Life Expectancy (Inequalities)

Debate between Richard Bacon and Diane Abbott

Thursday 3rd March 2011 Westminster Hall

[Mr Bacon]

That is right: people will do what they are paid to do. One criticism I have also heard is that the more we treat people like employees, the more they will behave like employees. In recent years, a lot of GPs have felt more bossed around, so they act like employees, rather than people who are running their own organisations.

[Ms Abbott]

Is it not also the case that in inner-city areas, such as the east end of London, large numbers of people who are reservoirs of disease are simply not on GPs’ lists? As we move to GP commissioning, it will be important that GPs commission for the population, not just for the people who happen to be on their lists.

[Mr Bacon]

The hon. Lady makes an important point. One issue is the number of GPs in deprived areas, and a chart in the report shows the variation in those numbers. At one extreme, we have about 110 or 115 GPs per 100,000 of population, although that figure is an outlier, and the rest of the figures start at about 80 GPs and go down to an average of about 59 or 60. At the other extreme, in Redcar and Cleveland, the number of GPs per 100,000 of population is only 25. In other words, there is a fivefold differential between the best and the worst. Even if we cut out the extreme outliers, the figures still go from just over 40 to about 80, which is double. If there are not enough GPs in a given area, it will be that much more difficult to identify and get on to the GP list all the people we should—those whom the hon. Lady calls reservoirs of disease. That is an important public health problem, as well as a policy problem in terms of where GPs sit.

If the Minister does not mind, I would like her to comment on single-practice GPs. Although the proportion of such GPs has dropped from 34% to 22% in the most deprived areas, there are still 371 single-handed practices. All other things being equal, a single-handed practice is almost certainly not a good idea. There may be good reasons why one exists in a particular locality, and it is certainly likely to be better to have a single-handed practice than no practice, although Dr Harold Shipman comes to mind. There is also the fact that a GP is much more likely to work well if they are with a group of people than if they are by themselves; most of us work better in groups than we do wholly by ourselves. I would be interested to hear the Minister’s comments on policy on single-handed practices and where the Government think we are heading on that. As I mentioned, I should also like to hear her comments on the proposed outcomes framework, and how she thinks the changes in the GP contract will make the kind of difference that is needed, both in getting GPs into the right areas, and in making sure that they focus enough on health inequalities.

The third part of our report applied the lessons to the wider NHS. There is of course considerable discussion and controversy about the Government’s health reforms. We are not a policy Committee, so our report does not address whether the GP consortia reforms are a good idea. People have different views on that. I have my own, and instinctively I have always been in favour of giving more authority and power to GPs, for one simple reason, which is to do with what happens whenever, in the 10 years in which I have been a Member of Parliament, I have sat down with a group of GPs. I accept that what happens may be because, although South Norfolk is not economically very prosperous, it is not massively deprived either, and it is a pleasant place to live. Some might even call it leafy, but we have plenty of socio-economic problems, and employment problems. I do not want to gild the lily, but it is not in most respects a deprived area compared with many others, so perhaps the GPs I meet are a biased sample. None the less, every time I sit down with general practitioners, from whichever practice in my constituency they come, I always walk away thinking, “My, what a sensible bunch of people. If only they were given more control and power in the running of the health service. Things would almost certainly work better.” Of course, the Government’s proposals are in that direction, so my instincts are to support what they are doing.

My experience of 10 years on the Committee, however, is that whenever the Government try to change anything of any kind, anywhere, they always underestimate the risk and over-egg the benefits. There are considerable risks to the change, including the fact that it is a change. All change, particularly when it involves big management change, raises risks. It is likely, I think, that the best of the people working in the primary care trusts, if they are good at managing health consortia, will be hired to do the job. If things works out as well as we all hope, we shall probably end up with better management, and fewer and better-paid people doing a sharper, leaner job than has happened with primary care trusts. In addition to lots of meetings with GPs over 10 years, I have had plenty of meetings with the primary care trusts in my constituency. When I was first elected, there were six PCTs just for my constituency, which was then one of eight in Norfolk, with a total population of 800,000. Each had its own finance director on a six-figure salary, and not all were particularly well qualified, which may be one reason why the PCTs began to get into serious financial trouble a few years ago, despite the fact that the NHS was receiving record funding increases.

I have probably dwelt on the issue a bit too long, and I am not trying to make a political point. I merely say that I instinctively have a degree of support for what the Government are trying to do in the context, but it still gives rise to a series of questions. I was quite surprised when I heard that public health would be moving away from the health service towards local authorities, because, on the basis of my experience of my local hospital, which is a good and fairly new acute hospital built in the past 10 years, and based on my experience of general practitioners, I would sooner that those responsibilities were left with clinicians than that they were given to the council.

When I see the proposal for health and well-being boards, I think “What if?” Let us think back to 1997, as the sun came up over the Thames and the then new Prime Minister Tony Blair said, among other things, that the Government were going to put reducing health inequalities at the heart of tackling the root causes of ill health. What if he had said after a couple of years, “I know; here’s another thing we’re going to do. We’re going to have something we will call health and well-being boards, and because we are in favour of democracy we’re going to give them to local councils”? What if we had then watched as not a lot happened for the next 10 years? I am just making this up, because it never happened, but say those bodies had been established, and had not achieved quite as much as we hoped: I can see that we might have gone into the general election saying, “As for those health and well-being boards run by the council, well you’ve all read about them in the Daily Mail and we’ll be getting rid of them on day one.” I am sure it will not work out in that way, and that my hon. Friend the Minister is well aware of the risks and has them under control.

I was interested that the Department told us that the money for the public health budgets would be ring-fenced. Paragraph 22—the final paragraph of our report—said:

“The Department told us that action for improving population-wide health and reducing health inequalities would be funded from a ring-fenced public health budget.”

One of the questions I have for my hon. Friend is, “When is a ring fence not a ring fence?” I have had meetings with my local council, which is rather eager to get hold of the £11.7 million coming its way for its public health budget. It is not its impression that it will be spending it all on public health. Some of us think that it may have other priorities in different areas, which have nothing to do with public health, but which it seems to believe have merit, and for which it can make a strong case—and, indeed, many of my constituents would make a similarly strong case. I want to understand exactly what the health and well-being boards will do, and what leverage they will have over the GP consortia, to ensure that they deliver the priorities they are supposed to—or what other methods there will be to make sure that the consortia deliver those priorities.

That all comes back to what I was saying earlier to my hon. Friend about the need for greater clarity about ensuring that the outcomes framework and the new GP contract deliver what they are supposed to. I do not care whether it is health and well-being boards who do it, or whether they exist. I care that it should happen, and it is not abundantly clear to me that there is yet a picture with all the dots joined up, so that we can be sure that if health and well-being boards are carrying out that task either they will have the correct leverage over GP consortia or there will be other mechanisms in place, through the outcomes framework or the new contract, to achieve what the Government, like the previous Government, say they want to do about health inequalities.

[Ms Abbott]

It has been my experience in my present Front-Bench role that local authorities throughout the country believe, broadly speaking, that what they call public health is public health, and that they can spend the money on that. As I said earlier, they can spend it on environmental health, social care or leisure services. I am concerned precisely with the point he made: when is ring-fencing ring-fencing? Because I do not believe that the money can be effectively ring-fenced for what we would recognise as public health expense.

[Mr Bacon]

I am interested in the hon. Lady’s comments. Of course, if we made sure that every schoolchild got a tangerine every day as part of their five a day, it would not be difficult to make a strong case for that being in the interests of public health. It would not be necessary to be a member of the tangerine growers association to make that argument.