debate.

Will the Minister tell us how far the Government have got with the pilot scheme under the clinical commissioning group in north Lancashire? The pilot intends to find out how the additional resources—£1 million has been put up—can be fed in without taking away from other parts of the health service, which it is important to emphasise. How is that working out?

That point came to my attention with the letter and prompted me to apply for the debate. The situation was highlighted in an early-day motion back in June. I did not sign it at the time but have rectified that. It was tabled by a Member who speaks for the Liberal party and seconded by two distinguished Labour Members, a former Chairman of the Select Committee on Health and my right hon. Friend the Member for Holborn and St Pancras (Frank Dobson), a previous Labour Secretary of State for Health—he was Secretary of State in one of the earlier Labour Administrations. An amendment that I would be interested in supporting was tabled by a Government Member. He said that money was available for that pilot study. I would like to hear how it is making services more effective and providing more resources effectively for the delivery of GP services.

There is a conundrum. Why are GP practices not as attractive as they ought to be to new entrants? Fewer of those qualifying in the medical profession want to go into general practice, hence we have a net decline in the total numbers at the very time when, for all the reasons I have given, we should be increasing those numbers. Why is it so difficult? When one gets into a practice, and before becoming a partner, one gets more than £50,000 a year. Beyond that, when people become partners, they get approaching £100,000 and sometimes more, even in the initial stages. The average pay for GPs in Coventry is more than £100,000 a year.

[Mr Jim Cunningham (Coventry South) (Lab)]

Some months ago, I visited one or two different general practices in Coventry. The disparity in medical technology was startling. I have raised that in the House before, but I hope the Minister will touch on the reasons why we get such disparities.

[Mr Robinson]

I am very grateful to my hon. Friend for his intervention.

Some 10,000 GPs—I am sure these figures are well researched by Deloitte—have expressed an intention to retire in the next five years. That is 2,000 a year, and Labour is promising to increase the number of GPs by 8,000. We will therefore need considerably more than that just to remain where we are now. What are the projections for doctor qualifications and the division between secondary and primary care? Are we catering for enough or will we have a continuing crisis with people blaming the previous contract, as they do in the press all the time, when in fact there are simply not enough doctors or resources to go around?

I do not want to say that all doctors are perfect. They are no more perfect than the rest of the human race. The simple fact is that they are under strain. I could cite many instances, but I would like to mention one in particular. Dr Jamie Mcpherson, the secretary of the local medical committee in Coventry, is a very fine and dedicated GP whom I have known for years—he was one of the first people to come and see me when I was first elected—through the troubled years when Lady Thatcher’s Governments were first introducing tremendous cost pressures. When there was the idea that GPs would be budget holders of practices, he came to see me and said, “We don’t want that. We are aware we have to improve, but we want to be doctors serving the community.” That was his view. There is always a tension between the pressure to make GPs into budget holders who look at costs and the need for them to be committed to what they are really there for: serving the community as doctors.

I said I would give plenty of time for my hon. Friend the Member for Coventry South to speak and I intend to do so. Before I sit down, however, I would like to raise a few more points. What are the Government’s plans to ensure that there are more GPs, not five years out but in the next year or two? Can we expect any net increase in resources and in the number of GPs? Do we have any plans to have 15,000 extra community care health workers? It seems to me that we have an undue concentration on the reorganisation of the secondary sector. We have always had, in this House and outside, a top-down preoccupation with the secondary sector, the acute hospital, as if we solve everything by a concentration on it.

When I received the letter from the Coventry GPs, I realised that an increasing problem relates to the place that GPs occupy within the health community. What progress is being made in north Lancashire? What are the Government’s plans in the next year or two—they must have them, because they budget over three years—for the number of GPs, increasing resources and the establishment of new buildings?

I would like to mention another point that has been brought to my attention. There has been some investment in new buildings for GP practices. Has that investment been made with a view to them becoming polyclinics and taking on more of the “routine” jobs, if we can call them that? They are still very specialist and require trained nurses, which is why Labour has plans for 20,000 more nurses—not all, perhaps, for GP surgeries—and 8,000 more doctors. They are very skilled jobs, even though they are more routine. How much of the investment in new buildings for GPs has been devoted to the provision of a wider range of care? I ask that because it is clear that the capital cost of investing in providing new premises for practices is one of the stumbling blocks to getting new entrants into GP practices.

The other point I want to draw attention to when it comes to the Government’s plans, in addition to whether there is a problem with the practices and the capital costs of buildings, relates to women GPs. Nearly half of all GPs are now women—I think it is roughly 50%—and they need to be able to work part time. We therefore need a flexible contract. Is it flexible and is flexibility encouraged? They have a tremendous and increasing role to play.

Those are the questions I wanted to put to the Minister. We are very pleased to see him in his place and I am very pleased that we are having this debate.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health (Dr Daniel Poulter)]

Thank you, Madam Deputy Speaker, and I thank the hon. Member for Coventry South (Mr Cunningham) for his kind regards in that respect.

I congratulate the hon. Member for Coventry North West (Mr Robinson) on securing this debate. Like his hon. Friend, he raised a number of important broader points about the future of general practice and the work force—I hope to provide some reassurance in that regard—and some important local issues, which I also intend to address.

I commend both hon. Members for their interest in local health care matters as they affect their constituents, and I pay tribute to the dedication and professionalism of all the GPs and other staff working in primary care in Coventry and surrounding areas. The House will agree, I am sure, that good quality patient care is expected, regardless of which part of the country we live in. GPs are the bedrock of our NHS, with an estimated 340 million consultations taking place in general practice every year. We want to ensure that we always give GPs the right support so that they can deliver the best possible care for patients.

I am aware that the Coventry and Rugby local medical committee of the British Medical Association issued an open letter on 26 September, giving its views on national and local issues in general practice.

Let me turn first to one of the important points raised in the debate, which was that there has quite rightly often been a focus on the NHS as viewed through the prism of secondary care, yet the majority of engagements with patients is in primary care and in the community. We need to recognise the role of pharmacy, too, as many people’s first point of contact will be with the pharmacist and, in the NHS, with their GP or another element of primary and community health care. It is therefore important to challenge that traditional prism through which the NHS tends to be regarded. We know that it is not just about hospitals; it is about primary care, too, and about ensuring that we invest to support GPs and deliver other high-quality community health care services.

[Mr Robinson]

We are greatly reassured by the Minister and agree with what he said. Will he confirm the figure—I was quite surprised to discover it—that at least 90% of all initial contacts with the NHS are through primary services? As he rightly says, it is mainly GPs, but chemists and others, too. Is the 90% figure correct?

[Dr Poulter]

I believe that that estimate is correct, although it is impossible to give a totally accurate figure, because some of the consultations, particularly with a pharmacist, might be informal rather than registered as an official consultation. For many people, it is important to get advice from their local pharmacist about how better to manage their medication regime or just to seek simple advice about what to take for an upset stomach. Those informal consultations are not usually registered in the same way as GP consultations, even though they happen every single minute of every day in our health service. Those points of contact are in the community, not in secondary care. This is how most people will come into contact with the health service, although in this place we sometimes talk about the NHS through the prism of secondary care. It is a legitimate challenge for all us of to recognise the importance of primary and community care and to continue to invest in and support those people who deliver that when we design health care services in the years ahead.

As a doctor myself, I particularly recognise the work of GPs and the vital role that they play. Shortly after the local medical committee issued its letter, as highlighted in the remarks of the hon. Member for Coventry North West, the Government were pleased to see that NHS employers, on behalf of NHS England and the BMA, reached agreement on changes to the GP contract. The BMA made the point that these changes will provide much needed breathing space for general practice and greater stability for patients. However, we accept there is much more that we need to do in the longer term to support general practice, such as recruiting more GPs to help tackle GP burn-out. I shall say more about that later.

We are of course pleased to have reached agreement with the BMA, and I think it is useful to set out a few points about what we have done nationally and what we want to do in the coming years, as this will help to address some of the concerns raised by the hon. Gentleman.

First, it is worth highlighting some of the investment in general practice that has taken place. We recognise the need for a reversal of the shift that the hon. Gentleman described so articulately—the shift that has taken place, over decades of investment, away from community care and towards hospital care. I hope the hon. Gentleman will be reassured by the latest figures, which show that the total investment in general practice increased in cash terms by 2.92% between 2012-13 and 2013-14, from £7,863.8 million to £8,093.4 million. I shall write to him to confirm those figures, but I think we should all welcome the reversal of the traditional shift in favour of secondary care, towards general practice and other primary care. The hon. Gentleman may be aware that NHS England published its “Five Year Forward View” last week. In that report, it committed itself to more investment in primary care over the next five years, including investment in infrastructure.

I know that the hon. Gentleman is rightly concerned about GP numbers. Although the headcount figure in this year’s annual work force census shows a very small decrease of 29, the full-time equivalent figure has increased by 423, or 1.2%, which represents a real increase in capacity in the system. There are now 36,294 full-time equivalent GPs working in the NHS, including registrars and retainers. That is an increase of 423 since 2012, and an increase of more than 1,000 since 2010. There are 329 full-time equivalent GPs working in the Coventry and Rugby clinical commissioning group area, compared with 305 in 2010, so numbers are beginning to increase locally. I hope that that, too, is reassuring.

I understand that the NHS England Arden, Herefordshire and Worcestershire area team is working with the deanery, examining work force development issues and, specifically, ways of improving the process for GPs who want to return to general practice after a career break. The hon. Gentleman made the important point that the work force now includes many women GPs. That is one of the great strengths of the profession, but we must bear in mind the need to enable women who take career breaks in order to start a family to return to general practice. I know that a great deal of work is being done in that regard, not just locally but nationally, involving the Royal College of General Practitioners and the General Medical Practice.

We accept that the work force must grow to meet rising demand from an ageing population. That is why our mandate to Health Education England requires 50% of trainee doctors, after graduation—3,250, on the basis of current forecasts—to enter GP training programmes by 2016; the current figure is about 40%. That will enable further increases to be made in the GP work force: we expect an increase of about 5,000 by 2020. Although numbers are rising, we know that GPs need more resources.

[Mr Robinson]

My hon. Friend and I are very reassured by what the Minister has said. As for the numbers—which, of course, we always have to plan for—does the increase of 5,000 by 2020 mean an increase in the total number of doctors, or an increase in the number of GPs? Will that be enough, given that 10,000 doctors will retire from general practice alone in the next five years? Does the 5,000 figure relate to the position after those GPs have retired? How does the calculation work?

[Dr Poulter]

The figures that I gave are based on what we assume will be the attrition rate over the next five years. The total number of doctors has increased by, I believe, about 7,000 over the last four years, but the 2020 figure relates specifically to GPs.

The hon. Gentleman has made a good point. The same consideration has historically applied to health visitors. When a large proportion of that work force has been close to retirement over a five or 10-year period, it has meant the loss of a great deal of experience, but that is not the only issue: there is also the need to plan for those retirements in advance. The figures that we worked out with Health Education England take account of attrition rates.

Part of that is about ensuring that half those medical students become GPs on graduation; currently, only 40% do so. That is where the extra increase in capacity will come from. That will also address the fundamental issue that we have been discussing today—namely, that we need more people working in the community and in primary care. We need to move the prism of the discussion about what good health care looks like away from it being just about delivering good health care in hospitals.

The work being undertaken by Health Education England will improve the applications and fill-rate for GP training. The work includes: a review of the GP recruitment process; development of a returner and refresher scheme; development of a pre-GP year to give prospective GP applicants exposure to the specialty; and careers advice for foundation doctors and medical students. That careers advice is important. When I was at medical school, everyone in my year wanted to be a hospital doctor. I entered a hospital specialty. It is therefore important that, from day one at medical school, students are encouraged and supported to recognise the tremendous opportunities that a career in general practice could offer.

Part of the challenge is to set the aspirations of medical students appropriately and to recognise that the work of a general practitioner is as important as—if not sometimes more important than—the work of a hospital specialist. We need to encourage greater recognition of that fact in medical schools, given that we want to deliver more care in the community. I believe that it is Lancaster medical school that has done a very good job of placing a greater emphasis on prospective GPs doing more community-based and primary care placements during medical school training. That has encouraged more students to enter general practice afterwards. I think I am right in saying that it is Lancaster medical school, but I will write to the hon. Member for Coventry North West after the debate to outline exactly where that kind of initiative has been effective. When looking at how we should train our future work force, it is vital to ensure that more medical students focus on a career in general practice from an early stage of their development if we are to encourage more of them to choose that route. We know that that has worked in the past.

I shall not detain the House by describing the work that Health Education England is doing nationally. Instead, I want to respond to the hon. Gentleman’s questions by talking about what we are doing now to support GPs through technology to enable them to provide a better service to patients. This applies not only to the service available during the current opening hours but to how we might facilitate community and primary care services on a more seven-days-a-week basis.

Last autumn, the Prime Minister announced a challenge fund of £50 million to support innovative GP practices in improving services and access for their patients. As well as offering seven-days-a-week access and evening opening hours, pioneer GP groups will test a variety of forward-thinking services to suit modern lifestyles, including Skype, e-mail and phone consultations. We need to recognise that this is about engaging with people on their own terms. Someone who is working might want to engage with their GP in a different way from someone who is retired, for example. The challenge fund will help to address those questions.

The challenge fund is now supporting more than 1,000 practices covering every region. The pilots will draw best and innovative practice from GPs on the ground to determine what is needed and works locally. We recently announced a second wave of access pilots, with further funding of £100 million for 2015-16. Yesterday, NHS England published details of how to apply to become a wave 2 pilot site, including the application criteria, process and time scales. I hope that practices in Coventry will take advantage of that fund and make applications to support local patients.

The £3.8 billion Better Care Fund combines existing funding in a single health and care pot, promoting integrated care and joint working between health and care services. It aims to ease pressure on services by encouraging greater prevention and by supporting people to stay independent for as long as possible. I have been informed that, in 2015-16, the Coventry clinical commissioning group will receive £9 million to improve services in the local area. Demand continues to grow nationally, and Coventry is no exception to that trend. However, I am told that significant work has been done over the past few years to increase access and to support local initiatives. Significant investment has been made in premises to improve better access to services and an improved patient experience. Four practices co-located to the City of Coventry health centre in 2012 and three practices moved to the new centre at Clay lane in 2013. The hon. Gentlemen raised some issues about practice closures—