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Dr. Andrew Murrison (Westbury) (Con): Will the Minister reflect on Warminster, where wards in the cottage hospital have closed because GPs have withdrawn their services, having taken the view that, although they are very happy to provide cover in the hospital as a bolt-on extra to their out-of-hours contractual obligations, they will certainly not do so in the absence of those obligations? That is happening right across the country. I am surprised that he does not know that.

Mr. Hutton: No, it is not happening right across the country. There certainly was a problem in Warminster, and there have been problems in one or two other community hospitals—I acknowledge that. However, they are not to do with the out-of-hours arrangements under the new contract. The hon. Gentleman is wrong about that. The Minister of State, my hon. Friend the Member for Doncaster, Central (Ms Winterton), will address that point in her winding-up speech, and I am sure that the hon. Gentleman will want further to reflect on his arguments.

Agreements that GPs may have with a community hospital are separate from their primary medical services contract and it has always been up to PCTs to decide locally how to commission that work as part of their broader commissioning strategy. The doctors and dentists review body itself expressed the view that the matter should form part of the wider review of staff and associate specialist grades that the Department is committed to undertaking. That is very much in line with how we would like to proceed. From 1 October, that will be a matter for the new NHS employers organisation.

The Opposition's case is misplaced, misinformed, opportunistic and completely devoid of any practical alternatives to the path that we are pursuing, on both the working time directive and the provisions of out-of-hours services. It is not clear to me or, I suspect, anyone who heard the hon. Member for South Cambridgeshire whether the Opposition are in favour of the new contracts for GPs, whether they support the provisions in the contracts for out-of-hours services, or whether junior doctors should be covered by the directive. In that sense the hon. Gentleman was at least consistent in ensuring that his arguments lacked any substance, any sense of proportion or any recognition of what is happening on the ground. That is another reason why my right hon. and hon. Friends should reject the motion standing in the name of the Leader of the Opposition.

2.4 pm

Mr. Paul Burstow (Sutton and Cheam) (LD): I start by referring to a speech that the Minister of State gave in January at a gathering organised by the Royal College of Surgeons. He said—[Interruption.] That is
 
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not this particular quote; I am afraid that the Minister of State will have to listen because this is a new quote from that interesting speech. On the working time directive, he said:

The deadline for introducing the maximum average working time of 58 hours per week is 1 August. In January, only months before the directive has its full effect, the Minister was talking to a gathering of medical professionals about starting to take the necessary steps to secure implementation, which beggars belief.

Mr. Hutton: The hon. Gentleman would have made a fair debating point if we had taken no action prior to my making that speech to the Royal College of Surgeons. I hope that he is prepared to be fair and acknowledge that.

Mr. Burstow: That was a very early intervention, and I hope to explore in a little more detail some of the steps, and their adequacy, that the Government have taken since the working time directive first appeared on the horizon in 1998 and they made a commitment to implement it over the following few years. I take no lessons from the Minister at this stage, but I am sure that if he does not agree with other things that I have to say he will take the opportunity to catch your eye, Mr. Speaker, and intervene.

The January speech is proof, if proof were needed, of the dither and delay that was exposed, and dealt with in detail, in the examination by the House of Lords European Union Committee. I shall outline my reasons for that conclusion. It is not as if the directive has come out of the blue. The Minister and his colleagues have had five years to grapple with its implications for the NHS. Ministers have known about the SIMAP judgment since October 2000. The NHS is now having to deal with the interactions of a whole series of decisions taken by this Government over the past five years. Both the GP and consultant contracts start to kick in just when the directive begins to bite. In combination, those three major changes have a huge effect on the medical work force and their capacity to sustain current levels of activity and, indeed, to deliver ever higher standards.

In their submission to the European Commission the Government stated that the UK requires between 6,250 and 12,550 more doctors to comply with the directive—a lot of extra doctors. The Minister outlined, both in his speech and in the amendment to the motion, the Government's progress on recruiting and training more doctors. The BMA says that compliance with the directive will result in the loss of the full-time equivalent of 3,700 junior doctors. I know that that figure is contested, but the Minister did not, in his speech, demonstrate why it is not an accurate assessment.

All that has to be seen against a backdrop of the poor, even non-existent, work force planning of the 1980s and 1990s and the legacy cost of neglect and under-investment by an earlier Administration. The failure of the last Conservative Government to expand medical
 
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training places and the current Government's decision to stick to Conservative spending plans for their first two years in office have undoubtedly exacerbated capacity constraints and the Government's ability to be in the right position to ensure full compliance with the directive by August. Even now, the Royal College of Physicians says that there are insufficient junior doctors in training. Some might say, "Of course it would say that," but it is nevertheless worrying that it flags that as a serious concern.

I agree with the Minister that the answer to the working time directive is not simply more doctors; it is about doing things differently. The hospital at night project, which has been discussed across the Dispatch Box, is one measure that needs to be taken. Whether it was suggested by the BMA or the royal colleges, or whether it was a Government initiative, does not much matter; it is what comes out of it that matters and whether it delivers the additional capacity to allow us to deal with the consequences of the directive

The 32 pilot schemes that are being trialled through the country provide opportunities to innovate and experiment in different ways of working, to manage demand and so on. However, although local initiatives such as the ones that are being implemented to change the skill mix, expanding the roles of nurses, midwives, therapists, pharmacists and others, point a way forward, and although there has undoubtedly been an improvement in the work force size over the last few years, the most recent work force survey suggests that we still have shortages of midwives and some of the key therapist roles that are key to making a reality of the individual initiatives being implemented throughout the country. Such initiatives have a part to play, but it is far from clear whether they can be implemented across the NHS before the 1 August deadline. The Royal College of Physicians said that its survey showed substantial scepticism about whether the introduction of nurse practitioners would enable hospitals to cope with fewer doctors. Indeed, the House of Lords European Union Committee argued in its recent report on the directive that although the Government are testing new ways of working in their pilot schemes, invitations for proposals, as we have heard, were not issued until April 2002, four years after the directive was first implemented. The results are unlikely to be ready by August, and the Committee concluded that it would take up to two years for successful schemes to be fully implemented across the NHS. Effectively, there will be a further two years of non-compliance with the directive, so it would be useful if the Minister of State, the hon. Member for Doncaster, Central (Ms Winterton) confirmed whether the Government agree with the Committee's conclusion and whether it will be two more years before the learning from the pilots is applied across the NHS.

The Committee went on to report that no more than 50 hospitals will be in a position to implement the methods trialled in the pilots. Do the Government accept that conclusion and, if not, why not? How do their conclusions differ from the Committee's? The Government acknowledged in their submission to the European Commission that the alternatives, as we have heard in today's debate, may not cost more than employing extra doctors but will certainly cost as much, so it is not a cheaper option for the NHS to get round
 
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the problem with upskilling, changes and skill mixes. In its brief for today's debate, the NHS Confederation states that it will not be possible for many NHS organisations to meet the compliance requirements by August 2004. The Government clearly agree, given what the Minister of State, the right hon. Member for Barrow and Furness (Mr. Hutton) told the House today. Indeed, the confederation goes on to warn that some trusts will not be able to provide safe medical care in some specialties if they introduce compliant rotas. Trusts face an invidious choice between damaging patient care and failing to comply with the directive. The confederation urges the Government not to adopt a punitive approach when dealing with non-compliance. It would be useful if the hon. Member for Doncaster, Central explained in her reply to the debate how the Government intend to deal with trusts that are not in compliance with the directive, not least because the right hon. Member for Barrow and Furness said that many trusts will not be compliant. Presumably, those trusts will be dealt with case by case.

According to the Royal College of Physicians, six out of 10 hospitals still do not have the 10 middle-grade staff necessary for a compliant rota. More worrying still, almost four out of 10 hospitals say that they have fewer than eight middle-grade staff, so they are well short of what is needed to deliver compliant rotas. In the speech that the right hon. Member for Barrow and Furness made in January he said that

Why, in January, did the right hon. Gentleman think it necessary to say that such a process should be in place? Surely it should have been in place for a long time.

The Government have issued inadequate and vague guidance to hospitals on the implementation of the directive. To start to develop a road map just months before the deadline for implementation is breathtakingly incompetent. Ministers say that the directive could have been complied with were it not for the European Court rulings in the SIMAP and Jaeger judgments. The SIMAP judgment, however, was made in October 2000, and dealt with the issue of what is meant by working time. That was further complicated last summer, as the right hon. Member for Barrow and Furness said, by the Jaeger judgment, which gave an unworkable definition of when compensatory rest should be taken. The European Commission made a welcome announcement on 4 March that it would propose legislation to deal with the problem, but the Minister of State did not explain the timetable for the legislation. It will be proposed by the summer, but the European election will inevitably cause a hiatus. It is speculated that it could be two more years before we have a legislative solution that gets us off the hook. It would therefore be helpful if the Minister spelt out the timetable.

The motion also deals with community hospitals and the link between their capacity and the GP contract. The right hon. Member for Barrow and Furness was right that there is not a direct causal link between the GP contract and the issues affecting community hospitals, but there is undoubtedly some interaction that is causing GPs who work in community hospitals to abandon that work. There are 400 community hospitals in the United Kingdom that provide 10,000 beds and rely on about
 
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4,000 GPs to provide key services. Those hospitals are crucial to the system. They provide a safety valve for district general hospitals, and are increasingly becoming centres for rehabilitation and intermediate care. There is a genuine possibility that the new GP contract will have the unintended effect of causing GPs to withdraw from work in community hospitals, as has already happened in Bolsover, Clay Cross and, as we have heard, Warminster. Wherever that happens, salaried medical staff are used as an alternative, but when they take on GP roles in community hospitals they are subject to the working time directive, so costs increase. That has not been factored into the Government's costings, and is connected to the point made by my hon. Friend the Member for Romsey (Sandra Gidley) about the inadequacy of resources to implement changes in the contract.

Will the Minister explain why her Welsh and Scottish counterparts have embarked on negotiations on community hospitals? They are more concerned about the issue than the Government in England, and have started negotiations to ensure continuity of care and to enable GPs to continue to fulfil that role. There is no similar process, however, in England to avoid the fallout after 1 January next year. Will the Minister therefore explain what negotiations are planned in England to deal with the problem of GPs deciding to give up working in community hospitals, and when those negotiations will start? If the problem is not resolved it will compound the pressures on district hospitals.

The new consultant contract, which aligns pay with sessions worked, is a welcome innovation in the NHS. However, the Government appear to have underestimated the amount of work that consultants have undertaken in their costings, plans and implementation of change. If those hours are not funded, they will not be worked. If they are not worked, the extra consultants trumpeted in the amendment will not provide extra services, and the Government will merely be treading water as a consequence.


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