HC Deb 14 February 1966 vol 724 cc946-55
Dr. David Kerr

I beg to move Amendment No. 8, in page 2, line 40, at the end to insert: (3) Every scheme under this section shall be submitted to the appropriate local authority or authorities for their approval and, if such approval is not given, the schemes shall thereupon be submitted to the Minister or the Secretary of State, whose decision shall be final. The Clause lays down the way in which the Corporation shall devise these schemes. I am not clear whether the scheme referred to in subsection (1) and thereafter is a scheme covering the entire future working of the General Practice Finance Corporation, or whether a scheme, particularly as it is, referred to rather ambiguously in subsection (2), is specific for every proposal for a loan from the Corporation. It may well be that the terms of my Amendment would be out of order if the entire scheme were one laid down and subsequently acted under by the Corporation.

However, I think that the substance of my Amendment remains apposite because of the, we hope, growing tendency of local authorities to implement a programme of health centres. We have heard recently from my right hon. Friend of the very encouraging growth of this facility, but this is not the whole story. There is also a growing demand, when local authorities are rebuilding large areas and creating new housing estates, for premises for general practice to be made available in those areas.

I confess that I am not wholly in favour of this method of progression, but this is what is happening. It is easy to conceive of a difficult situation arising where a group of general practitioners have one scheme in mind for promoting their group practice with the help of the Corporation while the local health authority has an alternative scheme the merits of which, of course, have to be weighed carefully against the other.

Where circumstances would allow for only one scheme to be effectively promoted, it is at least conceivable that the Corporation, lacking any further powers at its disposal, such as those disposed by the local health authority, would then find itself in some difficulty—a situation which might lead to embarrassment. The aim of the Amendment is to assist towards a satisfactory solution of any conflict which might arise where these alternatives are posed.

Mr. Gower

In such a case, could not a similar conflict arise at present? For example, if a group of general practitioners have certain premises in mind, they still have to obtain planning permission and to that extent, surely, an element of approval has to be given by the planning authority.

Dr. Kerr

Local health authorities are not necessarily also the local planning authorities. It is because the two have differing powers that this situation arises.

Dr. Miller

I support the Amendment, because, in these proposals, two authorities are involved—the Minister of Health, or, in the case of Scotland, the Secretary of State, and the General Practice Finance Corporation. Already, there is a sufficiently big gulf between the local authorities and those health services which are not under their control. Anything that can be done to bridge that gulf and bring closer together the local authorities, with their health services, and the general practitioner services, would be a very great advantage.

The Amendment would make it possible for local authorities to have a say in the way in which future developments were to take place in general practice. That would be of great advantage to the whole of the local medical services.

At present, there is a tendency towards too much power to be vested in the health executive councils which in turn, are dominated by local medical committees. The Amendment would provide a method whereby the local authorities would at least have some say in promoting general practice facilities in their own areas. The most important aspect is that it would lead to something eminently desirable in general practice in any area—closer co-operation between the local authorities and the local doctors.

Mr. Wood

I share the doubts of the hon. Member for Wandsworth, Central (Dr. David Kerr). I am not at all clear exactly what is meant by the scheme that the Minister of Health has in mind. No doubt, the right hon. Gentleman will explain what it is. The purpose of the Amendment seems not only reasonable, but essential. I can hardly see the right hon. Gentleman disagreeing with the necessity for the individual health authority's views to be consulted in an effort to gain its agreement. If that were not forthcoming, it would be for him to decide whether the site chosen by a group of doctors was in all respects the right place for the premises to be. Whether the scheme is a small one or a large one, the machinery to be setup—and I have read the report of his discussions with the B.M.A. interests—will, presumably, decide exactly this question of siting and priorities after consultations.

But the right hon. Gentleman may feel that, rather than go the roundabout way of various consultations with the health authorities and the central committee, if the scheme he has in mind is a small scheme it would be best directly to adopt the wording of the Amendment. Surely there would be a certain advantage in going directly to the local health authority and obtaining its approval before any of the rest of the machinery that he has in mind begins to operate.

Mr. K. Robinson

My hon. Friend the Member for Wandsworth, Central (Dr. David Kerr) said that perhaps the Amendment would be out of order if he had misunderstood the purpose of the Bill. It is not out of order. Had it been so, I am sure that it would not have been selected. But the Amendment is based on a misunderstanding which, I think, derives from the use of the word "scheme" and I welcome the opportunity to try to clear up any confusion that there may be.

When we say, in Clause 4, that The Corporation shall perform its functions in accordance with a scheme… we are talking about a general scheme of operations.

As I tried to explain on Second Reading, this is to avoid a whole series of separate directions on different aspects of the Corporation's functions. We want to get the general scheme of operations, particularly operations by Ministers, clear at the very start so that all parties know where they stand. When that one general scheme is approved, the Corporation can go right ahead without any undue day-to-day interference by Ministers trying to give directions on this or that. That is the purpose of having a scheme approved in advance. It does not refer to what I might call individual "projects" for group practice centres, or anything like that.

Perhaps I can reiterate, or, at any rate, clarify, what our intentions are about the processes of consultation that should take place over a particular project—and I hope that I may continue to use the word "project" in this short debate to distinguish it from the scheme, which is a general one. On Second Reading, I said: It is, therefore, intended…that the Corporation should ascertain from Health Ministers that premises are suitably sited and are of a suitable standard before making advances and that Ministers should look for advice to the Health Service authorities concerned."—[OFFICIAL REPORT, 3rd February, 1966; Vol. 723, c. 1380.] These words were very close to those in a paragraph in the first report of the discussions with representative of the general practitioners. We are working out plans for consultation at local level.

Before coming to any final conclusion on the nature of the consultations, we would first like to have the views of the central advisory committee to be set up. But I assure the hon. Members that it is fully intended that the local health authority as well as the executive council and local medical committee should be brought fully into the picture where a particular project is being considered.

Of course, this is of great importance, although possibly of not quite so much relevance in Scotland where, particularly in Glasgow, such considerable development of health centre provision is envisaged. Obviously, one would need to think of group practice centres as fitting in with the pattern of health centres which the Secretary of State intends to establish in the City of Glasgow.

But, quite clearly, it is most important that both the authorities, the executive council and the local health authority, should be consulted about the siting and the nature of the premises. That is certainly our intention, although we see no need whatever to write these detailed provisions into the Bill itself. With this assurance, I hope that my hon. Friend will feel able to withdraw the Amendment.

5.0 p.m.

Dr. David Kerr

May I begin by withdrawing any unintended imputation on the Chair? I am sure that my use of the words "out of order" was quite wrong; I should have said "inappropriate". I hope that I shall be forgiven.

I am most grateful to my right hon. Friend for the assurance he has given us. I, personally, find it perfectly satisfactory, and I beg to ask leave to withdraw the Amendment.

Amendment, by leave, withdrawn.

Question proposed, That the Clause stand part of the Bill.

Mr. Wood

I should like to begin by relieving the right hon. Gentleman of any anxiety I may have caused him—by suggesting, in an Amendment you have rightly not called, Mr. Grant-Ferris, to leave out this Clause—by saying that I do not intend to ask my hon. Friends to vote against it because I fully appreciate that, constitutionally, he and the Secretary of State for Scotland must preserve a final authority, and, therefore, it would, I think, be quite impossible to disagree with the powers which are here suggested to approve or modify any scheme suggested by the General Practice Finance Corporation, and it would be impossible to disagree, I think, that the Minister and his right hon. Friend should have ultimate power of direction.

My reason for raising the matter now is to ask whether the balance between the independence of the Corporation and Government control has been properly struck. On Second Reading, I asked a number of questions which the right hon. Gentleman, probably rightly, forbore to answer because, he said, they were matters for the Corporation to decide for itself. I find it perfectly reasonable that he should say so, and, indeed, I should like to see the Corporation given a very substantial degree of independence, and the question which I am raising now is whether, apart from purely commercial decisions, the Corporation will enjoy any real independence.

The right hon. Gentleman has told us before, and in the last short debate we had, that it could not be expected to form views on the siting of premises, and therefore, I understand that it would consult the Health Ministers, who would consult the Health Service Authorities concerned, and the real arbiter, the final adviser, would be the Central Committee, on which the medical profession would be represented.

Mr. K. Robinson

It would only be the real arbiter in case of any serious dispute and would obviously be giving its advice on matters of general policy.

Mr. Wood

I see. This would be the final adviser in a dispute. This system seems to me to be generally wise, because the Central Committee, and, indeed, the other authorities the right hon. Gentleman would consult, are likely to know more about siting and the priorities than the Finance Corporation itself even though it were to have members, as, I believe, is the intention of the Minister, who would themselves be general practitioners.

I am, however, still left with doubt whether all this does not make a rather empty shell of the Corporation. It seems to me that, if the right hon. Gentleman wants—I am disposed to agree that he is right to want—to keep a tight control of the new system, there might be something to be said for the loans to be administered by his Department itself, advised, as necessary, by perhaps two committees, the first committee giving advice on the kind of commercial decisions which it is now proposed the Corporation would itself take, and a second, a siting and priorities committee, or whatever machinery would be right to give advice on that sort of question.

I am prepared to believe the right hon. Gentleman has unanswerable reasons for the provisions he has proposed, and, in particular, he may be able to convince us that, although the Corporation appears to us to be somewhat pinioned, it will be able to fly strongly and freely over the heads of himself and his right hon. Friend. We are ready to be convinced that only the Corporation can adequately discharge the function of financing general practice, and that under the right hon. Gentleman's proposals the Corporation has sufficient independence to do so, but at the moment I do not know enough of what is in the right hon. Gentleman's mind to be so convinced. Therefore, I shall listen carefully to the reasons which the right hon. Gentleman will tell us have persuaded him to choose the particular method he has proposed in the Bill.

Mr. K. Robinson

I hope that I can convince the right hon. Gentleman both that this is the best method of proceeding and, also, that I am as concerned as he is that this shall be a genuinely independent Corporation.

Perhaps I could just give him an idea of the sort of directions which we might give to the Corporation after receiving advice from the central committee, provided, of course, that these things are not dealt with in the scheme itself. They would be directions about priorities—for example, purpose-built premises for improved practice, generally in groups, would I think, by general consent, have the first claim on resources; and loans for new premises and improvements. Similarly, a loan to a doctor taking over a practice would, for example, have priority over a loan to an established doctor to enable him to repay an existing loan for his present premises. These are just examples of the sorts of priorities I have in mind. Then, we should ask the Corporation, in making loans, to give special consideration to the needs of the under-doctored areas.

These are indications of what we have in mind, but of course, it is necessary to have a general power of direction under the Bill because one cannot anticipate the eventualities which may arise.

The right hon. Gentleman said he wants to be assured that the balance between independence, on the one hand, and control by the Ministers, on the other, is about right, and he thought that possibly under the proposed arrangements the Corporation might be something of an empty shell. He said I wanted to keep tight control of the new system, and he thought I was probably right to want tight control. I do not want to have tight control of the Corporation. I want Ministers to have as loose a control as is consistent with safeguarding the Treasury interest, which has to be safeguarded, and consistent also with the development of a proper pattern of provision for general medical services. As long as we can be assured of that, I want the Corporation to have as free a hand as it can, and I am sure that this is the desire of the profession also.

Equally, the profession—certainly the representatives with whom I have negotiated—recognise that the degree of control or direction which is proposed in the Bill is the minimum that the Government, in considering the responsibilities of the Treasury in a matter of this kind, could reasonably ask. I hope, therefore, that the right hon. Gentleman will accept that we want to give the Corporation reasonable freedom.

The right hon. Gentleman asked whether I could consider setting up a siting and priorities committee. The purpose of the proposal which I put to the House and which we shall put to the Corporation is to get local decisions. If we were to have a siting and priorities committee, however, the decisions would become centralised again. We already have the net work of local health authorities and executive councils, who know the conditions, who know the sort of place where a doctor's surgery or group practice premises are particularly needed and, equally, who would know where they would be inappropriate when considered alongside existing premises or premises to be planned—perhaps a local authority health centre—of which the applicant for the loan might be unaware. This is why it is important that the advice on siting should be decentralised and that there should be reference back to the central advisory committee only if there is a dispute which cannot be settled at local level.

Subject to that, however, the questions of how the Corporation borrows in accordance with the provisions of the Bill, the rate of interest which it charges and how it decides to interpret the provisions that it shall break even taking one year with another are commercial matters about which I am anxious that the Corporation should take its own decision.

I hope that what I have said has gone some way at least to reassure the right hon. Gentleman.

Mr. Wood

As I explained to the Minister earlier, I am only too ready to be convinced that the Corporation has adequate independence to do its job. I am still not clear exactly how the right hon. Gentleman envisages that it will work. He told us a few minutes ago that the scheme which we are discussing in the Clause would be a general scheme; and, presumably, the general scheme will contain certain lines of approach for the Corporation to follow.

It seems to me, however, that directly the general scheme begins to be particularly applied by the Corporation, the Corporation has immediately to go to one adviser or another concerning particular priorities in relation to the general needs in an area and certainly on the question of siting. This was why I raised the question of whether, in the carrying out of its general scheme, for which the Minister and his right hon. Friend will have given approval, the Corporation will have any degree of freedom or, because of its lack of knowledge on these questions, it will apply continually to the Minister and to other advisers about how to exercise its power in each individual case.

Mr. K. Robinson

The best analogy I can put forward in trying to convince the right hon. Gentleman further is that of a building society. The Corporation will be a money-lending body and all decisions about the creditworthiness of applicants and the like, which a building society would consider in the normal course of business, would be for the Corporation to settle. A building society is not, however, required to take decisions on whether, say, a new house on which it lends money is appropriately sited. That can be safely left to the planning authorities. It is, however, important that general practice premises should be in the right place. If the central body which was lending the money had to make judgments of that kind also, it would need to be a very different kind of organisation.

5.15 p.m.

I imagine that there will be a fairly simple and routine procedure whereby an application which is made for premises at a certain site will be automatically referred for advice on siting to either my right hon. Friend the Secretary of State or to myself, who will immediately get in touch with the local health authorities and the executive council in the area in question. Normally, they would probably say that there was no objection to the development in the area where it was proposed and within a short time we would be able to tell the Corporation that there was no objection from the planning and siting aspects. There would be no need to hold up the application on those aspects unless there were a dispute in an individual case.

The point which I am trying to make is that the Corporation would be a totally different kind of body if it were to be called upon to make that kind of judgment. I do not think that the procedures which are proposed will be unduly cumbersome or time-consuming. If they are, we can always reconsider them. This is not spelt out in the Bill. It would, no doubt, be part of the scheme to lay down the procedures which the Corporation would be expected to follow. As the right hon. Gentleman will see from the Bill, the scheme can be modified at any time.

I suggest that the right hon. Gentleman has faith and at least agrees with us that the scheme should be tried out and that if we find that any of the difficulties which he envisages are real, we can always consider modifying it. For my part, I do not think that the right hon. Gentleman's fears will prove to be well founded.

Question put and agreed to.

Clause ordered to stand part of the Bill.