National Health Service and Community Care Bill

HL Deb 30 April 1990 vol 518 cc779-856

3.7 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Baroness Hooper)

My Lords, I beg to move that the House do now again resolve itself into Committee on this Bill.

Moved, That the House do now again resolve itself into Committee.—(Baroness Hooper.)

On Question, Motion agreed to.

House in Committee accordingly.

[The CHAIRMAN OF COMMITTEES in the Chair.]

Clause 12 [Functions of Family Health Service Authorities]:

[Amendments Nos. 102 to 103ZA had been withdrawn from the Marshalled List.]

Lord Ennals moved Amendment No. 103A: Page 13, line 5, at end insert: ("( ) A Family Health Service Authority within the meaning of this Act shall seek to ensure that any person who is a member of its resident population shall be accepted as a patient of a General Practitioner who is able to meet the requirements of that person for primary health care services. ( ) A Family Health Services Authority within the meaning of this Act shall seek to ensure that any person who is homeless within the meaning of Part III of the Housing Act 1985 shall be accepted as a patient of a General Practitioner who is able to meet the requirements of that person for primary health care services.").

The noble Lord said: We start today's series of amendments with an extremely important amendment. It is designed to ensure that no one but no one shall be excluded from the right to be accepted as a patient of a general practitioner whether they be normally resident in an area served by that general practitioner or homeless within the meaning of Part III of the Housing Act. Its importance is due to the fact that inevitably, because of the nature of the legislation there will at least be a tendency among some GPs to accept those who may not place heavy calls on their practice and, because of the nature of the new contract, to accept those who can bring new income to the practice through services such as smear tests, vaccinations and so on listed on the contract.

Consequently there may be a tendency to discourage or even refuse patients who are bound to make heavy demands upon the practice. That is the subject of this amendment, which is strongly supported by a wide range of voluntary organisations. I refer to the Cystic Fibrosis Research Trust, the Save the Children Fund, the Family Planning Association, the National Schizophrenia Fellowship and a group of organisations concerned with the needs of the homeless.

In view of the importance that everyone should be able to register with a GP as, in a sense, a gateway to the whole range of health care services, the amendment seeks to place a duty on the family health service authority to assist individuals resident in an area, with or without a permanent address, to register with a GP. At present this proposed amendment is included in the 1974 regulations made under the National Health Service Reorganisation Act 1973. The justification for its inclusion in the main body of the Bill lies in the likely adverse effects of the changes affecting GP contracts, imposed upon them against their will, and the budgetary arrangements on access to health care services.

Assurances have been given in another place that GPs wishing to hold budgets will have them set to take account of greater than average numbers of chronically sick and disabled people on their lists. I certainly very much welcome that. The Secretary of State said that in no circumstances would any patient ever be refused the medication or equipment that he or she used. The Minister may feel that the position is therefore dealt with. However, I have to say that anxieties very much remain and many people who are concerned want to see that commitment written into the Bill. That is the reason for the amendment.

I give some examples. Cystic fibrosis and schizophrenia are both illnesses for which there is at present no known cure. Both illnesses usually present problems that are common to all chronic conditions. They need care, sometimes over decades, and will make significant demands of a GP both in terms of time and other services provided by the practice, including nurses, receptionists, and so on.

Clinical management is complex and varied for cystic fibrosis because the treatment is aimed at the secondary consequences of the illness: to enhance the patient's quality of life and to prevent respiratory diseases. Schizophrenia, because the illness fluctuates in severity, must be carefully monitored. It also imposes a heavy burden on general practitioners. The dosage of drugs needs constant adjustment to correspond to changes in patients' conditions.

General practitioners with particularly demanding patients are already asking them to leave their practice lists—they do, indeed—and it seems likely that the refusal rate of GPs to accept certain patients will rise sharply because of the nature of the contract. A hard-pressed practice, perhaps in an inner city, may not welcome the arrival of a family with one or more members with cystic fibrosis. It is absolutely certain that the needs of such families will consume above average time.

With schizophrenia the course of the illness is usually acute relapses alternating with more stable periods. Ninety per cent. of the 25,000 people admitted to English mental hospitals in 1986 were re-admissions. I emphasise that; 90 per cent. were re-admissions of patients who had been discharged and had returned, sometimes for the umpteenth time. Under those circumstances, therefore, medical oversight of discharge is of critical importance to prevent deterioration and re-admission wherever possible.

It is also increasingly important as half the schizophrenics spend less than one month in hospital and the vast number of them less than three months so that most are now in the community, treated as out-patients and often the responsibility of their GPs. They need a GP for physical problems and to take over psychiatric care when the consultant wants to hand over responsibility to the primary team.

It is not always easy. Schizophrenics can be unco-operative, disruptive and even aggressive patients. I say that, as president of MIND, with some understanding and knowledge of the problem. There can be crises which take up an inordinate amount of time. It is not surprising if they are not welcomed by GPs. The Save the Children Fund has reported similar problems with gypsy and traveller families, and other homeless families in temporary accommodation. I shall come on to those in a few moments.

The consequence for all these groups is that they may be obliged to make use of the casualty departments of hospitals as their point of access to health services. That is not the right way forward. They may well delay seeking treatment until the condition has significantly worsened and are unlikely to obtain access to the full range of health services—a problem affecting children in particular. All these groups and others with a mobile lifestyle are characterised by a combination of poor access to health services and widespread discrimination in their provision, together with an environment—sometimes living in hotels, sleeping rough, or whatever it may be—which is frequently unsafe and has inadequate sanitation and other facilities.

For some families the reluctance of GPs to accept them on their list is already marked. Many GPs will simply not take them. Attempting to force doctors to accept patients on to their lists is difficult. Usually it does not work. The arrangement whereby a family practitioner committee can require a nominated doctor so take on a patient is a palliative, but that is for three months only. More innovative measures are needed: specialist or mobile clinics; checks on GP registration before discharge from hospital and more health visitors and community psychiatric nurses attached to GP practices so that these patients can become acceptable.

Unfortunately it seems that the new contract and the Bill will increase the disincentives. I should like to add some comments on the position as it affects homeless people. Shelter has estimated that there are at present 150,000 homeless young people in Britain. These young people are homeless for three main reasons: first, not enough housing; secondly, insufficient money to obtain access to housing; thirdly, various forms of discrimination. I do not believe that there has ever been a time in our society when the problem of homelessness was greater than it is today.

In the past, privately rented bed-sits and flats provided a major source of first homes for young people. With the supply of private rented homes diminishing—30 per cent. of all homes in 1960 reduced to 10 per cent. in 1988—young people are increasingly dependent on other forms of housing. The abolition of rent Act protection and secure tenancies in the Housing Act 1988 has meant that what little private rented accomodation exists is less secure and more expensive. Other traditional sources of first homes such as tied accommodation for nurses and apprentices are disappearing and halls of residence for students are becoming more expensive, thus further reducing the supply of cheap housing for young people.

The problem of homelessness in our society, the difficulties this makes for local authorities and the way in which local authorities have failed to meet those needs is a matter that has been raised on several occasions in this Chamber and with the Minister. As I said, this amendment is strongly supported by a number of organisations. The amendment, if accepted, would ensure that everyone has the services of a general practitioner. There is no other provision in the Bill to give that assurance.

The media has already reported examples of patients being struck off GP lists because they were affecting doctors' chances of earning bonus payments under their new contracts which came into effect on 1st April this year. Several cases recently highlighted in the press involved sick children and the elderly. These groups were reckoned to compromise the GPs' earning ability because they require time-consuming treatment and emergency calls. One newspaper also reported that women aged between 25 and 64 have been removed from the list of a GP practice because they affected the doctors' ability to reach cervical smear test targets.

The Family Planning Association is deeply concerned that women requiring certain treatments due to reproductive health problems could either be at risk of being dropped from their existing GP's list or find it hard to register with another practice. I shall not quote it but I have from Age Concern a great deal of evidence of the degree of worry that exists among elderly people. I know that I shall have friendly and sympathetic assurances from the Minister. I and my colleagues on these Benches believe that it is essential to have more than verbal assurances. This is an issue which must be written on to the face of the Bill. I beg to move.

Baroness Robson of Kiddington

I support this amendment which was originally in the name of my noble friend Lord Winstanley, who is a GP. Unfortunately he is not here today and I am standing in for him. I have great concern about the homeless.

The first part of the amendment sets out to include in the Bill what was always the duty of family practitioner committees. If a person could not be included on a GP's register and that person appealed to the FPC, it was duty bound to find a general practitioner to take him. We want to make certain that that duty is passed on to the family health service authority and that it is not changed.

The noble Lord, Lord Ennals, mentioned many of the problems of the homeless. I shall mention only one. I have a particular concern for children living in bed and breakfast accommodation. Prior to the new GP contract introduced on 1st April of this year, every general practitioner was paid on the principle of an item of service. GPs were paid for each vaccination of a child. Under the new GP contract they will not be paid until three vaccinations have been given. One can imagine how difficult it will be for a GP to follow it up to make certain that a child living in bed and breakfast accommodation receives the right number of vaccinations.

Very often children move from one part of London to another. One general practitioner may give a child two vaccinations. The child will then move to the suburbs and come under the auspices of another general practitioner. It may or may not receive the third dose of vaccine. If the child receives the third dose, that is the time at which the GP is entitled to payment for doing what the Government have asked him to do. Who gets the payment? Will it be the GP in London who gave the first two vaccinations or the one in Staines, or elsewhere, wherever the family has finally managed to find a place to live?

That system is not going to encourage GPs to make certain that children living in bed and breakfast accommodation are given the same immunisation and care as other residents in the community. Apart from the necessity of adding this amendment to the Bill, it is important that the Government think about their policy on vaccination of children and particularly homeless children.

Baroness Hooper

The problem here lies not with the powers or duties of the FPCs or FHSAs, as they will become, which remain unchanged in this respect, but with reaching the homeless in the first place and encouraging them to come forward to receive the health services that they need.

Under our reforms in Promoting Better Health FPCs are already required to assess the health needs of all sectors of their local populations and actively to develop services to meet those needs. In areas where there are homeless people, FPCs obviously need to take account of the special needs of these groups. To impose a further, unnecessary, duty on FPCs, as this amendment suggests, would not make their task any easier.

In the particular case of homeless people, we have already funded pilot projects in the City, East London, Camden and Islington FPCs to assess the needs of homeless people and work out the best way of delivering primary health care to them. In addition, we are currently assessing proposals for further outreach projects for the homeless in other parts of the country. We have circulated a summary of a Policy Studies Institute report on this issue to all FPCs and to other health and local authorities so that the lessons learnt are shared with the rest of the health service.

There is nothing in the accusation made by the noble Lord, Lord Ennals, that this legislation will encourage GPs to refuse patients unnecessarily. There is a great deal in the new GP contract, for example, which helps patients to choose and change their GPs more easily. As regards the accusation that doctors will try to get rid of elderly patients who may cause them more difficulties, under the new arrangements doctors will have a greater incentive to take on new patients. The extra work which the elderly tend to make for doctors will be recognised by a larger than average increase in the capitation fee payable to doctors for each patient aged over 75 years.

I have chosen that example because care for the elderly is a very important area. I hope that I have reassured the Committee that FPCs, or the future FHSAs, already have sufficient powers to ensure that everyone has access to a GP and that work is in hand in FPCs around the country to develop flexible approaches to meeting the needs of all groups in society, including homeless people. Therefore, I hope that the noble Lord will feel able to withdraw his amendment.

Baroness Macleod of Borve

Before my noble friend sits down I wonder whether she can help those of us who are concerned with the homeless. I am very worried, as I am sure we all are, about the variety of people who are unable to be on a GP's list. Can she tell us how such people can get on a list, how they can find out whom to go to and which authority will tell them where to get medical help?

Baroness Hooper

I shall try to answer my noble friend's question as best I can. Anyone normally resident in the United Kingdom, including homeless people, is entitled to register with a GP for general medical services under the national health system. That includes people who have come to the United Kingdom to take up permanent residence, besides those who have been resident here for 12 months prior to needing treatment. Normally a person wishing to find out where he should register would approach the family practitioner committee or the FHSA, as it will become known. If a person is unaware of what a FHSA is or where to find it, he can go through the normal information channels, including, for example, the citizens advice bureaux.

Lord Peston

I got lost by the answers given to the noble Baroness, Lady Macleod, and to my noble friend. I understand that under the 1977 Act everybody in this country is entitled to be registered with a GP. I believe that is what the noble Baroness said. I also understand that if a specific GP will not take a person and that person cannot find a GP, the family practitioner committee will guarantee to find one. The point is whether the FHSA has exactly the same duty placed on it to guarantee a place. I cannot find a reference to that in the Bill. Indeed, I cannot find where it is referred to in the 1977 Act, where everyone says that this point is included. For all I know, the provision is included under regulations and not in the Act. That is one source of confusion.

The other problem is that when one tries to register with a GP, one is asked for an address. Many of the people we are concerned with here do not have an address. In those circumstances it is not clear what then happens. One does not use such words, but essentially one says "I am a homeless person and I live under the arches beside the National Theatre". So far as I can see, without an address one would be unable to fill out the relelvant forms. I cannot see how someone in that position could get a GP. There are further problems. I do not see how a GP could get in touch with such a person and so on. I do not regard these as trivial matters and that is why we have tabled the amendments. Can the noble Baroness at least clarify some aspects of the problem as it applies to the homeless?

The incentives question is a little more complicated. Perhaps we can return to that in a moment.

3.30 p.m.

Baroness Hooper

Perhaps I may suggest to the noble Lord that if he has difficulty in interpreting the 1977 Act he might turn to the noble Lord, Lord Ennals, on his left who would no doubt be able to point him in the right direction. Having said that, I confirm that the noble Lord gave an accurate summary of the position. Anyone resident or normally resident in the United Kingdom is entitled to register with a GP or with general medical services under the National Health Service. I can assure him that the FHSA is to have exactly the same power as the existing FPCs. The point of reference is in the General Medical and Pharmaceutical Regulations, which are not affected by the Bill. Therefore the point does not require repetition in the Bill.

Lord Murray of Epping Forest

I suppose that the concern felt all around the Committee on this issue is exemplified by the fact that the noble Baronesses, Lady Robson and Lady Macleod, and I served together as trustees on the charity Crisis at Christmas, which, apart from running the Open Christmas, funds many homelessness projects. One has only to come to the Open Christmas to see that the need for medical treatment, in particular for dentistry and chiropody, is endemic and widespread. For many of those who come to us, Christmas is the only occasion in the year when they can see a dentist or have their feet seen to.

I very much welcome the initiative the Government have taken to have this matter studied in more detail in parts of London and possibly in other parts of the country. That is very good indeed and we look forward to seeing the results. They took that initiative precisely because family practitioner committees do not address their minds to this issue. It is a proper and welcome response by the Government to say that FPCs have an enormous number of other things to do, but too few have thought about the problem of identifying homeless people, finding out where they are and making arrangements to bring them into contact with a GP.

Many of the people to whom I refer are single homeless who are probably not covered by the amendment. That may well be a matter to which we should address our minds at Report stage. But many of the people who come to the Open Christmas, and many of those who come to the Whitechapel Mission, with which I am involved, are on housing lists and are covered by the provision. They come to these places because, in the case of the Whitechapel Mission, they can get a free doctor, and in the case of Open Christmas, they can see a dentist and so on. We should carry the amendment, limited as it is, because it will put on the face of the Bill a provision which would gee-up the FHSAs and make sure that in the future they take this issue seriously. That is the argument for carrying the amendment.

There will be a further argument about how to deal with single homeless people, but I hope that the Government Front Bench will think about accepting the amendment as a first step in dealing with a major problem. We often think of homelessness as being concerned only with people with no roofs over their heads and not enough food in their stomachs. A great many of the issues of homelessness relate to ill health and derive from malnutrition and sometimes from self-abuse through alcohol and/or drugs. Many of the health problems could be relieved more effectively by action of this kind.

It is not an easy problem to solve. Many of these people are a little dirty and a little smelly. Many of the people in the waiting-rooms will not be anxious to see them there. But that is not an argument against tackling the problem. It is an argument for doing it in a systematic manner. I hope that we shall put this provision into the Bill.

Baroness Hooper

I emphasise that the Government are aiming to tackle the whole problem of the homeless in the round as it were and are considering what initiatives are necessary and appropriate in that respect. It is a difficult problem—and this aspect of the problem is especially difficult. I firmly believe that it will not be solved simply by writing an amendment of this kind into the Bill. It will be solved only if we can set up methods of approach to the homeless and methods of follow up, to take the point referred to by the noble Baroness, Lady Robson. The arrangements we have made—funded pilot projects, the Outreach projects and the circulation of best practice on this difficult subject—are the right approach.

Baroness Phillips

I should like to support the noble Baroness, Lady Robson. I am privileged to have many members of the medical profession in my family. It is very sad that a dedicated profession is now being called upon to think in terms of whether to put an account in now or at a later date. That was never the thinking of the family practitioner. Even in the old days the family practitioner served those who needed him. The great joy of the National Health Service was that one received attention whether or not one could pay for it and whether or not one was part of a scheme.

The point raised by the noble Baroness, Lady Robson, highlights the direction in which we are moving. Doctors, like everybody else, will be bogged down by masses of forms. Someone said to me the other day, "It's not much fun shopping nowadays. If you go into a big store they are all running round making notes on bits of paper". Will this also penetrate all our professional services? Will teachers have to spend more time writing on pieces of paper than teaching? Will doctors have to spend more time writing on pieces of paper in order to claim than carrying out their professional duties? That would be tragic. I think the whole Bill is tragic. Can the noble Baroness give a direct answer to the points raised by the noble Baroness, Lady Robson? Outreach, as I understand it, is a voluntary group. I may be wrong but I do not think it is sponsored by government.

Baroness Hooper

Outreach facilities are in many cases sponsored by government. It is the whole concept of having facilities closer to the community which they aim to serve.

Baroness Phillips

I hope that these assurances will be written into the Bill. The noble Baroness is able and caring. She knows only too well that what counts is what is written into an Act of Parliament. It is no use turning round and saying, "I happened to read that when they were debating this matter in the House of Lords they said this or that". Is it written into an Act of Parliament? We are asking a great deal of these people. They have to find out where to go and they have to fill in more forms. For heaven's sake, let us be merciful and helpful and think of the kind of people that we are dealing with in this amendment.

Baroness Carnegy of Lour

I apologise to the Committee. I did not arrive until after the noble Lord, Lord Ennals, had introduced the amendment and so I did not hear everything that he said. It is a great pity that the second part of the amendment is becoming mixed up with arguments from noble Lords who are not at all keen on the whole concept of the Bill. The question which the Government must address is this. Is there an obligation on the family health services authorities, through a system of choice—which I personally so much welcome—to ensure that no one will find it impossible to find a doctor?

If there is such an obligation, I suggest to my noble friend that she might consider, with her right honourable friend, a place where the Bill might just say that. However, if there is no such obligation, we need to know why. It is immensely important that through the system of choice, there is, as there always has to be with such arrangements, some kind of safety net.

It may be that I have missed the point; I came into the Chamber halfway through the debate on the amendment. If so, I apologise. It is important to look carefully at this matter. However, the proposal here is perhaps inappropriate: it is an issue that concerns not only the homeless. The limitation is unfortunate.

It is important to ensure, whatever the circumstances, that a person can find a general practitioner.

Lord Ennals

I am most grateful to the noble Baroness, Lady Carnegy of Lour, who has probably understood the argument better as a result of missing my introduction. She has certainly caught on to what I was trying to say. The first part of the amendment states that, any person who is a member of its resident population shall be accepted as a patient of a General Practitioner who is able to meet the requirements of that person for primary health care services". That is obviously the bulk of the provision. We are basically talking about a static population of people who live in an area but who may move in and out of it. Nevertheless, they live in that area. We are talking about the generality of the public. It is obviously important that those who are not part of the settled community—that is, the homeless—should also be able to receive the help and support of a general practitioner which they need.

It may be that the noble Baroness in response will say, "Well, I have not got the words right", or she may say, "There are two other places in the Bill where such a provision could be inserted". However, I am absolutely convinced that somewhere in the Bill it must be quite clearly stated that everyone is entitled to the services of a general practitioner. But it is not enough to say just that. The Bill must specify how the right will be applied. The purpose of the amendment is to ensure that the family health services authority will have such responsiblity.

There is no difference in principle between the position which all of us have taken. I am most grateful to the noble Baroness, Lady Robson of Kiddington, and to the noble Baroness, Lady Macleod. I am also grateful to my noble friends Lord Murray and Lady Phillips. They have put the argument very clearly. I believe that there is no argument as to the principle of the matter. However, it is not enough for the noble Baroness to say that we really do not have anything to worry about.

I was encouraged to put the amendment forward because of the worries expressed to me by so many people. The Royal College of Nursing takes a very strong position; the Family Planning Association is also deeply concerned. In its letter to me the association says that, women requiring certain treatment due to reproductive health problems would either be at risk of being dropped from their existing GP's List, or find it hard to register with another practice. These women need the security of the amendment … which places a legal obligation on Family Health Services Authorities to ensure that all people within its registered population have access to a GP who can meet their needs". The letter continues: Women needing treatment for infertility and for chronic gynaecological complaints such as endometriosis and pelvic inflammatory disease may require expensive drugs or referrals and many consultations making them 'unprofitable' patients in terms of the new GP contract". I shall not take that aspect further.

However, deep concern has also been expressed by the National Schizophrenia Fellowship. I am glad to see the noble Lord, Lord Mottistone, in his place. On many occasions he has pleaded with us to look after the needs of those suffering from schizophrenia in any way we can. I spent all this morning at the MIND conference discussing such issues. In my view, there is a coming together of minds on the matter.

The Cystic Fibrosis Research Trust is a body concerned with one of the most serious and distressing diseases which exists. The trust believes that there is a real worry here, as does the Save the Children Fund. It is not good enough for the noble Baroness to say that they need not worry, that everything is all right and that the same powers held by the family practitioner committees will be held by the family health services authorities. This is the moment to try to meet worries, some of which may be exaggerated or may not be totally justified, but which nevertheless are very genuine. That is what I seek to achieve.

3.45 p.m.

Baroness Hooper

In case the noble Lord wishes to move on rather rapidly to another topic, I feel I should intervene at this point. It is important that I repeat what I said earlier and perhaps I should do so rather more strongly. This is not a consolidating Bill. The provision which the noble Lord seeks to introduce is already covered by Section 29(2) of the National Health Service Act 1977 and the regulations I previously mentioned—namely, the General Medical and Pharmaceutical Regulations, and others—which were made under that legislation. I believe that that provides all the reassurance sought by the noble Lord and others. The Bill in no way affects those rights and duties.

Lord Hunter of Newington

In the White Paper and in the introduction to the Bill the Government made great play of the fact that patients will be free and able to choose and change their doctors. One does not disagree with that. However, people are responsible, irresponsible or compulsive. For that reason alone it is necessary to write the first part of the amendment into the Bill.

Lord Ennals

I am most grateful to the noble Lord. He has put the argument in a nutshell. As I said, I do not believe that there is an issue of principle between us. I know that when my noble friend Lord Peston intervened the noble Baroness said that I would know all about the 1977 Act. I see that my noble friend has great confidence in me; I am most grateful to him. It was a consolidation Act and, as always, was presented in this House by the Lord Chancellor and not by the appropriate Minister. Therefore, I do not have the contents at my fingertips. Moreover, it was 13 years ago. They were not wasted years; nevertheless, it was many years ago. Thus I cannot claim to be an expert on the matter.

However, in my view this Bill provides an opportunity to meet the genuine concern felt by thousands, and probably hundreds of thousands, of people across the country. The noble Baroness says that we do not need to do this: in my view, that is a very good argument for doing so if it will not hurt her. She is not saying that it would create great problems for the health service if we accepted into the Bill what was previously accepted in a 1977 consolidation Act.

The very fact that there has been so much pressure from highly respectable and very professional organisations for such a change is a reason why, if the Minister cannot give me an assurance that she will come back with a provision, possibly better worded that that which I put forward, I shall feel bound to press the matter to a Division.

Lord Mottistone

I apologise to Members of the Committee for my late arrival in the Chamber. Indeed, this is early for me, being a Monday. I wish such matters would not be dealt with on Mondays. I should like to be reassured by my noble friend that the regulations issued in 1974, made under the National Health Service Reorganisation Act 1973, are still in force and will remain so. As I understand it, the only purpose of the amendment is to ensure that the regulations will continue to apply in the future. If they are at present in force and are not to be repealed by this Bill, it would seem to me that there is probably no point in the amendment.

Lord Kilmarnock

Before the noble Baroness replies, would it assist the Committee if the Government were to issue a statement on which sections of the 1977 consolidation Act are not repealed under this Bill? There seems to be an area of doubt. There are various references in the schedule but it seems to me from reading the 1977 Act which is still in force that Section 1 involves the requirement on the Secretary of State to provide a comprehensive National Health Service for the United Kingdom—or perhaps for England and Wales, I do not remember the exact words. Those sections of the 1977 Act presumably remain in force. Much confusion would be removed if the Government would tell us what legislation has been repealed and what has not.

Baroness Carnegy of Lour

In replying to my noble friend Lord Mottistone, perhaps the Minister could tell us precisely what the Act says. It is clearly ridiculous to vote to insert a provision into a Bill when the legislation already exists. If I may say so to the noble Lords, we never do that twice just in order to make political points. We want a good Bill and we only want to make these provisions once.

I apologise to the Committee but I have not picked up whether the legislation is already in force. Perhaps my noble friend will do as the noble Lord, Lord Kilmarnock, suggested or write to us clarifying the matter. Were that to happen I should do my best to make sure that we did not insert the legislation twice in the same Bill.

Baroness Hooper

I do not have a copy of the 1977 Act with me and cannot quote Section 29(2) for the Committee. However, I gather that the noble Lord, Lord Peston, has one and perhaps he would be able to help the Committee. I repeat that this section of the Act is still there; it is not repealed by the Bill. This is not a consolidating Bill and I do not believe that primary legislation is in place for declaratory statements of policy, however pleasant and agreeable it might be to have them.

The Bill's purpose is to change matters, as my noble friend Lady Carnegy made clear. I can reassure my noble friend Lord Mottistone that because the provisions of the 1977 Act and the regulations made under it are still in place, this amendment is not necessary. The provisions of the 1977 Act which relate to the provision of general medical services remain unchanged. I believe that I have said that already and that I can leave it to the noble Lord, Lord Peston, if he chooses, to quote the Act verbatim.

Lord Ennals

My noble friend has asked me to do so; he knows that I have the Act imprisoned in my memory. I am grateful to the noble Lord, Lord Kilmarnock, for his suggestion; it would be helpful to list those matters which have not been repealed.

I have to say to the noble Baroness, Lady Carnegy, and to the Minister that this is new. It has already been stated that people are entitled to have a general practitioner, but our amendment does not stop there. It says that the family health services authority—the family practitioner committee as it was—"shall seek to ensure". We give to the authority the responsibility of helping people who are in difficulty. They are in difficulty today, they were probably in difficulty 10 years ago and 13 years ago when I was Secretary of State. There is no doubt that there are difficulties. Some people have gone from GP to GP without being able to obtain a response. Usually a GP says, "I have too long a list". I have recently moved myself from a different area and when I approached a GP he said, "I am afraid I have too long a list". It was not the case that he was discriminating against me either politically or because I have many health demands.

The provision in the amendment is new. It seeks to put upon the family health services authority a new obligation to seek to help those people which does not exist on the family practitioner committee. I have no doubt that we ought to face the situation today. It is not good enough to say that this is not a consolidation Bill. Of course it is not. It is new legislation. Let us get it right now and if we have problems then let them be dealt with now. The Minister is not saying for one moment that there is any difficulty in inserting the provision. If she will say to me, "Yes, we will put it in with slightly better words than yours", then I should not press the matter.

3.55 p.m.

On Question, Whether the said amendment (No. 103A) shall be agreed to?

Their Lordships divided: Contents, 82; Not-Contents, 98.

DIVISION NO. 1
CONTENTS
Annan, L.	Birk, B.
Ardwick, L.	Bonham-Carter, L.
Aylestone, L.	Boston of Faversham, L.

Bruce of Donington, L.	Molloy, L.
Carmichael of Kelvingrove, L.	Murray of Epping Forest, L.
	Ogmore, L.
Carter, L.	Peston, L.
Cledwyn of Penrhos, L.	Phillips, B.
David, B.	Pitt of Hampstead, L.
Davies of Penrhys, L.	Ponsonby of Shulbrede, L. [Teller.]
Dean of Beswick, L.
Diamond, L.	Porritt, L.
Donaldson of Kingsbridge, L.	Robson of Kiddington, B.
Ennals, L.	Sainsbury, L.
Falkland, V.	Salisbury, Bp.
Fitt, L.	Saltoun of Abernethy, Ly.
Gallacher, L.	Seebohm, L.
Galpern, L.	Serota, B.
Graham of Edmonton, L. [Teller.]	Shannon, E.
	Shaughnessy, L.
Grey, E.	Shepherd, L.
Hampton, L.	Somers, L.
Hanworth, V.	Soper, L.
Hatch of Lusby, L.	Stallard, L.
Hayter, L.	Stedman, B.
Hirshfield, L.	Stoddart of Swindon, L.
Hunter of Newington, L.	Taylor of Blackburn, L.
Hylton-Foster, L.	Thomson of Monifieth, L.
Jenkins of Putney, L.	Thurlow, L.
John-Mackie, L.	Tonypandy, V.
Kearton, L.	Tordoff, L.
Kilmarnock, L.	Turner of Camden, B.
Leatherland, L.	Underhill, L.
Listowel, E.	Wallace of Coslany, L.
Llewelyn-Davies of Hastoe, B.	Walston, L.
Lloyd of Kilgerran, L.	Walton of Detchant, L.
Lockwood, B.	Wedderburn of Charlton, L.
Longford, E.	White, B.
McCarthy, L.	Wigoder, L.
McFarlane of Llandaff, B.	Williams of Elvel, L.
Mackie of Benshie, L.	Winchilsea and Nottingham, E.
Mason of Barnsley, L.
Mishcon, L.	Young of Dartington, L.

NOT-CONTENTS
Aldington, L.	Fraser of Kilmorack, L.
Alexander of Tunis, E.	Gainford, L.
Allerton, L.	Geddes, L.
Ampthill, L.	Gridley, L.
Annaly, L.	Hailsham of Saint
Arran, E.	Marylebone, L.
Balfour, E.	Havers, L.
Bellwin, L	Henley, L.
Beloff, L.	Hesketh, L.
Belstead, L	Hives, L.
Bessborough, E.	Hooper, B.
Blatch, B.	Johnston of Rockport, L.
Boyd-Carpenter, L.	Kinnaird, L.
Brabazon of Tara, L.	Knutsford, V.
Brougham and Vaux, L.	Layton, L.
Butterworth, L.	Liverpool, E.
Caithness, E.	Long, V.
Campbell of Alloway, L	Lucas of Chilworth, L.
Campbell of Croy, L.	McColl of Dulwich, L.
Carlisle of Bucklow, L.	Mancroft, L.
Carnock, L.	Margadale, L.
Cawley, L.	Marsh, L.
Clanwilliam, E.	Merrivale, L.
Colwyn, L.	Milverton, L.
Constantine of Stanmore, L.	Montgomery of Alamein, V.
Cottesloe, L.	Mountevans, L.
Cullen of Ashbourne, L.	Munster, E.
Davidson, V. [Teller.]	Murton of Lindisfarne, L.
De Freyne, L.	Nelson, E.
Denham, L. [Teller.]	Newall, L.
Dilhorne, V.	Norrie, L.
Dudley, B.	Nugent of Guildford, L.
Eden of Winton, L.	Pender, L.
Elibank, L.	Pennock, L.
Ellenborough, L.	Quinton, L.
Elliot of Harwood, B.	Reay, L.
Elliott of Morpeth, L.	Renton, L.
Erroll of Hale, L.	Rippon of Hexham, L.
Fraser of Carmyllie, L.	Rodney, L.

Romney, E.	Sudeley, L.
St. Davids, V.	Swansea, L.
Sanderson of Bowden, L.	Teviot, L.
Selkirk. E.	Thomas of Gwydir, L.
Sempill, Ly.	Tranmire, L.
Skelmersdale, L.	Trefgarne, L.
Strange, B.	Trumpington, B.
Strathcarron, L.	Ullswater, V.
Strathcona and Mount	Vaux of Harrowden, L.
Royal, L.	Westbury, L.
Strathmore and Kinghorne, E.	Wyatt of Weeford, L.

Resolved in the negative, and amendment disagreed to accordingly.

4.3 p.m.

Lord Peston moved Amendment No. 103B: Page 13, line 27, at end insert: ("( ) Every Family Health Services Authority shall establish and publish details of its procedure for dealing with complaints including the maximum time before a decision will be reached.").

The noble Lord said: In moving Amendment No. 103B the groupings list is such that I should also speak to Amendments Nos. 103C, D, E, F, G and H. As I must have agreed to that grouping, I cannot complain about it. However, it seems absurd to me to discuss all these rather disparate points in one go. If the Committee will allow me, I shall discuss two or three of the issues at one time and then we can at least proceed logically as it were. I believe that will help the Minister when she replies.

My present frame of mind with respect to these amendments is to use them as probing amendments in order to clarify the clause that we are debating. The noble Baroness does not have to worry about rushing off into the Lobbies as we proceed through the next seven amendments.

The Explanatory and Financial Memorandum states on page iii of the Bill that Clause 12: puts RHAs into a management relationship with FHSAs".

Therefore Clause 12 and other clauses that follow on from it concern the management relationship referred to in the Explanatory and Financial Memorandum. This group of amendments seeks to throw some light on the management relationship and also to suggest various ways in which it might be pursued.

Amendment No. 103B concerns the procedure for complaints. I should say immediately that I do not wish to use this amendment to denigrate the medical profession and to suggest, for example, that all GPs neglect their patients. In saying a few words about complaints I should add that I do not believe that complaints are what the matter is all about. I am using the word "complaints" in the complaining sense and not in the illness sense, as clearly in the other sense the matter is all about complaints. The meaning of the word "complaint" is quite interesting from the legal point of view. I must reflect on that matter and come back to it on Report, but that is by the way.

What I am referring to is the fact that occasionally a patient feels that he or she has grounds for complaint. Those people who feel that they have grounds for complaint usually feel intensely about that matter. They usually feel extremely badly done by. They are not necessarily correct in that assumption, but the fact that they feel that way is an important matter. Therefore it seems to me that the criterion of openness and also, I would argue, the criterion of efficiency, lead one to the conclusion that it should be a duty of the FHSA to make its procedure for dealing with complaints clear. My own view is that as far as possible there should be some kind of public statement regarding the maximum time that could elapse in dealing with complaints. I believe that is a matter of good management practice. There is nothing more harmful or likely to lead to inefficiency and waste of resources than complaints which are allowed to drag on for no particular reason. The sensible thing to do is to take complaints seriously and investigate them and report on them as rapidly as possible.

As the issue of complaints is different from all the other issues that are dealt with in this group of amendments, it may be convenient for me to sit down now and hear what the noble Baroness and others have to say on the matter. I shall make the assumption that that is convenient because the issue of women is a quite different matter and will raise all kinds of other considerations. For the moment I shall sit down, having made my remarks on the complaints matter, and see whether any other Member of the Committee has anything to say on that. I beg to move.

Baroness Hooper

I should say with regard to the whole group of amendments that there is not much difference between us regarding the intentions behind the amendments. The aims of the amendments are clearly in general to improve information and access for patients. However, as might be expected, we differ in the matter of achieving those aims.

Amendment No. 103B would require FHSAs to establish and publish their own complaints procedures, including setting maximum time limits for complaints to be settled. Perhaps I should explain that, in the interests of consistency and fairness, complaints are handled according to a national scheme set out in regulations. The White Paper entitled Promoting Better Health set out our proposals for simplifying and streamlining complaints procedures, which came into operation on 2nd April. The new procedures provide for FPCs to accept oral complaints from people unable to make complaints in writing. Complaints received by health authorities within the time limits are also now acceptable. The time limit within which complaints may be accepted has also been extended from eight to 13 weeks. In addition, all FPCs are required to provide an informal procedure to patients who may not wish to pursue more formal procedures.

FPCs are already well aware of the need to avoid delay in handling complaints. We expect complaints that are handled informally to be resolved within four weeks. However, the formal investigation of complaints is designed to be both impartial and thorough. Investigations are intended to decide whether a family practitioner has failed to comply with his or her terms of service. If he or she is found to have done so, the FPC or the Secretary of State may direct that some of his or her remuneration should be withheld. That means that some complaints investigated by service committees are not always resolved as quickly as one might hope.

However, I am sure that the Committee will recognise that, while it is desirable to resolve complaints in as short a time as possible, in the interests of fairness and because of the serious consequences which might arise, it would not be practicable to set maximum time limits for reaching decisions of this nature. I hope that the noble Lord will find that information helpful.

Lord Peston

I thank the noble Baroness for her extremely helpful reply. Perhaps I may inquire about one matter. I was aware that there is a national policy on the matter. However, I should like guidance as to whether within the broad national guidelines it would still be open to the FHSA to interpret those guidelines as it sees fit, fine-tuning them to its own circumstances. To take an obvious example, an FHSA which deals with problems which arise in the inner city, particularly with a mobile population, will have a very different problem regarding complaints from that affecting an FHSA in a rural area

I had in mind that a particular FHSA might make it clear that because of the type of problem in its area it would choose to approach complaints in a particular way. I am thinking in terms of informal complaints rather than those of a formal nature which might involve litigation. Can the noble Baroness assure me that an FHSA has at least some room for manoeuvre? It may be that she cannot answer at the moment, but that is what I have in mind.

Baroness Hooper

We would have no objection to a particular FHSA building on the centralised information to meet the requirements of its area. In connection with the national scheme we have already published an attractive leaflet explaining the scheme thoroughly to the public. So far as I am aware it is being made widely available through FPCs and community health centres. Therefore they are obviously relying on that leaflet to some extent. However, if there is additional information which they wish to furnish for their local populations we would have no objection.

Lord Peston

I thank the noble Baroness for her additional answer. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Peston moved Amendment No. 103C: Page 13, line 27, at end insert: ("( ) Every Family Health Services Authority shall report annually on the percentage of general practitioners in its area who are women.").

The noble Lord said: I hope that the amendment is not controversial. It is a matter which in part concerns openness and in part the choice of general practitioner. It is very much in the spirit of the times. I am sure that I am not the only noble Lord who receives a great deal of material on this matter. There is no doubt that some members of the community, mostly women, are concerned that there should be sufficient general practitioners in their area who are women. There is considerable controversy as to whether sufficient notice is taken of women's needs in the matter. I hasten to add that I am not looking for a major debate this afternoon on the whole situation of women in society with special reference to women in medicine; we can do that on another occasion. I am much more concerned about the general question of the information that is available and using that information to encourage movement in the direction of what people want.

I stand second to none in respect of those parts of the Bill which I wish to criticise. However, as the spirit of the Bill is to try to meet the demands of patients—which I do not criticise—then in so far as what patients want the Bill ought to make it clear that that is what they should have. I beg to move.

4.15 p.m.

Baroness Carnegy of Lour

The noble Lord, Lord Peston, made an important point. People are very anxious that plenty of women doctors should be available. However, with the greatest respect, he has chosen a strange way to achieve that. If I were looking for a woman doctor locally I do not believe that it would help me if someone was reporting what percentage of general practitioners in my area were women. It is important that I or any other patient can find a practice where there is a woman doctor and can thus find a woman doctor.

The beauty of the system set out in the Bill, which I do not believe that the noble Lord has really grasped, is that the money will follow the patient and so the doctors will be paid for treating the patient because the patient has chosen to go to that particular practice. Therefore, if people are looking for a woman doctor in the area the practice will jolly well have to make an arrangement to have a women doctor.

I know that there is another argument which concerns the problems of employing women doctors and whether that would be financially advantageous to a practice. I do not believe that that will get in the way because the patients will be paying for it. I am sure that there will be very few areas in the country in which people will not say to their practice that they want a woman doctor. In that case the practice will have to employ one.

I do not believe that to publish the percentage of women doctors would be of any use, except to equal opportunity enthusiasts who want to bludgeon someone over the head because it is less than 60 per cent. I know that the noble Lord said that this was a probing amendment intended to raise the subject, but I believe that he could have thought of a better one.

Baroness Hooper

Under our Promoting Better Health reforms, which we introduced earlier this month, FPCs are required to produce and publish local directories of family doctors in their areas. These will be up-dated annually and will include as a minimum information about the doctors' sex, date of birth or date of first registration and qualifications. Patients will, therefore, have access to up-to-date information about the women GPs in their area if they particularly want a woman doctor. I recognise that that can be particularly important, for example, for people from certain ethnic backgrounds.

I do not see any other benefit for patients arising from the requirement for FHSAs to publish management information about the number of women doctors. People are hardly likely to move to a different area simply to find a woman GP.

We believe that a better approach is to require FPCs to assess local health needs and then plan service developments to meet those needs. That includes supporting the case for women GPs, where appropriate, to ensure that patients have a wider choice. That is what our Promoting Better Health reforms are designed to achieve.

In addition, the new contract for GPs requires all practices to produce practice leaflets for prospective patients and existing patients. Those will include basic practice information and any further details that the doctor himself or herself wishes to provide, including the availability of female staff at clinics and for screening purposes. Together, local directories and practice leaflets will for the first time provide information in an easily accessible form to enable people to make an informed choice of GP to meet their personal requirements.

In addition, under the new GP contract, it will become even more obvious that women doctors are a great asset in each practice. That is so because of the increased emphasis which we have placed on screening women for pre-cancer of the cervix, a test which many women prefer to have carried out by a woman GP. Women doctors will be in still greater demand if they can offer a specialty such as child health surveillance and minor surgery for which again new fees have been introduced.

Perhaps I may also point out that the number of women in general practice has increased by 70 per cent. over the past 10 years. Women now make up over 20 per cent. of all GPs and we firmly expect that proportion to increase further as the number of women medical school students has steadily increased and women now account for 50 per cent. of such students. I hope that all that information reassures the noble Lord.

Baroness Phillips

Before my noble friend withdraws his amendment, perhaps I may make one or two comments. I take the point made by the noble Baroness, but I hope that there will be more encouragement. Of the total number of GPs, 20 per cent. are women. We are not a minority of the population. We represent about 50 per cent. of the population, so that is not a very good reflection. When I was a Minister and asked how many women were accepted in medical schools, I was told that the figure was about 12 per cent. Is it 12 per cent. because that figure has been stipulated by the authorities, or is it 12 per cent. who apply? The figures are still not very good.

I heard on Radio 4 this morning that the Moslem community wants representation because of that kind of problem. As I understand it, a Moslem woman cannot be examined by a man any more than her daughter can go to anything other than a single-sex school. We must consider those people in our community. I therefore hope that the noble Baroness will, in her influential capacity, lean on the profession to say that we want more women in the profession because, oddly enough, women often prefer their own sex to attend them.

Lord McColl of Dulwich

Before my noble friend Lady Hooper replies, perhaps I may point out that it is rather difficult to guarantee what percentage of women enter a medical school each year. As I am sure the Committee is aware, you make offers to a large number of candidates on the basis that they obtain the necessary grades, so you never know whether there will be a predominance of women or men until the A-level results come out. You cannot therefore guarantee the percentage. When I was sub-dean of a certain medical school in London, it became clear that the ladies achieved much better A-level results than the men, so, inevitably year by year, the number of ladies that we recruited went up and up. That did not make me particularly popular in that medical school because I was accused of plotting to prevent the school from winning the rugger cup in subsequent years.

Baroness Phillips

In reply to the noble Lord I can only say that I remember talking to a distinguished head of a medical school. He said, "I'll put it to you this way: if I have the choice between a man and a woman, the woman will get married and I won't get the same value out of her as I would get from a man". I pointed out that the man might emigrate. Doctors do so and earn more money elsewhere, so nowadays the balance of taking on a woman as opposed to a man has disappeared. I hope that, in his capacity, the noble Lord has always considered quite fairly that one will get as much value from a woman as from a man. Indeed I would say that one gets better value from a woman than from a man.

Lord Walton of Detchant

Speaking as a former dean of a medical school, I can assure the noble Baroness that 50 per cent. of medical students in the United Kingdom are now women.

Lord McColl of Dulwich

Perhaps I may assure the noble Baroness that we are very much aware that one tends to get double the amount of work out of two half-time lady consultant anaesthetists as one gets out of a so-called whole-time man.

Baroness Hooper

I am grateful to my noble friend for assisting the Committee and to the noble Lord, Lord Walton, for reiterating what I said; namely, that the number of women medical school students is now up to the 50 per cent. mark. It is important to translate that figure into general practice. Again, I must turn to the new GP contract because it will be extremely beneficial to women in practice. For the first time, it will recognise both part-time and job-sharing GPs and allow them to be unrestricted principals. That will be of special benefit to doctors with domestic responsibilities such as women with young children. It will also remove the limitations on the reimbursement of women doctors for the cost of a locum employed during maternity leave.

Lord Peston

I thank all noble Lords for their remarks. I too have looked into the question of women in medical schools in some detail and can certainly confirm that what the noble Lords, Lord Walton and Lord McColl, said is entirely right. As I understand it, the problem is that we may have to introduce positive discrimination for men if we are to have any male doctors in the future. On the other hand, I regret to say in the presence of those two noble Lords that women have so far not thrust through at the higher levels of being consultants and deans of medical schools to the degree to which those of us who are equal opportunity enthusiasts look forward. However, I am so confident in women's ability in that respect that I do not think that they will need any help from us in both ruining the rugger in the university and in rising to more or less take over the medical professions, something which I enthusiastically support.

I entirely accept what the noble Baroness, Lady Carnegy of Lour, said about my lack of understanding of the Bill. As she well knows, I have great difficulty understanding any of the legislation in this place and I simply soldier on as best I can. I take her point that a market mechanism is being introduced here—namely, that if patients want women doctors, it will pay the system to respond. However, as someone who is allegedly an expert in the market mechanism, I must tell the noble Baroness that it works quite well, but usually a good deal less than perfectly. The point of pressing such measures is to enhance the way in which it works.

One of the points underlying my general thinking—I shall return to this point under another amendment—is the legal status of the GP contract. A number of the points that I am raising here will also come up with regard to certain other matters and are clearly connected with the GP contract. The new GP contract has been introduced at the same time as the Bill is going through Parliament, but it is not part of the Bill, nor should it be. As I understand it, it is a quite separate agreement between the Secretary of State and the medical profession. Although answers of the kind, "It is in the GP contract", are valid and helpful, they do not always deal with the point as we are discussing it in terms of the Bill. However, I shall perhaps raise that question later. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Peston moved Amendment No. 103D: Page 13, line 27, at end insert: ("( ) It shall be the duty of the Family Health Services Authority to visit each practice in its area at least once every year.").

The noble Lord said: It may well be that this amendment can be handled in exactly the same way as Amendment No. 103C was handled. For all I know, that is the standard practice and there need be no difficulty in the matter. However, wearing my normal education hat, I was rather taken aback to discover how infrequently individual schools were visited by inspectors, let alone how infrequently individual teachers had any contact with an inspector. Reverting to the FPCs, I hope that some light will be thrown on the question of how often an FPC is directly in touch with practices in its area. It seems to me to make perfectly good sense that every FHSA should visit its practices each year. I understand the argument that the Bill is perhaps not the place to put forward that suggestion. Perhaps it is just a matter of correct management practice. However, I should still welcome some response from the noble Baroness if the Government have anything to say on this matter. Again, since this is a fairly technical point, if it is not possible to have an answer immediately, I am perfectly happy to be written to and to have the matter explained in due course.

4.30 p.m.

Baroness Hooper

The enhanced management role of FPCs for the family practitioner services in their area will be taken a step further under Working for Patients, with the introduction of medical audit, indicative prescribing and GP fund-holding. In the natural course of carrying out their responsibilities we shall expect all FHSAs to be in regular contact with the practices in their areas. When and how often each particular practice will need to be visited clearly depends on the circumstances of the practice concerned. Some will need only infrequent visits and others will need to be in more regular contact. Clearly only the particular FPC is in a position to make this kind of local decision. We believe that stipulating any minimum requirements for visiting would simply limit an FHSA's ability to target resources where they are needed most. This would not be in the best interests of GP practices or of patients. I hope that that has been helpful to the noble Lord.

Lord Peston

My I thank the noble Baroness for her answer. I think it is probably the one I would have given had I been sitting where she is. I am not sure that it is one that I entirely accept. But one of the advantages of not sitting where the noble Baroness is sitting is that one has a certain freedom to open one's mind to relevant matters. I think that in the operation of the Bill and the way it is going to work FHSAs will have this burden placed upon them and they will have to take the matter seriously. However, we can wait to see how it evolves for the time being. It may well be that if the Bill remains on the statute book in any form after the electoral events of next year this aspect may need to be examined further. With that, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Peston moved Amendment No. 103E: Page 13, line 27, at end insert: ("() The Family Health Authority shall keep a register of all general practitioner practices in its area specifying whether that practice provides access for the disabled and disabled toilets.").

The noble Lord said: Again this is a matter which arises because we are discussing a health service Bill. It seems to me to be something that ought to be taken seriously, quite independently of the Bill. I have been taken aback—perhaps it is because I am getting older—by observing problems of access to GP premises. It is something that I had never noticed until recently. But I have discovered that, for example, there are premises in basements which have steep steps leading down to them. It does not bother me personally at the moment, but it may in due course. It may not bother many of your Lordships, but it would certainly bother many people. It has only recently dawned on me, as I say, in the case of certain general practitioners that up to now no one has stopped them using such premises. I do not understand how they deal with disabled people at all, because a person in a wheelchair simply could not get into one or two of the places I have in mind.

As for toilets for the disabled, I should have thought I that most GP premises had no such facilities whatsoever. If we can go back to the market mechanism analogy of the noble Baroness, Lady Carnegy of Lour, I certainly do not believe that the decentralised system we have in mind could solve that problem, or at least not in the time-scale that is envisaged. It seems to me to be something that the FHSA needs to keep a register on.

We ought to be doing something about this. As we come to the end of this century, for GPs to be in premises which disabled people cannot get into and which do not have suitable toilet facilities is absurd. It is something one might associate with a country in a backward economic condition but not something I want to see in a country as affluent as we are said to be. I beg to move.

Lord McColl of Dulwich

I agree very much that we need better access for disabled people and also that we need toilets suitable for disabled people. I am not sure that this is the right way to go about it. But when we talk about a civilised country having such services, I hope your Lordships will not mind my reminding you that the facilities here are none too good. We need at least another two toilets for disabled people.

Baroness Hooper

As the Committee may be aware, as part of the new contracts and terms of service, GPs are required to maintain their surgeries at a certain standard in order to receive rent and rate reimbursement. We have tightened up the standards from 1st April in the new contract to include a requirement for satisfactory access to GP premises for disabled persons and for toilets to be available with wheelchair access. I hope that this is welcome: I feel sure that it will be in view of the remarks that have been made. In addition, as part of their increased management role for family health servicer, FHSAs will already have management information about the facilities available for disabled people in GP surgeries in their areas. I have already referred to the local directories of family doctors which the FPCs are now required to publish. GPs could obviously include additional information about the services they provide for disabled people if they wish.

In addition, GPs are required by regulations to include in their practice leaflets a statement about whether their premises have suitable access for disabled patients and, if not, the reasons why the premises are unsuitable for perhaps particular types of disability: for example, that the only access is up steep steps or that it is not possible to provide for disabled parking, which is another problem. I am sure your Lordships will agree that this is the sort of information that patients need and that we have already provided for the information to be made available in the most appropriate way. Requiring local FHSAs to set up special registers for this purpose would actually provide no additional benefit but simply use up resources that could perhaps be better spent in improving patient services in other ways.

Lord Peston

Before thanking the noble Baroness for her answer, let me say how much I agree with the noble Lord, Lord McColl. I actually have a long running list, which I constantly update, of all the improvements needed on this site. I shall add the two that he has just mentioned to the many others I have developed in my three years as a Member of your Lordships' House. I thank the noble Baroness for her very helpful answer and beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Peston moved Amendment No. 103F: Page 13, line 27, at end insert: ("( ) The Family Health Services Authority shall publish every year a report listing every practice in their area and specifying for each practice—

1. (a) The percentage immunisation rate
2. (b) the percentage cervical smear rate
3. (c) the percentage of night visits conducted by a deputising service.").

The noble Lord said: This amendment follows on one or two points on the contract that I believe were raised by the noble Baroness, Lady Robson, earlier when she was discussing the incentive aspects. I should like to have some reassurance, because I believe that all the contracts involve GPs having immunisation and cervial smear targets. I believe that one purpose of the new contract is to deal with what the Government felt were certain abuses concerned with the deputising services. It seems to me that this amendment fits in with what the Government are doing with contracts anyway, and it is simply a question of asking whether the information that I take it will emerge from the new GP contract will move into the public domain. That is what this amendment is about: it is very much an attempt to question the noble Baroness about what follows from the contract in terms of information and of monitoring the contract. I beg to move.

Baroness Hooper

Practices vary enormously in the numbers and types of patients that they treat. For that reason, raw management information of that type is useful for FPCs as a base line for planning. However, I suggest that it is not much use to the general public. Requiring FHSAs to publish it would not enable patients to make any meaningful comparisons. Such bald statistics may mislead patients because they conceal the true situation. For example, a low rate may be due to the presence of children for whom immunisations would be entirely wrong because of the medical contra-indications. What patients need to know is what services are provided and at what times.

As we have already established, that information will be available from both local directories and the practice leaflets. I believe that requiring FHSAs to publish detailed management statistics of the type suggested would be a waste of resources. It would not provide patients with any meaningful information. If patents require further information, they can ask the GP himself or herself. Obviously that would put the raw statistics into local perspective.

Lord Peston

I do not fully understand the answer. Since the data are being collected, for many of us, not least those who are assessing efficiency of performance, it would be advantageous at least to make it clear that they should be available to interested people.

However, perhaps I may ask about the deputising service and night visits. The position has certainly changed very significantly over my adult lifetime. I remember when I was young and my children were very young that doctors visited at night. One saw the doctor whom one thought was one's own doctor. I have not been unwell for a long time, but I understand that nowadays one does not have the slightest idea who will come when one rings up. I do not suggest that the doctor who visits is inferior but he is not the person one knows. I should have thought that in the new era it would be perfectly reasonable for a patient to ask quite specifically about the percentage of night visits. The noble Baroness may say that that is not helpful to patients. Perhaps she will consider the matter a little more.

Baroness Hooper

I believe that that would be most helpful to patients. I fully anticipate that that is exactly the information that we shall be seeing in the practice leaflets.

Lord Peston

I thank the noble Baroness. However, that is not quite the same as making it obligatory. I do not believe that that is part of my lack of understanding of the Bill, if I may look at the noble Baroness, Lady Carnegy. It is part of my disagreement with the Bill, which is a different matter. I should have thought that it was an issue to which we could return. The FHSAs might wish to make it mandatory rather than optional. However, we have aired the matter. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

4.45 p.m.

Lord Peston moved Amendment No. 103G: Page 13, line 27, at end insert: ("( ) The Family Health Services Authority shall publish a list of all general practitioners in each area specifying which general medical practitioners have obtained a certificate of qualification from the Joint Committee on Contraception.").

The noble Lord said: Although there are not many on our side, we have a division of labour. I have therefore been unable to participate in the quite fascinating debates in the Chamber on embryos, abortion and such matters, although it will not surprise the Committee to know that I have very definite views. I am clear that at the present time we somewhat neglect giving contraceptive advice in our society. To some degree we are not pushing as strongly as we ought the role of the general medical practitioner in that area. Often the general medical practitioner is the one person to whom young people are likely to listen and take advice from. This is a personal view, but it is the general medical practitioner from whom I should be most inclined to take advice.

I am not clear from the GP contract whether it would pay any GP to be in this field of work. The practice leaflet to which the noble Baroness referred may typically include such information. However, I believe that she understands what I have in mind. I wait to hear the response. I beg to move.

Baroness Hooper

First, the local directories of family doctors to which I referred will contain information about whether doctors provide contraceptive services. This could include, if the doctors wished, details of whether they possess a certificate of family planning awarded by the Joint Committee on Contraception.

Although GPs have experience of family planning through their training, those who wish to provide this service under the National Health Service are advised to complete training courses approved by the Joint Committee on Contraception. However, that is not a requirement and it would not be appropriate therefore to require doctors to state whether they possess a joint committee certificate. In some cases, they may have acceptable alternative experience. In addition, as the noble Lord said, we expect that practice leaflets will give information about whether the individual doctor provides contraceptive services. If the GPs so wish they could include information about their qualifications in that respect.

Lord Peston

I thank the noble Baroness. It will be interesting to see whether we can rely on the decentralised system to produce what we wish. The certificate of qualification is a very good one and it would be a good idea if most GPs had it. It may well i be that that will result through the automaticity that is built into the system or that publishing a list from the FHSAs will encourage doctors to proceed in the appropriate direction. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Peston moved Amendment No. 103H: Page 13, line 27, at end insert: ( ) Each Family Health Services Authority shall establish peer review for the practices in its area and shall re-imburse general practitioners for the time they spend reviewing their peers.".

The noble Lord said: Last but not least we come to this amendment. We are getting through them in a most productive way. Again I seek clarification. When I read the White Paper and listened to various debates I thought that we were going to have peer review at GP level. I believed that that would be normal practice and would be provided in the Bill. As I understand it now, there will not be mandatory peer review and the sharing of good practice, the auditing of such practice and so on will again be left to happen, if it happens, or not. In particular no funds will be available for GPs if they are willing to devote their time and effort to try to raise average standards by peer review.

I may have misunderstood. Peer review may be built into the system and I may have missed it. However, it is not mandatory. Yet peer review formed part of the spirit of the government approach to the matter. Again, exposing my lack of understanding, I have put down the amendment with a view to enlightenment. I beg to move.

Baroness Hooper

It may help the Committee if I start by saying that in promoting better health FPCs have been given an enhanced role in the management of family practioner services which includes assessing health needs, developing services to meet those needs and targeting cash limited funds for practice team development. That will be taken further under Working for Patients, with FPCs taking on additional responsibilities for medical audit, for setting and monitoring indicative prescribing budgets and for monitoring fund-holding GP practices.

The Government and the profession have made it very clear that they are committed to medical audit. That gives me the opportunity to pay tribute to the profession for the enthusiasm with which it is carrying the proposal forward. It is indeed still part of the scheme of things. We issued last October a draft circular on medical audit in family practitioner services. We have now received comments on that and are revising the text for definitive issue in the next few months.

As regards reimbursement for most GPs, the Doctors and Dentists Review Board recommends an average target net remuneration to cover general medical services. Medical audit is one of those and therefore it follows that the DDRB will take that activity into consideration and recommend a pay award which covers audit. Therefore a special mechanism is neither necessary nor desirable.

However, as the amendment recognises, there will be certain doctors—for example, those on medical audit teams—who spend additional time working on audit on behalf of their FPC or FHSA. As part of their increased revenue funding, FPCs have been given resources to make appropriate payments to such doctors. The precise level of remuneration will be a matter for discussion with the GMSC in the usual way.

Lord Peston

Again, I thank the noble Baroness for her reply. I was glad that she underlined the importance of medical audit and also recognised what an onerous business this is. I have been involved in the equivalent only once, and it was the most tiring experience imaginable. Apart from anything else, auditing one's fellows is psychologically draining to say the least.

I understood the Minister to say that the contractual arrangements will be such that those who participate in principle—and one hopes in practice—will be partially and, we hope, suitably remunerated. That was a useful statement from the Minister and I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 12 agreed to.

Lord Ennals moved Amendment No. 104: After Clause 12, insert the following new clause: ("Family Health Services Authorities' oversight of admissions to and removals from practice lists. —(1) A general medical practitioner within the meaning of this Act shall be required to provide to the Family Health Services Authority at the request of any patient a written statement on the reasons for refusing that patient admission to or removing that patient from the practice list. (2) A Family Health Service Authority shall provide a copy of any statement provided under subsection (1) above to the patient upon application, (3) A Family Health Service Authority shall review the reasons provided under subsection (1) above at the request of the patient in respect of whom a statement is made. (4) A Family Health Service Authority shall each year publish a report showing in respect of each general medical practitioner in the area:

1. (a) the make up of the practice list by age and sex;
2. (b) the number of patients seeking a statement under subsection (1) above;
3. (c) the number of patients being removed from each practice list.").

The noble Lord said: This is part of the distribution of labour on these Benches to which my noble friend referred. The amendment I moved and the series moved and withdrawn by noble friend seek to increase the role and responsibility of the Family Health Services Authority, which is a good thing. The amendment might have been linked with Amendment No. 103A because in some respects it deals with the points which were then covered.

The purpose of the amendment is to strengthen the power of the Family Health Services Authority in order to secure a degree of consumer protection for patients. In moving the amendment I wish to make it absolutely clear that in no sense does this amendment or the other amendments represent an attack upon general practitioners in this country. We are extremely fortunate in having a standard of GP service which compares well with that in any other part of the world. The country is fortunate in having at its disposal that quality of service by doctors. However, there are problems which ought to be dealt with and this is the right time to do so.

Under the terms of the amendment any patient removed from a GP's list, or refused access to the GP's list of his or her choice, should be ably to apply to the FHSA to be told the reasons for that denial of access. The authority would obtain such information from the GP concerned and pass it on to the patient at the patient's request. That provision is dealt with in subsections (1) and (2) of the amendment.

The intention of subsection (3) is to place on FHSAs a requirement to look into individual cases and from the results of their investigations to monitor the reasons given by GPs for denying access to patients. It would enable authorities to detect any reluctance on the part of individual practices to accept particular types of patients; for example, the elderly, those expected to have a need for a high level of care, and the special cases to which I referred when speaking to Amendment No. 103A.

The authorities would also be in a position to identify practices which were consistently giving weak reasons for removing patients from their lists. The publication of reports on the make-up of GP lists under subsection (4) would enable comparisons to be drawn with local averages. That information, taken in conjunction with information collected about the number of patients complaining of being removed from or denied admission to a GP's list, could help the FHSA and other interested bodies to identify practices which were reluctant to take on particular groups of patients. Obviously it is a device designed to give more power and a bigger role to the authorities to ensure the highest possible quality of service by GPs.

I have been informed by Age Concern—a body with which I have had contact for many years and for which I have a great deal of respect, as have other noble Lords—that it has been contacted by a number of elderly people reporting difficulties in finding a GP willing to take them on in the first place or in finding a new GP after being removed from the list of their previous doctor. That can be most disturbing for elderly people who may have urgent needs. They may not pop in casually once or twice a year with a particular complaint but perhaps they have had a heart attack and need a doctor upon whom they can rely. Those concerned need greater than average care and attention which often requires a large number of home visits. That is most demanding upon GPs and I often admire the way in which they are prepared to take on such cases and are ready to fulfil their responsibilities.

The distress caused to elderly people by the practical difficulties of needing to find another GP is compounded by uncertainties over the reason why they have been turned away. For example, elderly members of one family were removed from the list of the GP with whom they had been registered for 25 years following a series of appointments made by one member of the family who had sustained a leg injury in a fall. The GP informed the family that they were being removed from his list and that he was not obliged to provide a reason. Perhaps the Minister will say that he has an obligation to do so but certainly the patients do not know that if it is so. The patients told Age Concern that they believed that their removal from the list was simply because of their age.

In the absence of any other reason being offered, it is perhaps understandable that such elderly people should believe that their age or the complexity of their condition explains the reluctance of the GP with whom they had been registered for many years to keep them on as patients. The belief that difficulties in finding and keeping a GP are related to age or to complex health or social problems is often expressed by elderly people. That information was given to me by Age Concern and it would not have given it to me unless it was correct.

I believe that by requiring doctors to provide a reason on request for refusing to accept or retain a patient the amendment will make it easier for the accuracy of those perceptions to be tested. A duty on FHSAs to review individual cases and publish details drawn from the information which emerges will also contribute to the process. I believe that the provisions in the amendment requiring the authorities to monitor the reasons why people are refused access and to publish details of the make-up of each list in their local area will help the Government to monitor the effect of capitation; and, if that proves successful, to discount suggestions that elderly patients are being penalised in any way.

We have a new capitation system which I welcome and we need to know how it will work. This method is one way of doing so. The existing family practitioner committees are already in a position to collect the details of patient lists and there would appear to be no practical reason why they should not be published. The effects of capitation are likely to be felt immediately and Age Concern believes that the measures introduced by the amendment would represent an important step forward in protecting the access to GPs of those elderly people who are already experiencing difficulties.

It is obvious to all Members of the Committee that one of the most important social issues that we face—I do not say that it is a social problem in all cases—is the fact that people are living to a greater age. Therefore, the issues with which this amendment seeks to deal will be even more important as the years go by than they are at present. I beg to move.

5 p.m.

The Lord Bishop of Salisbury

I suppose that ministers of all Churches in our parish experience have helped people who have been refused admission to a doctor's list. In many cases very complicated, psychological and personal reasons are involved. I wonder whether the right of access by the patient to a statement from the general practitioner might in some cases lead to vexatious litigation or complaints of various kinds. I sympathise with the overall thrust of the amendment, but I can see that particular cases could lead to bland or misleading replies or genuine difficulty for the practitioner in deciding how he should reply to the family health services authority.

Lord Pitt of Hampstead

I am glad that the right reverend Prelate spoke as he did. I have been reading the amendment and becoming more and more worried. I feel that we are in the process of introducing another element into the doctor/patient relationship which is unlikely to be helpful. I had intended to wait to hear the Minister's reply, but that is how I feel. I am not against the proposal, but I am worried about it. We may be starting something which will not be very helpful in terms of the relationship between doctor and patient at the primary care level.

Lord Somers

I agree with the noble Lord, Lord Pitt. There is a great danger particularly as regards older people that their privacy would be invaded by this sort of proposal. Not everybody wants to have the details of all their illnesses paraded before the public It is as well that they should remain a private matter between doctor and patient. If the amendment were to be inserted into the Bill, that privacy would vanish which would be a great pity.

Baroness Carnegy of Lour

When my noble friend replies, can she tell us the mechanism which exists to help a person in this predicament? The problem crops up from time to time but I can see that the amendment might lead to all sorts of difficulties including those which the noble Lord, Lord Pitt, has in mind. Those who are turned down by a doctor or who are told that he cannot continue to treat them should be able to obtain help from somewhere. It may be simply that I am ignorant as to how this matter works. It would be very helpful if my noble friend could explain in her reply. It is probably not something which needs to be written into the Bill. Presumably, it is a matter of practice.

Lord Rea

As another general practitioner, I have no objection to the spirit of the amendment. In the practice in which I work we very seldom refuse patients or strike them off the list. If that is done, it is for reasons which I have no difficulty in divulging to the family health authorities; for example, aggressive or threatening behaviour towards staff or altering or forging prescriptions which happens quite often. With regard to acceptance, our only criterion is geographical, although some people believe that we recruit from too narrow a zone. However, I can understand that there may be more subtle reasons for doctors wishing to unload patients which they may not wish to divulge.

To make this amendment rather more acceptable to GPs, perhaps my noble friend will consider a quid pro quo. If a doctor must say why he is removing a patient from the list, then a patient going from the list voluntarily must tell the doctor the reason. At present, the patient can leave without giving any reason. We are sometimes rather curious to know why patients leave.

Baroness Seear

I sympathise with the object of the amendment but I have the gravest doubts about how it will work. I believe that most GPs could find a form of words which would be perfectly acceptable as a reason without reflecting the real situation one iota. I believe that to talk in legislative terms of a patient being obliged to say why he is leaving a doctor is taking the matter to absurd lengths. The most probable reason is that the patient does not like the doctor's face or some other totally frivolous reason Perhaps the doctor just rubs the patient up in the wrong way. This is becoming absolutely ridiculous.

Baroness Hooper

Before I respond to the substance of the amendment, I take the opportunity to state clearly that we do not accept that the changes which we are introducing will make patients more or less financially attractive to GPs. That applies equally to the new contract for GPs and to the changes which we are introducing for indicative prescribing budgets and GP fundholding. Of course, we shall debate those matters in greater detail when we reach Clauses 14 to 18 and I shall not pre-empt that discussion.

It has always been recognised that in general practice some patients will need more care and attention than others. That has always been the case and our reforms take it fully into account. I quoted an example earlier but I believe it is most important to repeat it as often as possible in view of some of the very misleading scare tactics which have been employed by some of those who are against the reforms. Under the new contract the capitation fee for a patient aged over 75 is 2.5 times that for a patient aged under 65 so that there is a considerable incentive to a doctor to look after the elderly.

As is evident from our debate, the fundamental issue here is the nature of the doctor/patient relationship. This has always been like any other professional relationship—freely entered into by both sides and terminable by either side without notice or reason being required. That has been the case since the National Health Service was established. However, in the past the bureaucratic obstacles in the way of changing a GP meant that the advantage was slightly in the doctor's favour. That is why we introduced reforms to make it easier for patients to choose and change their doctor. We believe that any reason—even such a reason as offered by the noble Baroness, Lady Seear—would be adequate. However, the balance is now fair and we should be reluctant to change it further.

I can also assure my noble friend Lady Carnegy that there is no question of anyone being without a doctor. In the relatively rare cases where people are genuinely unable to find a doctor or where the doctor/patient relationship has broken down, as I said earlier, FPCs—or FHSAs as they will become—have powers to assign patients to doctors' lists. FPCs already monitor the levels of assignments and can investigate the reasons if they appear to be excessive in any particular case.

In the same way, indicative prescribing budgets and GP practice funds will be set at realistic levels to take account of the age and health patterns of the patients concerned. Doctors will have no reason for refusing to accept patients or for removing them from their lists. The amendment is unnecessary for that reason. However, I also reject it on practical grounds, as pointed out by the right reverend Prelate and others, including the noble Lord, Lord Pitt. When trust has broken down in the doctor/patient relationship there is little to be gained by either side by claim and counter-claim as to the reasons for the breakdown.

Similarly, requiring FHSAs to publish annual statistics regarding the removal of patients from GP's lists, as was suggested, will be of no real advantage to individual patients. The figures will mean little in isolation and could be open to misinterpretation. That in turn could lead to confusion and unnecessary anxiety. A better method is, as already happens, for the FHSA (or FPC as it now is) to be alert to excessive removals and take action if necessary.

I hope that I have said enough to persuade the noble Lord, if he has not already been persuaded, to withdraw the amendment.

Lord Ennals

I am glad that I tabled and moved the amendment, though I will not press it to a vote, partly due to the arguments I have heard. I hope that on other occasions the Minister, when taking a firm position negatively against a sensible proposal, will listen to the voices and be influenced by those voices, which is what I am about to do. I should like to set a good example to the Minister for future debates.

I am grateful to all who took part in the debate. My noble friend Lord Rea, with whom I normally agree, whether or not through his sparkling sense of humour, raised a question. However, there is a greater responsibility on GPs to their patients than on patients to their GPs. It is the doctor who serves the interests of the patient, not the patient who serves the interests of the doctor. There are aspects of the new contract which perhaps put that in reverse order, but the doctor wants the patients to attend and receive certain types of treatment which will increase his remuneration.

It is partly as a result of the GP fund holding, which we will be discussing later, and indicative budgeting that I believe—and I suspect that my noble friend agrees—that those two measures are likely to affect the relationship between doctors and their patients. I shall not spell the reasons out now, but I will later. I do not accept the arguments put forward by the noble Baroness that because FPCs have the responsibility the same responsibility should be passed on to the FHSAs. They will have a bigger job to do. They will have more responsibilities because I fear that relationships between doctors and patients will be under more strain and tension than ever before as a result of other parts of the Bill.

I was impressed by the arguments of the noble Baronesses, Lady Carnegy of Lour and Lady Seear. I do not believe that this amendment provides the best method of putting the provisions into practice. If I did I should press it to a Division, but as I do not believe so I shall not press it. I am glad to have had the opportunity for a debate.

Amendment, by leave, withdrawn.

5.15 p.m.

Lord Walton of Detchant moved Amendment No. 104A. After Clause 12, insert the following new clause: ("Family Health Service Authorities: publicity for services. .—(1) A Family Health Services Authority within the meaning of this Act shall take steps to publicise its principal functions and duties to the resident population. (2) Regulations shall make provision as to the steps to be taken by Family Health Services Authorities to carry out their duties under subsection (1) above; and the regulations may, in particular—

1. (a) require details of the functions of the Family Health Services Authority to be included in the practice leaflet
812
2. (b) require details of the functions of the Family Health Services Authority to be included in the Local Directory of Family doctors.").

The noble Lord said: The thrust of Amendment No. 104A tabled in my name and that of the noble Baroness, Lady Cox, relates to the provision of much better information being given to patients and potential patients. I am open to correction, but my understanding is that there is neither a legal obligation under the 1977 Act upon family practitioner committees to publicise the nature of the services which fall under their responsibility to the public, nor any existing regulations imposing any such duty upon them. So far as one can judge, there is nothing in the Bill which will impose a similar obligation upon the FHSAs.

Eighteen months ago I was president of the General Medical Council. I and a number of my colleagues appeared before the Monopolies and Mergers Commission on reference from the Office of Fair Trading on the issue of advertising by the medical profession. I am opposed to press advertising by doctors because experience in other countries, and indeed some experience in this country, of advertisements placed by lay administrators or owners of a number of private medical institutions convinced me that often those who are the most able advertisers prove in the end to be the least able providers of medical services.

I relinquished the presidential office in February last year, but my understanding is that discussions between the General Medical Council and the Monopolies and Mergers Commission are continuing. It is likely that the ban—if I may use that word—on advertising by consultants and specialists will continue, but the issue in relation to general practitioners is still open. The reason for the proscription of advertising by consultants relates to the essential preservation of the gatekeeper function of the general practitioner, whereby in this country by and large specialist services to patients are provided on the advice of a general practitioner, who refers the patient to a consultant or specialist for an opinion.

Having made that point, I am very much in favour, as is the profession, of the proper dissemination of information to the public in practice leaflets, annual reports and other documents which should be widely circulated to enable patients to make an informed choice of general practitioner. At the moment the provision of such information to the public by health authorities, including FPCs, is less than satisfactory.

The amendment seeks to place an express duty on family health service authorities to publicise their role and responsibilities to the people living in their catchment area. The two specific steps it recommends, if accepted, will require details of the work of the FHSA to be included in GPs' practice leaflets and in the local directory of family doctors.

On the first day of the consideration of the Bill in Committee, the Minister expressed the Government's belief that FHSAs will be, more responsive to the needs of the local community and thus be for the benefit of the patients".—[Official Report, 19/4/90; col. 196.]

Age Concern, a well-known charity, and many other charities receive inquiries every week regarding the services provided by community practitioners and GPs in particular. Where appropriate, and when, for example, an elderly person rings with a complaint about a GP, the charity organisation asks whether the person concerned has contacted the family practitioner committee. In the overwhelming majority of cases the person making the inquiry has no idea what the FPC is or does.

The Secretary of State acknowledged during Committee stage in another place that in his experience no one knows what a family practitioner committee is unless he or she has had contact with health service politics. He added that he hoped that the title of the strengthened body would make it easier for the public to recognise it. That view has been widely endorsed. It is particularly relevant to the issue of the homeless, the subject of Amendment No. 103A debated earlier today.

At present there is no statutory obligation imposed on FPCs to publicise their role and no indication that such a requirement will be placed on FHSAs in the future. The National Health Service (General Medical and Pharmaceutical Services) Amendment Regulations 1989 set out requirements for inclusion in the local directory of family doctors, but that does not include details of the role of the FPC. Compulsory features of the GP practice leaflets are set out in the same regulations, but again, inclusion of the detail of the role of the FPC is not mandatory.

It may prove to be the case that in taking on wider responsibilities the FHSAs will become better known to the public. We must hope that that will be so. However, I believe that there are a number of steps which the Government can and, indeed, should take to ensure that their role is fully undestood. The amendment mentions two in particular; namely, publicity through the local directory of family doctors and through GP practice leaflets. Those will be two of the main vehicles for conveying information to patients about GPs' services. However, there are many other possibilities which one hopes that the Government and the FHSAs will consider. For example, it might be possible for FHSAs to circulate information to all patients in their area informing them of the FHSAs' role and function. Other alternatives clearly arise.

Public awareness of the role of the FHSAs is essential if the authorities are to be able properly to oversee the delivery of practitioner services and patient satisfaction in their areas. That is essential if patients are to make full use of, for example, complaints procedures under the new guidance published in March of this year. The FHSAs can only be fully responsive to the wishes of patients if patients are aware that the FHSAs are there and of what their responsibilities are. I beg to move.

Lord Auckland

I have general sympathy for the amendment moved by the noble Lord, Lord Walton. My view is that paragraph (b) is more relevant than paragraph (a). How many people read leaflets, whether in a doctor's surgery, in this Chamber or anywhere else? I believe that there is far more chance of such information being read in a local directory of family doctors. I support the principle behind the amendment because I believe that people should be able to glean knowledge from these sources, but I have the gravest suspicion that paragraph (a) will be ignored. Leaflets being what they are, people take them and read them only superficially but I hope that the Committee and particularly my noble friend the Minister will take serious note of paragraph (b).

Lord Ennals

I also support the amendment and I am delighted that the noble Lord, Lord Walton, moved it. In regard to the intervention of the noble Lord, Lord Auckland, I have to say that I support both halves of the amendment. I believe that there will be a value in well prepared leaflets. The citizens advice bureaux will be able to make good use of them.

It so happens that in my family I have two children—one daughter and one son—who are welfare rights officers. They are constantly being asked all kinds of questions, some of which touch upon these medical issues and relate to GPs. Therefore, details of the functions of the FHSAs should be made known as widely as possible. As the noble Lord, Lord Walton, said, we could possibly i think of a number of other ways in which that can be done.

The noble Lord also said that compulsory features of the GP practice leaflets are set out in the same regulations but, again, inclusion in detail of the role of the FPC is not mandatory. I think that it should be mandatory and that is partly because, as I said on the previous amendment, the task and the role of the new FHSAs will be greater, and should be recognised as greater, than that of the existing FPCs.

The noble Lord, Lord Walton, referred to Age Concern, which had some correspondence with the Minister for Health, Mrs. Bottomley. Age Concern raised this question and the Minister replied that GPs will be free to include other useful information for patients. I do not consider that that kind of assurance goes nearly far enough. I note what the Secretary of State said in another place when emphasising the importance of the role of the FHSAs. He said that FHSAs will be responsible for important parts of the disciplinary procedure and for hearing complaints from the public. He went on to say that the more we can do to strenghten the authorities and give them greater responsibilities, the more effectively they should be able to undertake that duty. There is not only that duty but others that we have been discussing this afternoon, but perhaps one of the most important aspects is that the information about their work should be made widely available, as suggested in the amendment.

Baroness Hooper

We believe that family health services authorities should ensure that their residents know of their existence and how they can help them. Indeed, this duty is already included in the enhanced management role we have given to FPCs. The noble Lord, Lord Ennals, is correct in that it will be a larger role. It will place a strong emphasis on patients as consumers of health services and on responsiveness to local needs.

Under the National Health Service Act 1977, the principal functions and duties of FPCs are to administer arrangements for the provision of general medical, dental, ophthalmic pharmaceutical services in their areas. With all due respect to the noble Lord, Lord Walton, I do not believe that this information is of a great deal of interest or even use to the general public.

What patients need to know, as the noble Lord emphasised, is how their FPC—or FHSA—can help them directly; for example, by providing clear information on available services, by helping them to find a suitable practitioner and by dealing with complaints. We do not accept that imposing a duty in regulations would help achieve that. We take the view instead that FHSAs should have the flexibility to decide how best to communicate with their communities to suit the local opportunities open to them. We are encouraging them in that direction.

FHSAs already have a range of vehicles available for making their work better known to the patients they serve. For example, every patient has a National Health Service medical card and receives a new one each time he or she moves or changes doctor. This card contains the address of the local FPC and explains how it can help by supplying information about practitioners and investigating complaints. We have recently redesigned the medical card to make it more attractive and user friendly. I believe that will go some way towards meeting the concerns expressed by the noble Lord, Lord Walton.

In addition, FPCs across the country have been undertaking a wide range of initiatives designed to publicise what they can do for patients. Some issue regular regular bulletings and newsletters on health matters. Some have opened branch offices in high streets so that people can drop in while they are shopping or during their lunch hour. Others publish articles in local newspapers and journals.

Last autumn we also published guidance to FPCs on carrying out consumer surveys. This kind of action—to sound out the views of the local community—can equally be a very useful vehicle for reminding people about the role of the FHSA and the services it can offer. FPCs can also use displays—and some do—in public libraries and other public places as a means of publicity and information. Finally, FPCs can use the new local directories of family doctors, as suggested in the amendment. We believe it is right for each FPC to be able to make its own decisions about which methods are best for it in the light of local circumstances.

As regards practice leaflets, these are intended primarily as a vehicle for communication between particular practices and their patients or prospective patients about the services they offer. They would not, therefore, be an appropriate vehicle for more general information about the role of the FPC. As I said, each patient when registering with a new doctor receives a medical card with details on it of the local FPC. Should the FPC, or FHSA, wish to expand on that, it can easily include in the same envelope an information leaflet of the kind referred to by the noble Lord, Lord Walton. I see no difficulty about that.

This is an important matter. For the reasons I have given the amendment is unnecessary. In the light of the assurances that I have been able to give I trust that the noble Lord will believe that what I said at Second Reading is still correct; namely, that the FHSAs will be more responsive to the needs of the local community.

5.30 p.m.

Lord Ennals

Does the noble Baroness agree that the degree and extent of the existing publicity consciousness, by which family practitioner services let the public know what they are and what they can do to help, vary enormously? Some services have offices on the main street and issue attractive literature. For example, I am thinking of the citizens advice bureaux and the activities which they undertake. Does the noble Baroness agree that some family practitioner committees are not very much influenced by the needs of publicity and that many people do not know what they are or where to find them? Many people do not know where to find them in the Yellow Pages and they do not know what to look for. Does the noble Baroness agree that from the public's point of view there is a kind of anonymity about many of the family practitioner committees? If the Minister agrees with that, does she also agree that, in establishing new authorities—if that is what the Bill intends—it is necessary to ensure that the approach is very much more open, public and welcoming so that people know to whom to turn when in particular kinds of difficulties?

Baroness Robson of Kiddington

I support this amendment. The Minister said that the practice leaflet is supposed to give information to patients within the practice, or to those who are looking for a new GP, about the services provided by that practice. Does the Minister agree that it is absolutely correct that there should also be in the leaflet something about the FPCs so that if a patient is not satisfied with the practice, the leaflet explains where a patient can go for advice?

Baroness Gardner of Parkes

The point made by the noble Lord, Lord Ennals, is inappropriate. I do not believe that most people want a great deal of detailed information about the activities of the FPC or its successor. As the noble Baroness, Lady Robson, said, people want to know where they can find information. If a person has a complaint or needs a doctor, that is when information is required. It would involve a great deal of money to publish information about the activities of these authorities which would be of very little interest to patients. The situation is parallel to that of the Gas Consumers Council and the Electricity Consumers Council. There should be places where notices are available, but the provisions need not necessarily go so far as having offices in high streets. In some areas it would involve so much money to have premises in high streets where people could drop in for information. In others it might be quite practical. If such conditions were laid down as mandatory provisions they would be imposed on everyone. This amendment is neither necessary nor desirable.

Baroness Hooper

I reiterate that the basic information which is important and desirable is already available to the individual on the medical card which is issued to him. I agree with the newly enhanced role of the FHSAs which will involve assessing health needs, developing services to meet those needs and targeting cash limited funds for practice team development and so on. Those measures will go a long way to making people much more aware of the role of the FHSA than has been the case in the past as regards the slightly more limited role of the FPCs.

Lord Walton of Detchant

I am glad to hear that the medical card is being redesigned to make it more user friendly. I cannot think of a document less exciting than the earlier medical card. At a time when the medical profession has moved a very long way in response to public concern and demand in trying to publicise its own facilities through the practice leaflets which it provides, it is somewhat paradoxical that there is no obligation on the family practitioner committees or the family health services authorities to provide a similar range of information about what they do and what they are to the public at large.

Nevertheless, in tabling this amendment I did not expect that it would be included on the face of the Bill. I had hoped that there might be a regulation stemming from the Bill requiring family health service authorities to make available a wider range of information than is available at present. I accept the point made by the noble Baroness that many of them are now publicising more effectively and widely the nature of the services they provide and the responsibilities that they fulfil. In the light of the Minister's assurances, while I believe that there is still room for a great deal of improvement, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 13 [Financial duties in relation to Family Health Services Authorities]:

[Amendment No. 105 had been withdrawn from the Marshalled List.]

Clause 13 agreed to.

Clause 36 agreed to.

Clause 14 [Recognition of fund-holding practices of doctors]:

Lord Ennals moved Amendment No. 105AZA: Page 14, line 29, at end insert ("but no such fund holding practice shall be cash limited and have to limit the services purchased by the practice because of lack of funds").

The noble Lord said: In moving this amendment I shall also speak to Amendment No. 105ZAA which is identical but the Scottish equivalent. It is the first opportunity that the Committee has had to discuss fund-holding practices. I hope that the Committee will not object if I raise a few wider issues before I come to the terms of the amendment.

It is important that we should know the terms of the amendment because they may also be controversial. The amendment states: but no such fund holding practice shall be cash limited and have to limit the services purchased by the practice because of lack of funds".

That reveals both the controversial nature of the amendment and also the very controversial nature of the proposals which we are now beginning to debate in this clause and in others which follow. As I said earlier, there are many people who fear that this proposal is likely to do great damage to doctor-patient relations.

I wish to say something about the role of the British Medical Association in representing general practitioners. I wish to do so because no one has yet defended the British Medical Association which has come in for a great deal of criticism. To some extent that criticism may have been unfair. Some people may not have liked the form of advertising which it used and I shall not defend a particular advertising technique. I intend to look at the way in which it has represented the interests of GPs because that is what we are now talking about.

The BMA is a trade union and it has a job to do on behalf of the general practitioner. There is no doubt that there has been extremely strong and almost unanimous feeling against this proposal for fund-holding practices. The feeling runs very deep in the profession. Any constituency Member and any Peer who has connections with his former constituency knows that. At the request of general practitioners I have had several meetings in Norwich because of the depth of their feeling. When the GPs put up notices in their surgeries it is because they believe that the Government are on the wrong track. If they collectively believe that then it is the job of the BMA to argue their case for them.

It has been said that the BMA has been behaving as though it is party-political in its activities. I remember an earlier meeting with a Committee of your Lordships House at which a team of the senior representatives of the BMA presented its case. One Peer, with whose comments others agreed, accused the BMA of playing a party-political game. It is not doing that. It is not supporting the Labour Party. Occasionally GPs put up candidates of their own. There are no party politics in the matter. If we happen to agree with them that is a very different matter from whether they agree with us. I do not believe for one moment that the BMA has been playing a party-political game in the sense of supporting one party as opposed to another. The BMA is supporting the strongly held views of GPs themselves and I want to sustain its right to do so.

I am also talking about the views of the public. These views have become increasingly strong. An opinion poll was carried out in January on GP budget holding. In January, 19 per cent. said they approved and 70 per cent. disapproved. That was fairly impressive. By March 15 per cent. approved and 79 per cent. disapproved. Only 6 per cent. did not know. Among committed Conservative voters, by March of this year 34 per cent. approved and 56 per cent. disapproved. This issue runs deep among GPs themselves and also among the public whom they serve.

I hope that the Minister will be able to tell us something about the statistics of the scene. Working for Patients stated that 1,100 practices, which is about 9 per cent. of the total, covering 25 per cent. of patients were eligible. This was based on a practice size of about 11,000. When the prospectus was issued on 13th December 1989, it was stated that practices with lists of 9,000 to 11,000 patients might also be eligible but no estimate of the potential pool was given. I hope that the noble Baroness will be able to tell us where we stand. Any information she can give will be much appreciated.

On 14th March 1990 the department announced that more than 850 practices had expressed an interest. I want to pause on the phrase "had expressed an interest". It is one thing to be in favour, and it is another thing to express an interest. Many GPs felt that they ought to find out about it because they think it will happen so long as the Government are in power. They think it is going to happen and that they had better find out what it is about. As soon as they write in asking to be told more about it, they are put on the list as if they are showing an interest. Some are showing a great deal of opposition. The figure by no means reflects the number of GPs or practices wishing to proceed with fund holding. In my own area I know that many GPs who are totally opposed to the concept of fund holding wrote away for further information. Those doctors are presumably included in the figure of 850.

Practices expressing an interest which are deemed by the regional health authority to be suitable will be eligible during 1990-91 for the £16,000 management allowance. I am a little confused about that figure because a £32,000 management fee is also mentioned. I am not certain whether there are two and how they are calculated. The 1990-91 Supply Estimates issued by the Treasury in March indicate that a sum of £6 million is being allocated for, preparatory costs in relation to the adoption of practice funds".

This would seem to imply that the first tranche of practices will number 375–44 per cent. of those expressing an interest.

The problems will be very great indeed. I do not know whether the Minister saw the report published in the Health Service Journal on 25th January of an exercise carried out in East Anglia. The exercise showed the confusion and uncertainty which exists about how the new proposal will operate. There is great anxiety in different parts of the country. The Secretary of State, Mr. Kenneth Clarke, told the Social Services Select Committee: They are coming in in hundreds. The clear impression I have at the moment is a high proportion—probably a majority—of eligible practices are interested in the idea".

But a closer look reveals that the apparent enthusiasm is rather misleading. Even the practice in Cheshunt, Hertfordshire, heralded as the first to register an interest—after Mr. Roger Freeman, the junior Minister, personally delivered its form—is not fully committed. One of the partners said: I am sure there is not a practice in the country that does not have reservations".

Dr. Carne, one of five partners in Stamford Hill, North London, explained that he and his colleagues felt forced to register for a budget in the interests of patients. He said: We do not feel it is necessarily the right way to go, but if it is going to go that way we feel we are better off being budget holders than not being budget holders".

His colleagues fear that they may have to ration services to patients if funds are less than generous in future years. But the alternative—of the health authority setting up block contracts to govern GP referrals—would, he believes, be even worse. I could quote examples from all over the country of GPs who are worried but who are opting to show an interest because they fear that unless they do so they may be left behind in the rush.

There are severe worries about the way in which general practice fund holding will affect the relationship between doctors and patients. It is a radical departure from the basic philosophy of the National Health Service. Doctors oppose these proposals because they believe that they are not in the best interests of patients. They give several reasons for being worried and opposed. They say that a patient's confidence in his doctor could be affected by the knowledge that the doctor is a budget holder and that the doctor might make a financial calculation rather than a medical calculation about the needs of the patient. The patient's trust in the doctor could be undermined when advised that medication or investigation is not necessary. The patient may ask whether it is because the doctor cannot afford it in terms of his budget. Disputes over the cost of clinical treatment will damage relationships between GPs and hospitals. Another point is that the cheapest care is not necessarily the best care.

We have tabled this amendment because we are worried that unless some such provision is included in the Bill the quality of treatment will be affected. The effects of the budget will have to be assessed and renegotiated. That is a time-consuming exercise. Doctors have always been seen as the patient's advocate and an intermediary in his contact with hospital services. Under these proposals they would be perceived as being the controllers of access to health care. That puts them in a very different light.

Doctors are also worried about the administrative costs. This £16,000 or £32,000 is money which they have not been given before. It is offered presumably to pay the administrative costs of operating the new scheme. Doctors fear that even with this extra money they will have to spend more time on administration than on looking after their patients.

How can a doctor know what demands on him will be made during the course of a year? That is the real worry. The demand may be affected by weather. There may be an unexpected flu epidemic or some patients may require very expensive treatment. How can a region or a doctor make a responsible assessment of what the costs will be for a year? We want through this amendment to make absolutely certain that no such fund holding practice will need to limit services purchased by the practice because of lack of funds. We can be certain of that only if we say that a practice should not be cash limited or that although it is cash limited we are prepared to make assessments and go above the cash limit. I move this amendment with the support and sympathy of, I believe, most GPs in the country and of most patients who are deeply concerned about the proposals. I beg to move.

Lord Pitt of Hampstead

I hope that the Minister will accept the amendment. It goes to the kernel of the worry which most people have about this proposal for budget-holding GPs. We all know that every year around the month of March problems arise in hospitals where their funds have run out and they are obliged to close wards in order to save money for that period of time. That happens every year.

The general worry is that if financing is now in the hands of the GP, he will also be in that position in the month of March. If every year in March general practitioners found themselves unable to provide the services required because they have run out of funds, that would be a serious matter. The amendment seeks reassurance from the Government that they will ensure that that does not happen. I hope that we shall receive from the Minister a ready acceptance of this proposal in principle. However, how it will be implemented is a different matter. The principal is that there should never be a situation where, because of a lack of funds, a patient cannot receive the treatment he requires from the GP. More often than not it would concern hospital services which have to be paid for.

There are ways of meeting such a situation. A fund could be established in order to meet such circumstances. The regional health authority could keep the fund or it could be kept centrally. All that is required is that there is some assurance on the matter. It is not only an assurance to the GP; it is also an assurance to the average patient that no such situation will arise. That is all the amendment requires.

Up until this time general practice has not been cash limited. I shall say now what I proposed to say later in respect of indicative budgets: when hospitals are cash limited, they tend to give outpatients only a limited supply of drugs. They leave it to the patients to obtain further supplies from their GPs. That is how they get around the problems which they have with their limited drug budget. We shall have indicative drug budgets which will limit that practice to some extent.

Patients must be assured that, whatever system we adopt, there will be no such thing as a situation in which a patient cannot receive the treatment he needs because of lack of funds. That is what the amendment seeks to achieve. As I said, I hope that on this occasion the Minister will be in a position to say that the Government will accept the amendment.

Baroness Oppenheim-Barnes

I listened with great interest to the opening remarks of the noble Lord, Lord Ennals, on this amendment. I have no doubts at all about his sincerity and anxiety. However, I must question at least two of the premises which he raised. The first concerns the question of the budget and its effects. He spoke as if to say that a budget was something which the medical profession was above. Every company and, indeed, every small company, has a budget. Moreover, every housewife has a budget. If she does not keep reasonably within it, it is likely that she may not be able to feed her children that week.

However, this is a much more emotive situation when it comes to the question of health and medical treatment. The noble Lord spoke about the uncertainties and the fears which are felt among patients. I fear that a great many of those uncertainties and fears have been inspired. Indeed, to continue to inspire them in this way when, in my view, it is not necessary, serves only to make the situation much worse.

I should also like to take up the point which the noble Lord raised about the political complexion of the BMA. I entirely agree with him that obviously it will be a mixture of political allegiance much as it is elsewhere. There is probably an element of self-interest in the BMA. After all, as the noble Lord said, it is a trade union. It has certainly been behaving very much like a trade union in recent times.

However, on the political aspects, there is one point I should like to make. It concerns the doctor who went on television saying that he was resigning from the National Health Service because he could not possibly continue. I see that the noble Lord is nodding his head and doubtless he remembers the situation. That doctor is the same doctor to whom I took my cut finger last summer.

Lord Ennals

I nodded my head because I thought that the noble Baroness was about to refer to a GP in Norwich who wrote to me on the subject. In the circumstances, I withdraw my nod.

Baroness Oppenheim-Barnes

I am not referring to the GP in Norwich; I am referring to the GP who appeared on television day after day stresssing the fact that he was resigning from the National Health Service because this was such a serious situation and because he thought the whole service would be undermined. As I said, he was the same GP to whom I took my cut finger for treatment. While looking at my finger he said, "You know I am very much to the Left". I replied, "I'm not interested in your politics; I am more concerned in your qualifications". That doctor was very willing when holding my cut finger to tell me what were his politics; but when he went on television to say that the National Health Service was being undermined by the Government's proposals, he did not feel it necessary to tell the country about his politics. Therefore, I would not go so far as to say that there are no politics in the matter.

Finally, and I hope by way of reassurance to the genuine anxieties which I know noble Lords opposite, and other people in the country, share, I should tell the Committee that I have heard my right honourable friend the Secretary of State on numerous occasions stating publicly that if budget-holding GPs run out of funds, there will be no question of them running out of resources. If at the end of the year they have not met their budget, they would simply be called in and their budget would be compared with that of a similar doctor who had met his budget. Explanations would be sought as to how the situation could be improved in future years. That would be the Government's approach. I hope that we shall receive reassurance on that point from my noble friend; and, if we do, I also hope that that will reassure both noble Lords opposite and Members of the Committee.

Baroness Hooper

I am most grateful to those who have contributed to this discussion. Perhaps I may start in the general way in which the noble Lord, Lord Ennals, opened his speech. I should like to reiterate what I said at an earlier stage. The whole idea of the GP-funding initiative is that the scheme is voluntary; no one will be obliged to join it. The practices with list sizes of around 11,000 patients will be eligible, and those with between 9,000 to 11,000 patients will be considered on an individual basis. Smaller practices can group together to apply.

Of the practices containing over 9,000 patients in the country, the total number in England is 1,640. The number of expressions of interest has been around 850. The noble Lord, Lord Ennals, referred specifically to that fact. We made it clear at the time that not all the practices concerned would meet the eligibility criteria, and some would decide not to pursue their interest further. Regional health authorities, together with FPCs, are now working with the practices to determine which ones should undertake the preparatory work in order to become fund holders. That is all part of the evolutionary nature of our reforms which we have considered on previous occasions.

The phrase "expressing an interest" was also questioned by the noble Lord, Lord Ennals. That phrase has been used advisedly. Until the Bill receives Royal Assent, and regulations are made, GPs cannot apply for recognition as a fund-holding practice. Any application might be said to be anticipatory and assuming Royal Assent. GPs have therefore been asked to "express an interest"—a rather neutral phrase to which no such objection could be raised.

Lord Ennals

Before the noble Baroness moves on, I should be grateful if she would allow me to intervene. That puts GPs in the same position as those who wish to consider an NHS trust but cannot apply, for the same reasons. Is that right?

6 p.m.

Baroness Hooper

That is correct, as I stated previously. Perhaps I may reiterate some of the benefits and advantages of the proposal for the practice budget. One of the new advantages is that for the first time GPs will be able to back their choice of hospital and consultant with money to pay for treatment, including those in the private sector. GPs will also be able to spend any savings on their budgets for the benefit of their patients.

As for the allowances to which the noble Lord, Lord Ennals, referred and on which he raised some queries, an allowance of up to £32,000 per year will be available to manage the fund. Fund holders will also be able to claim 75 per cent. of computer costs, and software is being developed to run the fund. Practices which agree with their regional health authorities that they should undertake preparatory work to enable them to become fund holders will be entitled to an allowance in 1990-91 of up to £16,000. However, the full allowance to which I referred of up to £32,000 will be available to practices which join the scheme in due course, subject to Royal Assent.

We do not accept that practice funds will damage the doctor-patient relationship. Funds will be set individually with each practice at a level that will ensure that patients receive the treatment they need.

In response to the remarks of the noble Lord, Lord Pitt, and turning to the amendment before us, I wish to make it absolutely clear that funds will not be cash limited at practice level. In setting the level of the fund, regions and health boards will take account of a wide range of factors. They will need to examine the previous hospital treatment and prescribing patterns of the practice and take account of the nature of the practice list. This will include such things as the age and sex composition of the list, the number of chronically sick and disabled people and other potentially high cost patients. If during the year a practice considers that the fund is likely to be insufficient because of, for example, an influx of new patients to the practice or an increase in patients requiring expensive drugs it will be able to discuss this with the FHSA and if necessary the fund can be increased. Regional health authorities and health boards will be required to hold adequate reserves to deal with this possibility. There is no question of patients not receiving the treatment they require as a result of practice funding either in relation to referral to hospital or for a prescription which they need.

On overspends, in paragraph 6.14 of Working for Patients and paragraph 4.11 of Working Paper 3, we said that overspends of up to 5 per cent. would be recouped in the following year. This will not now happen. As I said previously, there may be good reasons for the overspend, and in recognising that the Government will make provision in directions given by the Secretary of State for the regional health authority and the health board to meet that overspend.

The Government believe that there will be enough safeguards to ensure that fund holding practices will have a sufficient level of funding to meet the hospital treatment and prescribing needs of their patients. I wish to repeat that there is no question of patients not receiving the treatment that they may need. I submit that these amendments are therefore unnecessary. I trust that the noble Lords will feel able to withdraw them.

Lord Ennals

I thank the noble Baroness for her constructive approach to the amendments that I tabled. Perhaps I may return to the points she raised in a moment. First, I wish to answer the point made by the noble Baroness, Lady Oppenheim-Barnes, that every company has a budget and every family has a budget. It is difficult to compare a general practice with a company which is surely designed to make a profit as a business concern. A general practice fulfils a social and health need of the nation.

It is even more difficult to compare a general practice with a family budget. My wife said to me over the weekend that she would like me to take her to a certain country for a holiday. I said, "I have a family budget and that is not part of it". Therefore we had a slight disputation. I said that if a little extra money came in then maybe I could take her to Prague which is where she wanted to go. It is quite right that if we have a family budget, we have to trim our demands. A doctor cannot, say, "All right, I have my budget" and then along comes this person who does not wish to go to Prague but wants an expensive form of treatment which may last over many months. The answer to that dilemma was given to me satisfactorily by the Minister. If there is no question of patients not receiving the treatment they need—and I very much value that assurance—if it is true that, if the practice cannot cope because of extra demands, its funds can be increased, I do not know what the cash limit is.

That does not mean that I shall press the amendment; I shall not. I may seek a vote at a later stage. However, it seems to undermine the concept of a cash limit which must be observed by health authorities as well as by companies and families—to quote the noble Baroness—if it can be overspent and there is no danger that one will not be able to give a certain treatment.

I also welcome what the Minister said about recouping an overspend. However it will be an expensive operation. I asked whether it would be £16,000 or £32,000. The noble Baroness said, "No, it would be both". It would be £32,000 to manage and an allowance of £16,000 with 75 per cent. of computer costs.

Baroness Hooper

Perhaps I may take the opportunity to clarify the matter. I said that the management allowance was intended to be £32,000. That is obviously not now available for the reasons that we have discussed. However, amounts up to £16,000 are available now which can help practices with their preparatory work.

Lord Ennals

Therefore one can well understand why many general practitioners in a practice with the appropriate number of patients do not like the idea at all. With the prospect of receiving £16,000 soon and 75 per cent. of computer costs, and, if that is accepted, then obtaining £32,000, it is not surprising that GPs think the idea terrible. They will come along and say, "Here is all this extra money and the department does not seem to know how to spend it". Why these sums of money will be spent—unless it is thought that they will produce a remarkably improved service to patients—I do not know—nor do the doctors. That is why they object to it, and why—as I gave notice—I shall have something to say on the debate as to whether the clause should stand part of the Bill. However, in view of the assurances given to me by the noble Baroness, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Rea moved Amendment No. 105BZ: Page 15, line 10, at end insert ("including such conditions as may be required in respect of the quality of services supplied by the practice in question;").

The noble Lord said: This amendment is exploratory in its intent. Both Clause 14(6)(c) to which the amendment refers and Clause 14(2), which we are discussing at the moment, refer to the conditions necessary for recognition as a fund-holding practice. But nowhere in the Bill are those conditions laid down. I can understand that this is an appropriate matter for regulations as circumstances may change from time to time and I would guess that the detailed regulations may not yet be fully worked out. I am concerned, however, that when these conditions are made known they should include not only measures of financial and administrative competence—such measures will probably feature computerisation, as 75 per cent. of the cost of computerisation is already available—but should also specify certain clinical services including those encouraged in the contract such as child health surveillance, immunisation, ante-natal and post-natal clinics, health education, health promotion activities and minor surgery with the appropriate attached staff such as employed practice nurses or attached nurses from the district health authority and other members of the wider primary health team. The latter might include midwives and a geriatric visitor, who is now known as a health adviser for the elderly, together with various counsellors, physiotherapists, chiropodists and others.

I am aware that most applicants for fund holding status will probably have more facilities to offer than a smaller practice simply because of their size and, possibly, their administrative competence. I do not know what the position is, but I imagine applicants will not be considered for fund holding status if that is not the case. However, I am also aware that there is at least a theoretical possibility of abuse in that a financially oriented practice may divert any savings it gains from economies in referrals to hospitals, from investigations or from cutting drug or staff costs. It may use those savings not to improve services for National Health Service patients but rather to develop facilities and to buy expensive equipment, perhaps to satisfy a particular hobby horse of some doctors in the practice. The savings may even be diverted to provisions for private practice.

For a practice to hold a series of clinics and employ various paramedical staff does not necessarily guarantee a high standard of personal care, although it makes that more likely. Ideally, the results of clinical audit should be available before a decision is made to promote practices. Whatever data are available—from annual reports, the opinion of community health councils, the local standing of the practice with hospital consultants or with nearby medical shools—should be taken into account before assessing whether practices should be potential budget holders or allowed to retain their budget holding status when they have already achieved it. That is more or less the point of the amendment. I shall be most interested to learn how far government thinking has reached as regards the detailed regulations for the conditions necessary for recognition as a fund holding practice. I beg to move.

6.15 p.m.

The Parliamentary Under-Secretary of State, Department of Social Security (Lord Henley)

The amendment seeks to treat fund holders differently from non-fund holders. I see no reason why we should make special provisions for fund holders, particularly as the Government believe that the practice funding is likely to enhance the quality of service for patients.

The noble Lord, Lord Rea, expressed concern because the scheme allows practices to make savings. Perhaps I may offer some reassurances. Savings can only be spent after a practice's accounts have been completed and audited, and then only on specified purposes. Practices will be able to use savings for any of the purposes of the fund; that is, hospital services and prescribing costs and practice staff. In addition they will be able to spend savings in improvements to the practice which will benefit patients. These might include buying diagnostic equipment, funding health education campaigns and providing more and better facilities for patients. Savings cannot be used for the direct personal benefit of the members of the practice. I am confident that practices will use savings well to the benefit of their patients, thus enhancing the quality of service offered.

The Government are concerned that practice funds should be used to the best advantage of patients. RHAs will have overall responsibility for the scheme, but FHSAs will be given the responsibility of monitoring fund holding practices. Practices will be required to submit monthly and annual reports to the FHSA which will give details of how the fund is being used. The FHSA will be in a position to recognise if practices are unnecessarily overspending or indeed underspending. If there is any cause for concern, the practice will be required to take remedial action. I hope that, having given those reassurances, the noble Lord will feel that his amendment is unnecessary.

Lord Rea

I should have liked rather more detail. Clause 14(6)(c) states that regulations may make provision with respect to, the conditions to be fulfilled for obtaining and continuing to be entitled to such recognition".

However, we do not yet know what those conditions are, apart from the fact that a practice must be above a certain size. I hope that the noble Lord can enlighten me a little more.

Lord Henley

As the noble Lord knows, that will be a matter for the regional health authority to decide after discussion with the individual practice concerned. The noble Lord mentioned the figure of 11,000, but I believe that practices of over 9,000 patients would be considered as suitable for this provision, if they show an interest in it and the regional health authority thinks they are suitable.

Lord Rea

We would like more information but at this stage I shall not press the amendment. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

On Question, Whether Clause 14 shall stand part of the Bill?

Lord Ennals

I believe the Government should now drop this proposal in the face of the opposition that has been shown by the profession—the Government cannot doubt that it exists—and by the public. Another reason why I say the Government should drop the proposal is that the Minister has given me such significant responses and assurances today. I fail to see the main purpose of establishing cash limited fund holding general practices which will not really be cash limited and which will be costly. The Government would be unwise to proceed with the proposal. They have enough to cope with already concerning the internal market for the health authorities to be introduced on 1st April. I have said previously that I do not think the health service is anywhere near ready for such a proposal. The noble Lord, Lord Nugent, who is in the Chamber has said the same. I would have wished, if I had his eloquence, to use the words of the noble Lord. I do not believe that the health service will be ready on 1st April to introduce the provisions of the internal market.

We have also discussed NHS trusts for self-governing hospitals. I shall not take the matter further except to say, as the noble Lords, Lord Nugent and Lord Carr, have said, that the health service will not be ready for that measure on 1st April, even if it is only a matter of two or three dozen health authorities implementing the proposals as opposed to all those which have supposedly written postcards expressing an interest.

It is unrealistic to add this third proposal, at a time when it is so much opposed and when it seems to offer nothing at all to the patient. I shall be very interested if the Minister can tell me, when she comes to reply, what the patients will get out of it. I do not know any doctor who knows. I know why doctors are expressing interest: because a carrot of money is dangled in front of their faces and they believe that if they do not apply someone else will get it and they had better be in on the act. However, to assume that doctors are keen on the proposal and are writing in out of enthusiasm is untrue.

I have expressed my views on the matter before. They are not only my views. Every Member of the Committee has seen the conclusions reached by the royal colleges—the medical colleges, the nursing colleges, the college of occupational therapy and the rest. They have said, as they have said in the case of GP practices, that without evaluation they have no reason to believe that the proposal will improve conditions for patients. I believe, and the Labour Party believes and has said on a number of occasions, that budget holding will damage the doctor-patient relationship. We share the concern voiced by most professionals' and patients' organisations that GP budget holding will undermine the trust in the relationship between doctor and patient. Patients may fear that their doctors' decisions about treatment, especially whether to refer them to hospital for tests or other care, are influenced by financial factors.

The noble Baroness has given me some assurances that at the end of the day, or in the middle of the year, it is possible to exceed the cash limit and come back for more. However, she cannot give me an assurance—I should be very interested if she did—that financial factors will not be taken into consideration when judging how best to meet the needs of a patient.

The General Medical Services Council, which is a very responsible body, has said that fund holding, represents a radical departure from the basic philosophy of the NHS which will harm patient care and put a straitjacket on general practice … A GP who until now has been the patient's advocate and intermediary in his contacts with hospital services would be perceived as the controller of access to health care". Doctors also fear that disputes over the costs of clinical treatment could damage the very important relationship between the GP and the hospital to the detriment of patients.

One GP has written a letter which is of special interest to me as patron of the National Association of Non-Smokers. He asked: Do I, as a budget holding GP, refuse to accept smokers on my list and thereby allocate more resources to people judged by me not to have self-inflicted illness? I do not know what answer I am supposed to give to that question. He went on: Do I decide that certain treatments are so expensive that it would be better to choose, albeit deviously, not have such liabilities on my list? A survey was conducted by the Daily Telegraph, which reported: While Kenneth Clarke insists that there will be more time, more choice and more participation by health consumers, many of those writing to us fear that there will be less doctors' time available because doctors will have to work out how to be managers, computer operatives and hold their own budgets as well as doing the job for which they are trained", which is the care of patients.

I mentioned in connection with an earlier amendment the operation which we used to call TEWT—tactical exercise without troops—which was used when I was in the army. That principle was applied in Norwich. The workshop, dubbed the "rubber windmill", took 22 managers, playing the role of providers, purchasers, GPs, regional officers and family practitioner committee staff, through the process of contracting for services up to 1st April 1993. An article on the exercise reports that those attending concluded that unless health authorities developed clearer quality objectives the contracting process will not produce benefits for patients.

The Peterborough district general manager, Alan Burns, said that the seminar showed that financial constraints could put units under great pressure to reduce standards. Mr. Burns said that the seminar also showed the need to talk to and convince GPs of the benefit of reforms. A logical move seemed to be districts combining together to form purchasing consortia. The regional internal market project manager, Barry Tennison, said that the seminar had thrown up fears that GP budget holders might upset the internal market.

So it went on. Mr. Tennison finished by saying: Clearly there is a tension there in the system. I think the regions and others can see the difficulties in this". I believe that it would be unwise to introduce this new measure, affecting not only GPs and their patients but also district health authorities, at precisely the time when district health authorities are having to face up to an entirely new way of doing their business as part of the internal market. I believe that the Government would save themselves and the country a great deal of trouble, time, misery, cost and anger if they were to withdraw this proposal. That is why I wish to oppose the Motion that the clause stand part of the Bill.

Lord Rea

I too do not believe that we have reached a stage to be able to introduce this measure. There are other ways of informing general practitioners of the costs which arise from their clinical decisions. Those arrangements are available now and are nothing like as costly as the fund holding exercise. I believe that those methods should be developed, made available, tested and evaluated now before the fund-holding practice goes ahead.

An example of the alternatives is the arrangement known as PACT—prescribing analysis and costs—which is run by the Prescription Pricing Authority. Under that arrangement a detailed breakdown of every doctor's prescribing is sent to him or her in three levels of detail. Level 1 is sent to all GPs; levels 2 and 3 are sent on request. At level 1 the number of prescriptions written and their average cost for each doctor is compared with national and local rates and costs.

The system started only in 1988 and therefore it is very early days to judge its effect. However, during that time the percentage of prescriptions written for the generic equivalent of a drug, which is usually cheaper than the proprietary drugs, has risen from 36 per cent. to 40 per cent. As I said, the scheme has not yet been fully evaluated and it could be that other factors have operated, but it appears that it may be at least partially due to the PACT system.

Much more use could be made of the enormous amount of data which the facility has provided. Our practice has asked for the more complex level of information, which provides far more data than we can process. Therefore we are dealing only with level 1, which compares our costs with those of other practices. I believe that more work should be done on that basis without including drug costs in a fund-holding practice budget, or, as we shall discuss later, starting indicative drug budgets for non-budget-holding practices.

I have given the PACT system as one example. There are other clinical decisions, apart from prescribing, which result in requests for investigations and/or referrals to out-patient or in-patient care in hospitals. General practitioners could be given details of their use of those services. The noble Baroness and her right honourable friend repeatedly tell us how much doctors differ from one another in their use of those facilities. Details of their use of those services should be given to each doctor in the same way as PACT information is provided now. However, the mechanism for supplying even that basic information is not yet in place. It seems to me that that should be done before any fund-holding practice is even contemplated. I believe that the clause is premature and that the Government should drop it.

6.30 p.m.

Baroness Carnegy of Lour

This clause relates to England and Wales, but another clause—I believe that it is Clause 36—has a similar effect in Scotland. The principle of the amendment is the same. I see that my noble friend the Minister of State at the Scottish Office, Lord Sanderson of Bowden, is in the Chamber. I should like him to know that I do not think one of the main points made by the noble Lord, Lord Ennals, is generally the case in Scotland. We have been told by my noble friend Lady Hooper that the adopting of budgets by doctors will be a gradual process and that people will be granted budgets only if they are ready to have them and are competent to operate them.

I do not know whether the noble Lord, Lord Ennals, has talked to doctors who are enthusiastic about that way of running a practice or whether he has simply read the briefs which have been sent to him, most of which, if they are anything like the briefs that I have been sent, are from organisations which claim that all their members are against general practices having budgets. I do not know whether the noble Lord has perhaps simply talked to doctors who are personally against the idea.

Lord Ennals

Perhaps I may answer the noble Baroness. I have not yet found any GPs who are in favour of the idea, so my discussions have been with those who have asked to speak to me because they are so much opposed to it. With regard to the point made by the noble Baroness about those organisations which have written to say that their members are opposed to the proposal, I hope that she is not casting aspersions upon the sincerity and genuineness of the conclusions reached by some worthy voluntary and professional organisations.

Baroness Carnegy of Lour

I am casting aspersions on no one. Perhaps I may be allowed to continue.

It is an enormous insult to doctors who are keen to operate the system to suggest that they are likely to be keen on it simply because they are in it for the money, which is the gist of the comments of the noble Lord, Lord Ennals. The practice which I attend in my part of the world supports the proposal and a number of others are interested. I do not know whether they will qualify or will pursue the issue, but they are interested and keen. I have not the slightest doubt that those doctors belong to the BMA. They want to take up the proposal and have explained to the public that they want to do so. They believe that, if they have the ability to make the decisions themselves on the ground about what is best for their patients and if they have the leverage to get the hospitals to do what they want so that the hospitals will accept their patients more quickly and more effectively and so that there will be a choice of hospitals for their patients, that will be good for the communities in my part of the world and for patient care. That is why they are doing it. They have made it quite plain.

I have no idea how GPs will stand financially as a result of it and, I should think, nor have they because it is difficult to judge at present. I have not the slightest doubt about the integrity of those doctors. It is ill becoming to this Chamber and insulting to suggest that first-rate general practitioners dedicated to their profession and with a proven record of excellence in patient care—in my part of the world patient care is excellent—are in it for the money. I hope that the noble Lord will not leave that comment on record and take the matter to a vote, claiming that the clause should be omitted from the Bill on those grounds.

Lord Butterfield

Perhaps I may ask one question of the noble Baroness before she responds. One of the points in the White Paper which appealed to many of us was the clear indication that, if you took on one of those fund-holding practices and found that it was not to your liking, you were able to withdraw. I am an ingenue. I am not clear whether an escape clause, as it were, is embodied in the Bill or whether the White Paper is a kind of umbrella held over the Bill, part of which people would be able to use if at some time—in some cases it might be after one year and in others after a decade—they felt that they wanted to withdraw. We should be told about that. I know doctors who are doubtful about holding budgets, but I agree with the noble Baroness, Lady Carnegy of Lour, that some doctors are looking forward to having their own budgets.

Lord Pitt of Hampstead

Perhaps I may ask the Minister whether budget-holders will also be able to dispense. If they are to take charge of the whole of the management of their patients, dispensing should be part of the issue. I have not noticed any suggestion that that should be so, but, if they are to be in charge of the whole, I should have thought that dispensing would be included.

Baroness Hooper

Perhaps I may start by saying, yes—this is a voluntary scheme and any doctor or practice which becomes involved in it has the right to withdraw from it if it should so wish. The relevant provisions are contained in Clause 16.

The scheme provided for by Clause 14 is a key part of the Government's proposals for improvements in the National Health Service. Within the scope of the scheme, GPs will have the freedom to use their budget in the way that they consider best for patient care. That is why GPs like it and why so many have expressed an interest. We have already mentioned the figure of 850 expressions of interest. I do not believe that it is simply a case of mercenary motivation, as the noble Lord, Lord Ennals, suggested. I agree far more with my noble friend Lady Carnegy of Lour. I do not believe that GPs are simply the money-seekers suggested by the noble Lord.

As a result of the proposal, GPs will for the first time have the opportunity to back their clinical judgment with money to meet their patients' needs in the most effective way. That is why they like the proposals. They will be able to back up their referrals with cash, so giving hospitals every incentive to provide more timely and responsible treatment. Effective management of the fund will allow GPs to develop a range of other practice services; for example, the employment of additional staff and facilities. That all adds up to a better deal for the patient.

There should be no threat to the doctor-patient relationship. Financial factors should not affect decisions on referral for any individual patient. If the cost of hospital treatment for an individual exceeds a given limit—£5,000 in the first instance—the cost of subsequent hospital care will be met by the local district health authority.

The noble Lord, Lord Ennals, suggested that GPs will be diverted into administrative tasks. We do not want GPs to be diverted from their major task of providing patient care. The point of providing a management allowance is so that practices can employ someone to undertake the day-to-day operation of the fund on their behalf.

The noble Lord, Lord Rea, referred to the PACT system run by the Prescription Pricing Authority. I agree that that is an excellent system. It will be continued and enhanced to help practices run their funds or indicative prescribing budgets in the case of non-fund-holders. The enhanced system, with reports from the PPA being provided more quickly to practices, will be in operation by 1st April 1991.

The noble Lord, Lord Pitt, referred to dispensing. If fund-holders are at present dispensing doctors, they will continue to be dispensing doctors, but there are no plans to allow all fund-holders to dispense.

I hope that I have said sufficient to make it clear that the importance of the provisions of the clause is that GPs will be able to decide where their patients are treated. As a result of that right of decision, patients will have less time to wait for treatment and will receive higher quality care. We are all agreed that the patient is and should be the main beneficiary of all the proposals in the Bill. I am not quite sure of the motives of the noble Lord, Lord Ennals, having withdrawn his previous amendment as a result of my assurances and now apparently wishing to divide your Lordships on this clause.

Lord Ennals

I am most grateful to the noble Baroness, and I was glad to have her assurance that it is not the intention that GPs should now start fulfilling the role of pharmacists. That would be a very unfortunate step to take. It is difficult to know people's motives. I heard what the noble Baroness, Lady Carnegy of Lour, said in relation to some doctors, in Scotland. I heard the noble Lord, Lord Butterfield, say that he knows of some GPs who are enthusiastic. There are 11,000 GPs and not all of them would want to apply; but there must be many different views. There is no doubt that in recording their votes through the organisation of which they are members, the British Medical Association, it has been shown that the vast majority of GPs are against it. We can all say, "Yes, I know one who is not", and I am certain the noble Baroness knows three or four—

Baroness Hooper

I must reiterate that I know over 850 who are.

Lord Ennals

The noble Baroness knows 850 who have written in to express an interest. For heavens' sake! I am surprised the number is not more than that. I should have thought that every GP who could qualify would write in to express an interest. It would be sheer nonsense if they did not find out what was on offer. They now know what is on offer, and I suppose that some may act against their better judgment: I do not know. I also heard the Minister say that this was going to improve conditions for patients. That is not the impression that most general practitioners have. If the noble Baroness asks me what my motive is—

Lord McColl of Dulwich

Would the noble Lord give way?

Lord Ennals

Certainly.

Lord McColl of Dulwich

Did the noble Lord, Lord Ennals, say that the GPs, in voting, voted against this? Can he tell us the details of the voting carried out by the BMA, please?

Lord Ennals

No, I am afraid I do not have the statistics in front of me; but it was a very large majority of GPs who expressed the view that they were opposed to this and did not believe that it would produce better services for their patients. As I said in answer to a question put by the noble Baroness, Lady Carnegy of Lour, I do not doubt the motives of the GPs. The majority of them in expressing this view, are thinking of the interests of their patients. I do not think they are a bunch of rogues at all. I paid a tribute to GPs earlier, because I think that here we have one of the best general practitioner services in the world. I feel very proud of the role played by most of them, though not of course all of them. However, I do not believe that we should go in for unproven and unevaluated changes at this time, expecially when so many other changes are being proposed by the Government. It would be gravely disadvantageous to the interests of patients, and that is why I shall vote against the Question that this clause shall stand part of the Bill.

6.44 p.m.

On Question, Whether Clause 14 shall stand part of the Bill?

*Their Lordships divided: Contents, 98; Not-Contents, 53.

DIVISION NO. 2
CONTENTS
Ailesbury, M.	Brougham and Vaux, L.
Allerton, L.	Butterfield, L.
Arran, E.	Butterworth, L.
Auckland, L.	Caithness, E.
Aylestone, L.	Campbell of Croy, L.
Balfour, E.	Carnegy of Lour, B.
Bauer, L.	Carnock, L.
Belstead, L.	Clanwilliam, E.
Bessborough, E.	Craigavon, V.
Blatch, B.	Craigmyle, L.
Boyd-Carpenter, L.	Davidson, V. [Teller.]
Brabazon of Tara, L.	Denham, L.
Brentford, V.	Derwent, L.
Bridgeman, V.	Eden of Winton, L.

Elibank, L.	Mills, V.
Elliot of Harwood, B.	Monk Bretton, L.
Erroll, E.	Montgomery of Alamein, V.
Faithfull, B.	Mottistone, L.
Glenarthur, L.	Mountevans, L.
Gray of Contin, L.	Munster, E.
Greenhill of Harrow, L.	Murton of Lindisfarne, L.
Hailsham of Saint Marylebone, L.	Nelson, E.
	Newall, L.
Harmar-Nicholls, L.	Nugent of Guildford, L.
Henderson of Brompton, L.	Oppenheim-Barnes, B.
Henley, L.	Orr-Ewing, L.
Hertford, M.	Pender, L.
Hives, L.	Peyton of Yeovil, L.
Holderness, L.	Prior, L.
Hooper, B.	Reay, L.
Hunter of Newington, L.	Renton, L.
Hylton-Foster, B.	Rodney, L.
Jenkin of Roding, L.	Russell of Liverpool, L.
Johnston of Rockport, L.	Sanderson of Bowden. L.
Kaberry of Adel, L.	Seebohm, L.
Killearn, L.	Skelmersdale, L.
Kilmarnock, L.	Stedman, B.
Kissin, L.	Strathcona and Mount
Knutsford, V.	Royal, L.
Lauderdale, E.	Strathmore and Kinghorne, E.
Long, V. [Teller.]
Lucas of Chilworth, L.	Swinton, E.
Lyell, L.	Thomas of Gwydir, L.
McColl of Dulwich, L.	Thurlow, L.
Mackay of Clashfern, L.	Tranmire, L.
Macleod of Borve, B.	Trumpington, B.
Mancroft, L.	Ullswater, V.
Margadale, L.	Vaux of Harrowden, L.
Marshall of Leeds, L.	Walston, L.
Mertivale, L.	Westbury, L.
Mersey, V.

NOT-CONTENTS
Addington, L.	Llewelyn-Davies of Hastoe, B.
Airedale, L.
Blackstone, B.	Lockwood, B.
Brooks of Tremorfa, L.	Macaulay of Bragar, L.
Carmichael of Kelvingrove, L.	Mackie of Benshie, L.
	McNair, L.
Carter, L.	Mason of Barnsley, L.
Cledwyn of Penrhos, L.	Mayhew, L.
Cocks of Hartcliffe, L.	Molloy, L.
David, B.	Morton of Shuna, L.
Davies of Penrhys, L.	Mulley, L.
Dean of Beswick, L.	Nicol, B.
Ennals, L.	Oram, L.
Galpern, L.	Peston, L.
Graham of Edmonton, L. [Teller.]	Pitt of Hampstead, L.
	Ponsonby of Shulbrede, L. [Teller.]
Grey, E.
Hampton, L.	Rea, L.
Harris of Greenwich, L.	Robson of Kiddington, B.
Hatch of Lusby, L.	Shackleton, L.
Houghton of Sowerby, L.	Stoddart of Swindon, L.
Howie of Troon, L.	Taylor of Blackburn, L.
Hughes, L.	Tordoff, L.
Jeger, B.	Underhill, L.
Jenkins of Hillhead, L.	Wallace of Coslany, L.
Jenkins of Putney, L.	White, B.
Kilbracken, L.	Williams of Elvel, L.
Kirkhill, L.	Winchilsea and Nottingham, E.

[*The Tellers for the Not-Contents reported 53 names. The Clerks recorded 52 names.]

Resolved in the affirmative, and clause agreed to accordingly.

6.52 p.m.

Clause 15 [Payments to recognised fund-holding practices]:

Lord Peston moved Amendment No. 105BZA: Page 15, line 29, at end insert ("having due regard to factors such as the age composition of the practice list; proportions of chronically sick and disabled people on the practice list and the social and economic characteristics of the area.").

The noble Lord said: I speak also to Amendments Nos. 105EZB and 105ZAB. The principle involved is exactly the same for all three amendments. There is therefore no need to go into detail other than for the first amendment.

The amendment follows on from Clause 14. Apart from the content of the amendment which is easily argued for, what I wish to hear from the noble Lord who will be answering is a rather more explicit explanation of what Clause 15(1) means. It states that, Every Regional Health Authority shall be liable to pay …a sum determined in such manner and by reference to such factors as the Secretary of State may direct".

First, I seek clarification on how that will happen. As I read the Bill, that will not happen via regulations or matters of that kind. The Secretary of State will simply determine in such manner and by reference to such factors".

Is my reading of the Bill correct that the Secretary of State will not lay down how he will proceed to fix the principles of fund-holding practices by regulation or in any other way? So far as I can see, he may not lay down such provision in a form that will be debatable either by your Lordships' House or in another place. That is the general problem that lies behind the three amendments.

Secondly, my noble friend Lord Ennals and I have put down an amendment which seeks to provide on the face of the Bill the factors that the Secretary of State ought to take into account. Those factors are fairly obvious. I cannot believe that in laying down factors, the Secretary of State would not lay down those that we mention in the amendment. Those are, The age composition of the practice list; proportions of chronically sick and disabled people on the practice list and the social and economic characteristics of the area".

Those seem clear cut to me. The list of factors may not be long enough, but they are important and ones that I should have thought the Secretary of State would take into account. However, I believe that it is better to have them on the face of the Bill.

My third endeavour is to have some clarification of the relationship between the fund-holding practices and the GP contract. I still have great difficulty in putting the two together because much of what falls within the ambit of the GP contract also falls within the ambit of the fund-holding practice. I do not understand how the two overlap.

I could produce an argument that stated that the fund-holding practice, properly set down with the proper factors, would lead to the view that the GP contract would be completely irrelevant. I could also put forward the argument that given the way that the GP contract has been justified, all concepts of fund-holding are irrelevant. I have some difficulty in marrying the two together.

Those are the three issues about which I should like to hear from the noble Lord. The most important is this. Will Members of the Committee and Members of Parliament in another place have a chance to debate how the provision, in such manner and by reference to such factors as the Secretary of State may direct",

will be decided upon and applied in practice? I beg to move.

Lord Henley

As did my noble friend Lady Hooper, perhaps; I may stress that these schemes will be voluntary. Practices will arrive at their conclusions as to whether they wish to take part after discussion between the regional health authorities and the practices.

Bearing that in mind, practice funds will be set on an individual basis after detailed discussions with each practice participating in the scheme. Having agreed on a figure, there is no reason then for the practice to feel bound by it. It can then decide whether or not to accept. I shall come to the noble Lord's points about Clause 15(1) in a moment. I see the noble Lord looking anxiously at the provision.

Regions and health boards will take account of a wide range of factors in setting the level of funds. They will need to examine the previous hospital treatment and prescribing patterns of the practice, and take account of the composition of the practice's list. That will include such matters as the age and sex composition of the list, the number of chronically sick and disabled people and other potentially high cost patients. Directions will be issued by the Secretary of State as the noble Lord will know from Clause 15(1). He will issue directions to the regional health authority on what factors need to be taken into account—is the noble Lord listening to me?—by the regional health authorities or health boards when setting he fund. The clause is drafted appropriately widely.

It is purely for the Secretary of State to direct the regions as to what should be taken into account. It is then for the regions to negotiate with practices as to what is the appropriate sum. It is then for the practices to decide whether they wish to take up this offer.

7 p.m.

Lord Peston

I apologise to the noble Lord; my mind was on matters of business while listening to his excellent answer. I was not concerned to debate whether they are voluntary or how the regions will operate. I was more concerned about the Secretary of State's role in the matter. The Minister appeared to be saying that the Secretary of State will decide the factors and that is that. He will not come to this Chamber and lay down regulations on the factors but will say, "You will take these matters into account". Then the region will go ahead and negotiate on that basis. Is that what the noble Lord is saying?

Lord Henley

Put simply, the region determines the sum and then in directions the Secretary of State tells it how to get there. Is that what the noble Lord is asking because it strikes me as being a simple concept?

Lord Peston

Then I am being stupid because I found that answer more difficult to follow. The subsection reads: a sum determined in such manner and by references to such factors as the Secretary of State may direct". I had assumed that the sum would be determined by the rules and criteria laid down by the Secretary of State. The authorities decide the sum but they do so according to the rules and criteria laid down by the Secretary of State.

Put bluntly, I am asking whether Members of the Committee, and myself in particular, will have a chance to debate matters such as the Secretary of State saying that age is not one of the criteria when I think that it should be? That would happen if we had to lay down regulations but there is no reference to regulations of any kind. The Secretary of State will lay down criteria and the regions will act accordingly. I believe that that is what the noble Lord is saying and if so it is not satisfactory. However, for the moment I should like to be clear about what will happen.

Lord Henley

The noble Lord is on the right track but I shall repeat what I said. As the region determines the sum the Secretary of State decides on the factors which push the region into determining it. That can be done by directions. There is nothing new in directions being used and, as the noble Lord knows, it follows normal practices in legislation on financial allocation. I quote the example of the RAWP system instituted by the noble Lord, Lord Ennals. It was achieved by directions and was not regulation based. Does that answer now satisfy the noble Lord?

Lord Peston

The noble Lord has now clarified what will happen although we have not yet agreed that it is right. However, I thank him for at least clarifying the matter.

Lord Henley

I thank the noble Lord and wish to deal with only one other point that he raised. He asked about the relationship between fund-holding and what he called the GP's contract. The contract covers the relationship of all GPs, fund-holders or not, with the health service as a whole. Fund-holding simply provides opportunities for willing volunteers—and again I have no hesitation in stressing that they are volunteers—to improve still further the services that they offer.

I hope that the noble Lord now accepts my explanations. I hope that he also accepts the fact that the amendment would duplicate what will be contained in the directions to be issued and that it is therefore unnecessary. Perhaps the noble Lord will feel able to withdraw the amendment.

Lord Peston

I thank the noble Lord because I now understand what we are talking about. However, I do not believe that the matter can be dealt with in the course of our deliberations on the Bill. I am not convinced by the statement referring to GPs' contracts and fund-holding practices. It is not obvious that the two are logically compatible and I believe that major difficulties will arise. However, we can face them at the time.

I am aware that Secretaries of State, this one and others, are in the habit of giving directions. However, it still appears to me that with an area as new and important as the fund-holding practice innovation it is desirable that the concept of the manner of, and the reference to, such factors should be debated in this Chamber and in the other place. That is precisely the kind of issue in which Members of Parliament tend to be interested. Therefore, it is a pity that the noble Lord has not even considered the suggestion that regulations might be a sensible way of proceeding.

Lord Henley

Obviously I do not accept the suggestion that it would be sensible to have regulations. However, as I said earlier I can assure the noble Lord that when my right honourable friend gives his directions they will include, regarding the composition of the list, such points as age and sex, together with a number of chronically sick and disabled people and other potentially high-cost patients. Does that assurance help the noble Lord?

Lord Peston

There is nothing between us. I do not assume that the Secretary of State is an idiot—even the abstract Secretary of State rather than the specific one that we have. As I said earlier, the points on my list are points that any sensible Secretary of State would take into account. I still believe that any Secretary of State is occasionally capable of getting certain aspects wrong and I should have liked to have had the chance to debate them.

Having made that point, the best way for me to proceed is to think of an amendment which might contain my ideas of regulations. I wish to place on record the fact that I did not intend to insult the Secretary of State by suggesting that the factors I mentioned are not ones that he would be advised to take seriously. I thank the noble Lord for his answers and beg to leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Ennals moved Amendment No. 105CZA: Page 15, line 29, at end insert: ("(1A) In determining a fund holding practice's allotted sum under subsection (1) above, the relevant regional health authority shall not have regard to any deficit the fund holding practice in question may have accrued in any previous financial year.").

The noble Lord said: The amendment touches on an issue which we debated with the noble Baroness and on which she gave me certain assurances. However, I now wish to move it and to hear her explanation. The amendment is straightforward and would prevent a regional health authority from financially penalising a fund-holding practice that went over its budget. It would stop a fund-holding practice having to carry over a deficit from one financial year to the next.

There are many reasons why a fund-holding practice may run over its budget in a particular year. For instance, it may have experienced an influx of extra patients mid-year; its budget may have been inadequate because it was worked out wrongly; and possibly, because running a budget was a new experience, it had not been as efficient as was hoped. Whatever the reason, it is important that practices are not expected to fund one year's deficit by taking money from the next year's budget. That would simply compound the error and exacerbate a practice's financial difficulties.

For the sake of patient care a practice must be able to start each year with a clean sheet. If an RHA were able financially to penalise a practice it would create all the wrong incentives in relation to patient care. A practice which found itself in the red would surely be forced to adopt harsh measures in order to claw back cash. For example, practices might be tempted to reduce the number of so-called expensive patients on their lists. In particular the chronically sick and the elderly could find themselves under pressure to change their GP as a fund-holding practice took steps to get back on an even keel financially.

I am sure that the Minister will be able to satisfy me because I was encouraged to hear her say that the cash limit could be reviewed part way through the year and that some additional funds could be provided. I hope that in the same way she will reassure me that GPs' practices will not find themselves in the kind of deficit situation that I described and which the amendment is designed to avoid.

Baroness Hooper

The level of the practice fund will depend on the composition of the lists and there will be strong safeguards to ensure that all patients continue to receive the treatment that they need. That is an assurance that I have already given. The safeguards will include powers to increase the level of the practice fund where necessary. As the noble Lord, Lord Ennals, admits, I also made it clear that the Government have moved on from their approach taken in the White Paper to the clawing back of under-spends.

After further work in the development of the scheme, we do not believe that it would be desirable to have any form of clawback. That is a good example of the sensitive evolutionary approach to the implementation of the reforms as a whole which we have already discussed and on which I hope I have convinced the Committee. Therefore, I am happy to assure the noble Lord, Lord Ennals, that there will not be any automatic deduction of past deficits or overspends from the practice budget.

However, this amendment goes further and seeks to debar regional health authorities from giving any account of those matters in setting budgets. I believe that that is unrealistic. It would prevent regions learning from experience as fund holding develops and might prevent regions from increasing funds in order to meet legitimate extra expenditure. In the light of those assurances, I hope that the noble Lord, Lord Ennals, feels able to withdraw his amendment.

Lord Ennals

I am grateful to the Minister for her assurances. The fact that there will be no form of clawback immediately removes the necessity for this amendment. Therefore, with pleasure, I beg leave to withdraw it.

Amendment, by leave, withdrawn.

7.15 p.m.

Lord Ennals moved Amendment No. 105DZA: Page 15, line 29, at end insert: ("(1A) The Secretary of State shall maintain a fund for the purposes of ensuring no fund-holding practice shall be denied funds where in the clinical judgment of a medical practitioner who is a member of such a fund-holding practice, a patient on his list requires medical treatment, the cost of which cannot be met from within his allotted sum.").

The noble Lord said: I speak also to Amendment No. 105EZA. This amendment centres on the same situation. Its aim is to ensure that a fund-holding practice can go over its budget if halfway through the year it finds that it is overspending, and that it will not be penalised for doing so. I drafted this amendment before I had the very positive assurances from the noble Baroness. The idea is that a fund should be maintained for the purpose of ensuring that no fund-holding practice would be denied funds where, in the clinical judgment of a medical practitioner, a patient on his list requires medical treatment and the cost of it cannot be met from within the allotted sum.

I expect that once I have explained the amendment the Minister will say that it is not necessary because the situation will be covered in another way. However, the money will come either from the regional health authority or the Secretary of State. The amendment would make a reality the assurances given by the Government. It would oblige the Secretary of State to maintain a special fund for the purpose of helping any fund-holding practice which found itself unable to pay for the treatment of its patients from within its own budget. That contrasts with the Government's assurance in another place that RHAs would have to make any mid-year payments, which is what the noble Baroness implied to me. Such a measure may be especially important in the early years of fund-holding practices. Without the benefit of an evaluation scheme it may take a little while for the GP budget proposals to settle down and for the level of budgets allocated accurately to reflect costs.

Equally, with so many other changes taking place throughout the NHS to which I referred in our debate on clause stand part, many with huge resource implications, an RHA may not be responsive to the needs 0f individual GP budget holders and may find its resources already stretched in other directions. I hope that the noble Baroness will reassure me on that and give me an assurance that mid-year extra money can be found. If so, I want her to tell me from what source that money will come.

If it is to be found from the regional health authority, will it have to cut back on other services? After all, a regional health authority is subject to cash limits, as well as a district health authority. Giving the Secretary of State the responsibility of providing extra funds to fund holding practices would solve that problem. From the Government's point of view this amendment should prove attractive because it would allow the Secretary of State to play a more direct role in determining the fate of his proposals for GP budgets. More importantly from the patient's point of view, this amendment ensures that care will continue to be provided in the future.

Amendment No. 105EZA pursues the same theme. As Clause 15 stands, there is provision for RHAs to grant a budget for fund-holding practices at the beginning of each financial year. That is termed an allotted sum. However, there seems to be provision for RHAs to grant only one allotted sum. That calls into question the Government's commitment in another place that RHAs will be able to make futher mid-year grants to GP budget holders.

This amendment would allow an RHA to grant more than one allotted sum to a practice in any particular year. It would provide the mechanism by which practices could receive extra funds if they run into financial difficulty. Having stated the case for these two amendments, I ask myself again why it is called a cash limit if it really is not that. However, if it is called a cash limit, let us see how it is to work. I beg to move.

Lord Kilmarnock

I have a certain amount of anxiety on this point although I support the idea of the fund-holding practice in principle because I believe that it can lead to considerable extension of the flexibility of primary care. However, I am rather anxious about the situation when very expensive therapeutic drugs have to be prescribed. In my capacity as chairman of the All-Party Parliamentary Group on AIDS, I am thinking particularly of a drug like zidovudine which may be prescribed for someone who is HIV-positive or an AIDS sufferer. That drug will have the effect of keeping such a person out hospital. Of course, hospitalisation would incur far higher costs.

Therefore, I should like to hear from the noble Baroness what arrangements the Government have in mind so that fund-holding practices should not be deterred from prescribing drugs which are very expensive when the patient's condition seems to require them and when long-term savings may be made by avoiding hospitalisation. I should be grateful if the noble Baroness could clarify that point.

Lord Rea

I should like to mention this point of single, expensive drugs taking up the cost of the total drugs bill. Information we have received through the PACT system which I mentioned earlier gives an example of one expensive growth hormone drug. The cost of that drug is perhaps equivalent to that of zidovudine. The prescribing costs for one doctor with 2,000 patients increased by 6 per cent. because of that one drug.

Baroness Hooper

An important aim of our proposals is precisely to avoid the sort of crisis management which exists at present in the National Health Service and to ensure that the relevant bodies plan and budget appropriately.

We shall expect RHAs to maintain contingency funds to enable additional payments to be made to fund-holding practices if the fund needs to be increased in-year. Clause 15 of the Bill and its associated directions will allow for these funds to be held back and for their subsequent allocation. I believe that the responsibility for this should lie at regional level, rather than with the Secretary of State as suggested in the amendment, as it will be RHAs who make the initial allocation and, through FHSAs, will be responsible for the oversight and monitoring of the scheme. Should an overspend appear likely because of an influx of new patients, for example, or an increase in the prescribing of expensive drugs, the practice will in the first instance discuss the problem with the FHSA and a subsequent allocation can be made if necessary.

I also emphasise to the noble Lord, Lord Kilmarnock, that all patients will receive the treatment that they need. The Bill contains explicit provision for a ceiling to be placed on the cost to the practice fund of hospital treatment for an individual patient in any one year. After that, the costs of hospital treatment will fall to be met by the DHA. We envisage that this limit will be £5,000 in the first instance. There is therefore no possibility of an individual patient being seen as a drain on the resources of the practice as a whole.

The noble Lord, Lord Kilmarnock, specifically referred to AIDS. Of course, such costs as expensive drug therapy for AIDS treatment will be reflected in the level of the fund in the first instance, as I made clear. I hope that in the light of those assurances the noble Lord will feel able to withdraw his amendment.

Lord Ennals

I am most grateful to the noble Baroness for her reply. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 105EZA and 105EZB not moved.]

Lord Peston moved Amendment No. 105EZC: Page 16, line 48, at end insert: ("(7A) No fund-holding practice shall receive any contributions from patients to cover the cost of any treatment that would not have been paid in any practice that was not a fund-raising practice.").

The noble Lord said: In moving Amendment No. 105EZC I speak also to Amendment No. 105ZAC, which I believe is the Scottish equivalent. I also add my name to the list of noble Lords who claim not to understand how a fund-holding budget can at the same time be a constraint and not be a constraint. I am totally unable to follow the logic of the position that the Government are pursuing. Either GPs are prevented from spending all the money that they would like, in which case they are cash constrained, or they are not prevented from spending all the money, in which case I do not see the point of the fund-holding practice in the first place. I thought I should add my name to the "idiot's list" of those who fail to understand what the Government are up to.

Amendment No. 105EZC and its Scottish equivalent add a further point. They seek to make clear that the Government remain from last week to this fully committed to a free National Health Service that is not charged for. They therefore make it abundantly clear that no fund-holding practice that ran out of money could turn to its patients and say that in order to proceed it requires them to meet some of the costs of the treatment. I find the Bill odd in that I cannot see anything in it which will stop a fund-holding practice from doing that. Essentially, I should like the Minister to say that it absolutely cannot do so and, secondly, what stops it doing so. I beg to move.

Lord Henley

I assume that the intention of the amendment is to prevent practices accepting contributions, in money or in kind, from patients to top up the fund to ensure that they receive treatment under the NHS in a private hospital. The Government agree that that should not happen.

Under their current terms of service GPs are not normally allowed to accept money from NHS patients to receive NHS treatment. I appreciate that that does not cover the situation that Members of the Committee have in mind. We clearly stated in Working Paper 3 of Working for Patients, paragraph 4.16, that "topping up" of funds would be made a breach of GPs' terms of service. Regulations under Clause 14(6)(c) will make it a requirement that to continue to receive recognition as a fund-holding practice, a practice should not allow "topping up" of its fund in money or in kind.

I hope, in the light of that answer, that the noble Lord will feel able to withdraw his amendment.

Lord Peston

I thank the noble Lord for his excellent answer. I am delighted that it will be done by regulation. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Robson of Kiddington moved Amendment No. 105FZA: Page 17, line 10, at end insert ("the result of which shall be made public").

The noble Baroness said: This is a small amendment but one that I consider very important. I hope that the Government will accept it.

Family health services authorities are required in the Bill to monitor the expenditure of the recognised fund-holding practices. They may also undertake a full audit if they consider it necessary. The amendment seeks to ensure that the way in which allotted funds are spent by fund-holding practices is made public at the end of the monitoring or auditing procedure. That will go a long way towards satisfying the public in general. The relationship between patient and doctor could also be helped by public knowledge of the fact that the allotted sums have been audited together with details of how they have been spent. It will also ensure that any surplus that exists will be used purely for the benefit of the patient. It is not very different from any public or other company publishing annual accounts. I hope that the Government will accept that the monitoring and auditing should be made public. I beg to move.

Lord Henley

The Government recognise that there need to be safeguards to ensure that funds are not misspent. While the regional health authority will have overall responsibility for the operation of the scheme, FHSAs will be given the specific responsibility of monitoring practices to ensure that the fund is managed properly. Practices will be required to submit monthly and annual reports to the FHSA which will give details of how the fund has been used. The FHSA will discuss with the practice any apparent unnecessary overspending and indeed any underspending to the deteriment of patient care. The practice will be expected to take any necessary remedial action to prevent it happening again.

If the FHSA has reason to believe that a fund is not being properly managed, it will be able to institute an audit and review of the use made by the practice of its fund. Taking that action will not necessarily mean that the: practice has been using the fund either improperly or dishonestly. It could mean that the practice needs to improve on its ability to administer and successfully manage the fund. However, where a practice is failing to manage its fund properly and patient care is being put at risk, the FHSA can advise the RHA that fund holding status should be removed from the practice.

The Government do not believe that any useful purpose will be served by making the results of a review public and that to do so might simply generate unnecessary alarm among the patients on the practice list.

I hope that the noble Baroness, in the light of that reply, will feel able to withdraw the amendment.

Baroness Robson of Kiddington

I fail to understand why so many things should be secret and hidden under and behind the backs of some organisation or another within the system. The health service is run for the patient. I should have thought that the patient had the right to know what was happening. I very much regret that the Government cannot see their way to agreeing to this small amendment.

If I understand the Minister correctly, if the family health services authorities who carry out the monitoring and auditing find anything wrong it goes up to the regional health authority for further action. Can he confirm that?

Lord Henley

Yes, and they can then remove the status from that practice.

Baroness Robson of Kiddington

I can see that they will need to know, being the people who, in the last analysis, hand out the cash. However, I feel that the people living in the area of the family health services authorities are also entitled to know something of the economics of the system.

I regret that the Government cannot accept the amendment. I will not divide, because we all want to go to dinner, but I will certainly come back at Report state. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Colwyn moved Amendment No. 105ZA: Page 17, line 10, at end insert: ("( ) In making regulations under this section and in specifying goods and services to be approved under subsection (7)(b) above the Secretary of State shall secure that the members of a recognised fund-holding practice may avail themselves of such alternative and complementary therapies as they may deem appropriate.").

The noble Lord said: This amendment is self-explanatory and may give the Government a chance to show that they intend to accept some amendments to the Bill. It has all-party support.

The White Paper and the Bill envisage increased interchanges between public and private sectors. It is anticipated that general practitioners, who will in the future control their own budgets, will refer increasing numbers of patients to complementary or alternative practitioners. This increased referral will occur, partly because of the low cost of the therapies and partly because of the fact that the alternative and complementary therapies are being considered more seriously by a gradually enlightened medical profession.

As general practitioners begin to look at patients as individuals and become more aware of health maintenance, prevention and promotion and begin to discover other philosophies of health care—placing more emphasis on individual responsibility for one's own health rather than reliance on synthetic drugs—patients are more likely to be referred to complementary therapists. However, patients will remain the ultimate responsibility of the referring GP, not being transferred to the sole responsibility of the complementary practitioner.

The initial basic principle of the NHS was that good health care should be available and freely accessible to all who need it. This Bill stresses the importance of patient choice, and of increasing patient choice, which I feel sure will extend much more to the complementary therapies as their benefit and low cost is realised. In past years the non-inclusion of the complementary therapies might have been condoned because of the lack of scientific research into their therapeutic efficacy or the need to protect the public from fraudulent practitioners.

The Committee will be aware of the growing body of medical, social and public opinion research evidence in support of complementary health practices. A 1988 report of the Royal College of Physicians noted the current interest in complementary medicine and agreed that most patients use unconventional treatments to complement rather than as an exclusive alternative to orthodox medicine.

A MORI poll in November 1989 found that 74 per cent. of the general public supported the hypothetical principle of these therapies being available on the NHS. My amendment ensures that when the Government become similarly enlightened, the therapies will be included. I beg to move.

7.30 p.m.

Earl Baldwin of Bewdley

Complementary medicine is growing fast in popularity and usage and now represents a substantial slice of health care in this country. More than four years ago the Lancet described it as, a growing and substantial subsidiary health care system in the UK". It has developed considerably since then. We shall be looking at it in depth in a debate on 9th May so today I shall be brief.

The purpose of the amendment, as the noble Lord, Lord Colwyn, said, is to ensure that whatever else appears in subsequent regulations under this clause, complementary medicine is not excluded from the list of those services on which GPs may spend their money. No doubt there will be practices which will continue to have nothing to do with osteopaths, homoeopaths, acupuncturists, and so on. I am sorry for their patients but that is their choice and their right. One of the significant features of recent surveys is the greatly increased interest among doctors in the complementary therapies. A major study by the University of Sheffield medical school has just been completed, and although the results are not yet publicly available it is expected to show a considerable and welcome increase in the channels of communication between complementary and general practitioners.

Therefore, we are speaking here about consumer choice not only in respect of patients but in respect of their doctors who are taking a growing interest in other ways of looking at health and disease. There are three aspects which will increasingly attract GPs to the judicious use of complementary therapies: their effectiveness, their lack of side effects and, as the noble Lord, Lord Colwyn, said, their cheapness compared with conventional treatments.

I feel sure that it is not the Government's intention to restrict GPs' clinical freedom to refer patients to other practitioners if that seems the right thing to do, but it would be good to be assured of that at an early stage. It would also be good to see complementary medicine appear on the face of the Bill. After all, we are now speaking, in terms of consultations, of perhaps 10 per cent. of the health care of this country. For too long policy has been made, laws passed and regulations drawn up as though it did not exist. It is now time for it to come out into the open. I support the amendment.

Lord Ennals

I also support this amendment, and my name is among those who tabled it. I must declare an interest. The noble Lord, Lord Colwyn, and I are joint presidents of an all-party parliamentary group. Of course, that is not a financial interest. I am also one of the patrons of the Council for Complementary and Alternative Medicine.

As was said by both noble Lords, there is considerable growth in the use of complementary therapies, and their acceptance by the public and by many in the medical profession; though I believe the medical establishment is still a little frosty. Alternative and complementary therapies should go together with orthodox medicine, sometimes as an alternative and sometimes as a complementary form of treatment. As was stated in the journal of the Royal College of General Practitioners in 1989, homoeopathy will attract continuing public, professional and political discussion. That report shows that within general practice more than three-quarters of a million consultations involving homoeopathic treatments take place each year in the UK. That represents a level of clinical activity which needs to be taken seriously and examined carefully.

A study of GPs in Avon, published in the British Medical Journal in 1986, showed a surprisingly high interest in complementary medicine, covering treatment utilising acupuncture, homoeopathy, herbal medicines, spinal manipulation, hypnosis and others. In fact, 59 per cent. of the GPs interviewed thought that complementary medicine techniques were useful for their patients. That is an interesting figure. Nearly 60 per cent. thought that complementary techniques were useful for their patients. Over the previous year 76 per cent. had referred patients for this type of treatment to medically qualified colleagues, and 72 per cent. referred patients to non-medically qualified practitioners. Ninety-three per cent. believe that complementary practitioners need statutory regulation. The most favoured regulatory method was through a central independent national body, and the Minister may well use that argument. However, all of us who support the amendment want to see that the Bill recognises a growing role for complementary therapies and that GPs are not restricted in their opportunities for referral and for using such therapies themselves if it is appropriate.

The timing is good. These are issues that may be much debated in Europe after 1992. It will be good for some of the very able and well qualified practitioners in this country to stand to their position in 1992 if this legislation recognises that what they have to offer is not only useful to them but is accepted by general practitioners.

The Earl of Balfour

I should like to add just a few words to the debate. I am glad to say that the homoeopathic hospital in Glasgow is very much respected and is supported by the National Health Service. I entirely support what has been said so far in the debate. It is high time the allopathic doctors accepted some of the homoeopathic treatments as well as acupuncture and other fields of medicine.

That is certainly the case in France. It is easier in France and in parts of Germany for doctors to study what is sometimes regarded as fringe medicine. They can do so to a far greater extent than can be done in this country. Many of the homoeopathic medicines were being used more than 2,000 years ago and they are still proving to be extremely successful. Acupuncture is widely practised in China and Japan. In many cases it can do a tremendous amount of good. There are various herbal medicines which may be antiquated, but there is nothing wrong with them. I hope that the Government will support some of these alternative medicines. Do not let us have (if I may say so) the pill rollers' associations having a complete monopoly.

The Earl of Clanwilliam

I entirely agree with what my noble friend Lord Colwyn has said and also with what has been said by the noble Lord, Lord Ennals and the noble Earl, Lord Baldwin, especially as regards the costs and choices in respect of complementary medicine.

I plead specifically for the cause of medical herbalism. There are about 250 practising medical herbalists in this country of whom 25 are academically qualified and a further seven have GP status or better. The National Institute of Medical Herbalists was started in 1864. It has pulled itself up by the bootstraps in the past 20 years in a most remarkable way. It has seven training clinics throughout the country which provide the final two years of the four-year course which starts at the school developed by the medical herbalists out of their own funds.

Therefore, these facilities have been paid for by the patients of medical herbalists. It also indicates the very considerable interest and ability of medical herbalists who make for themselves a very satisfactory but, on occasions, sparse living. The clients pay for their services without recourse to the National Health Service or to private insurance. There are a great many patients. There is one clinic in the Midlands with over 80,000 patients which makes it a very remarkable general practice. It has its own budget which may be of interest to Members of the Committee, and it has a proper computer system installed. I imagine that it is quite competitive.

The task of medical herbalists is to assist those who are deprived of treatment of their chosen therapy through the NHS. I ask that my noble friend the Minister suggests to her right honourable friend the Secretary of State that he applies some pressure to the General Medical Council in order to allow some democratic process to obtain in this matter. We have heard about democracy and ballots in the running of hospitals, but what about democracy for the patients?

Baroness Blatch

GPs in a fund-holding practice will be able to purchase for their patients certain hospital inpatient and day-case treatment as well as a majority of outpatient services and diagnostic tests. The cost of prescriptions will also be met from the fund.

The services covered by this scheme will be specified in a list in regulations under Clause 15(7)(b) The list will also incorporate those treatments for which GPs can directly refer their patients rather than go through a consultant. The direct access services at the start of the scheme will be physiotherapy, occupational therapy and speech therapy. The range of treatments covered by the scheme can be reviewed in the light of experience.

However, in using the term alternative and complementary therapies I am assuming that Members of the Committee mean treatments such as osteopathy, chiropractic and others which are not available under the National Health Service. However, homoeopathic services are available under the National Health Service. Treatments at homoeopathic hospitals and prescriptions for homoeopathic medicines not specified under Schedule 3A of the National Health Service and Pharmaceutical Regulations 1974 may therefore be covered by GP funds in the way I have just oulined.

The Secretary of State already has powers to extend the range of services available under the NHS. Therefore, this amendment is not necessary. This clause would only allow fund-holding practices to purchase those services and not non fund-holding practices. In effect that would create a two-tier service. I am confident that that is not what the Committee wishes to create. Patients are of course free to choose to have conventional National Health Service treatment as prescribed by their GP or consultant or they can opt to pay to have treatment provided by alternative and complementary therapists.

As I have said, homoeopathy treatment is already provided under the National Health Service. If other alternative and complementary therapies were to be included they would need to be specified by the Secretary of State through the powers already given to him under Section 3 of the National Health Service Act 1977. I know that will come as a disappointment to many Members of the Committee who have spoken in this debate. I hope that, with the reassurance that the powers are there to extend the list, they will feel able to withdraw the amendment.

7.45 p.m.

Lord Colwyn

I am grateful to all noble Lords who have taken part in this short debate and also for the comments of my noble friend the Minister. The desire for natural medicine is a worldwide phenomenon. Its practice is growing steadily. It cannot be long before it is better established and recognised by the government of this country if we accept that the complementary therapies are intrinsically safe from most conditions currently afflicting the human race and that there is clear evidence that therapy is becoming more popular.

I shall read my noble friend's comments. Perhaps with the additional persuasive arguments that will be reinforced during the debate on 9th May she may consider a similar amendment which displays some official recognition of complementary therapies at the next stage of the Bill. However, at this stage I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 15 agreed to.

Clauses 16 and 17 agreed to.

Clause 33 [Fund-holding practices]:

[Amendments Nos. 105ZAA to 105ZAC not moved.]

Clause 33 agreed to.

Clause 18 [Indicative budgets for doctors' practices]:

[Amendment No. 105ZAD not moved.]

Lord Peston moved Amendment No. 1054YAD: Page 18, line 44, at end insert ("but there will be no sanction, financial or otherwise, applied against a practice which exceeds its indicative drug budget.").

The noble Lord said: In moving this amendment I shall also be speaking to Amendment No. 105ZAG and the Scottish equivalent, Amendment No. 105ZAK. These amendments are about indicative drug budgets. I declare an interest by saying that I am a member of the council of the Royal Pharmaceutical Society of Great Britain. That does not mean that I have a pecuniary interest; it means that I am very interested in the subject. I am also very biased in favour of the efficient and rational use of drugs.

With the exception of the amendments, this is an area where the Government and Members of the Committee on this side of the Chamber are very much of one mind. Successive governments have tried to promote the cause of rational prescribing and economy in the use of drugs, by which one means not simply saving money but using drugs efficiently. One can argue about the total pharmaceutical expenditure in the NHS, but it has been kept under control to some degree relative to total expenditure.

I shall not bore Members of the Committee with international comparisons of expenditure on drugs. Certainly, we in the United Kingdom are far from being at the top end of the scale. We are spenders at about the medium level for drugs. I am not sure whether I am speaking entirely for my noble friends in saying that the Government's initiative as regards the limited list seemed a very sensible measure when it was introduced. However, I have some evidence put forward by one of the pharmaceutical companies which disturbs me and I wish to place that point on record.

The company claims that since the limited list was introduced about five years ago, which I supported as an idea and as a practical concept, there have been no new product introductions in the seven therapeutic categories covered by the limited list. In terms of the future development of drugs in this country one is worried by that. Nonetheless I do not seek to withdraw my view that the Government and their predecessors in endeavouring to control drug budgets are and were proceeding along the right lines.

As a matter of principle I do not regard the idea of indicative drug budgets as ludicrous. The whole notion of indicative budgets seems to be the correct way to proceed. I would prefer indicative budgets, used more generally, to the fund-holding approach that the Government have used. I press the point strongly because whenever the Government are criticised on fund-holding practices they seem to end up regarding them as indicative budgets anyway. It is all a little puzzling.

That is very much the context in which we look at these matters. On the one hand, there is the desire to keep the drug budget under control, and on the other hand, there is the desire to proceed rationally. There is also the factual point that, at least in my view, while we need to be alert all the time I do not regard expenditure on pharmaceuticals as out of control or leading to a crisis.

I should like to add two further points before speaking specifically to the amendments. First, and again to reveal my bias, I am convinced—I know that the Government accept this view—that in determining the efficient use of drugs the pharmacy profession has a key role to play. I congratulate the Government on going out of their way over the past few years to emphasise that key role. I was also delighted to hear the noble Baroness, in responding to an earlier amendment, state something which I wholeheartedly support. She said that the Government have no intention of extending doctor dispensing. It would be foolhardy if the Government were in any way to go down the road of extending doctor dispensing.

I now come to the amendment. Indicative drug budgets and similar formularies are a good idea and help doctors to improve their prescribing practices. However, there is in economics, when we are discussing monetary matters, what we call the moral suasion of telling a doctor that his drug budget is more than one standard deviation away from the mean, asking for a rational explanation of why he is so far from the mean and seeking to argue with him. That is the role of indicative budgeting and that is why it is desirable. But one should not go beyond that to introduce sanctions. In the end, if the medical judgment of a general practitioner is such that, first, on a certain occasion he feels that the drugs are what is right for his patient, and, secondly and more significantly, having gone through the process of being criticised and being asked to justify his prescribing, the general practitioner persists in more than average drug expenditures, we have to accept that GP's judgment and agree that there should be no sanctions.

I understand that the Secretary of State has said in terms that there will be no sanctions. I have understood him to say on more than one occasion that indicative drug budgets are meant to be indicative. But I should be happier—and I am certain that most medical personnel would be happier—if that did not rely simply on the Secretary of State's personal pledge but was on the face of the Bill. I beg to move.

Lord McColl of Dulwich

Before my noble friend replies I should like to ask the noble Lord, Lord Peston, a question. Would he have any objection to identifying a general practitioner or a hospital consultant who spends a vast amount of money on a drug which is known to have no value? Presumably there would be no problem about applying sanctions or giving advice to such a person.

Lord Peston

The noble Lord takes us into a very deep water. He must have had some experience in this area. I do not know whether in his hospital there is a formulary, and so on. There is undoubtedly a conflict and it is one which occurs not only in medicine. It happens in other professions.

The noble Lord gives an extreme case of a drug that is known to have no therapeutic value. The homoeopathic people have left the Chamber so I shall not say anything more on that. The noble Lord takes the extreme case of the drug that has no therapeutic value. But the more likely case concerns drugs which have no extra therapeutic value to justify the enormous increase in cost. There is a key question of how one deals with professional people. In the end I believe that one should put pressure on them, which is the case for the indicative drug budget. One asks them whether they can justify their prescribing. But if I were in the noble Lord's hospital as a doctor, I do not know whether with colleagues I would be able to go as far as saying that a doctor must not do it.

I am not certain that I dare answer the question. I can see the conflict between the desire for rationality and efficiency and the fact that I am rather loath to interfere with the exercise of professional judgment. It is a difficult question. It matters much more in the noble Lord's profession than in mine. I have not given as clear-cut an answer as the noble Lord would like but I hope that he at least recognises the nature of the difficulty.

Lord Pitt of Hampstead

I wonder whether in replying the Minister will tell us how the indicative budget will be worked out. That is what worries me. When speaking to an earlier amendment I pointed out that in order to escape the stiff cash limits hospitals prescribe limited amounts of treatment and expect GPs to provide the rest of the treatment. I hope that in deciding on the indicative budget the Government will take that into account. I should like to hear from the Minister how the indicative budget will be worked out.

Lord Henley

The noble Lord, Lord Peston, is correct in his assumption that the budgets are indicative, but the noble Lord's amendments are obviously based on a misconception. There will be no new sanction or penalty for simply exceeding the budget, and no powers to do so are being sought. Disciplinary action will, as now, be contemplated only in the last resort when there is clear evidence of over-prescribing. Regulations already provide for action to be taken against doctors who prescribe excessively. I hope that the noble Lord will agree that it would not be acceptable for there to be no effective mechanism to take sanctions against doctors who over-prescribe. We have discussed with the medical profession how these existing procedures can be modified, based on a hearing by a professional committee, to develop a fair and equitable system in which the profession and the public can have confidence.

The noble Lord asked about additions to the list. I can assure him that procedures exist to add drugs to the selected list and that those have been fully used in the past. The noble Lord, Lord Pitt, asked how the indicative prescribing budgets will be set. They will mainly be set on past prescribing patterns. But the department will publish in May a working paper giving details of the manner in which the scheme will work, including details of the way in which firm budgets for regional health authorities and FHSAs and indicative budgets for general practitioners will be calculated. Having said that, I hope the noble Lord will agree that the amendments are unnecessary. I urge him to withdraw them.

Lord Peston

I thank the noble Lord for that reply. I am aware of his discussions with interested parties. I look forward to hearing what comes out of them. I utter the plea that what we do in the drug field will be an agreed move forward—one involving satisfaction on the part of the Secretary of State who is anxious to protect the taxpayer but also one that will not be deeply offensive to the professional people; involved. I may want to come back to the matter on Report, but for the moment I thank the noble Lord for his reply and I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 105ZAE to 105ZAG not moved.]

Clause 18 agreed to.

8 p.m.

Clause 34 [Indicative budgets]:

Lord Carmichael of Kelvingrove moved Amendment No. 105ZAH: Page 41, line 6, after ("shall") insert ("following consultation with that practice").

The noble Lord said: We have been patiently waiting to deal with an amendment which does not completely follow on from the English amendments to the Bill. The purpose of the amendment is reinforced by previous debates which have taken place on the question of indicative budgets for doctors' practices. In Amendment No. 105ZAH we suggest that indicative budgets should be introduced, following consultation with that practice".

In other words, the practice should not merely decide that it will spend so much nor should the health board, from on high, write to the practice and say, "That is what you will be allowed to spend". The health board must consult with the practice before giving a notice in writing about the budget. The practice must discuss its budget with the health board.

In Amendment No. 105ZAJ we suggest that the health board should consider the area involved. It is important that the area should be examined and that the health board should know and visit the area and take into account its previous history. The Minister may be aware that the importance of such consideration was rather emphasised in today's edition of the Scotsman. One wonders just how close some health boards are to the facts on the ground when they now admit that they are working in certain areas with figures and ideas which are at least nine or 10 years old. For example, the merchant city in Glasgow is defined as a deprived area, whereas parts of Easterhouse are not. Similarly, the Royal Mile in Edinburgh is defined as a deprived area, whereas certain parts of Wester Hailes are not.

The implementation of the amendment would mean that a health board would need to visit the practice and discuss the situation with the people on the ground in order to ascertain what is happening. Then, as the practice has been looked into and approved, there should be no power for the practice to refuse the place a patient on its list because that patient's potential drug bill was too high. That situation should be met in another way. For example, the practice should approach the health board informing it of the fact that there is a patient with a particularly large and expensive drug requirement and stating that they would like a special allowance to cover the situation. I beg to move.

The Minister of State, Scottish Office (Lord Sanderson of Bowden)

I thank the noble Lord for moving the amendment and, I gather, speaking also to Amendment No. 105ZAJ. The amendment seems to be motivated by two worries—both of which I believe are misplaced. One is that indicative drug budgets may not be set at the right level. The other is that budgets will be cash limited and therefore, among other things, give doctors an incentive to reject patients with expensive drug needs. I shall deal with both those misapprehensions.

Indicative budgets will be set to take full account of the needs of patients in each practice. The Scottish Working Paper Number 1 makes it quite clear that health boards will allocate budgets only after discussions with local area medical committees, consultation with individual GPs and guidance from the department of the Scottish Office. The starting point for setting a budget will be a GP practice's current spending patterns. Boards will need to take into account a variety of factors, such as the list size, the age and sex profile of the practice, the proportion of patients with special needs which may call for particularly expensive treatment—that is particularly relevant to Amendment No. 105ZAJ—special interests of practices, numbers of temporary residents and local social and epidemiological factors.

I turn now to the second misapprehension. I should make quite clear the fact that budgets will definitely not be cash limited, as has already been said, either at health board or at individual practice level. The word "indicative" is used advisedly. The budget will quite simply be a guide to expected spending and the Bill requires doctors to attempt to conform to this guide. Any overspending by a GP practice of its drug budget will be met by the health board. Where the board considers the overspend to be clinically justified, this will be met without further action. A good example of that would be an influx of patients needing expensive treatment on the doctors' new list. On the other hand, if the board believes that the practice has exceeded or is likely to exceed its budget for good clinical reasons, it will seek to help the practice reduce unneccessary spending. This will most commonly be done by discussion between health board advisers and the practice, and I fully expect that most problems would be sorted out at that time.

As a last resort, as has already been said, boards will have power to withhold remuneration from doctors who are considered, following a full hearing by a professional committee, to have over-prescribed, as measured against clinical and therapeutic criteria only. Two important points need to be made in this regard. First, this ultimate sanction would have no bearing on the funding of the practice's drug costs, which would continue to be met. Secondly, any withholding of remuneration would be done under existing criteria: the Bill contains no new power to discipline doctors.

I hope by making these few remarks on both amendments that the noble Lord will consider what I have said. I feel that both amendments are unnecessary. As a final pointer, I shall forward to him a copy of the indicative prescribing budget working paper Working for Patients dated March 1990 and issued by the Scottish Office. On the last page it contains some very interesting comments from Scottish GPs who say quite clearly, as regards the figures which we have, that improvements can be made with indicative drug budgets.

Lord Carmichael of Kelvingrove

I am most grateful to the Minister for his very explicit reply, and also for his promise to send me a copy of the paper he mentioned. It will be churlish of me at this time of night—and also on the occasion of his birthday—to take the matter further. In the circumstances, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 105ZAJ and 105ZAK not moved.]

Clause 34 agreed to.

Baroness Blatch

I beg to move that the House do now resume.

Moved accordingly, and, on Question, Motion agreed to.

House resumed.