Health and Care Bill — House of Lords, 2022-01-20
Topic: Health
Philip Alexander Hunt (Labour, Centre-left): My Lords, I have Amendments 117 and 218 in this group. I have also put my name to the series of amendments put forward by the noble Lord, Lord Crisp, but I start by endorsing what the noble Lord, Lord Low, had to say. I hope the Government will come back sympathetically in relation to that My Amendment 117 would ensure that primary care professions would have mandated roles within integrated care partnerships, with members appointed by each of the four practitioner committees: the local medical, dental, pharmaceutical and optical committees. Secondly —and this is very consistent with the amendments from the noble Lord, Lord Crisp—this would ensure that, in preparing their annual strategic forward plan, the integrated care board and its partner trusts and NHS foundation trusts would need to consult the relevant primary care local representative committees and publish an explanation of how they took account of those views when publishing their plan I have the same arguments as the noble Lord, Lord Crisp, and I will not repeat them because he put them so well. History has shown that, even when clinical commissioning groups were nominally under the control of GPs, they often found it very difficult to get the rest of the system to listen to their issues and concerns. I agree with the noble Lord that there is now so much pressure on primary care that there is a great risk that they will be ignored in the work of the ICBs in particular. That would be a great pity. It is not just GPs, but the other parts of the primary care world. The noble Lord, Lord Low, already referred to ophthalmologists and opticians, but there is also this conundrum about the ability of pharmacists to take some of the load off the system but there is also often the inability of the local NHS to talk to them and embrace them sufficiently I hope the Minister will be sympathetic. If he says that he is not willing to tell ICBs that they must embrace representatives of the local committees then there is now a clear conflict. He is saying that it is up to the local ICBs to decide, but it has become abundantly clear that NHS England is giving out very heavy-handed guidance about who should be on ICBs. I would make this point to him: you cannot have it both ways. Either you leave it up to ICBs and withdraw this guidance, or Parliament has a role and a right to determine the governance arrangements. The action of NHS England in being so heavy-handed, such as saying that local councillors cannot serve on ICBs, means that the argument he put forward really does not stand up any more. I move to my Amendment 218. On this one I must remind the House of my membership of the board of the GMC. The noble Lord, Lord Crisp, talked about the crisis in workforce issues generally, which I am not sure we are going to get on to today now. In relation to GPs, it is very apparent that not only do we have a chronic shortage but there is a grossly inadequate distribution of GPs throughout the country. Recent data, published by NHS England in November, shows that the primary care network covering an area in Gloucestershire described as 4PCC and comprising Cadbury Heath, Close Farm, Hanham and Kingswood had an average list of 1,138 patients per full-time equivalent GP. There are some others with similar figures. At the other end of the scale, Shore Medical primary care network in Dorset had an average list of 7,317 patients per full-time equivalent GP. York Priory Medical Group PCN had an average list of 7,154 patients per full-time GP and the Marsh Group PCN in Kent had an average list of 7,040 per full-time equivalent GP. These are huge disparities and there are many other areas that have average lists of under 1,600 and plenty with averages of more than 6,000 The situation is really reminiscent of the situation before the start of the NHS. That is why in 1948 the Medical Practice Committee for England and Wales started work. It was charged with ensuring equitable distribution and, to a large extent, I believe it achieved its objectives. It was abolished in 2001 and I had better confess to the House that, I am afraid, I took through the legislation abolishing it. However, we were at the start of a massive expansion in the workforce at that time and felt that at that point the kind of bureaucratic way in which the MPC worked probably was no long fit for purpose We have a real problem here and confirmation of the dire situation was provided recently in research by the University of Cambridge’s department of primary care. A team including Dr Rebecca Fisher found that the significant GP workforce inequalities I have talked about are increasing and that workforce shortages disproportionately affect deprived areas. If you look at the situation in deprived areas, practices often have lower CQC scores, lower quality and outcome framework performances and lower patient satisfaction scores. Patients in those areas often have shorter GP consultations despite the fact that they have more complex health needs General practice is paid according to how many patients they have, with an adjustment made for the workload associated with those patients. Since 2004, the global sum allocation formula, known as the Carr-Hill formula, has been used to make that adjustment. However, Fisher argues that the consultation length is a flawed proxy for need and that the formula has long been widely acknowledged to be incapable of accurately weighing needs associated with socioeconomic deprivation. In 2020, after accounting for need, practices serving deprived areas received about 7% less funding per patient than those in non-deprived areas There is also the targeted enhanced recruitment scheme. This offers trainee GPs a one-off payment of £20,000 when joining a practice in an area that had long-standing difficulty in getting more doctors. However, this has not made a significant difference and clearly is not the answer to this enormous problem. In the amendment—and I am very glad to have the support of the noble Lord, Lord Warner, and the noble Baroness—I have proposed the creation of "the General Medical Practitioners Equitable Distribution Board" as a first step. I envisage the board being invested with discretionary powers of negative direction, as was the MPC. It would consider applications from primary care networks, and they would be expected only from adequately doctored, or more than adequately doctored, PCNs. It would be a way of intervening in the market and making it more difficult to appoint GPs in those areas that are already very well supplied with doctors I accept that this is not the only approach, but it is an approach that has worked in the past. Frankly, I do not think that we can carry on without some major intervention to try to spread the load, because it is clear that all the odds are stacked against you if you are in an area of high deprivation where there are many more patients per GP. You get burnout among the professions and things become very difficult indeed. It looks as though financial incentives are not the answer. Clearly, we need to get more GPs into those areas to lessen the load, and then improve the quality and outcomes. I hope the Minister will be prepared to take this back and give it some consideration.