“NHS 111 has been a complete disaster. Lay people/call centre staff working from a crib sheet/flow chart are creating huge demand in both primary care and A and E. Quite a bit of controversy about this in the last few days. They call for ambulances at the drop of a hat and seldom advise the patient to self-care. The callers not admitted are advised to see their GP within a few hours. The contact summaries are unintelligible.”

Those words are not mine but those of a GP: NHS 111 has caused some real concerns.

The Government have also cut GP training. The shortage of GPs is, without doubt, one reason why we are finding it harder to see a GP. It is also holding back the NHS from meeting the challenges of the future, such as providing better care outside hospital to support an ageing population. Of course the right hon. Member for Chelmsford (Mr Burns) will remember that that was one of the key reasons why the Government introduced the Bill they did.

My right hon. Friend the Member for Leigh (Andy Burnham) has stated that a future Government will raise something like £2.5 billion for a time to care fund from a mansion tax on properties worth more than £2 million, cracking down on tax avoidance and a new levy on tobacco firms. Such investment will enable a Labour Government, by the end of the next Parliament, to provide 20,000 more nurses and 8,000 more GPs to help people stay healthy outside hospital and to tackle GP access problems.

In 1997, only half of patients could see a GP within 48 hours. The previous Labour Government rescued the NHS after years of Tory neglect. By the time we left office, 98% of patients were being seen within four hours at A and E and the vast majority of patients—80%—could get a GP appointment within 48 hours.

One of the Prime Minister’s first acts was to scrap Labour’s guarantee of getting a GP appointment in 48 hours and to cut the funding for extended opening hours.

The Parliamentary Under-Secretary of State for Health (Dr Daniel Poulter): The hon. Gentleman is making some important points, but does he recognise the fact

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that it takes a number of years to train any medical specialist, including a GP? While he is talking about the previous Government’s investment in the NHS, would he like to explain why that forward work force planning was not done and how such planning may have helped with some of the issues that he is raising today?

Derek Twigg: The Minister makes an interesting point. At Prime Minister’s Question Time, we keep hearing the Prime Minister say, “Look how many extra GPs and nurses we have recruited,” but how long does it take to train them? I suggest that the Minister look at the figures on the number of additional GPs and nurses recruited between 2003 and 2009.

Mr Henry Bellingham (North West Norfolk) (Con): What is the hon. Gentleman’s view on the last Labour Government’s decision to change GPs’ contracts to relieve them of out-of-hours cover?

Derek Twigg: Again, that is an interesting point. There is a perception that every GP practice provided out-of-hours cover with the GPs themselves going out to see their patients. Of course, some of them did that, but many did not. Many of them were already using locums. During my childhood, I was a particularly bad asthmatic, and most of the doctors who came out to see me were locums, not my GP. We must look at how we organise out-of-hours services, but the key thing to focus on today is that we have not got enough GPs.

Dr Poulter: On long-term work force planning, the hon. Gentleman suggests that there is suddenly a crisis in GP recruitment—which I do not think is necessarily correct—but if the previous Government were serious about investing in general practice, they should have trained a lot more GPs than they did.

Derek Twigg: I know the Minister’s background, but he should read the figures on the number of GPs recruited by Labour when we were in power. Between 2000 and 2009, there were thousands of extra GPs, compared with the additional recruitment since this Government came to power. He should compare the two records.

I will not take any more interventions, Mr Speaker, because other Members want to speak.

Many local initiatives are trying to deal with the crisis in general practice and gaining access to GPs, or certainly to mitigate the effect. Clinical commissioning groups, such as Halton CCG, are working closely with partners to develop a strategy within the financial constraints. Halton CCG has told me:

“Delivery may be across the whole CCG on a Halton-wide footprint; by bringing more than one GP practice together to service distinct communities through a ‘hub’ based approach; by sustaining individual practices wherever appropriate and by giving local people and communities more opportunities to self-care and create resilience”.

It is working with partners to try to improve the situation, despite the financial constraints and the shortage of GPs, but we must attract more GPs.

The Royal College of GPs has told me that, in its view, it is vital that we increase the share of the NHS budget spent on general practice in England from 8.3% to 11%. That is one of the key parts of its campaign.

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That increase would help to reduce pressure on other parts of the NHS by supporting the delivery of more patient care in the community and keeping people out of hospital wherever possible.

The fact is that general practice cannot go on in this state. We need a sustainable, funded plan to ensure we have enough GPs to meet the population’s needs and to provide better care outside hospital. Clearly, patients should not have to wait days and sometimes weeks to see a GP or be constantly denied the opportunity to see the GP of their choice. We need to relieve the pressure on hard-pressed GPs, by ensuring that general practice is where more young doctors want a career, and in doing so we would have much better integrated care. We need better buildings to make general practice a more attractive place. We must of course constantly challenge the medical profession on how they can work better and deliver better services to patients within available resources. In the end, both politicians and clinicians must put the interests of patients first, while getting the best value for the taxpayer.

Several hon. Members rose

Mr Speaker: Order. I am extremely grateful to the hon. Member for Halton (Derek Twigg) for his courtesy and consideration of other Members. I was not intending to impose a formal limit on Back-Bench speeches, but it might be helpful to the House to know that 12 Back Benchers want to speak in the first debate and seven in the second. This debate might run until approximately 2.30 pm. If Members can confine themselves to 10 minutes, there should be no difficulty and it will be possible to accommodate everyone.

11.49 am

John Howell (Henley) (Con): It is a great pleasure to follow the hon. Member for Halton (Derek Twigg). I congratulate him on securing this debate, which highlights a very important subject.

Over the past few months, I have had discussions with GP practices across my constituency. I have had a number of meetings with GPs, usually during their lunch hour, and we have covered a wide range of topics, some relating to the new hospital being built in Henley as a re-provision of the old one, and some relating to the individual situation of GPs. These discussions arose out of my speaking to a conference of GP practice managers. It is important to stress the crucial role of managers in running GPs’ practices. There was a lot of agreement between myself and the right hon. Member for Oxford East (Mr Smith) about how the health service is organised. My meetings with GPs have also come about as a result of talking to patient groups.

GPs are excited at the possibility of providing a range of services, through new methods, in the hospital in Henley, and are very much part of the discussion with the CCG on this. There is a real possibility of an emergency multidisciplinary unit there.

When talking to GPs, I have raised the subject of access to GPs and services. In my constituency, access is not an issue. If people need urgent appointments, GPs will make themselves available. People can ring for an

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appointment and be given one very quickly. I have found that to be the case with my own surgery, for example, and I applaud the dedication and the willingness to work in co-operation that have been shown by GPs in these circumstances. Sometimes, though, if people ask to see a specific GP urgently, that may not be possible, but these are small practices where there is good communication and discussion of medical issues between the limited number of doctors there. Access does become a problem when practices are essentially outposts of another practice. This occurs in the north of my constituency in a village called Chinnor, where the practices are outposts of practices across the border in Princes Risborough. Managing that can create certain problems for GPs.

The major problem put to me by GPs is patient expectations. I would not want to limit patients’ genuine expectation of good service provided in a timely manner, but we expect things without a wait, so the issue is the expectation, rather than the GP’s availability.

Michael Fabricant (Lichfield) (Con): Does my hon. Friend agree that another problem facing GPs and the NHS in general is patients who make appointments with GPs and consultants and do not turn up?

John Howell: If my hon. Friend will give me a chance, I will come to that very point, which is one that I discussed with GPs and patient groups.

There is also the expectation of what a GP can do. The number of visits per patient may be up, which is increasing demand, but the causes, according to GPs, are, first, the desire for an instant cure. People are not giving minor ailments time to heal themselves, but expect medicine on tap for everything. Thus going to a GP as soon as symptoms occur is part of the expectation. Secondly, people are motivated to see their GP by advertisements listing symptoms and encouraging people to go to a GP if they have them.

Liz McInnes (Heywood and Middleton) (Lab) rose—

Duncan Hames (Chippenham) (LD) rose—

John Howell: I give way to the hon. Member for Heywood and Middleton (Liz McInnes).

Liz McInnes: The hon. Gentleman talks about patient expectations, but in the Heywood, Middleton and Rochdale CCG, which serves my constituency, 16% of patients report that they are unable even to speak to somebody to get an appointment. I do not think it is an unreasonable expectation that patients should be able to contact somebody who can get them an appointment with a GP.

John Howell: I will give way to the hon. Member for Chippenham (Duncan Hames) and then respond to both interventions.

Duncan Hames: I do not find fault with the patients, but does the hon. Gentleman agree that a significant difference between the funding patterns for primary and secondary care is that in secondary care the more treatment provided and the more patients seen, the more funding provided by commissioners to the provider, yet the same pattern, where funding is proportionate to the amount of activity undertaken, is not typically seen in what we ask of general practice?

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John Howell: I will talk a bit about funding later. I say to the hon. Member for Heywood and Middleton that we are trying to put together a picture on the basis of individual constituencies. It is no use taking an overall, theoretical picture and then trying to work out what is happening in individual constituencies; it has to be done the other way around, by individual constituencies saying what is happening with them. I am setting out precisely the situation in my constituency.

Richard Graham (Gloucester) (Con): On that point, in Gloucester we had exactly the same problem that Members have referred to, so our clinical commissioning group managed to arrange funding for 300 additional hours in GP surgeries a week, which is proving very effective. That is the sort of thing that can be done locally by using the budget creatively. Does my hon. Friend agree that others might be able to explore that?

John Howell: I agree that that is a very good local initiative that could be spread across general practice.

Let me give the House an example. I happened to be visiting a surgery one afternoon, so I asked the staff what the problem with access was. I was told that a good example was a lady who had come in that morning to have her plaster changed. I imaged plaster being removed from a suppurating wound, but it was actually a small plaster on her hand. She was told to go away. I think that is an abuse of a GP practice by a patient.

Mr Bellingham: Will my hon. Friend consider the role of pharmacies in providing more cover and more care, for example for the type of complaint he has just mentioned? Surely those people should be going to their local pharmacy, rather than their GP practice.

John Howell: I completely agree. If I manage to get through my speech, I will say a few words about that.

The way forward is for patients to take responsibility for their own health, but there is a basic education point that stands in the way. I have a minor condition that requires my blood pressure to be monitored. I do that myself at home, and then send the results remotely to the surgery. We then have a conversation about it remotely, hopefully by e-mail. It is ironic that the internet is increasingly used by the over-50s, but the view of GPs providing a public service stands in the way of, and even contradicts, the over-50s being able to use the internet to achieve that result.

Mr Simon Burns: Is there not also a problem with some patients using the internet to self-diagnose, as there can sometimes be unpleasantness and arguments when GPs do not agree?

John Howell: That risk does exist, but I am talking about a treatment regime that I have agreed with my local practice, and this is the best way of dealing with it.

I have discussed the impact of no-shows with local practices. No-shows can affect surgeries by denying appointments that are the equivalent of up to one doctor each week. We looked with patient groups at various ways of dealing with that, including a ring-back system that allows surgeries to send text messages to remind patients not to forget an appointment the following day. What is missing, though, is an ability for the patient

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to ring back and say, “Yes, I’m coming”, or “No, I’m not coming.” I understand that the scheme that was going to put that in place centrally has been cancelled, and I ask the Minister to look at that carefully. Some practices use no-shows positively as a potential indication of symptoms; if someone is a consistent no-show, that might be a sign of dementia or something else. When I discussed charging for no-shows with patient groups, there was great hostility to this, tempered by the admission that it was administratively impossible and raised too many issues about access to services.

The hon. Member for Halton talked about the role of GPs in planning locally. I have asked about this in my area, where a whole lot of places are going for neighbourhood plans. I fully support them in doing that. It is the first time that communities have had the ability to determine where houses will go—and, indeed, what they will look like, because there is a very important design element. When I asked GPs what role they had in the neighbourhood planning process, the answer, basically, was none at all; they had not participated in the discussions. I sent them back to have those discussions with the people putting the neighbourhood plan together. This cannot be left to the CCG to determine for GP practices; GP practices have to do it themselves. The risk is that if they do not have their wish-list regarding what is to be done, they will lose out in the allocation of community infrastructure levy money that will eventually come through.

Mr Prisk: On the development of local plans, in east Hertfordshire and elsewhere, the problem is that our rather nice, but historical and inadequate, premises restrain the ability of practices to provide modern facilities. Is that my hon. Friend’s experience of the local planning process in his constituency?

Mr Deputy Speaker (Mr Lindsay Hoyle): Order. May I make a suggestion? The Speaker suggested a time limit of about 10 minutes, and the hon. Gentleman has now had 13 minutes. I hope there will not be too many more interventions, and that the hon. Gentleman is coming to the end of his speech.

John Howell: Thank you, Mr Deputy Speaker. I am coming to the end, but let me respond to my hon. Friend’s intervention. It depends on where the practice is and what its buildings are like. Some are quite modern, and one would not want to change their facilities. Even those practices may need to add an extra surgery, if the village is going to grow by several thousand people, so they need to plan for where it will go and for the doctor that will use it.

The trend in the population has been towards more elderly patients and more patients with long-term, chronic or multiple conditions. That leads to an increase in the number of patients per year. There is no doubt that the age profile is having an impact. The Government’s allocation of a named doctor to a patient is useful for the co-ordination of services, even though in an emergency the patient may not be able to see that doctor on the day when they require them.

Yes, there is a need for money to be provided for GP services, but this is possible only if we have a strong economy. The Government have evened out the payments between practices so that they do similar things in

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similar parts of the country and there are not wide variations between them. That has to be the right way to go. It also has to be right to increase the strength of the economy in order to provide these services.

12.4 pm

Stella Creasy (Walthamstow) (Lab/Co-op): I congratulate my hon. Friend the Member for Halton (Derek Twigg) on securing what, for me, is an incredibly important debate. I am pleased to follow the hon. Member for Henley (John Howell), because he and I have probably been doing the same thing in going to talk to people in our local community about local health care. I must say that my experience is of a very different health care system—one that is under real pressure and, frankly, very much in danger in my local community.

I wanted to speak in this debate to put my concerns on the record and to ask the Minister and officials at the Department of Health to look at my area, because I am so worried about these issues. As an MP, I see it as my job first and foremost to help the patients of Walthamstow—my neighbours, as well as my family and friends in the area—who can see how our services are falling apart. As their MP, my very real worry is that, as much as I have tried to raise such concerns, all I hear is that those problems are for someone else or for some other organisation to resolve. I want to put on the record some of the issues, and to explain the situation in our local community and how it is having an impact on doctors. By doing so, I hope to convince the Minister to pay special attention to Waltham Forest.

There are 45 GP member practices in Waltham Forest CCG. We have one of the fastest growing populations in the country, but many of the practices are in poorly maintained buildings and are single-handed. They serve a community that has a very high incidence of what we might call lifestyle diseases—diabetes, heart disease, cancer—and GP access is absolutely critical to the outcomes achieved for patients.

Mr George Howarth (Knowsley) (Lab): Will my hon. Friend be a bit more specific? Type 2 diabetes is lifestyle-related, but type 1 is not.

Stella Creasy: I apologise for using shorthand. My right hon. Friend is completely right. I am talking about type 2 diabetes. For example, many people from the south Asian community in my constituency have type 2 diabetes.

We are told that our local GP work force needs to grow by 40% by the end of the next Parliament if it is to serve the community I represent. However, I can already see very real problems with our local community service, and that is bad for the patients and for the rest of the NHS. We know how difficult it is to recruit and retain doctors, but in my part of town, with the high cost of living in London, it will get even harder.

Since 2011, complaints about GP access have rolled into my constituency office. Let me give the Minister some examples. Just the other day, a resident rang me and said: “Look, the receptionists were perfectly polite. They said call at 9 o’clock or queue up before the surgery opens to get an appointment, but the line was

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constantly engaged from 9 o’clock. My phone shows I called 28 times between 9 am and 9.30 am, and I could not get through. When I did get through, it was only to be told that there were no more appointments left.” That is not unusual in my community.

Little wonder that residents in Walthamstow routinely report that it takes two weeks to get an appointment with a doctor. Nationally, we know that one in four people wait a week or more. The problem—this is why I disagree with the hon. Gentleman—is that it is very hard for people to know whether or not they need to see a doctor, especially if they are worried about a child.

Let me give another example of a complaint I received just the other day: “I have had constant problems trying to get a GP appointment for my 13-month-old daughter since she was born. A couple of times, even only last week, I was asked by reception staff at the doctors why I hadn’t gone to A and E.” That is the constant question for residents in my local community when they cannot get through to the surgery—should they wait or should they go to A and E?

I agree with the hon. Gentleman that not everybody needs to see a doctor, but another resident told me: “I fell and cut my hand deeply on glass. I went to the doctors to ask if a nurse could check that there was no glass left in. They told me to go to hospital. The cut was really not that bad. But they said they don’t have any nurses on a Friday and I would have to make an appointment to see a nurse—two weeks as usual, no doubt—so I just left it, as I do with most pains, coughs or small lumps, and hoped it would sort itself out. My hand is healing now and seems to be glass-free. I hope so anyway.” That is not unusual in my area. At least that elderly lady could have seen a nurse, but many constituents tell me that they do not bother to see a doctor because of how long that takes, and they take the risk of waiting.

Douglas Carswell (Clacton) (UKIP): I am very interested in what the hon. Lady is saying, because it sounds ominously like the situation in Clacton. Indeed, in one Frinton surgery in my constituency, one doctor was trying to serve 8,000 patients. She is absolutely right to avoid the temptation to blame the patients or to suggest that they are the problem. Does she agree that part of the answer is to ensure there are far more attractive terms for would-be GPs? That does not necessarily mean higher salaries—

Mr Deputy Speaker (Mr Lindsay Hoyle): Order. Mr Carswell, interventions are meant to be short, not speeches. I am sure you have got to the point.

Stella Creasy: It is unusual for me to agree with the hon. Gentleman, but I agree that we need to look at how we can attract and retain doctors. We also need to look at what these problems do to the rest of the NHS.

Let me tell the hon. Gentleman about a constituent of mine who had a problem with his eyesight that was caused by high blood pressure. Because he could not get a doctor’s appointment, he left the condition alone. He has now gone blind in one eye and his other eye is at risk. His elderly wife came to me because she did not want to bother the doctor. We have to change that culture and to consider the consequences of not using our resources to deal with those early problems. When

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we leave somebody like that and they end up going blind, the cost to all of us to help them is much greater than if they had been able to access a GP. We must look at the terms of the job, but also at where the resources are not going. I have been raising those questions with local health care providers.

Michael Fabricant: I am very interested in what the hon. Lady has to say. She said that in her constituency—she must tell me if I have got this wrong—there are a large number of single-doctor practices. Does she not think that that is the cause of the problems, and that the Government should encourage practices to consist of a number of doctors working together?

Stella Creasy: Although I am a doctor, I am not a medical doctor, so I warn the hon. Gentleman that if he needs treatment, he should not come and see me. However, I could tell him why he has no friends—that is the sort of doctorate I have.

There are many issues and the number of single practices might be one of them. My point is that nobody has got a grip of this issue over the past couple of years, despite the fact that I, as the Member of Parliament, have raised concerns. In 2011, the complaints about access to GPs started coming in. I went to the primary care trust, but because of the reorganisation of the NHS, nobody was interested in the case that we were trying to make. The PCT said, “Wait until the CCG is organised.” I tried the new CCG, but six months after saying that it would look into the repeated complaints that I had raised, it said that this was not its issue and told me to go to NHS England.

Initially, NHS England told me that I could not raise the issues on behalf of patients because of patient confidentiality. It could not respond to any of the concerns that I was raising because they related to patient records. It then tried to say that unless the residents had complained to the GPs about GP access, it would not look into the issue, even though I had a binder full of complaints, which showed that it was a problem not just with an individual practice, but with many local practices in my local community. There was widespread concern. The problem continued and, eventually, NHS England came back to me and said, “It’s all right. We’ve spoken to the practices and they have said that if people want an appointment, they can ring up and get one.” It was a circular and deeply frustrating experience.

Mr Bellingham: Will the hon. Lady give way?

Stella Creasy: I will happily give way one last time, but then I want to get on.

Mr Bellingham: I understand the hon. Lady’s annoyance and frustration with her CCG and local health service. In my patch, the CCG is chaired by a GP. It has been incredibly responsive to my concerns and has worked with GP practices. I am just sorry that she has not found that in her patch.

Stella Creasy: I appreciate that that is the hon. Gentleman’s experience. This is precisely my point: why is nobody taking a strategic view of these issues?

I will give the hon. Gentleman an example and it goes to the heart of what the hon. Member for Henley was saying. One concern that people have raised is about

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missed appointments. The appointments that doctors give people do not always match the times when people need to see them. There is no recording of missed appointments because of the fragmentation of the NHS. Who should take responsibility for that?

A snapshot survey that my CCG did, possibly because of nagging from me, showed that on average 10% of appointments are missed in my local community. However, that is an average. In one surgery, 40% of appointments are missed and in another only 12% of pre-booked appointments are used. Irrespective of whether that is just because patients are missing appointments or because appointments are not at the right time, it is a waste of resources. Surely there is a public interest in having a central co-ordinating body that looks at these issues and at where there are problems in the NHS. It is a waste of money for everyone concerned. Crucially for my constituents, it means that they are not getting access to doctors, even though there may well be the facilities to see them.

Even if people can get access to a doctor, the quality of the practices in my local community is very poor. I know that other Member have raised similar concerns. That might be one reason why it is difficult to retain doctors. I have one practice that has been waiting 25 years to be rebuilt. It serves 12,000 patients. Because of the poor quality of the facilities, it cannot offer some basic services such as blood tests. It has not had central heating since January 2014. That is not an acceptable environment in which to provide a health care service.

The problems with GPs in Walthamstow are not just about the facilities. Since becoming an MP, I have worked with a group called WoWstow, which is a group of women who are fighting to get basic sexual health care services in Walthamstow, because we do not have them. When I talk about basic sexual health care services, I am talking about the provision of contraception, the provision of the coil and the provision of basic facilities to help women maintain their public health. We have doctors who refuse to prescribe such things, and then people wonder why my local area has a level of sexually transmitted diseases that is significantly worse than the national average.

There have been widespread complaints about other doctors, to the extent that the General Medical Council is involved. As far as I can see, there is little concern about how we deal with patients who are asked to go to doctors in respect of whom there are known to be concerns about the quality of care that they provide. Nobody is picking up the pieces. Nobody is gripping the issue to ensure that we do not see health care problems in my local community, which very much needs to be able to access GPs.

As my hon. Friend the Member for Halton has set out, all of this means that there are pressures on my local hospital, Whipps Cross university hospital. There are concerns about Whipps Cross itself. One resident wrote to me to say, “All I want is to be able to get an appointment for my child and not have to worry that if she or another member of my family ended up at Whipps I would have to fear for our lives, and that is not an exaggeration.” Barts Health, which runs my local hospital, is a large provider of acute services. It serves a population of 2.5 million in north-east London. The Care Quality Commission has taken enforcement action against it in the past couple of years because of the quality of care.

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The CQC pointed out that if patients in my local community had access to an urgent care centre, they would be able to see somebody and it would improve the quality of care. However, I have just been told out of the blue that the commissioning process for more urgent care centres has been paused because of a lack of remaining bidders. Again, that is a separate part of the NHS from the GP surgeries and the hospitals that is also trying to deal with patients. The system is fragmented and piecemeal, and that is causing problems in a community that needs health care. Without the urgent care centres, there is a risk that many of the health care services in Walthamstow will simply collapse.

I have written to the Secretary of State about GP access. I have raised it with the CCG and NHS England. We have even organised local patients to act as mystery shoppers and go to doctors’ surgeries to ask to join their patient involvement groups. Not one of those people has been able to join a patient involvement group. That is a problem.

In 1958, Nye Bevan spoke in this place about the point of the NHS:

“Many people have died and many have suffered not because the knowledge was not there, but because they did not have access to it. To all the suffering which attends illness, there was always added the bitterness that, if the poor could have had access to the knowledge available, they might have been saved or, at least, might have been helped. It was this situation that the National Health Service was intended to put right.”—[Official Report, 30 July 1958; Vol. 592, c. 1383.]

Sixty-seven years later, the same concerns remain for a new generation of patients facing lifestyle diseases. I am making an open plea to Ministers at the Department of Health urgently to review the provision of health care in Waltham Forest. Please, let us not make early diagnosis a provision only for the rich in this country.

12.18 pm

Sarah Newton (Truro and Falmouth) (Con): I am very proud to be part of a governing team that has spent more money on the NHS. We faced some incredibly difficult choices when the coalition was formed and protecting the NHS was at the top of our list. I have seen for myself some of the benefits of the reforms. Many more decisions about NHS services are now taken in Cornwall, led by clinicians and local people. That is very welcome.

I very much welcome the “Five Year Forward View” that NHS England has put together to cope with the considerable increase in demand on the NHS that is anticipated. Whoever is in government will face the challenge of how we can deliver the first-class services that everyone in this House wants for every constituent in every part of the country.

In the short time that I have, I will share with the House four observations that I have made from talking to staff in the NHS in Cornwall and to patient groups in my constituency, and we could usefully take them forward to help us to tackle some of the challenges we will face in the future.

The first is the role that women can play in addressing some of the work force challenges faced by the NHS as a whole and, in particular, by general practice. The

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second is how we can expand the services provided by GPs’ surgeries. The third is the role that GPs can play in A and E departments, and fourthly I wish to share some of the learning we have had from our great fortune in Cornwall in being part of the integration pioneer.

Mr John Redwood (Wokingham) (Con): Does my hon. Friend agree that our party’s excellent policy of extending GP opening times and days is crucial, but it will require more GPs to work more flexible hours on an agreed basis?

Sarah Newton: My right hon. Friend makes a good point. The plan that NHS England has put forward is about shifting resources from the acute emergency care sector into primary care sectors, especially GP practices. The point that he makes about flexible working fits well with my point about enabling more women to stay in the NHS or to return to it. Many walks of life are addressing the issue of enabling women to combine their caring responsibilities with their desire to play a full part in society, whether that is in public service as a GP, as a Member of Parliament or in business. Much more work needs to be done by the NHS to look at ways to enable women to combine caring for children or elderly parents with being a GP or fulfilling other roles in the NHS.

Women often take a break to look after their families—it is something that I did myself—and it can be difficult for women in their late 30s or 40s to find the ladder back into their previous careers and occupations. I note that many former GPs could make excellent GPs again if they were given the opportunities to retrain and reskill. They could contribute enormously, through working flexibly, to enable GP practices to open more hours.

Dr Poulter: My hon. Friend makes an important point. I hope that she will welcome the opportunity we may have to revisit the issue of the annual performers list. At the moment that means that if a GP is out of practice for a year, it is very difficult to return. That is something that we need to address, and I hope that she will be supportive of the Government’s efforts to address it with NHS England.

Sarah Newton: I welcome the Minister’s intervention. That sounds like an excellent initiative and I am sure that more will follow, because we need to use the talents of everyone in our nation to address the challenges that we face. Women can play an enormously important role in the NHS, as they can in all other walks of life.

Michael Fabricant: I was very interested in the intervention from the Minister, who is of course also a GP. I was also impressed by some of the points made by the hon. Member for Walthamstow (Stella Creasy) about sole GP practices. If we are to have flexibility, so that people can go and see doctors quickly and to enable women and others to go back to work as GPs, it surely requires multi-GP practices, not sole practices. Otherwise, it is just not practical.

Sarah Newton: That is a good point. We have to look at how general practices are set up these days. Not all general practitioners want to be part of the old partnership model, which is a sort of small business. Many now would like to be salaried and work particular hours in

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particular settings. I would not want to prescribe a particular model: we need to look flexibly at different models of provision that meet patients’ needs, taking into consideration what the work force need to enable them to play their full part.

GP practices in my area are expanding the range of services that they are able to provide to the community. As hon. Members will know, I represent a large, remote, sparsely populated part of the country, and such expansion is especially important for rural areas. One example is the Probus surgery of GPs, which serves many villages in its rural community. It is expanding into many areas, including minor surgery. I have yet to come across anyone who has anything other than praise for the Probus surgery, which provides the normal services one would expect from a surgery, but also works closely with its primary care partners and district nurses. It also links up with care managers for people with chronic conditions and elderly people living at home.

By comparison, a very different group of GPs work at Penryn surgery. They serve a large campus that is home to Exeter university, Falmouth university and parts of Plymouth university. There is a growing student population and the surgery has been able to expand its services to provide mental health services, prescribing services and on-campus surgeries. In attracting additional funding for services to meet the needs of the young people—we welcome them into the constituency to study there—they have additional resources from which the whole community can benefit.

Those are two very different examples of how GPs are working positively and constructively with local commissioners to expand services, bring in additional resources and improve patient outcomes for the local community.

Roger Williams (Brecon and Radnorshire) (LD): My hon. Friend represents a very rural constituency, as I do. We do not have any single GP practices, but many of our practices have fewer than five GPs. Our experience is that when one leaves and the practice has difficulty recruiting, it really puts the practice under pressure. Can anything be done to make rural GP practice more attractive to young doctors?

Sarah Newton: That is a very good point, and I was just about to make the point that although I have given two good examples of larger GP practices that are doing very well, I also have similar issues to my hon. Friend in more sparsely populated areas of my constituency, such as the Roseland peninsula. It has an older population and it is difficult for GP practices to innovate and bring in additional services to make their future sustainable. I am in regular correspondence with NHS England, which has taken away some of the specific funding that used to be available to support remote rural GPs, in the expectation that they will be able to attract additional funding for providing additional services. That is really not possible or viable. In order to maintain access for people living in sparsely populated areas, where the population is unlikely to grow rapidly, NHS England needs to look again at funding for GP practices in such areas. I hope that my hon. Friend will make common cause with me in writing to NHS England to ask it to reconsider that point as part of its five-year plan.

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The third point I wish to make is the positive work I see at the accident and emergency department at Treliske. The Royal Cornwall hospital is the only acute hospital in Cornwall and I am proud to have it in my constituency. The head of the A and E department at Treliske has worked innovatively with his primary care partners to introduce GPs into that setting. As people arrive at the hospital, a triage system is in place so that if people would be better served by seeing a GP, they can do so, which takes pressure off the A and E department.

Finally, I wish to share some of the learning from the integration pioneer work that is happening in Cornwall. The Government designated 14 areas of the country as pioneer areas to look at how we can better integrate care services with the NHS. GPs in Cornwall have provided an essential foundation for that work. Our pioneer bid is led by Volunteer Cornwall and Age UK Cornwall—I think it is the only voluntary sector pioneer bid in the country, and it is very much supported by the NHS right across Cornwall, and by Cornwall council.

By working carefully with GPs to identify frail, elderly and vulnerable groups of people with chronic conditions who tend to use the NHS a great deal—GP services, care services or the acute sector—the pioneer discovered that having a trained volunteer attached to a GP surgery to work alongside families, linking up all available support and enabling them to reintegrate into the community around them, leads to a huge reduction in the use of acute and GP services, and, most importantly, significant increases in self-reported well-being.

There are a lot of lessons that can be learnt from the reforms we have put in place. I am confident that if NHS England’s five-year programme learns the lessons from the pilots and the past five years and puts proper resources into primary care, we can see the improved health outcomes I know we all want.

Several hon. Members rose—

Mr Deputy Speaker (Mr Lindsay Hoyle): Order. May I just stress that if we stick to 10 minutes, I can give everybody 10 minutes? If we run over, people will end up having their speeches cut and I do not want to do that to anybody.

12.31 pm

Caroline Lucas (Brighton, Pavilion) (Green): I add my congratulations to the hon. Member for Halton (Derek Twigg) on securing the debate. I am very pleased to have worked with him to have this opportunity today to discuss the vital issue of building sustainable GP services.

Proper funding for our GP services is vital for good patient care, easing pressure on hospitals and ongoing sustainability. The question we need to ask is this: why have Ministers allowed a trend of consistently falling GP funding? The Royal College of General Practitioners made its own concern clear back in June 2013 with an urgent call for an increase in GPs’ share of the NHS budget, so that 10,000 more GPs could be hired. However, recent figures reveal funding to be at an all-time low of 8.3%, something which shows a worrying complacency. In response, more than 300,000 people, including many in my constituency, have signed the RCGP’s petition, “Put patients first: back general practice”. The petition calls for more money to be allocated to GP services.

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Alongside the campaign, the BMA has conducted clear analysis of the serious work load pressure facing GPs, an issue so many hon. Members have raised today.

As the Minister well knows, the drop in share of the NHS budget for our doctors’ surgeries comes at a time when GPs are under increasing pressure and are having to see more and more patients. A situation in which they are seeing 40 to 60 patients a day is simply unsustainable for both patients and doctors. It is horrifying that 80% of GPs say that they do not have sufficient resources to provide high-quality patient care.

GPs in my constituency are telling me that good patient care is being destroyed because of what they see as impossible demands, including as a result of privatisation and a lack of funding for primary care services. For example, in a joint letter to me, seven local GPs said:

“There is no doubt that general practice is really suffering from the lack of investment, impossible demands and never ending re-organisations. If we could stop having administrative battles and spend our precious hours on patient care we would all be much happier, and the service would be better and significantly cheaper to run.”

Dr Poulter: I commend the hon. Lady for making points on behalf of her local GPs. She talked about privatisation. Would she not accept that the funding model for GPs as small businesses in their own right has existed since 1948, when Nye Bevan created the NHS?

Caroline Lucas: I accept that, of course. When I talk about privatisation, I guess what I am referring to is constant fragmentation: the way in which NHS England, CCGs and others are still struggling to get a streamlined process, which makes it more difficult for patients to be seen when they need to be seen and by the person who needs to see them.

Paul Burstow (Sutton and Cheam) (LD): The hon. Lady is now drawing a very important distinction between some fragmentation and fracturing in how decisions are made. That criticism has been levelled at the legislation, but it is not the same criticism she was making initially, which was about privatisation. We know that only 6% of NHS activity and expenditure goes into the private sector.

Caroline Lucas: The right hon. Gentleman is certainly right about the figures, but I would argue that the direction towards greater privatisation is adding to the problem of fragmentation. I am happy for us all to focus on the issue of fragmentation. That is the bigger point I am raising right now and it is the biggest barrier to people receiving the care they need and deserve.

Intolerably long waiting times to see a GP have become a scandal that is putting A and E under strain and people’s health at risk. The inconvenience of increasingly unacceptable waits for an appointment will mean some people simply do not see a doctor about a persistent mouth ulcer or worsening mental health problem that they are trying to get checked, meaning that serious conditions that could be treated will be missed.

One GP told me this week that she knew of two colleagues who are leaving to go abroad. For her, retention of GPs is a crucial problem. Female GPs in particular,

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who have children and perhaps work part time, are finding themselves having to work long into the evening and sometimes long into the night. The issue of retention is ever more pressing as more GPs retire. The current older generation of GPs is starting to do so, and getting enough young doctors to become GPs to replace them is a serious issue.

Tim Loughton (East Worthing and Shoreham) (Con): As my constituency borders the city of Brighton, some of the problems the hon. Lady recounts are similar to those in mine. I spent a lot of time with my GPs recently, sitting in GP surgeries. Does she acknowledge that part of the problem is the shortage of GPs being recruited and the heavy reliance on locums, if one can find them, which is much more expensive? GPs say to me that, despite the very best of intentions from central Government, they are still spending too much of their time filling in paperwork, chasing targets and doing admin when they should be spending that time with their patients.

Caroline Lucas: I very much agree with the hon. Gentleman and thank him for his intervention. Locums are costly and break up the continuity that so many GPs say is vital to being able to provide a good service to their patients.

The Nuffield Trust points out that in October the proportion of GP training places left vacant rose to an historic high of one in eight. NHS England has recently made efforts to make the sector more attractive, but it faces a difficult job with an underfunded, creaking primary care service beset by constant reorganisation and the kinds of fragmentation I mentioned earlier. The Royal College of General Practitioners estimates that about 543 practices in England could face closure in the coming years as GPs retire. Hundreds of thousands of patients could be forced to seek care from other overstretched surgeries, and there is a danger that this could put even more pressure on our hospitals. That exact scenario played out recently in Brighton, with what looked like the imminent closure of Eaton Place surgery in my constituency. That would have left 5,600 patients in limbo and put serious pressure on neighbouring practices. At the very last moment a solution was found, but not before many patients had been seriously worried about the future of the surgery and had started queuing to join other surgeries further afield.

There are serious questions to be asked about what we ask of our general practitioners and the burdens we place on them that are not directly related to patient care. Family doctors want to get to know their patients and to treat them. When I speak to GPs, the message that comes through loud and clear is that continuity is key for doctors and patients. It allows doctors to be more efficient and to get admissions to hospital right. One GP told me that doctors may be more likely to admit patients unnecessarily if they do not know them terribly well, because they do not know what their family or community support might be or how best to judge how great their needs are. On the other hand, the GP who knows their patients well is more likely to spot the early signs of psychosis in a patient who has previously never presented with mental health problems, enabling them to be admitted to hospital sooner rather than later before they have a major episode that puts them at risk.

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The Health and Social Care Act 2012 has mitigated against GPs having the time to get to know their patients. New research from the Nuffield Trust and the King’s Fund finds there has been a significant drop, from 19% in 2013 to 12% in 2014, in the numbers of GPs who report being highly engaged in the work of their CCGs. GPs do not have the time to invest in the new structure and there are now fears that the CCGs could become unsustainable. Ministers should be seriously considering how to lift unnecessary burdens from GPs instead of adding to them, so that doctors can spend their time on patient care. With more resources, general practice can keep more people out of hospital.

I pay tribute to the innovative work on well-being that can take place when doctors have sufficient time to see their patients properly. That could genuinely transform lives. For example, in my constituency a GP told me how, after getting to know her patient well, she prescribed a dog to a man who was depressed after a heart attack. That might sound funny, but it was a simple solution that worked: it was more sustainable, made him much less socially isolated and provided him with regular exercise. Another example of innovative work in my constituency is the homeless health care project. It is incredibly impressive. It works solely with homeless people and people in insecure accommodation—for example, people in hostels or who do not have a permanent address—but it needs a more flexible funding formula to extend its groundbreaking work.

That kind of work captures where the health service needs to be going. The current system was designed for acute infectious diseases, which were a 20th century phenomenon. The current phenomenon is of chronic, complex, multi-morbidities with poly-pharmacy. The trusted family doctor who can spend time with an elderly patient with three long-term conditions and 12 different medications and who brings his wife in to discuss his care is not only providing a good, thorough and caring service, but saving the NHS money; helping to make it more sustainable; preventing the crisis by focusing on their physical, psychological and social needs; and treating them as a family and members of the community.

The local GP who gave me that example is meant to have that elderly couple dealt with and written up in her notes in fewer than 15 minutes—and she is lucky because most GPs are given only 10 minutes. Her practice decided that 15-minute appointments were more efficient, because allowing more time kept more people well, but the system will not cope if there are not enough hours in the day and not enough GPs doing that work. The kindness that is shown by giving longer appointments to prevent the elderly man and his wife from having to come back another time to discuss the different chronic conditions comes out of lunch breaks and evenings. The part-time GPs with kids give a lot in this system, and they are not going to stay if things do not get better.

I want to reiterate the importance of celebrating what happens in our NHS today, in spite of the conditions faced by some people. It is essential that we increase GP funding.

12.41 pm

Paul Burstow (Sutton and Cheam) (LD): I thank the hon. Member for Halton (Derek Twigg) for securing this debate. My name was on the application, but he

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was the person who made the argument that persuaded the Backbench Business Committee. I apologise to him for not being here for his opening remarks or for those of others who have contributed so far.

I was keen to contribute to the debate because it goes to the heart of how we make the NHS fit for the future and do more in the community. As the hon. Member for Brighton, Pavilion (Caroline Lucas) said in her closing remarks, the focus has moved from treating episodes of ill health and diseases of individual body parts to people living with a complex range of diseases. It is that complex co-morbidity that is driving the need to change how health care is organised and delivered in this country. If that does not happen, the system will become unsustainable. At the heart of that is the family doctor and their relationship with their patients and communities, which is a key component of building the system we need for the future.

About two months ago, I and my right hon. Friend the Member for Carshalton and Wallington (Tom Brake) met a group of GPs in my constituency to discuss some of the issues being aired today—Dr Chris Elliott, Dr Brendan Hudson, Dr Alan Froley and Dr Mark Wells—along with a practice nurse. I was pleased that a practice nurse was present, because although we are discussing the sustainability of GP practices, we need to recognise, as I am sure others have, that we are talking about the wider primary care family and the contribution made by many other professionals. We discussed the pressures on practices in our constituencies. The demands have been well documented, but I want to rehearse a couple. One frustration—it has long existed, but some of the GPs felt it had got worse—concerns the expectations around paperwork and reporting, which they feel have now got out of control. That needs to be kept under review and, where possible, streamlined. I hope the Minister will say something about that.

According to data available at CCG level on the performance of primary care and, in particular, access to GPs, in my patch, Sutton scores above average when it comes to getting an appointment, which is good news, but once someone has an appointment and arrives at the surgery, it turns out they have to wait longer than average to actually see their GP. So they can get there, but then have to wait far longer than is acceptable, and often in substandard accommodation. My constituency is a suburban part of Greater London and most of its GP practices are situated in larger houses that cannot accommodate the 21st century primary care we need. We need the investment from the infrastructure fund to flow through and allow for innovation.

Dr Poulter: I thank my right hon. Friend for his point about the money from the Government for GP infrastructure, but is there not also a responsibility on local authorities, when there is additional house building, to look at the contribution developers can make to support local GP and health services by developing GP and other community health care facilities?

Paul Burstow: Absolutely, and certainly in its local planning my local authority does exactly that—it looks at what the community facility needs are. In the southern part of my constituency, in south Sutton, there has been some controversy over plans for a new GP centre. It is planned on a piece of land that was NHS land but

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which does not sit within easy reach of public transport and is perceived to be in the wrong place. It is also less than a mile from a soon-to-be-unused hospital site that many of my constituents feel would be a more sensible location. It will be the basis of a new housing development in the coming years and so will be the perfect place for a consolidation of existing substandard GP surgeries currently based in houses.

In its briefing, the Royal College of General Practitioners has set out some of the pressures on GPs, including increased levels of stress and depression. In a ComRes poll it conducted, eight out of 10 GPs expressed concern that those pressures were leading to an increased risk of misdiagnosis. Yesterday was world cancer day but there are still serious issues with the number of people who do not get a cancer diagnosis until they are in an accident and emergency department, by which point it is far too late, and consequently their lives are cut short.

GPs are at the heart of delivering health care: nine out of 10 NHS consultations take place in a GP surgery, while the number of consultations has increased by 40 million since 2008 to 340 million. Interestingly, according to the 2012 GP patient survey, 1.2% of patients went to a walk-in centre or A and E department because they could not get a GP appointment at a time that worked for them, but that figure has now risen to 1.7%. I am sure the Minister will tell us that those are very low percentages and therefore not a cause for concern, but given the number of consultations—340 million—it does not take a very high percentage to have a significant impact on our A and E departments. Given that there are nearly 14.6 million A and E attendances, we can see that the gearing is such that ensuring sustainable and easily accessible GP and primary care services is critical to getting the balance in the system right.

I hope the Minister will say something about the piloting of 24/7 access to GPs and ensuring we have the right data to better understand which areas are under-doctored so that we do not have to rely on anecdotal evidence. There is clearly a concern about deprived and rural areas not having sufficient doctor cover, but at the moment we cannot map that accurately. I hope he can tell us what is being done to target resources to support areas crying out for better GP coverage. In addition, I hope he can say what will be done to address the fact that, despite the Government’s having identified the need to train more GPs and despite the number of places having increased significantly under this Administration, not enough places are being filled. What is being done to get up to the right number?

Annette Brooke (Mid Dorset and North Poole) (LD): I have visited a number of GP practices and I agree that while they are desperately trying to meet the increased demands, the frustration at not being able to recruit is adding seriously to their stresses and strains.

Paul Burstow: It is said that we need about half of all trainees to go into general practice and, at the moment, only 2,700 of the more than 3,250 places that are available are being filled. That is an issue, but it sits in the context of a global workforce pressure when it comes to medical staff. The opportunity to fill this gap by recruitment overseas will be difficult as well.

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I am conscious that others wish to speak so I shall end by asking the Minister to address the issues of access, of how we make sure that more deprived areas do not suffer a double disadvantage by not having access to good quality primary care and of what will be done to ensure that we cease to have this distortion of funding priorities caused by a payment-for-activity system in our acute sector and a contracting model for primary care that has disadvantaged primary care for too long and led to this reduction in funding that other hon. Members have talked about. I look forward to the rest of the debate and the Minister’s response.


Natascha Engel (North East Derbyshire) (Lab): It is a pleasure to follow the right hon. Member for Sutton and Cheam (Paul Burstow) who, in his previous role as Minister responsible in this area, gained a wealth of knowledge of primary care, mental health and social care, something I want to pick up on in terms of GP services.

I do not want to repeat everything that has been said before, but without a doubt GP services are facing a real crisis. Everybody has mentioned how many people use their GPs. Most people have a GP. Over 90% of all contacts made in the NHS are made through GP services. GPs and GP practices are the absolute bedrock on which the NHS is founded, so we must get this right. At the moment something is going very, very wrong.

I want to put this in context. The hon. Member for Clacton (Douglas Carswell) said earlier that this was about patients, not doctors. Unless we get right the framework in which the doctors are working, it is the patients who suffer. We also need to understand that, over the last 20 years, the number of GP consultations has risen by 25%. There are many more appointments, without the system having changed that much to accommodate that. The average person now sees a GP six times a year, which is double what it was a decade ago, but the word “average” hides something. I represent a constituency with quite high levels of deprivation, but there are a couple of perfectly well-to-do areas where the GP services are not in crisis and are absolutely fine. The problems are in those areas of greatest deprivation. Arguably those are the areas that most need GP services to be running as well as they can. It is also where GPs are under such a lot of strain; some are retiring early and others are not going into GP practice in the first place. I want to emphasise that if a person is deprived, they will use their GP services as much more of a lifeline than others who go to see their GP.

My hon. Friend the Member for Walthamstow (Stella Creasy) spoke passionately on behalf of her constituents. We found in one of our practices where services were starting to crumble that problems compounded each other. Once things start to go wrong, there is a terrible domino effect. A high number of patients are signed up to my practice and one of the partners retired. That one retirement caused the GP practice to go into crisis. We can all sometimes make the situation worse by highlighting an individual practice, in order to try to help as much as possible, and saying that it is in crisis. That means that GPs will not then apply to work there, when actually the issue is not about that one practice; it is one piece of an entire jigsaw. Patients then leave that practice and sign up at a neighbouring practice, causing that practice to

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go into crisis. We need to look at this not from the perspective of North East Derbyshire or Walthamstow, but as a national problem.

Mr Jamie Reed (Copeland) (Lab): Does my hon. Friend share my concern that unless we as a country address these problems quickly, holistically and in a detailed way, we run the risk of creating a two-tier NHS service, in which those who, as she rightly points out, most need care are less able to access it?

Natascha Engel: Absolutely. I am deeply concerned about that, and about where the pots of money are that people are accessing. I will come to that in a moment. One thing I hear a lot locally is, “The problem is that we are all living longer.” Of course it is not a problem that we are living longer; it is fantastic, but we need to change the way we look after people as they get older. The problem is not just dementia, cancer or heart disease; diabetes, as we have heard, is an absolute killer. We need to invest much earlier to make sure that people can manage their illnesses or, hopefully, avoid them altogether. GPs have a fundamental role in that.

What I really wanted to talk about was the interconnection locally. We have had enormous cuts to the budgets of local authorities. Derbyshire county council, which is responsible for social care, has had its budget slashed to a point where it is difficult to provide the levels of care that were provided before. I have a sheltered housing facility called Mallard Court, where 50 people are living independently because they have a warden service. That warden service and the care line allow people to live active, social and healthy lives with a minimum level of support. Cuts to local authority funding mean that that social care can no longer be provided. We are looking at finding other ways to provide it, but taking that warden away means that those people will, in a matter of weeks or months, go into crisis, whereas now they are living independent lives. In looking at GP services, we need to look at that issue as well, as it is the local GP practices who will feel all the pressure of those 50 individuals.

That goes back to my point about pots of money and the ring-fencing of them. We can have social services, GP services and acute care in different places, which sucks up all the money in the NHS. Unless we start to look at all of this, as my hon. Friend the Member for Copeland (Mr Reed) said, as one big picture, the solutions will not be found.

Younger generations are much more demanding, and people have access to the internet. It is good that people are more demanding. That gives a rocket boost to the NHS by making people develop and keeping them on their toes, but we really need to make sure that people are realistic in their demands. The group of practice managers that I meet regularly—they have joined us here today—would say that it is a question of people being realistic in the demands they make on GP services. As MPs, we need to promote that.

I want to talk about normal GP practices. Most of my practices have multiple members. At the moment, there is immense stress and strain on GPs who are partners and own the building that the practice is in. Those employed just as GPs in the practices do not have the same pressure, financial uncertainty and risk that a partner does.

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What often happens is that partners retire young and sell their shares in the ownership of the practice. People are not taking on that risk, but are instead working, often in the same practice, as locums. As locums, they can earn around £100 an hour, and that is before they start charging for additional things on top. Rather than having all that stress and strain, and never really having the time to take a step back and look at the bigger picture of where the GP practice is going, partners are standing down and working as a locum, doing the work that they want to do and getting highly paid for it; that is, so far as I can see, a no-brainer.

Tim Loughton: The hon. Lady makes a very good point. I, too, mentioned locums. Are not the pressures on and requirements of partnered GPs deterring many people? That is why it is easier for Worthing hospital to recruit doctors; it is looking to take on directly salaried GPs to place in the A and E department to relieve pressures there.

Natascha Engel: Absolutely, and we ought to look at the issue of ownership of GP practices quite quickly; perhaps more imaginative ways can be found of ensuring that NHS England and those in the areas finding things most difficult can take on ownership of individual practices and GP services. We need to consider all these different issues. The Royal College of General Practitioners has said that there is a shortage of 10,000 GPs, and we need to get on top of that urgently. We need to make it more attractive for GPs to go into practice. As the hon. Member for Clacton said, it is patients who suffer when there are not enough GPs in the service.

I have worked closely with Steve Lloyd, a GP who is chair of the Hardwick clinical commissioning group, which covers the southern part of my constituency. He took me through all the facts and figures, but the big point he made at the end was, “Cherish it or lose it.” I want to end on that note.

1.2 pm

Anne Marie Morris (Newton Abbot) (Con): There is absolutely no question but that we all have a huge respect and admiration for our general practitioners. They do a fantastic job, and I am immensely proud of our GPs in Devon. Indeed, my GPs do the out-of-hours services themselves; they created Devon Doctors. Although it is accessed through the 111 service, we all love it because we see it as our doctors.

It is unquestionable that GP services are currently challenged—in large part because there has been an awful lot of change. As previous speakers have commented, there are simply more people; we are building more houses; there are more homes. Although being able to live longer is a wonderful benefit, the fact that we have more elderly individuals with more complex needs puts a different level of pressure on GPs trying to deal with this challenge.

The issue of GP numbers is a complex problem. The issue involves training places, attracting people and a whole range of other things. As others have dealt with the matter very competently, my comments will not focus on that particular challenge, but I would reiterate some of the comments made by the hon. Member for North East Derbyshire (Natascha Engel) about the challenges of keeping partners and passing partnerships on to the next generation. The hon. Lady was right that

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the burden of paperwork and bureaucracy acts as a deterrent, and that being a locum provides a much easier lifestyle.

Capital cost is a major issue. I understand that in the old days a loan could be acquired through the primary care trusts—not directly, but there were schemes to enable people to buy into a practice so that the partner could retire—but that that option is no longer there. That shows that there are problems beyond the bureaucracy and red tape—particularly about financing the challenge of GP numbers.

One of my greatest concerns is about rural and deprived communities. I would like the Minister to undertake a proper analysis of where those deprived and those rural communities are. I am absolutely convinced that it is possible to work out what is where, and consider the quality and adequacy of the GP services within those different areas. We need to unpick the problems before we can ever find solutions.

I believe that we need a new model. This has been talked about for many years and under a number of Governments, but I am hopeful that, under Simon Stevens’s leadership, we will come up with something fit for purpose, on which all parties can agree. He is already indicating some changes. I would certainly not advocate another major reorganisation, but he is looking sensibly at the use of GPs in hospitals and similar issues. As I say, we need a new model.

Clearly, we need to consider the possibilities for integrating within primary care and across primary and secondary care. I do not believe in a one size fits all, but we need to look at a variety of models. I am pleased that in my local community, whether it be NHS, social care, the third sector or indeed the private sector, they are all working together to give the quality of care that constituents need. That is greatly to their credit.

I am pleased, too, that in Newton Abbott we have had funding from a pot of £3.5 million for a pilot scheme on dealing with the frail and elderly. It deals with how to look across the spectrum to ensure that these individuals can, with the right sort of support, stay for longer in their own homes, which is clearly better for them as well as reducing pressures on A and E. I very much look forward to seeing the results from that.

The overall model needs to take integration into account, because for too long primary and secondary have been seen as separate sectors, never mind their separation from social care. We need to look, too, at a new physical model. We talk about public health—a responsibility now given to our county councils or unitary authorities—and we need to consider what we can do to keep people healthy and fit. The concept of a hub is important, where medical care and social care, perhaps along with a gym, could be provided. We need something to pull all those things together—a way forward in some areas. I would like to think that that could be a practical solution in one of my towns such as Kingsteignton. It is challenging to find somewhere for a new GP practice: one integrated in that way would enable us to support the serious funding challenges . I would love to think that NHS England has limitless pots of money, but that is simply not true. That is why we need to involve the private sector—providing the gym or other attribute—in making the new hubs work.

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We also need to look at non-physical structure, by which I mean telemedicine. A particular challenge for rural communities is how to use telemedicine more effectively. That could be an additional challenge, of course, because it depends on whether we have the internet and whether individuals know how to use it. It is a challenge that we need to take seriously none the less. We must be careful to ensure that we do not say, “If you live in a rural community, you can have just telemedicine”. That would be a great mistake. One of the greatest fears of my local rural community is that as it becomes more sparsely populated and people become older, they will effectively be forgotten. That would be absolutely wrong. Telemedicine has a place, but it cannot be the only solution.

The main challenge is to meet the need for a long-term plan. I hope the Minister will tell me that he and NHS England have a vision of how to deal with—or at least look at—urban and rural issues, how to deal with deprived and less deprived communities, how to deal with the physical versus the non-physical solution and how to deal with the issue of integration versus stand-alone. We must ensure that we have space and place for the new solutions and the new models.

One of my deepest frustrations is that a good local authority will take into account the housing numbers and the need for a new hospital or a new GP surgery, but because the NHS is not a statutory consultee of the planning process, it is not properly thought through. The challenge is to get the NHS involved. The average GP and indeed the CCG have enough on their plate without getting involved in planning issues. That said, it is crucial for us to get this right, because otherwise we shall be landed with huge challenges. New homes will be built, and there will be no local GP services. Our local plan for Kingsteignton, which was completed recently, provides for a substantial number of new houses, but does not reflect the clear need for additional general practices. We need to find, somewhere in the area, a new space and a new place.

When it comes to planning applications, the NHS is—again—not a statutory consultee, and therefore faces considerable challenges. The number of houses involved in an application can suddenly start to increase exponentially. In the north of my constituency, in the Dawlish and Starcross area, we were to have 1,000 new houses; now we are to have more than 2,000. The local general practices are very worried about how they will cope. Having looked at their existing sites to see how they can develop them, they apply to the council for planning permission, and they cannot get it. They are feeling incredibly frustrated, because they want to provide a service, but there is absolutely no way in which they can do so.

In the case of a development in Newton Abbot, a surgery has relocated, which is great—the accommodation is much better and more fit for purpose—but the issue of bus services has been overlooked, and many people have complained to me that it has not been thought through. That is partly because the NHS has simply not been involved, in any guise.

Local residents are deeply concerned about the changes, and I am regularly approached by patient groups who say, “What are we going to do? We absolutely need to support our local communities, but we cannot see a way forward. We face challenges because existing practices

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cannot expand, because we need funds so that new partners can replace those who wish to retire, and because the grand plan has not been thought through and our local NHS body has run out of money.” Although the financial year has not yet ended, there is no money, and if we are to have a new general practice, we must find another way of securing that money.

There is a huge fear that if the Government cannot come up with a better way of dealing with those challenges, large private organisations such as Boots will suddenly become the new general practices. Boots currently provides flu vaccinations and the like, but it is clear that it is only one step away from starting to look into how it could provide GP services alongside a supermarket or health hub. Access is obviously important, but the fear is that people in rural areas and the elderly who cannot get to Boots will not receive those services.

We need a plan, and that plan needs to be articulated. We must have a strategy to establish how we are to plan for all this—“plan” as in “planning”—and patients and residents must be involved in the decisions. At present, they feel that they are out of the loop. There is a real fear among rural and elderly communities that they will lose out, and we absolutely must ensure that that does not happen.

1.13 pm

Mr George Howarth (Knowsley) (Lab): Let me begin by congratulating my hon. Friend the Member for Halton (Derek Twigg), first on securing the debate—with the agreement of the Backbench Business Committee—and secondly on the typically well-argued way in which he put his case. I agree with every word that he said about the problems, both local and national, that have resulted from the reorganisation and the policies that the Government have pursued since 2010.

I want to draw attention to problems in two general practices in my constituency, particularly in respect of the buildings in which they are housed. I should mention that they are used both by my constituents and by those of my hon. Friend the Member for Liverpool, West Derby (Stephen Twigg). I know that my hon. Friend wanted to be present, but he is having to perform other duties elsewhere in the House.

The two general practices, which I visited last October, are the Roby medical centre and the Pilch Lane surgery. About five years ago, the primary care trust acquired a site close to four surgeries which it originally planned to move into new purpose-built premises. Unfortunately, the development did not go ahead, for two reasons. First, the proposals were caught up in the abolition of the PCT and its replacement by a clinical commissioning group. Secondly, there were some problems with the lease on the premises where one of the practices is currently housed, as a result of which the PCT could not contemplate proceeding with the move. However, both practices are still keen for it to go ahead, and they have the strong support of the CCG: it hopes to develop the site, which is conveniently placed near the existing surgeries.

Let me say a little about those two surgeries. The Roby medical centre has about 1,900 patients, and, because of local housing development, is still growing on an almost daily basis. As well as providing the normal GP services that we all expect, it is involved in

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the teaching of medical students, and is working towards becoming a training practice. It already provides a wide range of services, but would like to provide quite a few more if it had more suitable premises. Obviously, some of the pressure on hospital services would be removed if patients could visit their GPs instead.

The building itself consists of two converted semi-detached houses. It lacks consulting rooms, and the waiting area is restricted, with the inevitable result that patient confidentiality suffers. Some of the staff are housed in a totally inadequate conservatory which is tacked on to the back of the premises. It is clearly not suitable for the staff, and certainly not suitable for the patients. Because of the size restrictions, it is impossible to conduct two surgery sessions at the same time. There is not enough space to accommodate the patients, or to allow movement from the waiting area to a consulting room. Moreover, very little parking is available.

The Pilch Lane surgery has 4,700 patients. Like the Roby centre, it is very successful in that regard. However, it does not meet the current NHS dimension criteria. The toilets are inadequate, one treatment room doubles as a consulting room, and access for disabled patients is almost non-existent. The building is, in fact, wholly inadequate for the needs of both the patients and the people who work there. Earlier today I talked to one of the patients, who, by coincidence, had had an appointment at the surgery yesterday evening in connection with a minor problem. She summed up the position by saying that, although the service that she had received from medical and other staff had been exemplary, the building was simply not equipped to provide the sort of service that we should expect in the 21st century.

In December, I wrote to the Under-Secretary of State for Health, the hon. Member for Central Suffolk and North Ipswich (Dr Poulter), to put all the arguments to him. He will be aware of the problems I have referred to; if he refers back to the correspondence, he will recognise some of the problems I am concerned about. In January I received a response from his ministerial colleague, Earl Howe, which was quite interesting. He basically said that he could not intervene and that there was no action he could take. He concluded with a rather odd use of words; he said that he could not be directly helpful, for which he apologised. The reason he could not be directly helpful is that Ministers have absented themselves from the process and left it to others. I am interested in whether, if Earl Howe could not be directly helpful, the Under-Secretary of State could be indirectly helpful, because this situation cannot be allowed to continue.

I do not want to detain the House any longer. There is a real problem for patients and for the staff in the two surgeries concerned. That problem has been recognised by the CCG—the chair and excellent chief executive have recognised it. I hope that Ministers will use whatever influence they have, whether direct or indirect, to ensure that this long-standing problem is resolved as quickly as possible.

1.21 pm

Jim Fitzpatrick (Poplar and Limehouse) (Lab): It is pleasure to follow my right hon. Friend the Member for Knowsley (Mr Howarth). I congratulate my hon. Friend the Member for Halton (Derek Twigg) and his supporters on securing this important debate.

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I first raised this question on behalf of GP practices in Poplar and Limehouse on 13 May last year and the issue has not gone away, as the Minister is aware. The motion states that the House

“notes the vital role played by local GP services in communities”.

I am sure that we all feel that we do more than note those services—we are very appreciative of them, we value them and have high regard for them. Doctors at the Ettrick Street practice on the Aberfeldy estate in east London, especially Dr Phillip Bennett-Richards, do a first-class job for us and are highly regarded by the local community.

I was grateful last year when the Minister’s colleague, Earl Howe, agreed to meet me and a small delegation from two practices in my constituency.

Mr George Howarth: Earl Howe refused to meet me to discuss the problem I described earlier, which is an unusual thing for a Minister to do.

Jim Fitzpatrick: I am surprised that the Minister declined to meet my right hon. Friend. The Minister certainly showed me every courtesy and I was grateful for the opportunity to meet him, his officials and officials from NHS England. As a result of that meeting, we identified solutions for both the Jubilee Street practice and the St Katharine’s Docks practice, which were under severe pressure at that time. Indeed, last Friday I had the pleasure of attending the opening of the refurbished St Katharine’s Docks practice, which is run by Dr Sarit Patel. I pay tribute to Ms Sue Hughes and the Friends of St Katharine’s Docks for the central role they played in supporting their local GP and his practice. The Jubilee Street campaign, also supported by its local community, was also effective.

Now we have a borough-wide save our surgeries campaign, with banners across Tower Hamlets outside every GP practice. The Jubilee Street and St Katharine’s Docks practices have solutions, but they are not permanent. On Tuesday, I received an e-mail from Sue Hughes. She reports, among many other matters, that

“Dr Patel has found it impossible to have a meaningful dialogue with our local representative of NHS England to discuss in detail the future funding of the Practice. NHS England insist on using one size fits all formulas to calculate additional financial support for GP Practices which clearly have differing requirements. NHS England are not paying the Practice for work they already do over technicalities which NHS England refuse to discuss with them. NHS England disregard ‘quality of outcomes’ when deciding on funding formulas—why is this?”

Having received that e-mail, I wrote to the Minister and I look forward to a response in due course.

The Limehouse practice in Gill street is also struggling to secure its future and is under great threat. I have written separately to the Minister on the Limehouse practice. Other GP practices are under huge pressure. In addition, there is the worry over the future of the walk-in centres at the St Andrews and the Barkantine health centres.

I wrote to the Department of Health about Barkantine because it combines a walk-in centre with a 10-handed GP practice and as a result is able to offer 8 am to 8pm, seven-day-a-week services to patients, which are under threat. The Prime Minister announced some time ago

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that the Government were going to spend significant sums trialling 8 am to 8pm, seven-day-a-week services, but there was not any need. The Department could have easily sent officials to east London and we could have shown them how such services can operate efficiently and effectively. However, that is all under threat.

During recent years, when the PCT was in charge, we had the fastest improving GP services in the country. The CCG has done excellent work and is staffed by first-class people. It is doing all it can to assist but we need NHS England and NHS England London to provide reassurances that all will be well.

Yesterday I received this e-mail in response to my correspondence on the walk-in centres—I thank my hon. Friend the Member for Halton for securing this debate because it is a great coincidence that the e-mail arrived the day before it. The response from the Department of Health is efficient and I am grateful for it. It has some good news. It says:

“NHS England have agreed to extend the existing break clause”—

this is in relation to the walk-in centres—

“in each of these two contracts by 9 months moving this date from 30th September 2015 to 30th June 2016.

Tower Hamlets CCG has applied to become the commissioner of primary care services under delegated approval arrangements from NHS England. If approved, this will become effective from 1 April 2015 and this will become a matter solely for the CCG.”

That is good news as it lifts the immediate threat to the walk-in centres, but it is not a permanent solution; it is a temporary reprieve. However, this is clearly new, certainly to me, and shifts the focus from the Department of Health and NHS England to the local CCG, which I hope will be able to fund the right decisions for local residents on a permanent basis.

On the temporary solution for the Jubilee Street practice, the practice manager, Virginia Patania, reports that meetings have been held with Department of Health officials, including Simon Stevens. She says that there should be protections for

“practices whose MPIG”—

the minimum practice income guarantee—

“has been removed”,

and that

“NHSE is completely ignoring the issue of cumulative losses. In any reply to our challenges to NHSE, there is no mention of the cumulative effect of losses—this has not been addressed by NHSE in any correspondence or response. It is unfathomable to us that NHSE is not or cannot be held to account for having only looked at 25%...of overall losses and estimating these as final.”

She concludes that

“we can demonstrate that populations of the most deprived adults attend GP surgeries up to twice as often as populations of the country’s wealthiest adults. This makes the Carr Hill formula entirely inadequate for areas such as Tower Hamlets”.

Tower Hamlets GPs have offered solutions and we have asked for another meeting with Earl Howe. I hope that we will be successful in that.

Like other colleagues, I have received briefings from the BMA, the RCGP and Londonwide LMCs. What is significant are the stats they all have in common, which my hon. Friend the Member for Halton and others have mentioned. Only 8.3% of the overall NHS budget goes to GPs but they are dealing with 90% of patient contacts. The royal college has estimated that at least 500 practices are at risk of closure and that nationally we need to

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recruit 10,000 more GPs, which has also been mentioned. I got a sticker from Londonwide LMCs this morning saying, “I love my GP.” I refer to it cautiously because I do not want to suggest that I am trying to have a relationship with my GP, no matter how much respect I have for him. Everybody does love their local GP, however, on the basis of the service we receive in east London.

The most threatened practice in Poplar and Limehouse is Limehouse. I have mentioned that I have written in detail about its problems, and I would appreciate a response. There has been extensive contact with NHS England and between NHS England and the practice manager Mr Warwick Young on the minimum practice income guarantee, the quality and outcomes framework and other issues. It is looking like it will lose more than £600,000 over the next seven years. That makes a great deal of difference and the practice could close.

Last year I began my remarks by saying the debate I had asked for was about three things. The first was to find out the nature of the problems facing GP services. The second was to determine whether the Government accepted there was a problem. The third was, hopefully, to identify a solution. We are still looking at the problem. The Government seem to accept that there is a problem and are trying to find solutions, but they have only been partly addressed and not resolved. There is still great concern not only among clinicians and staff, but among patients and residents in Tower Hamlets, that their GP services are not safe.

I know the Government have their five-year forward review and their focus on giving GPs a more central role. I look forward to hearing more about that from the Minister in due course, but the issues are not resolved, and I would be grateful if he would take back my request to Earl Howe for a meeting with him, or at least with his officials, on the three main practices I have mentioned and collectively on GP services in Tower Hamlets.

1.31 pm

Mark Reckless (Rochester and Strood) (UKIP): I thought that GPs had it rather good after their new 2004 contract. They were able to give up out-of-hours care on attractive terms, they saw their pay go up, and there was a system of quality and outcomes framework points which saw many GPs and practices move towards the maximum numbers quite quickly in what seemed to be more of a box-ticking exercise than had been anticipated, and for which there was further income.

However, the more I have looked at this and the more I have spoken to GPs in recent years, the more sympathetic I have become in relation to the pressures under which they operate. There clearly has been a great increase in demand for GP services. There is not agreement on the causes of that or on the importance of various factors, but several factors clearly have played a part. One of them is our population rising by close to 4 million in a decade. A significant part of that is due to immigration, and some is due to natural increase. The population is also ageing, which drives greater demand.

I am also concerned about the change from NHS Direct to the 111 service. I do not pretend to be an expert on this and to be able to give a definitive view, but there is at least some evidence to suggest that the

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111 service with untrained staff, or at least not qualified nurses, taking calls has a significantly greater tendency to err on the side of sending people to their GP than the NHS Direct service did, and that that has been at least a partial cause of the increase in NHS demand.

There is great variety in how often people go to their GP. I am not a regular attender, although I have two young children and lean more towards going—and certainly taking them—than I did in the past. I think people generally come to fairly sensible judgments as to when they need to see their GP and when they can deal with a situation themselves or by visiting a pharmacy. I am not sure it is helpful to have a 111 system that leans so far in favour of being on the safe side and recommending people go to their GP. Clearly the 111 operators and the people running that service do not want to be blamed if someone is not sent to a GP or for medical intervention when they need it. On the other hand, they need to understand that if large numbers of people are sent on to those services when they do not strictly need to be, that will mean others do not get appointments and might not get the treatment they need.

Medway has seen significant population growth. We have particular challenges, but I am extremely impressed with our CCG and in particular Dr Peter Green and Dr Nathan Nathan who lead it. They have a go-ahead, ambitious attitude to what they can do both in their commissioning generally within the health service and now in the very positive approach of co-commissioning with GP surgeries, with GPs in the lead. They know best, and it is a very good basis for making commissioning decisions. I recognise the potential conflict of interest GPs have in commissioning for GP surgeries, but it is good to lean more in favour of having services provided in GP surgeries rather than in hospitals. That can be a positive thing, and I hope the three different models and working with NHS England will be a success in getting the right trade-off in this area.

Medway wants to attract and retain more GPs. That involves in part promoting Medway as a place and showing the opportunities it offers, such as relatively good value housing for somewhere as accessible to London, and a very good and improving living environment in both our rural and urban areas. I had the opportunity myself recently to attract quite a lot of publicity to the constituency and in particular to Rochester, which I hope will be to the good.

We must also deal with the large number of single-handed GPs. Some of them deliver very good care, and there are one or two who, in a self-deprecating way, may say there is a reason why they are single-handed when they are pressed to do things differently. Of course, single-handed GPs have a place in our system, but I believe it will be good if we can persuade larger numbers of these single-handed practices, even some of the smaller ones, to work more closely and to amalgamate. They could share the fixed costs, do less administration and be able to see more patients, or even have more time off in some cases.

It is also key to show that GPs in Medway are doing extra and interesting things. I am particularly impressed by the work that has recently been done on familial hypercholesterolemia. I am interested in that because there has been a collaboration between Medway GPs and the charity Heart UK, which was co-founded by my father. I understand that there is shortly to be a

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study of the success of this programme in Medway in the

British Medical Journal

. That could be an example to other areas. This work has been able to identify hypercholesterolemia not in one in 750 people as before, or in the one in 500 that was suggested may be the rate across the country, but in close to one in 350. By identifying those who suffer from that condition, we can put in place preventive measures to improve health and prevent heart attacks as well as other negative medical developments. The GPs in Medway should be congratulated on this groundbreaking project, of which I am very proud.

Finally, on the difficulties in getting appointments at our GP surgeries, I recognise that there is no perfect appointment system that everyone will be happy with, but we have a particular challenge in the rural part of the Hoo peninsula. The Elms medical practice has its main centre in Hoo and outposts around the peninsula. I recently talked to people in Allhallows, which is perhaps 10 miles from Strood, and Grain, which is 13 miles away from other care and facilities. There used to be two GP medical practices in Grain, but now there is just one. I understand that it is open only between 9 am and 11 am three days a week, although some people in the village say it may not even always be available during those hours—but I would like to speak to the Elms medical practice before saying anything definitive on that. Similarly, I have spoken to many people on the doorstep in Allhallows and although many are satisfied with their GP services, there is a perception that they are not available for as many hours during the week as they should be, and that one day or morning may be set aside for training at certain times. Again, I will check whether that is correct. People in those areas feel under-served. We have talked about a great increase in demand for GPs, but I am not sure that the supply has responded, at least in these rural areas, where there clearly is a need for greater GP services.

In two practices in Rochester people have faced problems with the booking system. At one, people are not allowed to book in advance by telephone or they find it difficult to get through—a lot of hon. Members will be aware of similar stories. This practice then allows people who come in person and queue up outside to jump the queue of people who are telephoning in. I have seen a large number of elderly and often ill people queuing, before 7.30 am in some cases, to try to get an appointment. That cannot be right and I hope we can find ways of ensuring that people do not have to do that.

At another practice in Rochester a lady called up on 30 January to ask for an appointment only to find that the first one that can be offered to her is on 16 March. Waiting for more than six weeks for a GP appointment cannot be right. I am also told that people who book online have preference, and people such as this lady, who do not have internet access, are clearly at a disadvantage. It is also difficult to get through to the telephone booking system, and then it has eight options and only when someone gets through to option 8 are they even allowed to start making an appointment. I recognise that there is no perfect system, but I hope to work with these surgeries to improve their accessibility to the public. I would also like to thank all the GPs and those who work with them in Medway for the work that they do.

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1.41 pm

Grahame M. Morris (Easington) (Lab): I congratulate my hon. Friend the Member for Halton (Derek Twigg) and the hon. Member for Brighton, Pavilion (Caroline Lucas) on securing the debate, and all those right hon. and hon. Members who supported the bid to the Backbench Business Committee, and the Committee itself, on accommodating the debate.

It has been said before that when someone is the last person to speak in a long debate they find that perhaps everything has been said—but not everything has been said today. I will try not to repeat the arguments that have been rehearsed, but I wish to air two specific points that have not been covered. One is about the importance of GP work force planning, and the other is about the north-south divide and the need to refine our recruitment to address inequalities in areas of particular need.

We must accept, although Government Members are reluctant to do so, that we have a crisis on the front line—primary care and GP services are the first line of our NHS. I do not want to apportion blame—I can see the Minister staring at the heavens thinking, “Here we go again”—because I will let others do that. However, I wish to identify some problems and propose some practical solutions to address this crisis, because we face an unprecedented health challenge and it certainly has a bearing on what is happening elsewhere in the health service, particularly in accident and emergency.

We are all aware now, because it has been repeated many times, that we have an ageing population; people are living longer, and they are living with multiple and much more complex long-term conditions. Numbers have been given on the rapid increase even between 2008 and 2018, when we estimate that the number of people living with multiple long-term conditions will rise from 1.9 million to 2.9 million. Dramatic projections are made about the numbers of people who will have dementia, who will be living with cancer—surviving it and living beyond that—who will have diabetes, and who will have heart disease. Despite the increase in the age of the population and rising demand, GP numbers have not kept pace with population growth and with this increase in demand.

As today’s motion states, local GP services play a “vital role” in our communities, with 1 million patients every day receiving care from their family doctor or a nurse based in a GP practice. Many Members have mentioned being contacted by the Royal College of General Practitioners about its Put Patients First campaign, which highlights some alarming statistics: as many as 90% of doctors are saying that general practice does not have sufficient resources to cope; and spending on GP services as a share of the NHS budget has been falling and, at 8.3%, is at an all-time low. Surveys carried out by the BMA have been showing that six out of 10 GPs were considering taking early retirement because of the stress of an increasing work load, with a third of them actively planning for their retirement.

The problem we face relates not only to early retirement, but to retention and recruitment. A large number of GP trainee vacancies are unfilled and there is a stark north-south divide; almost all trainee posts were filled in the south, but in my region of the north-east—an area with the highest levels of deprivation and health inequality, where

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there is already an acute shortage of GPs—30% of training places were unfilled. That was confirmed by the deputy chair of the BMA, Richard Vautrey, who said:

“These figures are deeply concerning and represent a serious threat to the delivery of effective GP services to patients.

They show that we are experiencing serious shortfalls in the number of doctors choosing to train to become GPs, which will ultimately mean fewer GPs entering the workforce across large parts of the UK, most worryingly in already under-doctored areas such as the North”—

including the north-east—

“and the Midlands.”

We need to address the imbalance in posts between the north and the south, because if we do not, as my hon. Friend the Member for Copeland (Mr Reed) indicated from the Front Bench, we will see a division in the standard of care. There is always a risk of this in different parts of the country.

I also recommend the “Securing the Future GP Workforce: Delivering the Mandate on GP Expansion” report by Health Education England. It states:

“There is a variation in availability of GPs of more than 40% between the most under doctored areas”—

which include the area I represent—

“and the areas with most GPs. Our most under doctored areas tend to be those with most deprivation, and therefore with the highest incidence of health inequalities.”

The Centre for Workforce Intelligence analysis shows that GP coverage is especially critical in the north-west and north-east.

I welcome my party’s announcement in this area and the important commitments that have been made to improve the NHS and, in particular, access to GPs. Our £2.5 billion “time to care” fund will help to integrate health and social care services, with more health services delivered in our communities. Inevitably, that will create additional pressures on primary care, and I fully support the aim of setting aside funding to employ 8,000 more GPs. I wish, however, to raise a question with my Front Benchers as well as the Government’s. Increasing the number of GPs alone will not address health inequalities, nor will it improve the health care services of my constituents if those resources are not properly targeted to the areas of greatest need, so I want to see real and practical solutions to the crisis.

First, I would like the Government to take a long-term approach, targeting and offering careers advice to children in secondary schools, sixth forms and colleges in areas where there are GP shortages, raising aspirations and promoting medicine as a viable career choice. If we increased the number of people from the north-east going into medicine, we would increase the pool of medical students willing to work in our communities, particularly if they have an affinity with and personal connection to the health and well-being of the community where they would be in general practice. The problem is that many newly qualified medical students are going back to their home areas in the home counties in the south and south-east.

Secondly, what steps are the Government taking to improve the number of GPs in under-doctored areas? Will they encourage postgraduate training in areas where there is the greatest work force need? One practical suggestion is to pay the student loans of medical students

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who are willing to work in under-doctored areas. In exchange, medical students would be expected to train and spend a specified number of years in employment in an under-served area. A survey by the BMA showed that up to 80% of medical students reacted positively to that option.

I am delighted to support today’s motion. I am interested to hear the responses from the Front-Bench teams on how we intend not only to increase GP numbers but to target and direct GP services to the areas of the greatest need. Without that distinction GP services will never be sustainable in the areas of highest deprivation, and the very communities that need access to greater GP services, such as east Durham, will not have it.

1.51 pm

Mr Jamie Reed (Copeland) (Lab): I congratulate my hon. Friend the Member for Halton (Derek Twigg) and the hon. Member for Brighton, Pavilion (Caroline Lucas) on securing this incredibly important debate. We have had a series of genuinely good speeches from right across the House. I thank the following for their contributions: the hon. Member for Henley (John Howell), my hon. Friend the Member for Walthamstow (Stella Creasy), the hon. Member for Truro and Falmouth (Sarah Newton), the right hon. Member for Sutton and Cheam (Paul Burstow), my hon. Friend the Member for North East Derbyshire (Natascha Engel), the hon. Member for Newton Abbot (Anne Marie Morris), who made a brilliant contribution, my right hon. Friend the Member for Knowsley (Mr Howarth), my hon. Friend the Member for Poplar and Limehouse (Jim Fitzpatrick), and the hon. Member for Rochester and Strood (Mark Reckless), who told us about his constituents who have to wait up to six weeks for an appointment, which is clearly not acceptable,

Finally, I thank my hon. Friend the Member for Easington (Grahame M. Morris), who made some incredibly important points. He mentioned that 1 million people today will visit a GP in England, and that 1.6 million will visit a pharmacist. Some of the answers to the questions he raised lie in making better use of the interfaces that patients have with medical professionals, whether it be GPs, nurse practitioners, district nurses or pharmacists. We need to look at the capacity that we have across the system to do more. He said that 30% of training places for GPs in the north-east remain unfilled, and I am with him on that. It is a real issue affecting my community in Cumbria. I hope he forgives me for calling him telepathic, but I think that we need to produce our own doctors to serve our communities.

We should approach the Royal College of General Practitioners, higher education institutions and further education institutions about identifying people at a young age and encouraging them to go into medical careers and to stay in their communities to practise. I am trying to do that in my own community with the university of Central Lancashire. If that idea is to take wings, it will need significant support from the centre—the Department. Hopefully, we will reach a cross-party consensus on that. My hon. Friend hit the nail on the head with his practical solutions to the problems that so many communities face, particularly in the north-east, north-west and the midlands.

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I also extend my thanks to the Backbench Business Committee for ensuring that this debate took place. The sustainability of our GP services is crucial to the health of the nation and to the overall performance of the national health service.

There are 372 million GP consultations each year and that number is rising. As my hon. Friend the Member for North East Derbyshire pointed out, around 90% of all patient contacts with the NHS are through a local GP. No one can dispute that GPs provide a vital service, but increasing pressures on this service are having a major impact on the NHS as a whole. The service does not exist in isolation, and so a holistic approach to our national health service must be taken if we are to have a system that is fit for the challenges of the 21st century.

I wish to touch on three key tenets to our GP services: the issues surrounding the work force and the impact that they have on the profession; the concerns regarding access; and the wider impact that all these pressures are having on the NHS as a whole. Before I address those issues, I wish to pay tribute to the Royal College of General Practitioners and its chair, Dr Maureen Baker, for its Put Patients First campaign, which has put the problems facing general practice to the top of the political agenda. Like other MPs, I thank GPs around the country for their work under such extreme pressures. They really do perform superbly in difficult circumstances.

The latest GP patient survey was a timely reminder of the problems facing both medical practitioners and patients. It found that one in four people is waiting a week or more for a GP appointment, or not getting one at all. If such a trend continues over the course of this Parliament, we will find that by 2020-21, the number will have risen to more than 22.5 million people. A Patients Association survey revealed that four in 10 people are concerned about the impact that the wait for a GP is having on their health. We may disagree over the causes of those concerns, but there can be no doubt that the Government have overseen a deterioration in the patient experience. Colleagues across the House will have repeatedly heard that from their constituents. Hopefully, the one thing we can all agree on is that there are not enough GPs.

In March 2014, the Government’s taskforce report, “Securing the Future GP Workforce” was published. It said:

“The taskforce has concluded that there is a GP workforce crisis which must be addressed immediately even to sustain the present role of General Practice in the NHS.”

The Government’s own report paints a damning picture. It says that GP recruitment has remained “stubbornly below” the Government’s target, and that

“this cumulative recruitment shortfall is being compounded by increasing numbers of trained GPs leaving the workforce, most significantly GPs approaching retirement, but perhaps more worryingly women in their 30s.”

We have heard that concern from Members across the House.

The report goes on to say:

“Disturbingly, evidence is also emerging from the NHS Information Centre that the GP workforce is now shrinking rather than growing.”

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It also shows that the number of GPs per head has fallen below levels seen in 2009. At a time when demand is rising, such a reduction is having a profound impact on the service that GPs can provide. We know from personal experience and from our constituents that the vast majority of GPs work tirelessly in extremely trying conditions to provide the best care possible for their patients, but under this Government that is becoming harder and harder for patient and practitioner alike.

I speak to GPs from all around the country, including in my constituency, who are on the verge of burning out. GPs are concerned that they are so overworked that they are at risk of harming a patient. I have written to the Secretary of State with regard to comments made to me by a local GP, who said that unless something changes, unless recruitment improves and unless service pressures ease, “we are going to kill someone”. Clearly, that is an untenable and unacceptable state of affairs.

The increase in demand and workload is having a detrimental impact on the morale of GPs. A BMA survey in March last year revealed that more than half of GPs reported that their morale was either “ low” or “very low”. This is a matter not of professional whinging, but of patient safety. The chair of the BMA GP committee said at the time of that report:

“It is clear that General Practice is facing a workload disaster that is threatening its long-term future.”

The Government’s inaction is only making things worse. The work force issues that I have outlined now mean that more GPs are considering early retirement, thus potentially exacerbating an already unsustainable situation. The BMA survey showed that more than a quarter of GPs were considering leaving the profession, six out of 10 were considering early retirement, and a third were already planning for that decision. Instead of delaying, I hope that, in the days remaining before the election, the Government will back Labour’s time to care fund, which, with a budget of £2.5 billion a year, would recruit 8,000 more doctors, 5,000 more care workers and tens of thousands of other new staff by 2020. We would do that by taxing mansions, clamping down on tax avoidance, and raising a levy on tobacco companies. We can fund new medical professionals to ease the work force pressures and to give GPs the support that they need to provide a service on which we all rely.

In response to Labour’s announcement on the time to care fund, particularly on our pledge to produce 8,000 more doctors, the chair of the Royal College of General Practitioners, Dr Maureen Baker said:

“It is good to see that the Labour Party have recognised the resource and workforce pressures facing General Practice and their pledge of 8,000 more GPs by 2020—something the RCGP has long called for—is very welcome.”

In contrast, the Government have missed their own recruitment target, which is having a profound impact on the overall service. I hope that they will back our plans to ease the work force crisis that they have, in part, helped to create.

Moving on to access, despite the best efforts of GPs and other professionals, work force pressures are having adverse effects on patient experience. More than one in four people do not get a GP appointment within a week. The GP patient survey shows a deterioration in access to GP services. When Labour left office, the vast majority of patients could get an appointment within 48 hours, but one of the first acts of this Government—

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something I am sure that they now regret—was to scrap Labour’s guarantee. As a result, it is now getting harder and harder for patients to see their GPs. That is not surprising, given the worsening work force pressures that the Government have presided over.

The Government have failed not just on overall access, but on the continuity of care. They talk of the continuity of care and access to a named GP, yet the GP patient survey shows that one in five people are unable to see their preferred GPs regularly. This, too, is unacceptable. The overall picture of GP access is one of deterioration, not improvement. The Government have heaped pressure on primary care, and now, as we all know from our constituency surgeries, patients are feeling the effects.

By cutting competition and rolling back the market that the Government have imposed on the NHS, Labour has committed to investing an extra £100 million to deliver new options for GP access. The Government should back Labour’s plans to give patients three options for accessing their GP: first, a same-day consultation at their GP surgery; secondly, a GP appointment at their surgery within 48 hours; and thirdly, the ability to book ahead to see the GP of their choice. All Members who have spoken today have raised precisely such issues, and only the Labour party has produced the solutions to those issues, which so many constituents are taking to colleagues. Where possible, some GP surgeries already provide those options, and with Labour’s extra funding and new doctors, we want to give all practices the ability to deliver them.

Timely access to GP services is essential for the whole NHS. The GP patient survey has shown that almost 1 million people have gone to A and E because they were unable to get a convenient GP appointment. That is creating unprecedented demand on our A and E departments, manifesting itself in the number of patients now waiting for more than four hours—something that we all see—and causing reverberations throughout the whole system. The Government’s cuts to social care have also increased pressure on primary care services, and that, in turn, is also increasing pressures on A and E

The constituent services of the NHS do not exist in isolation, and the Government’s failings in easing work force pressures for GPs have had profound effects throughout the system. Instead of addressing these issues, most of which were predictable, the Government blew precious time and more than £3 billion on a reorganisation that was deliberately hidden from the public before the last general election. Only by backing Labour’s plans for thousands of new doctors, funding to improve GP access, and moving towards the greater integration of health and social care, can we really ensure that all parts of the NHS, including GP services, are sustainable for the future.

We have heard about profound difficulties in Walthamstow and other communities. I am one of those fathers who hang on the phone for 30 minutes or longer, trying to get an appointment for a sick child. I do not blame GPs; they are under huge pressures and we have heard about recruitment problems all over the country. I have written to the Secretary of State for Health about recruitment problems in Cumbria, but sadly, I have yet to receive a reply. Will the Minister, if nothing else today, commit to write to every Member who has expressed concerns in the debate to illustrate in

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detail what the Government will now do to help those communities to assist with GP recruitment and sustainability? Universal services require universal standards and the ability of patients to access these services universally.

2.3 pm

The Parliamentary Under-Secretary of State for Health (Dr Daniel Poulter): I thank the hon. Members for Halton (Derek Twigg) and for Brighton, Pavilion (Caroline Lucas) for securing this debate today. I commend them for raising important issues about the resourcing of general practice, access to GP services and the future shape of general practice and how it will continue to deliver high-quality care to patients. In particular, I should like to praise the many GPs who work exceptionally hard every day for our NHS and deliver high-quality care to patients.

The hon. Member for Halton made some other important points about mental health training for GPs. Historically, GPs have not always received training in mental health. That must change. The Royal College of General Practitioners and the Royal College of Psychiatrists support that change, and that is why we have stipulated in Health Education England’s mandate that GPs should receive compulsory training in mental health in future. Health Education England is now working with the royal colleges to put that in place. That important step forward will benefit many patients throughout the country.

I will ask my right hon. and noble Friend Lord Howe to look into the issues raised by the right hon. Member for Knowsley (Mr Howarth) and the hon. Member for Poplar and Limehouse (Jim Fitzpatrick) and to get back to them in due course. Although the hon. Member for Halton raised some important issues, some of which were echoed by the shadow Minister, the hon. Member for Copeland (Mr Reed), it is frankly not good enough to complain now about a GP work force crisis when they were in power for 13 years. It takes three years from the end of foundation training to train a GP, and training a part-time GP takes longer. If there is a work force crisis in general practice, it is because the previous Labour Government did not have the foresight to train enough GPs when they were in power.

Derek Twigg rose

Dr Poulter: I will give way in a moment.

Under this Government, 1,000 more GPs are working in the NHS or training. That is a move in the right direction. We have put in place long-term work force plans to ensure that there are 5,000 more by 2020. We have recognised the pressure that GPs are under, and we have trained and are training more. I hope that the hon. Gentleman will do better than he did in his speech and at least acknowledge the point I have made.

Derek Twigg: With respect to the Minister, I am not suggesting that everything that the Labour Government did was perfect or that we met every demand on us. I tried to make it clear, although he does not want to recognise this, that there were massive improvements in the number of GPs. The Library’s figures for 2003 to 2009 show an extra 5,000 GPs. Many of the GPs now coming into place were trained under the Labour Government.

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Dr Poulter: Indeed, there was an increase in the number of GPs, as there has been under this Government, but it is not good enough to lay the blame for a lack of GPs at this Government’s door, as the hon. Gentleman and the shadow Minister tried to do, when it takes a long time to train more GPs. What may have been a better decision for the previous Government in the advanced work force planning would have been to follow this Government’s example, by saying that 50% of medical graduates should become GPs. Currently, the rate is 40%. That needs to rise to 50%, and we need to encourage more people to become GPs. If we had more equality in where medical graduates end up practising medicine, that would be a big step in the right direction in training the extra GPs needed. If that had been done 10 years ago, we might not have some of the problems that the hon. Gentleman outlined. Indeed, he said that only 27% of GPs were under the age of 40. That reinforces my point about medical graduates.

Duncan Hames: I agree with the Minister that there is no substitute for persuading more medical graduates to train as GPs, but will he look at what can be done to attract women who were GPs back into general practice after they have started a family if that was the reason why they left? Will he also look at the working practices that we require of GPs to find out how that can be a more reliable way to make the most of the GP training that we have committed to?

Dr Poulter: Indeed. My hon. Friend makes an important point and echoes that made earlier by my hon. Friend the Member for Truro and Falmouth (Sarah Newton). At the moment, a valuable part of our general practice work force, perhaps due to life circumstances or the fact that they have started a family and have had two children quickly one after another, face difficulties in going back into practice. Issues to do with the operation of what is called the performers list need to be looked at, and I will ensure that NHS England does so and considers how we can better support GPs to get back into practice when they have had career breaks for legitimate family and other reasons.

Grahame M. Morris: Will the Minister give way?

Dr Poulter: I hope that the hon. Gentleman will forgive me. I may give way later, but I want to make some progress because this is a debate for Back Benchers. I will address the points that he made a little later on.

General practice funding is, of course, important. We must have regard to the primary care work force, how patients access their GP and how we structure primary care to get the best results for patients. It is only by looking at all these together that we can properly ensure the sustainability of the general practice services, which we are all so rightly proud of in each of our constituencies. Some excellent points on local sustainability were made by my right hon. Friend the Member for Chelmsford (Mr Burns) in an intervention, and by my hon. Friend the Member for Henley (John Howell). They spoke about the importance of co-ordinating local planning processes with the local NHS to better support GPs to develop practices in areas of housing growth. I am sure all local authorities will want to look at that in more detail.

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On work force issues, being a GP is still a rewarding and well-paid career, with the average salary for a GP close to £110,000 per year. GPs are often the first point of contact for patients when they use our national health service. We should not lose sight of that in this debate. We have already delivered an increase of 1,051 full-time equivalent GPs who are working and training in our NHS since September 2010. This brings the total number of full-time equivalent GPs to 36,294, which represents a real increase in capacity under this Government. However, we know that there is still more to do. A report undertaken by the Centre for Workforce Intelligence last year warned of a demand-supply imbalance emerging by 2020 unless there is a significant boost to GP training numbers.

Before the report came out we had already made plans through work that Health Education England was undertaking to increase the number of GPs. NHS England has been working closely with Health Education England, the Royal College of General Practitioners and the British Medical Association to produce a 10-point action plan to increase the size and capacity of the general practice work force, which we have backed with £10 million of funding. This plan covers a wide range of measures to recruit more young, aspiring medical students to take up a career in general practice, retain those doctors already working there, and provide support for those GPs who have taken a career break and help them to get back into work—an issue that a number of Members raised in the debate.

Grahame M. Morris: Will the Minister address the point that I raised about under-doctored areas, particularly deprived areas, where we find it difficult to attract GPs? Would he consider writing off the student loans of those individuals in order to make it attractive to work there?

Dr Poulter: The hon. Gentleman and I do not often agree, but I agree with him on this. We have to do more to support medical students and to encourage people from all backgrounds to become medical students. It was a sad indictment of the previous Government that social mobility into many degree courses was falling, and that was particularly the case in medicine. We have been working with the medical schools to look at the importance of early engagement, supporting people from a much younger age, and universities engaging with local communities, as is the case at my medical school, Guy’s, King’s and St Thomas’, where people from more deprived backgrounds are supported and encouraged into medicine by the medical school’s engagement with schools and with pupils from an early age. That is the sort of approach that works.

One of the challenges is the distribution of medical schools and medical places often around our larger cities. The challenge is to support smaller and important medical schools, such as Lancaster, which does a great job of supporting local young people to become medical students and then into medical careers. We need to support those universities to expand where that is appropriate. Many of our traditional models of medical training at medical schools tend to focus from day one on encouraging people to become surgeons. We know that we need to support more people to become general practitioners. What works well and what Lancaster and

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Keele universities in particular do through their syllabus is to encourage more young people to undertake more placements in general practice. That has a good effect in encouraging those medical students to want to become GPs in their later medical careers.

Sarah Newton: Does my hon. Friend agree that the university of Exeter medical school at the Royal Cornwall hospital is an important medical school because it enables people to see general practice in remote rural communities? We know from previous contributions to the debate that that is important in attracting people into remote rural areas.

Dr Poulter: My hon. Friend is right. I spoke to medical students and those teaching them in Cornwall on a visit earlier this year. It is important, particularly for rural areas, to encourage more placements in rural areas in general practice. Often at my hon. Friend’s medical school and other medical schools in remote rural areas, there is a good track record of recruiting more local young people so that they are being educated locally. The hope is that those people will stay and work in the local work force and contribute to the local NHS after they graduate. I hope all hon. Members will agree that that is a good thing, particularly in more deprived areas.

I must make progress as I do not want to intrude upon the House’s time for too much longer. There are two or three important points that I want to make. I mentioned that in the health education mandate in 2014 we mandated to increase the number of GP trainees from 40% to 50% of all trainee doctors. That will make 5,000 extra GPs available by 2020. It is important to note, however, that as well as having the appropriate size work force, we must plan for the future shape of the work force. The new models of care set out in the NHS England “Five Year Forward View” will require different models of staffing, and we need to plan with that in mind. That is why Health Education England has established an independent primary care work force commission, chaired by Professor Martin Roland of the university of Cambridge.

In line with the contributions to the debate from a number of hon. Members, including my right hon. Friend the Member for Sutton and Cheam (Paul Burstow), the commission will identify models of primary care that will meet the needs of the future NHS, including a greater emphasis on community and primary services and the more integrated delivery of care, which will involve the better use of multidisciplinary teams. We have been talking about GPs today, but delivering better care in the community is also about nurses, physiotherapists, occupational therapists, pharmacists, speech and language therapists and the many other health care professionals who play a part in delivering high-quality care to patients in general practices and in the community every day through our NHS.