§ Motion made, and Question proposed, That this House do now adjourn. — [Mr. Lennox-Boyd.]
§ 10.3 pm
§ Mr. Michael Colvin (Romsey and Waterside)
I wish to raise the problems of the funding of general practice training for medical students. We all accept that primary health care is the foundation of the National Health Service, yet it is the one aspect that we need to take more seriously when medical students enter their clinical courses. It is an issue with which I came face to face when visiting the Aldermoor health centre on the edge of my constituency last summer. I wish to thank the head of that facility, Professor John Bain, for having sparked off the inquiry that led me to ask parliamentary questions on this subject and also to introduce this debate.
Everyone knows that there have been remarkable technical advances in medical care during the past three decades, and more can be expected. At the same time, there has been a matching growth in awareness of the importance of the social and psychological implications of being ill. General practice in this country must respond to both developments. Teaching medical undergraduates about medicine in the setting of the family and community and about how patients should be most sympathetically and effectively cared for outside the hospital is a special responsibility of all departments of general practice which have been created in the 31 medical schools in this country.
Such new departments face important problems. Most are understaffed and all are under-resourced. They practise, teach and research a discipline which attracts high public demand but which does not enjoy the drama of acute hospital services to catch the public eye or perhaps the public purse. Their teaching is necessarily based on small groups and clinical experience on one-doctor to one-student attachments. We accept that such methods are expensive of the time which would otherwise be given to patient care.
The shortage of university funding also puts pressure on medical school budgets. Although NHS funding may be well ahead of the rate of inflation, it is not ahead of public wants and expectations, and the ability of the NHS to supplement the shortfall in medical school budgets has been exhausted. One good way to guard against the misuse of high cost specialist services in the NHS is to promote their more sensitive use through more teaching of medicine in the setting of general practice, but this comes at a time when the NHS and medical schools are finding it difficult to fund this new and major academic discipline.
I shall say a little about the background to the debate. Just over a year ago, the Mackenzie report, which is entitled "General Practice in Medical Schools of the United Kingdom", described the achievements of the departments of general practice in the years since the first chair was established in the United Kingdom. Indeed, the first chair anywhere in the world was established in Edinburgh in 1963. The report also described the problems that are faced by the discipline in the immediate period ahead, and referred to the need for simple and relatively inexpensive measures to be taken to allow proper growth to take place.
I take this opportunity to pay tribute to the work of Professor John Howie, head of the department of general practice at Edinburgh university. As one of the main 275 architects of the Mackenzie report, he is a leading campaigner for the implementation of its recommendations.
The interdependence of the links between the DHSS and the DES in the funding of medical education is well known. The DHSS contribution to undergraduate education, which is required under section 51 of the National Health Service Act 1977 for England and Wales and section 47 of the parallel 1978 Scottish Act, is recognised, or perhaps rationalised, in what is known as SIFT, the service increment for teaching element in the teaching hospital funding, and ACT, the additional for clinical teaching in Scotland.
It is difficult to quantify how much money this involves and what proportions represent the tertiary health care service, and the teaching and research functions of teaching hospitals, but the total sum involved is now between £20,000 and £30,000 per clinical student year, which, for 4,000 students in each of three clinical years, represents between £240 million and £360 million annually.
Alas, by a series of mischances—mainly historical—departments of general practice do not benefit from the notional budget, although their present and potential contribution to medical practice, medical thinking and medical education is considerable. Their need for service increment is as great as that of any of the hospital components of medical education. Their request for new investment to correct that anomaly is modest — £4 million a year. That is only a little more than 1 per cent. of the NHS contribution to teaching research in hospital specialties.
That raises three questions: first, is the cause a good one and does it attract widespread support; secondly, is it affordable and will it create benefit; thirdly, is there a mechanism for meeting the request or, if not, can one be found, and found quickly? On the first question, there seems no doubt that the cause of providing proper resources to allow properly supported departments of general practice to make a proper contribution to medical school and medical education is a good one. In the Green Paper on the future development of primary health care, Cmnd. 9771, the Government stated:However, the undergraduate course content varies widely between medical schools, and in some general practice still forms only a relatively small part of the curriculum. There is scope for greater emphasis on the role of primary care and its interface with the hospital and specialist services. This would benefit not only those who then decide to seek entry to a general practice vocational training scheme, but also those students wishing to pursue a career in a hospital speciality since they would carry with them a greater understanding of the central role primary health care plays in the health of the nation.No one argued with that during the consultation period on the Green Paper. When the Social Services Select Committee discussed it during the 1986–87 Session and published its report entitled "Primary Health Care", it specifically requested investment in that area. Paragraph 25 states:
The case for introducing all undergraduates to primary health care is surely overwhelming and we suggest that University Departments of General Practice should be expanded to become Departments of Primary Health Care, not only to allow future general practitioners to be introduced at an early stage to medicine in the community but, perhaps more importantly, to introduce doctors who will spend their careers in hospital to an area of health care responsible for the 276 majority of episodes of illness and which, to be successful, must integrate closely with the secondary care provided in hospital.Furthermore, the education sub-committee of the General Medical Council has now joined in calling for proper investment, which it sees as an essential prerequisite to the basic medical education of the nation's future doctors. The responses to the Green Paper from the GMSC and the Royal College of General Practitioners, which are sometimes seen as representing the "political" and "educational" wings of general practice, are also agreed that the case presented in the Mackenzie report needs to be met urgently. The medical sub-committees of the Committee of Vice-Chancellors and Principals of the Universities of the United Kingdom and the University Grants Committee have been equally wholehearted in their support.
Only today I received a letter from the British Medical Association, which sent me a copy of the resolution that was passed by the Conference of Medical Academic Representatives in 1987, which states:That this Conference supports the Mackenzie report and is disturbed by the low level of government funding which is available to academic departments of general practice.Hearts and minds seem to have been won across a remarkable and probably unique width of political, medical and educational opinion.
What about the cost? Of course, the £4 million for which the departments of general practice are asking is either a lot of money or not much money, depending on how it is viewed. Compared with the £1.5 billion that was the cost of the general practice prescriptions issued in England in 1985–86, or with the sum of about £10 billion that was spent on the acute hospital services that are used when patients are referred to hospital for investigation and treatment, the sum is negligible. However, for hospital doctors and future general practitioners, attitudes to the prescribing of drugs, the investigation of patients and the use of hospital services are learnt early in medical training. A more broadly based early undergraduate teaching with greater emphasis on the role of good general practice will produce a more balanced use of services, which will be better for the patient and less expensive for the nation. The investment of £4 million, representing 1 p in £50 of NHS resourcing, will be recouped many times over. It is good value for money.
On the mechanism, I am aware that active discussions are in hand involving, among others, representatives of the heads of departments of general practice and senior officials at the DHSS. Those discussions are mentioned in the recent GMC report. But similar discussions have fallen in the past because of legal advice to the DHSS that no mechanism existed to allow a payment giving the same benefits as SIFT to be paid by the NHS to ensure adequate base line funding of departments of general practice.
The purposes of the debate are, first, to hear confirmed the Government's acceptance of the merit of the case being argued by departments of general practice; secondly, to hear from the Government that they accept the need to allocate an annual figure equivalent to £4 million at current prices to be paid through DHSS channels; and, thirdly, to ask whether a mechanism has been found to allow such funds to be administered, or whether such legislation is needed and, if so, when it can be expected. To work equitably and efficiently, the mechanism will need to reflect medical student numbers and to be available through the regional health authority budgets, or their 277 equivalents in Scotland, where our 31 medical schools are sited. The distribution will need to reflect the different legal arrangements which apply and will thus need to be apportioned on the advice of the head of the department of general practice in each medical school.
My hon. Friend the Minister has a reputation for getting things done, so I should be grateful if she would reassure the House of effective progress on all three fronts. May we be told how soon the discussions, which in one form or another have occupied the time of three Administrations, can be satisfactorily completed? In short, will the DHSS and the Department of Education and Science acknowledge that they have a joint responsibility for funding medical education and get their act together rather than continuing to pass the buck to and fro?
§ The Parliamentary Under-Secretary of State for Health and Social Security (Mrs. Edwina Currie)
I congratulate my hon. Friend the Member for Romsey and Waterside (Mr. Colvin) on his success in the ballot and on the lucid and thoughtful way in which he introduced this important subject.
Undergraduate medical education is primarily the responsibility of the universities, which means the University Grants Committee and the Department of Education and Science. However, the health departments have a close interest, first, as providers of clinical facilities through which clinical training takes place and, secondly, as customers, for most medical graduates will be employed by, or be general medical services contractors in, the National Health Service. It is also important that training, especially in primary health care, relates to NHS policies and objectives.
Section 51 of the National Health Service Act 1977 lays a duty on the Secretary of State to make available such clinical facilities in connection with medical teaching and research
as he considers are reasonably requiredby the universities. That provision goes back to the early days of the NHS and is the basis for the service increment for teaching — or SIFT — in the allocations of health authorities under the RAWP formula. Although the Act may require health Ministers to provide general medical services within which undergraduates can be introduced to general practice, that type of training is comparatively recent and no specific financial arrangements have been made to cover service costs. For its part, the General Medical Council has stressed the need for this part of the syllabus.
Earlier this year, the Croham report on the review of the UGC called for closer liaison between the Department of Education and Science, the UGC and the health Departments and between education and health at local level. As a result, co-operation between the DHSS and the Department of Education and Science has increased. One result was the issue in March of a note of guidance by the two Departments to health authorities and to universities about the planning and funding of undergraduate medical education.
That joint note did not refer to the general medical services and did not cover clinical training and general practice. However, for many years the health Departments 278 have accepted the role that university departments of general practice can play in the improvement of standards of primary care.
The Mackenzie report, to which my hon. Friend for Romsey and Waterside referred, provides a new and important survey of the development of what we might call academic general practice. General practice is relatively new as an academic discipline. It is only 30 years ago that the first university department of general practice was created, sadly not in England, but in Edinburgh. It was only in 1986 that every medical school in the United Kingdom had at least one GP appointed to a university post with responsibility for teaching the discipline. The development of general practice as an academic discipline has therefore been somewhat uneven. Many of the arrangements that had been made have been reflected in local university and clinical opportunities and needs, as the Mackenzie report pointed out in chapter 1.
My hon. Friend may not be aware that last Friday I had dinner with one of the other authors of the Mackenzie report, Professor Hannay in Rotherham. In between the pate, the cream soup and the roast potatoes we discussed these issues and many others. I was grateful to him for his wise advice.
There is, however, agreement that general practice is an essential part of every undergraduate medical student's medical training. It is now required by the General Medical Council. As my hon. Friend rightly pointed out, the Government document "Primary Health Care: An Agenda for Discussion" published last year, noted:
Undergraduate course content varied widely between medical schools.It suggested that there was scope for greater emphasis on the role of primary care in undergraduate teaching. My hon. Friend is right that those proposals have had widespread support since they were published.
Only a minority of the staff of departments of general practice are full-time salaried academics. Similar to other academics, these people are clinicians who see patients as well as teach in the medical school. In fact, many are National Health Service GPs with a part-time commitment to the medical school and may be compared with hospital clinical staff who have honorary academic appointments.
The hospital-based academics appear to have substantial advantages over their GP counterparts. The professor or consultant has junior medical staff who can assist him in the provision of services to patients and often in the clinical teaching of undergraduates and research. The university GP has no subordinate medical staff and he retains a personal responsibility, as does any GP, to provide continuing cover to his patients. That is in the nature of general practice.
It is a concern of teachers of general practice that their general practice service work may take a large part of their time, leaving them little time for their research and teaching which are crucial to their intellectual development and the academic recognition that they deserve. In a recent letter to "GP" magazine Professor Metcalfe—I read that magazine every week — claims that the university GP's average list is 79 per cent. of the average GP and therefore that is bound to effect his income.
For some years Professor Howie has argued, including in the Mackenzie report, that there should be more NHS support for teaching in general practice and that specifically there should be an equivalent in the GMS to
279 the service increment for teaching that exists in the hospital and community health service. In our view it is not as simple as that. The differences in the ways the GMS and the hospital services are funded makes the proposal of a service increment for teaching analogue difficult. In the allocations to health authorities under the RAWP formula the SIFT is identified in recognition of the fact that teaching hospitals have higher costs than other hospitals, and of the duty of the Secretary of State to provide clinical facilities in support of teaching.
In the GMS there is no comparable allocation. General practitioners are independent contractors. The target level of remuneration is determined in relation to the service workload and individual GPs are paid on the basis of the services they provide.
The Mackenzie report argues that GPs who have a student attached to their practice take longer over their consultations and over their GMS work generally. The authors estimate that this might amount to an extra two hours a day or an extra 40 hours for a typical four-week attachment. There is considerable variation between medical schools in the lengths of attachments. The health Departments do not have conclusive data on the extra hours involved, but our inquiry suggests that a GP — whether in a university practice or any other practice — who is providing suitable clinical training for a student will take significantly longer over his GMS work.
GPs who teach postgraduate trainees, known as vocational trainees, receive a training allowance. However, the NHS pays no such allowance to GPs who take undergraduates on attachment. Some GPs outside the university practices are recognised as tutors and are paid small sums by the university as part-time lecturers, but the majority of GPs who take undergraduates receive only an honorarium, if anything. They do it, therefore, out of the goodness of their hearts and because of their belief in the importance of the training for the future of their profession and for the quality of care.
As my hon. Friend said, the Mackenzie report calls for support of up to £4 million a year from the Health Service. However, the specific proposal that it makes is for a payment of GPs on the basis of the extra hours' work involved in having a student attached. At, say, £400 for an average four-week attachment for 4,000 students, which is the typical medical school intake per year at the moment, the cost would be not £4 million but £1.6 million. That only emphasises that there are administrative and financial details that would need to be worked out with great care if a scheme were to be introduced, hut, as my hon. Friend realises, at present it would he illegal to make such 280 payments and it would require primary legislation. However, with the appropriate primary legislation, it would be tolerably easy to devise methods of payment, possibly through the existing payments system — the family practitioner committees in order to have convenience and keep administrative costs under control.
I hope that what I have said demonstrates that the value that the Government place on general practice is evidenced by the discussion document on primary care. We also have a White Paper that will be forthcoming shortly. Most patients' episodes of illness requiring medical treatment are handled by GPs. The primary care services are both the front line and the public face of the NHS. Indeed, I have seen suggestions that for a typical person in this country, the total period of in-patient service that he will require is about 10 days every 10 years, yet half a million people consult their GP every working day. That gives our view of how important general practice is.
General practice and primary care are an essential part of the training that we give to doctors and are likely to become increasingly prominent. My colleagues in the other health Departments and I are keen to improve standards in general practice. The university practices have an important role in raising standards, especially in the inner cities and in other difficult areas.
§ Mr. Colvin
My hon. Friend said that there would be a White Paper, which I welcome. A White Paper normally follows a Green Paper—in this case it was a blue paper. Often White Papers are intended to outline the Government's intentions. My hon. Friend has also hinted at primary legislation being required to overcome the legal difficulties of making those payments. Do I take it, therefore, that the White Paper will contain the seeds of a Bill that might come before Parliament before long?
§ Mrs. Currie
The Government may propose, but the House disposes. Ultimately, it will be for this and the other place to decide. A number of the changes that are suggested in the White Paper will require primary legislation. We hope that we might be able to make progress before long, with the will of the House.
I am very glad that we have had this short and most useful debate. In recommending that my hon. Friend reads the forthcoming White Paper with the greatest of care, I hope that he realises that the Government are not at all unsympathetic to the views that he has expressed tonight.
§ Question put and agreed to.
§ Adjourned accordingly at twenty-eight minutes past Ten o'clock.