Lords Sitting of 3 December 1996

Preamble
The House met at half-past two of the clock: The LORD CHANCELLOR on the Woolsack.
Prayers—Read by the Lord Bishop of Coventry.

Lord Rogers of Riverside
Sir Richard George Rogers, Knight, having been created Baron Rogers of Riverside, of Chelsea in the Royal Borough of Kensington and Chelsea, for life—Was, in his robes, introduced between the Lord Rothschild and the Baroness Blackstone, and made the solemn Affirmation.

Overseas Development Assistance
2.48 p.m.
Lord Judd Lord Judd asked Her Majesty's Government:
What, in the light of the provisions made in the Budget, is their policy towards overseas development co-operation.
The Minister of State, Foreign and Commonwealth Office (Baroness Chalker of Wallasey):The Minister of State, Foreign and Commonwealth Office (Baroness Chalker of Wallasey): My Lords, the purpose of the UK development assistance programme will continue to be to improve the quality of life of people in poorer countries by contributing to sustainable development and reducing poverty and suffering.
Lord Judd: My Lords, does the Minister accept that we are sad that yet again, however the figures are juggled, she has been let down by an 8.4 per cent. cut in real terms in the aid programme after the severe cuts of last year? What now will really be the priorities? Why is only 27 per cent. of our bilateral aid programme devoted to the poorest countries? Why is only one-fifth of the programme spent on education and only 1 per cent. on primary education? What of last week's report on Indonesia by the National Audit Office? Why was not one of seven projects examined primarily for the benefit of the poor? Does the Minister accept that it is now essential to reassure taxpayers that the sadly declining aid budget is being used where it is most needed to fight poverty?
Baroness Chalker of Wallasey: My Lords, it might be helpful to everyone in your Lordships' House if we got some facts right. First of all, the reductions in the ODA budget are fully attributed to the lower forecasts of draw-down by the multilateral organisations, particularly the European Community. For some time the estimates from Brussels have been larger than the amounts paid. Secondly, our core programme has been guaranteed in this Budget for the next three years. The core programme is the part of the overseas development budget which we decide ourselves—in other words, the bilateral provision and the discretionary multilateral
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programmes. We shall deliver no less than was planned. The poorest countries, those in Africa and Asia, receive about three-quarters of the bilateral budget. That is well above the average for all donors. Eight of the 10 biggest recipients were the poor countries in sub-Saharan Africa and South Asia. Therefore, the noble Lord is not right.
The noble Lord mentioned the NAO report. That was initiated to examine contracts between the UK and Indonesian Governments. It was clearly found that the primary reasons for supporting activities were developmental. That is right because more than 14 per cent. of Indonesia's population live in absolute poverty.
Lord Judd: My Lords, does the Minister agree that she has repeatedly complained to the House that she is unable to do bilaterally what she would like to do because of commitments to the European Union? Is it not a fact that when the aid programme was cut by £124 million last year the House was assured that it would increase by £47 million this year? Instead, there has been a further cut at a time when the Minister desperately needs funds for bilateral programmes. As for Indonesia, does she agree that the NAO has said that not one single project has been in the interests of the poor?
Baroness Chalker of Wallasey: My Lords, the NAO report states that the primary reasons for supporting the activities that were examined were developmental. As far as concerns the other matter referred to by the noble Lord, no promise was made to get back the £47 million.
Lord Redesdale: My Lords, if over the next three years the core funding for bilateral projects is to drop, is the Minister guaranteeing that the bilateral budget will drop over the next three years?
Baroness Chalker of Wallasey: My Lords, no. The noble Lord, Lord Redesdale, was not listening. The Chancellor has guaranteed that if non-discretionary spending exceeds the revised forecasts, the Exchequer will meet the bill. He has further guaranteed that the core programme—which we decide ourselves—is protected for the next three years.
The Lord Bishop of Coventry: My Lords, can the Minister inform the House whether the Government's decision to cut overseas aid, which was announced in the Budget in spite of the pleas of many of us, is compatible with their decision to join the programme announced by OECD nations in May 1996 to halve the number of people living in poverty, to reduce infant mortality by two thirds and to achieve universal primary education by 2015? That has been described as a strictly quantifiable and ambitious programme but one which is achievable.
Baroness Chalker of Wallasey: My Lords, we must view our programme in the light of what happens in aid programmes generally. In 1995 we provided 0.28 per cent. of our GNP for development assistance. That was above the average for all donors. Among the G7 countries we devoted a larger share of GNP than Japan, the US or Italy. There are only four OECD

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members who meet the targets and all are countries with much smaller programmes than ours. We are doing our best to meet them, but none of the OECD countries has yet met the targets to which the right reverend Prelate has referred.
Lord Renton: My Lords, is my noble friend aware that in most of the countries that we are trying to help the overseas aid programme will fail unless they accept her splendid advice to try to do something about the problem of overpopulation?
Baroness Chalker of Wallasey: My Lords, my noble friend is right. I am pleased that since 1988 the percentage of our bilateral assistance allocable by sector which has been spent on health and population has doubled from 6 per cent. to 12 per cent. Last year the percentage spent on education was 18 per cent. We have good pipelines for health, population and education. I hope that they will increase as time goes by because they are at the heart of the problem of poverty from which far too many people in the world suffer.
The Earl of Sandwich: My Lords, is the Minister aware that at the present rate of decline next year our aid programme will be worth less than a farthing—a quarter of a penny—in the pound of our national wealth? How does she reconcile that with the OECD target that has already been mentioned? Does the Minister feel that proportionately too much aid is spent on emergency assistance at the expense of long-term development?
Baroness Chalker of Wallasey: My Lords, the emergency assistance to which the noble Earl has referred is provided for in the budgeting process, but that amount varies greatly. If there is a major call for emergency assistance, as in 1991, it is a matter that is not programmable. In that event, I can turn to the Treasury for assistance, as I did and as I received in 1991. As far as concerns the OECD targets, one of the matters on which that organisation is very keen is to increase combined private and official flows. The noble Earl may be aware that the target in that regard is 1 per cent. Britain achieved 1.15 per cent. in 1994. The attraction of private investment to these countries can do just as much as public investment, but their economies must be put in order first.

Helms-Burton Act
2.58 p.m.
Viscount Montgomery of Alamein Viscount Montgomery of Alamein asked Her Majesty's Government:
Whether they are satisfied that the proposed European Union initiative to counteract the adverse effects on international trade of the Helms-Burton Act is adequate.
Baroness Miller of Hendon: My Lords, Her Majesty's Government have been working closely with their
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European partners to create a firm and effective response to the United States' Helms-Burton legislation which will protect our companies and trading interest. Her Majesty's Government believe that the current EU initiatives will provide a strong response to the US legislation and help to counteract adverse effects on international trade arising from Helms-Burton.
Viscount Montgomery of Alamein: My Lords, the Minister's Answer is quite encouraging. Can my noble friend ensure that the UK delegate and other EU colleagues who attend the WTO Summit in Singapore next week make the strongest possible objections to this extra-territorial legislation which runs totally contrary to the whole concept of improved world free trade?
Baroness Miller of Hendon: My Lords, we will be reaffirming with other countries in the WTO the primacy of the multilateral trade system and the rules on which it is based. We will be looking to ensure that the United Kingdom's objectives are reflected in the new work programme of the World Trade Organisation. The substance of the dispute settlement case will not be raised because that is subject to separate confidential procedures.
Lord Peston: My Lords, the noble Viscount is right that this is a disgraceful infringement of all that has happened with free trade in the 50 years since the war ended. It is most alarming that the USA, the country which took the lead in that, should be the one that now damages it in this way. Does the so-called EU initiative involve any sanctions against the USA if it proceeds, because as I understand it the USA is not backing down in any way? That means that it will damage some of our companies. Is it not time for us at least to intimate that we might act in a way that could damage one or two of its companies if it proceeds in that way?
Baroness Miller of Hendon: My Lords, the current initiatives about which I was talking include the recent announcement of the WTO dispute settlement panel, a European Community regulation, and joint action designed to counter the extra-territorial application of the legislation. The EC regulation is fairly tough, and I hope that the noble Lord will be satisfied. It obliges individuals and companies to inform the European Commission if their financial and economic interests are directly or indirectly affected by the operation of specified pieces of US legislation, which includes the Helms-Burton Act. There are other points to it, but that should reassure the noble Lord that we are doing all that is possible.
Baroness Young: My Lords, does my noble friend agree that now the American elections are behind us there might be an opportunity once again to raise directly with the American Government our very real concern, which is felt in all parts of the House, about the terrible effects that Helms-Burton is having, not just because of its extra-territorial aspects but because of its effects on individuals in Cuba itself?
Baroness Miller of Hendon: My Lords, I am pleased to be able to tell my noble friend that we shall continue to

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make representations to the US Administration and Congress about the Helms-Burton Act, with the aim of having the Act repealed. In the shorter term, we shall be seeking a renewal of the suspension of the right to bring private cases under Title 3 of the Helms-Burton Act.
Lord Wright of Richmond: My Lords, is the Minister aware that there were 10 senators, no less than one tenth of the US Senate, in London two weeks ago? Was the opportunity taken to impress upon them the views of Her Majesty's Government about extra-territoriality and the Helms-Burton Act?
Baroness Miller of Hendon: My Lords, I am not sure whether that opportunity was taken. The last time I answered the noble Lord on this question I am afraid that I said that as I was not sure it was not appropriate to give him an answer. I shall find out. I shall write to the noble Lord and put a copy of the letter in the Library for all other interested noble Lords.
Lord Williams of Mostyn: My Lords, is it the Government's view that the Helms-Burton Act is or is not lawful under international law?
Baroness Miller of Hendon: My Lords, we very much hope that the panel will find that the US action is inconsistent with her obligations under international trade rules. The case is complex and that is the very best answer I can give at this time.
Viscount Waverley: My Lords, is the Minister aware of the depth of opinion against the approach of the United States by all Latin and Caribbean states, including Mexico and Canada?
Baroness Miller of Hendon: My Lords, yes, and I am aware of the feeling of this House.
Lord Taylor of Gryfe: My Lords, while I agree with all that has been said this afternoon, have any representations been made to Fidel Castro to improve his human rights record, which might enable us to make considerable progress in abolishing this undesirable Act?
Baroness Miller of Hendon: My Lords, we are doing our very best to ensure that the Cuban position on human rights, and everything in that order, is done. This country and Europe believe that continuing with trade and relations is the best way to ensure that human rights eventually prevail in Cuba.

Building Society Share Distribution Schemes
3.5 p.m.
Lord Ewing of Kirkford Lord Ewing of Kirkford asked Her Majesty's Government:
Whether they will make representations to building societies in the process of converting to banks regarding free share issues in respect of accounts
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where the first name on the account is acting for a person whose medical condition prevents them from acting for themselves.
The Minister of State, Department of Social Security (Lord Mackay of Ardbrecknish): My Lords, although under building society schemes account holders who are first-named generally receive shares from a distribution, those who manage accounts on behalf of others are accountable to them for the distribution which they receive. Societies and their members decide, and vote on, the distribution scheme which is adopted, and they decide on who benefits from it. The Building Societies Act gives them a degree of discretion in the form which schemes can take.
Lord Ewing of Kirkford: My Lords, is the Minister aware that he has not answered my Question, in the sense that I am asking whether the Government have made any representations on this matter to the building societies? Is he further aware that I am grateful to Alistair Burt, the Minister for the Disabled, Angela Knight, the Treasury Minister in another place, and Tom Clarke, the Shadow Minister for the Disabled, for the representations they have made, as this matter relates almost entirely to people suffering from mental illness or mental handicap, or who have learning difficulties, where the first name on the account is usually the charge nurse in the establishment where these people reside? There are cases where one charge nurse is the first name on upwards of 30 accounts. The building societies are saying that they can have only one allocation of shares. Does the Minister accept that this is neither a political nor a financial matter, but a moral matter? It is wholly wrong of the Alliance and Leicester and the Halifax Building Societies to treat these unfortunate people in this immoral way.
Lord Mackay of Ardbrecknish: My Lords, I am grateful to the noble Lord for what he said about my honourable friend Mr. Alistair Burt, who has indeed met building society representatives on this issue. The issue is a bit more complex than at first appears. Many other accounts are held jointly with first names and subsequent names; for example, husband and wife, father and child, and grandfather and grandchild. Indeed it may be even the local club secretary and the club. The existing Building Societies Act allows societies to devise a variety of schemes involving, for instance, making a payout to each member, a payout for each account, and a payout for each name on an account, through the first-named account member. It is for the building societies themselves to decide which scheme they feel is most appropriate, and, of course, for the building society members to decide.
Lord Taylor of Blackburn: My Lords, have any discussions been held by any government departments with the Court of Protection on this matter?
Lord Mackay of Ardbrecknish: My Lords, I am aware, as I said, that disability unit officials have talked to the building societies, as has my honourable friend

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Mr. Alistair Burt. I cannot answer the question that the noble Lord asked. Perhaps I may add that ultimately of course whether or not this is discrimination under the terms of the Disability Discrimination Act will be a matter for the courts to judge.
Baroness Gardner of Parkes: My Lords, I declare an interest as a former director of the Woolwich. Is my noble friend aware of the great concern felt at the moment by building societies which have already declared that they intend to convert? This is one of the many problems that they should consider. They are concerned about the uncertainty surrounding the law and their future after conversion. It is having an inhibiting effect. I am sure that he will have seen that in the financial press.
Lord Mackay of Ardbrecknish: My Lords, I appreciate what my noble friend has said. My understanding is that all the converting societies have taken advice from learned counsel. They have been advised that what they are doing is not against the law. But, as I said a moment ago, that will of course ultimately have to be tested in the courts. As I think I said, my honourable friend Mr. Burt is concerned about this matter. One of the problems is that many of these processes started before this week, which is when the Disability Discrimination Act has, at least in part, come into effect.
Lord Rix: My Lords, will the Minister confirm that meaningful talks are taking place between the building societies concerned and a number of voluntary organisations, including MENCAP, with the view to sorting out the problem? Will he also confirm that he will encourage a solution to be found?
Lord Mackay of Ardbrecknish: My Lords, I am pleased to hear that talks are taking place between the building societies and the organisations representing mentally handicapped and mentally ill people. As I have indicated, my honourable friend has also had discussions with them. I do not believe that the building societies can be in too much doubt about the feelings of many people on this issue.
Lord Addington: My Lords, does the Minister agree that a case of such legal complexity provides an example of where a more vigorous campaigning legal body might have been beneficially introduced under the Disability Discrimination Act as opposed to the rather weaker body which was introduced?
Lord Mackay of Ardbrecknish: My Lords, no matter how vigorous a body is it cannot act other than inside the law. I believe that the noble Lord's question invites me to suggest that organisations should be empowered to act outwith the law and I do not agree with that. The law in the Disability Discrimination Act is quite clear. As I said, ultimately, this matter may be for the courts to test.
Lord Skelmersdale: My Lords, within Parliament we have rules of hybridity which deal with those in the
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same class being treated differently. Does my noble friend agree that this is not a matter of disability discrimination but of general discrimination?
Lord Mackay of Ardbrecknish: My Lords, the matter is good deal more complicated. One of the principles of mutuality, which is the basis on which many building societies were founded, is that the rights are conferred on members on the basis of one member one vote and not on the basis of the number of accounts held. That is perhaps why the position is that no matter how many accounts are held and for whatever reason—that is perhaps why I answered in the way I did—a person can be considered only once as a member, once as a vote and, as the building societies have developed their schemes, once with regard to any distribution.
Lord Dubs: My Lords, does the Minister agree that there is a tremendous sense of unfairness on the part of second-named account holders which runs through the whole of this business? It is difficult for people to understand why, when we have tight regulation in the financial services generally, the Government should adopt such a laissez-faire attitude towards building societies, allowing them to treat people in a way which is not just.
Lord Mackay of Ardbrecknish: My Lords, I believed that I answered that question with regard to the principle of mutuality. If the noble Lord is inviting government to interfere in private sector companies and to change the laws of mutuality, I shall resist that invitation.
Lady Kinloss: My Lords, is there a provision in the Building Societies Act which prevents a building society from making a bonus payment to account holders who are not members of the society?
Lord Mackay of Ardbrecknish: My Lords, as I indicated in an earlier answer, it is up to the building societies to decide which scheme is most appropriate.

BSE: Selective Cull
3.13 p.m.
Lord Carter Lord Carter asked Her Majesty's Government:
What is the latest assessment of the number of cattle required to be slaughtered for a BSE selective slaughter scheme to be successful.
Lord Lucas: My Lords, the estimate given at Florence for the maximum number of animals to be slaughtered under a selective slaughter scheme was 128,000. No more recent estimate is available. Whether such a scheme might be regarded by the noble Lord as successful would depend on, among other things, his definition of success.
Lord Carter: My Lords, is the Minister aware that on 4th July his right honourable friend the Prime

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Minister, in reply to a question from the Leader of the Opposition, Mr. Tony Blair, said of a slaughter scheme that there are:
"two fundamental reasons why the policy is necessary. The first is to ensure public health".—[Official Report, Commons, 4/7/96; col. 1049.]?
At the end of that reply he also referred to the need to deal with the matter in the interests of public health. If, according to the Prime Minister, there was a fundamental public health requirement to introduce this scheme why have the Government done nothing since April when they first announced it?
Lord Lucas: My Lords, I do not have with me the particular quotation with which the noble Lord has enlivened the House. However, from all that has been said of the selective slaughter scheme it is clear that it has no public health implications. We in this country are dealing with a situation in which no possibly infected material does or can reach the consumers. Slaughtering animals early may have the advantage of allowing the European Union to relax its restrictions, but as far as I am aware the procedure has no other possible advantage.
Lord Peyton of Yeovil: My Lords, does my noble friend agree that British beef is now at least as safe as any other beef in Europe? That being the case, if neither the Commission nor the member states have yet been able to produce a definite number or a date by which the ban can be suspended, does he also agree that to continue the cull would be both pointless and cruel?
Lord Lucas: My Lords, I entirely agree with what my noble friend said at the beginning of his question. British beef is safe and certainly as safe as beef from any other country in Europe. However, whether or not to undertake the selective cull is a matter of fine judgment. If we undertake it we shall be putting our partners on the spot; we shall have complied with all the five points agreed at Florence and it will be up to them to carry out their part of the bargain. If my noble friend has doubts about whether our partners will do that, so do I.
The Countess of Mar: My Lords, does the Minister agree that the selective cull, together with the newly introduced scheme for killing dairy cross-beef cows, will in a very short time lead to a dearth of beef in this country? What is to happen about imported beef, upon which we must rely if we continue to eat beef, in order to ensure that it meets the health standards of this country?
Lord Lucas: My Lords, there is very little that we can do that we do not do already to make sure that beef coming into this country meets the proper health standards.
Lord Hylton: My Lords, can the Minister tell the House how many cattle have so far been slaughtered under the various schemes? Does he agree that the eradication of BSE is the objective?
Lord Lucas: My Lords, I entirely agree with the noble Lord's second point. Under the over 30 months
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scheme we have slaughtered about 1 million cattle. All the predictions are that following that course we will see the end of the disease for all practical purposes by about the year 2001.
Lord Carter: My Lords, in reply to my first supplementary question, the Minister said that there is no public health implication. I quoted the Prime Minister saying on 4th July that the fundamental reason was to ensure public health. Whom do we believe, the Prime Minister or the noble Lord?
Lord Lucas: My Lords, one would always believe the Prime Minister. I do not have the particular quotation that the noble Lord gave and therefore I do not have its context. I can give the noble Lord only my understanding, which is certainly junior to that of the Prime Minister.

Business
3.18 p.m.
Lord Strathclyde: My Lords, at a convenient moment after 3.30 p.m. my noble friend Lord Mackay of Ardbrecknish will, with the leave of the House, repeat a Statement that is to be made in another place on ECOFIN.

Sea Fisheries (Shellfish) (Amendment) Bill [H.L.]
Baroness Wilcox: My Lords, I beg to introduce a Bill to make provision for fisheries for lobsters and other crustaceans. I beg to move that the Bill be now read a first time.
Moved, That the Bill be now read a first time.—(Baroness Wilcox.)
On Question, Bill read a first time, and ordered to be printed.

Town and Country Planning (Scotland) Bill
The Lord Advocate (Lord Mackay of Drumadoon): My Lords, I beg to move that this Bill be now read a second time. This Bill is the first of a package of four Bills standing on the Order Paper in my name. With the leave of the House, I shall speak briefly to all four together and then remove the remaining Bills formally.
The purpose of the four Bills is to consolidate legislation on town and country planning in Scotland. The legislation was last consolidated in 1972. Each of the Bills incorporates amendments to give effect to recommendations of the Scottish Law Commission which are intended to remove certain minor anomalies in the existing law.

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The Town and Country Planning (Scotland) Bill is the largest of the four measures. In consolidating enactments relating to town and country planning in Scotland, it seeks to restructure and clarify existing legislation. The Planning (Listed Buildings and Conservation Areas)(Scotland) Bill consolidates enactments relating to special controls in respect of buildings and areas of special architectural or historic interest. The Planning (Hazardous Substances)(Scotland) Bill consolidates enactments relating to special controls in respect of hazardous substances. Finally, the Planning (Consequential Provisions) (Scotland) Bill deals with the repeals, consequential amendments, transitional matters and savings which are consequential on the consolidation package.
This consolidation package runs in total to some 407 sections and 25 schedules. It is a considerable testimony to the industry, painstaking application and skill of the draftsman. His considerable efforts have not just brought together the Scottish legislation and town and country planning and related topics. They have added a much needed restructuring and coherence to the Scottish planning code. I am sure that the whole House will welcome the efforts that he has made which will also be welcomed by all those involved in planning in Scotland—those who seek planning permission, local authority officials, planning experts and lawyers and reporters within the Scottish Office Inquiry Reporters Unit.
It is also notable that no fewer than 43 separate recommendations by the Scottish Law Commission for the resolution of inconsistencies and anomalies were initiated by this process of consolidation. The Scottish Law Commission is to be commended for its efforts in assisting with this important piece of consolidation.
In my submission, these legislative measures are worthy and extremely beneficial. I commend the Bills to your Lordships. If your Lordships are content to give all four Bills a Second Reading, they will be referred in the usual way to the Joint Committee on Consolidation Bills. In the case of the fourth Bill, the Planning (Consequential Provisions)(Scotland) Bill, which is not itself a consolidation Bill but which contains sweeping-up provisions consequential on the other three Bills, there is a Motion in my name on the Order Paper that this Bill should also be reserved to the Joint Committee. I commend the Bills to your Lordships.
Moved, That the Bill be now read a second time—(Lord Mackay of Drutnadoon.)
Lord Carmichael of Kelvingrove: My Lords, I welcome the Bill and thank the noble and learned Lord for his explanations. There is general agreement that the package is beneficial, but perhaps it is only fair to mention the fact that I have had representations from the Scottish Law Society. The noble and learned Lord will be aware that the society has been most helpful to us in our deliberations in this House. Indeed, we have received many helpful suggestions from the society which the Government have taken up.
Although the Law Society agrees that the measures will considerably improve the structure of planning law, it feels that it would have been better if a little more
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time had been allowed for pre-legislative consultation, considering the fact that the committees were meeting during a holiday period. Therefore, it was a little more difficult to have quite as much time to consider the very complicated provisions in the Bill. Of course, I am speaking about people who face the problems of planning on a daily basis. As I am sure the noble and learned Lord knows, they can make a contribution. However, having said that, I hope that the noble and learned Lord will take note of what I have said, and that perhaps in, say, another 10 years or so when we have another Bill, a great deal more time will be given to pre-legislative discussions.
Lord Mackay of Drumadoon: My Lords, I am grateful to the noble Lord for his support for the Bills. I was mildly surprised to hear about the Law Society's observations which may, to some extent, proceed on a misunderstanding of the purpose of the legislation which is primarily to consolidate existing legislation, not to amend the law. However, my officials will take account of those concerns and, if appropriate, some cognizance will be taken of them in the future.
On Question, Bill read a second time, and referred to the Joint Committee on Consolidation Bills.

Planning (Listed Buildings and Conservation Areas) (Scotland) Bill [H.L.]
Lord Mackay of Drumadoon: My Lords, I beg to move that this Bill be now read a second time.
Moved, that the Bill be now read a second time.—(Lord Mackay of Drumadoon.)
On Question, Bill read a second time, and referred to the Joint Committee on Consolidation Bills.

Planning (Hazardous Substances) (Scotland) Bill [H.L.]
Lord Mackay of Drumadoon: My Lords, I beg to move that this Bill be now read a second time.
Moved, that the Bill be now read a second time.—(Lord Mackay of Drumadoon.)
On Question, Bill read a second time, and referred to the Joint Committee on Consolidation Bills.

Planning (Consequential Provisions) (Scotland) Bill [H.L.]
Lord Mackay of Drumadoon: My Lords, I beg to move that this Bill be now read a second time.
Moved, That the Bill be now read a second time.—(Lord Mackay of Drumadoon.)
On Question, Bill read a second time.
Lord Mackay of Drumadoon: My Lords, I beg to move that the Planning (Consequential Provisions) (Scotland) Bill be referred to the Joint Committee on Consolidation Bills.

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Moved, That the Bill be referred to the Joint Committee on Consolidation Bills.—(Lord Mackay of Drumadoon.)
On Question, Motion agreed to, and it was ordered that a Message be sent to the Commons to seek their concurrence thereto.

Scottish Borders Council (Jim Clark Memorial Rally) Order Confirmation Bill
Considered on Report.
Western Isles Council (Berneray Causeway) Order Confirmation Bill
Considered on Report.
Horserace Totalisator Board Bill [H.L.]
Report received.

National Health Service (Primary Care) Bill [H.L.]
3.26 p.m.
The Parliamentary Under-Secretary of State, Department of Health (Baroness Cumberlege): My Lords, I beg to move that this Bill be now read a second time. The Bill provides legislative powers to allow a number of important developments in primary care. Before turning to these in detail, I should like to say a few words about the genesis of the Bill.
This nation's primary care has been described as the jewel in the crown of the National Health Service. This is not just hyperbole. Other countries have looked with envy at our system, with its emphasis on a direct lasting relationship between patient and healthcare professional, local accessibility and high standards. General practice, general dental practice, community pharmacy, optometry and community nursing are among the health services that we most frequently use. We rely on them to be there when we need them.
Over the last decade as the Government have invested heavily there have been significant improvements in the range and quality of primary care. The NHS has more GPs, working with more nurses and therapists than ever before, and there has been an unprecedented investment in premises. We have seen the introduction of hospital at home schemes which allow people to leave hospital and return home quickly if that is their wish. We have seen sophisticated equipment such as ultra-sound made available in surgeries and health centres enabling GPs to undertake diagnostic procedures unthinkable 10 years ago, and specialist clinics for diabetes, asthma and other conditions provide for high quality care near to people's homes. NHS dentistry has also continued to grow steadily, and the role of pharmacists has gained in importance.
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The introduction of GP fundholding has been pivotal in changing the relationship between primary and secondary care. It has allowed GPs, both fundholders and non-fundholders, to use their knowledge of their practice population to improve efficiency and provide services which are responsive to the needs of the people they serve.
Although the current national arrangements have served most people remarkably well, they have proved too inflexible to tackle some of the specific local problems, such as low standards of general practice in some inner-city areas or poor availability of general dental services in parts of the country. Nor, by its very nature, can a national system be tailored to tackle the health needs and priorities of very different communities. Wick, Widnes and Worthing are all very different. Aural health in wrinkly Worthing means adjustment to hearing aids; oral health in Wick means preventing dental decay in children.
In the past 16 months Ministers have carried out a listening exercise with all those involved in primary care. The principles of quality, fairness, accessibility, responsiveness and efficiency were identified as being at its heart—principles common to the whole NHS and which we embodied in the White Papers, Primary Care: the Future and, more recently, A Service with Ambitions.
Along with these principles there was a strong wish for more local flexibility so that services can be delivered in a way which meets local needs and circumstances. Increased flexibility could allow services to be organised differently to meet different health needs; it could provide greater opportunities for professionals to use their skills to the full; and it could provide for employment and contractual arrangements to meet the changing needs of a modern workforce.
The Government have listened and our response is set out in the White Paper, Choice and Opportunity, which we published on 15th October. The National Health Service (Primary Care) Bill takes forward the proposals in the White Paper and it establishes the voluntary principle in trying out new schemes. No one will be forced to take part in any pilot scheme and those who do will be protected by the Bill's provisions should they wish to return to national arrangements.
Let me now turn to the contents of the Bill and to our proposals for greater flexibility in medical and dental services. The Bill offers no blueprint; rather it acknowledges that different local needs call for different local solutions. It provides a legal framework within which medical and dental practitioners can work with health authorities and boards to develop new ways of delivering primary care. These new arrangements will be developed through local contracts between purchasers of services, health authorities and boards and the providers of those services. Clause 1 refers to these new arrangements as "personal medical services" and "personal dental services".
The White Paper sets out a number of key principles on how the new arrangements should be taken forward. These are that participation should be voluntary; no doctor or dentist should be required to take part. The new arrangements should be piloted and evaluated

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before being extended more widely. Proposals should emerge from those working on the ground after local discussion: we do not want to impose from the centre. Local flexibility should be balanced by national safeguards for patients and practitioners. In particular, patients must retain the right to be registered with a GP and be able to choose their GP and dentist. This should safeguard the essential character of British general practice, based on a relationship between individuals and their GP. Finally, the Bill allows for those in pilots who wish to return to the existing system to be able to do so.
The commitment to piloting is crucial. The whole of Part I of the Bill therefore sets out a legal framework under which pilot schemes will be set up and run. Our aim is to allow local initiatives to flourish within a framework of appropriate controls. We need to safeguard the interests of patients and provide stability so that medical and dental practitioners can continue to provide high quality services.
Clauses 2, 3 and 4 set out the application and approval process for pilot schemes. Clause 2 enables GPs, dentists and NHS trusts to make proposals for pilot schemes and, so long as the proposals are correctly prepared, requires health authorities and boards to submit them to the Secretary of State for approval. Pilot proposals put forward by others will be considered by health authorities and boards, which will decide whether or not to submit them to the Secretary of State.
The potential variety and scope of pilot schemes is very wide. For GPs, they might involve practice-based contracts, recognising the important part which nurses and therapists play within the primary healthcare team. They may involve a GP practice having a contract for much the same range of services as it already provides under existing arrangements but with a number of additional services—say, increased hospital at home schemes—built in. Alternatively, it could involve GPs working as salaried employees, freeing them from the task of running a practice to concentrate on their clinical work. This option may be an attractive and effective way of securing better general medical services in some inner-city areas where GPs have sometimes been reluctant to set up a practice partnership.
The nursing profession already plays a major and growing part in the delivery of primary care. We want to encourage that trend and also greater integration of the different primary healthcare professions. Our proposals will enable nurses to develop proposals with GPs which include a range of services in which they take a lead, such as child health clinics or monitoring of asthma.
For dentistry, applications for pilot schemes might propose contracts which pay dental practitioners to bring the oral health of the people on their list up to a certain standard and then to maintain it, instead of offering a range of individual item of service payments, as under present arrangements. They might also involve special initiatives and incentives to encourage the registration and treatment of additional patients in areas where there is poor access to services.
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There has been a lot of chatter about the possibility of GP services being provided by supermarkets. That is no doubt a good story, but it is time to bring speculation down to earth. To the best of my knowledge, no supermarket has shown any interest, so the speculation we have seen misses the point. The skills and expertise needed to provide excellence in primary care do not lie outside the NHS but within it, with those who are already delivering services. The Bill's provisions give them the opportunity to do more and to do it better. I am confident that they will seize it with both hands.
Clause 3 requires the Secretary of State either to approve pilot schemes, to approve them with modifications or to reject them. In reaching his decision, the Secretary of State will consider the potential benefits in terms of the quality of services to patients, the extent to which pilot schemes tackle local needs and the value for money which they offer. He will also take into account the outcome of the consultation on proposals which under Clause 2 he can require health authorities and boards to undertake.
I wish to stress that the innovative proposals we seek cannot be squeezed out of unwilling practitioners. Willing volunteers are a critical feature of pilot schemes. We appreciate that in many cases the existing arrangements substantially meet both the needs of patients and the needs of medical and dental practitioners and remain the best way of delivering services. The Bill therefore leaves intact the legislation, in Part II of the National Health Service Act 1977 and the National Health Service (Scotland) Act 1978, under which general medical and dental services are delivered. To put the matter beyond doubt, the Bill also contains provisions in Clauses 3 and 4 spelling out the right of practitioners to withdraw from new contractual arrangements either before or after pilot schemes are implemented.
Once a pilot scheme is approved by the Secretary of State, the providers and the relevant health authority or board will draw up local contracts under which services are to be delivered and to prepare for implementation. Clause 13 allows providers of services to apply to the Secretary of State for recognition as "health service bodies" within the meaning of the National Health Service and Community Care Act 1990. This will allow them to make NHS contracts with health authorities and boards. The advantage of these contracts is that they provide for the resolution of disputes by the Secretary of State, avoiding potentially expensive and time-consuming court cases. The option of ordinary contracts will, however, be available for those providers who would prefer it.
The Bill includes important provisions to ensure that pilot schemes are implemented effectively, operate according to plan and are of the highest clinical standards. Clause 14 gives the Secretary of State powers to require health authorities and boards to make funding available for the preparatory work. This will ensure that proper preparations are made for implementation and there is no disruption in services for patients during the changeover. Subject to Royal Assent, we plan for the first pilot schemes to come into operation on 1st April 1998.

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Clause 6 gives the Secretary of State powers to specify the circumstances where schemes may be varied without requiring the Secretary of State's authorisation, and also to terminate schemes. This is a reserve power and would allow the Secretary of State to stop a scheme in an emergency, for example where services were shown clearly to be unsatisfactory. Under Clause 7, the Secretary of State will also have the broad direction-making powers in relation to pilot schemes that he has for other NHS services.
Clause 5 requires the Secretary of State to undertake a review of each pilot. We clearly want to learn lessons from the schemes and the process of evaluation and review will allow us to establish what has worked well and what could work better. The clause gives participants an opportunity to comment on the evaluation.
Part I of the Bill also includes a number of provisions relating specifically to either medical or dental practitioners. Clause 9 provides that a medical practitioner who performs personal medical services in a pilot must be suitably experienced. It ensures that the definition of suitable experience that applies to those providing general medical services now will also apply to those who will perform personal medical services in the future. This will help to safeguard consistent standards of training and experience. For dentists, directions to health authorities and boards will ensure that contracts are made only with those with appropriate training and experience.
Clause 10 requires medical practitioners who transfer from the national arrangements to new ones through pilot schemes to leave the medical list of the relevant health authority. This will ensure that there is no scope for confusion as to which system they are working in. However, Clause 11 enables the Secretary of State to provide for these GPs to have a right of return to a medical list should they wish to do so. This is a further important expression of the voluntary nature of the new arrangements. No equivalent provision is needed for dental practitioners, as they continue to be entitled to join a health authority list so long as they have the appropriate qualifications.
Clause 15 allows medical practitioners performing personal medical services to apply for recognition as a fundholding practice in much the same way as GPs can apply to become fundholders under the existing national arrangements. We have all seen the benefits of fundholding, which has enabled GPs to purchase certain hospital and community services for their patients. There is every reason for allowing those benefits to extend to the patients of medical practitioners who in the future provide personal medical services. The Bill will extend provisions in the NHS Act on dispensing doctors to medical practitioners working in pilots. We intend to make sure that existing rules on such dispensing apply to pilot schemes as well as the current system.
Clause 16 allows the Secretary of State to make regulations setting a tariff of charges to be paid by patients receiving dental treatment under pilot schemes. It is only right that those who receive the treatment
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under new schemes should pay exactly the same and be eligible for the same exemptions from charges. Clause 16 explicitly ties charges in the new regime to those which apply under the current arrangements.
I have spoken so far of arrangements for piloting new ways of delivering medical and dental services within primary care. It is likely that over time certain kinds of new contractual arrangements will become established with proven success. These arrangements will no longer need to be authorised by the Secretary of State. The first part of Part II of the Bill provides for arrangements to be made without the Secretary of State having to authorise each one. Of course permanent arrangements should be introduced only after pilot schemes have been found to work. Clause 17 sets out this relationship between pilots and more permanent schemes. It effectively prohibits the Secretary of State from making an order bringing the clause covering permanent schemes into force until he is satisfied that the arrangements are workable and in the best interests of patients. This is a clear confirmation of our intention not to rush ahead with the introduction of new arrangements but to allow them to develop gradually, through voluntary participation.
While the more permanent arrangements will not need to be authorised by the Secretary of State, the Bill enables him to govern the way such schemes are to be set up and conducted. In particular, Clause 18 gives the Secretary of State powers to make regulations setting the scope and the rules on matters such as consultation, the variation and determination of schemes, and the right of return to medical lists.
The firm intention is that the rules governing these more permanent arrangements should be based closely on those which I have described for pilot schemes, so that the permanent arrangement is in all respects a natural progression from the pilot. One of the provisions of Clause 18 requires regulations to ensure providers of services can withdraw from a more permanent arrangement if they wish—a further expression of the voluntary nature of the new arrangements.
Part II of the Bill also contains provisions which relate to both pilot schemes and the more permanent arrangements. Clauses 19 and 20 extend the existing rights of patients, enshrined in the 1977 and 1978 Acts, to choose their medical and dental practitioner. Right of choice will apply to services provided under existing arrangements and to services provided under pilot schemes or to the more permanent arrangements. Clause 19 also provides that where a patient is unable to find a medical practitioner health authorities and boards will continue to have a duty to find one who is operating either under the existing arrangements or under the new ones. The provisions will ensure that the flexibilities we are permitting will not undermine the existing rights that patients enjoy in the NHS, nor lead to some patients being treated according to different rules.
I have concentrated so far on the provisions setting out new flexibilities for medical and dental practitioners. I should now like to turn to the provisions which deal with services provided by community pharmacists and optometrists.

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The core service provided by pharmacists is the dispensing of prescriptions. However, in addition they can provide a range of other services, many of which are best managed locally. These services include the provision of advice on the safe keeping and storage of medicines in residential and nursing homes or the matching of opening hours to patient needs. At present these services have to be prescribed in national regulations. This means that health authorities and boards cannot tailor the services they purchase to local needs. Clauses 23 and 24 provide for health authorities and boards to have much greater control over additional pharmaceutical services. We shall of course ensure that again, as now, consultations are held with the appropriate bodies.
A further important flexibility provided by Clause 24 is to allow a health authority or board to purchase services from a pharmacy in another health authority or board area. It is already possible for a patient to take a prescription to a pharmacy in another health authority—indeed, it may be his nearest pharmacy. At present though the pharmacist could not be asked to deliver oxygen to that patient's home. The Bill removes that anomaly.
Finally, Clause 26 will give NHS contract status to certain agreements which health authorities or boards may make with both pharmacists and optometrists. This will allow arbitration by the Secretary of State in the event of disputes and should make these arrangements more attractive to health authorities and boards.
I turn now to Clause 27 of the Bill, which amends the 1977 Act to provide for changes in the appointment procedures for GPs. The changes deal with a number of long-standing anomalies in current arrangements and implement one of the recommendations in the Chief Medical Officer's report, Maintaining Medical Excellence.
The existing legislation requires that a GP vacancy is declared by the Medical Practices Committee, the post is then advertised, a selection is made by the health authority or board and the doctor is then admitted to the authority's or board's medical list by the Medical Practices Committee. The legislation does not, however, provide for all the circumstances which can now arise. It does not, for example, provide for the appointment of partners; nor does it prevent unsuitable applicants being appointed to vacancies.
New provisions under Clause 27 will provide for the appointment of medical practitioners to single-handed and partnership vacancies and ensure that unsuitable candidates do not have to be selected. Under these procedures, an application will be made to the Medical Practices Committee by the health authority or board to identify that a vacancy exists. That is similar to current procedures. The post will then be advertised and a suitable candidate will be selected. Where no suitable candidate is found, health authorities and boards will no longer have to appoint the least unsuitable candidate. Where the vacancy is for a partner, the selection process will be undertaken by the partner or partners in the practice where the vacancy has arisen. Finally, the
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health authority or board will admit the selected candidate to the list of medical practitioners who provide general medical services in their area. In the case of partnership selections, the authority or board will endorse the selection before admitting the medical practitioner to the list. This will provide for more open and fair appointment procedures while at the same time streamlining processes.
I turn finally to Clause 30. This amends Section 97 of the 1977 Act to simplify the arrangements for allocating funds to health authorities. In doing so it also provides for cash limited payments to be made where GPs and health authorities agree local developments to existing general medical services in line with local needs. Such payments might, for example, be made where GPs develop local services for mentally ill people which meet an agreed local need. This provides an avenue for GP practices to develop local services without entering into new pilot forms of contract where this would not be suitable in the circumstances.
I hope I have been clear in setting out what the Bill seeks to achieve. This is, in the best sense of the word, an enabling measure. It has been welcomed by the professional associations and the NHS. It will enable practitioners who feel constrained by current national arrangements to develop new ways of providing services which make better use of their skills and experience. It will enable health authorities and boards to target local primary healthcare needs more effectively. It will enable those who wish to continue providing high quality services under existing arrangements to do so. It provides a framework for us to proceed gradually, through appropriate piloting, and to learn as we go, so that we retain the best in existing primary care and build on it.
This Bill opens the door for further improvements in our primary healthcare services. I commend it to your Lordships.
Moved, That the Bill be now read a second time.—(Baroness Cumberlege.)
3.50 p.m.
Baroness Jay of Paddington: My Lords, first I thank the Minister for introducing this important and, if I may say so, somewhat surprising Bill with great clarity. No one on these Benches disagrees with the ambition of creating a health service which is primary care centred, if not in the immediate term primary care led. That is, after all, the basis of the proposals for local commissioning groups which my honourable friend Christopher Smith introduced this morning. It is obviously in the best interests of all patients to give overall priority to those personal services—the family doctor, the local dentist, the health visitor and the local pharmacy—which we all use regularly. They are, after all, most people's most frequent contacts with the NHS. We therefore welcome the principle of seeking to improve these frontline services and there is undoubtedly cause for concern and need for improvement in the state of primary care at the moment.

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Traditionally, the family doctor has provided the secure foundation stone of excellent care in the NHS, yet today the British Medical Association describes the GP service as,
"gripped by low morale and a crisis in recruitment".
This afternoon the Minister spoke of using the Bill before us to build on the successes of GP fundholding, but in our view it is precisely the introduction of individual GP fundholding, together with the internal market, which has caused the low morale among doctors and growing uncertainty among patients.
Patients, who have always rightly expected that their own doctor would be a helpful gatekeeper to the other services they may need, now often find themselves discriminated against in a two-tier system, a system where hospital services, for example, may be closed to anyone who is not registered with a fundholder. Every week we hear of this happening in different parts of the country. For example, there is surely something wrong when Lincoln County Hospital writes to all non-fundholding GPs in its area cancelling outpatient appointments for the rest of the financial year, although if you are a patient of a fundholder you can still be seen; or when Norfolk and Norwich Hospital cancels all routine surgery for patients of non-fundholding GPS; or when patients in Tooting are told that they can have a fast-track service for endoscopy only if they are under a GP fundholder.
Of course, in dentistry it is not a question of being in a fast lane or a slow one; it is simply a question of finding an NHS dentist at all. A recent national poll for the British Dental Association showed that one in three people has difficulty getting any health service dental care in their local area.
The Minister has explained that the primary care Bill, by loosening the contract system, may give opportunities to develop and extend those much needed services and that is certainly to be welcomed. We welcome the proposed flexibility of local contracts which may enable the contracts to be practice-based. It is clearly important to include other health professionals, to increase their authority and to involve people such as nurses and health visitors as equal partners in primary care schemes. Provided we have assurances that improvements can be made on an equitable basis within health service funding, we will not oppose the Bill in principle.
But nonetheless the timing and nature of the Bill are somewhat surprising, not least because in recent Sessions successive measures have been introduced to alter NHS structures and organisations. Each time, your Lordships have been told that this was the last, that the present Government's somewhat notorious grand design for the health service was complete. Now, in the last few months of this Parliament, we have before us these proposals for major change which incorporate principles and mechanisms which seem to fly in the face of the earlier approach to reform and which I hope and expect the Government will not survive to implement.
The most surprising element of the primary care Bill is its emphasis on piloting and evaluation before permanent changes are introduced. As the Minister
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explained, the whole of Part I of the Bill—the first 16 clauses—deals with proposals for organising a wide variety of experimental schemes which are based on local initiatives. Further, in all the background documents and briefings which accompanied the earlier White Paper and the Bill, the Secretary of State has insisted that a driving force behind these pilots is the ambition of improving equity in primary care.
Frankly, that is astonishing. As we are all too painfully aware, the Government have up till now relied exclusively on the internal market to determine service patterns, with little explicit regard for equity. They have relentlessly pursued the "big bang" method of health service change. The House will recall that when the internal market was first mooted in the National Health Service and Community Care Bill 1990 the then Secretary of State for Health, Mr. Kenneth Clarke, said that requests for piloting before radical change was introduced were merely an attempt to obfuscate, filibuster and delay. All the attempts by my noble friends in your Lordships' House and honourable friends in another place to get incremental change were resisted. They were resisted then and they have been resisted on subsequent Bills ever since.
The internal market was introduced overnight across the whole country and has produced the present alarming state of escalating administrative costs and a lottery of care. Of course, the internal market system has never been properly assessed and evaluated by the Government.
In stark contrast, today we have before us a wide-ranging enabling Bill to encourage voluntary experimental schemes designed to increase local flexibility and equity in service provision. The British Medical Association has described the proposals as,
"a welcome change from the Government's previous dogmatic initiatives which were imposed on an unwilling profession".
My noble friends and I join it in those sentiments. Indeed, I would go further. I think it is not inappropriate in the circumstances that we have before us today to describe this, the final piece of NHS legislation this Government can introduce, as a deathbed conversion. We may be sceptical about the motives for that deathbed conversion, but we accept the overall aims of the Bill.
However, there are substantial areas of concern which we will want to take up in detail at later stages. The first is the extent and scope of the possible pilot schemes which could in turn become permanent arrangements. The Secretary of State has been enthusiastic about,
"letting a thousand flowers bloom".
I do not think that the Minister allowed herself such flowery metaphors this afternoon. But our anxiety is that weeds could also flourish—poisonous weeds which might choke the fundamental principles of the NHS. In other words, the Bill could create backdoor privatisation of primary care.
The Minister described that as speculation, but Clause 2 appears to limit proposers of new schemes to NHS trusts or to practising GPs, dentists and pharmacists who appear on existing regulatory health service lists and hold existing NHS contracts. But although these "qualified people" will have to initiate

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pilot projects, they could work in co-operation with so-called "other bodies" to formulate and carry out schemes. The fear must be that the most enterprising "other bodies" are likely to be private companies and that although schemes may formally be led by NHS providers, behind the scenes sponsors may well be commercial organisations.
Further on in the Bill, Clause 13 allows that a person who is not a health service body but who provides or proposes to provide pilot scheme services may make an application to become a health service body and thus make NHS contracts. This again opens up wide possibilities, with the spectre of any organisation becoming de jure as well as de facto a health service body.
In the debate on the gracious Speech in another place, the Secretary of State did not deny this possibility. This afternoon, although the Minister said that this was speculation, she did not specifically exclude it. Perhaps I may say to your Lordships—in case anyone thinks that this is simply fanciful scaremongering—that over the past few days I have spoken to GPs in London who have already been approached by private companies with an interest in pursuing new contracts through them. One indeed has already had three specific proposals from organisations, including American health maintenance organisations, interested in becoming involved. As the Bill progresses we will certainly seek much greater clarity in this area to ensure that pilot schemes are limited to those who are genuinely qualified NHS providers and do not allow a cover for commercial companies to become directly involved in primary care.
Another major concern is that of maintaining and improving national standards of care across the whole range of medical and dental services. There is not very much in the Bill—except the provision that practitioners proffering services in pilot schemes must be suitably experienced—which addresses the issue of quality.
Deregulation in the form the Bill proposes may well lead to greater variety and flexibility in meeting different patients' needs in different circumstances. But it will only be of real benefit to those patients if different forms of care and service provision are of equally high standard. This can best be achieved in a national framework of accountability and standard setting.
There has been some interesting recent work and proposals for adopting a type of national franchising scheme for primary care to protect standards. Fidelma Winkler of Queen Mary and Westfield College, who has long practical experience of the health service, in an interesting collection of essays published this summer called A Primary Care-Led NHS—the Lead Phase, wrote:
"The franchise method of combining equity and access with a standard product is well known in Britain. Each outlet remains independently owned but must adhere to quality and service standards".
She goes on to describe how in the voluntary sector the citizens advice bureaux most closely follow this model. Local agencies can only call themselves citizens advice bureaux if they conform to the standard practices laid down by the national body. Users develop
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expectations and confidence and get a service guarantee. If some way of ensuring a wider choice of services on that basis can be achieved through this Bill it will be acceptable, but what we do not want is diversity which leads to wide variations in standards of care.
Of course quality could be tested and monitored through the evaluation process but the Bill as it stands contains no indications that quality and effectiveness will be specifically measured in that process. We welcome the proposal that the Secretary of State must conduct at least one review of each pilot scheme but, like the relevant representative professional bodies and, indeed, organisations such as the National Consumer Council and the Consumers' Association, we are concerned that the scope and nature of those reviews has not been made more specific. There must clearly be thorough, wide consultation before any pilot is made permanent.
The Bill does allow, as the Minister explained, local health authorities and contributing providers to comment on a review but does not include any wider independent evaluation and, particularly, does not include a requirement to consult the users of any experimental service. The process and methods of evaluation is an area to which we will certainly wish to return.
As I said earlier, we are pleasantly surprised by the Government's new-found interest in positively promoting equity in health care. It is important that the Bill allows the possibility of salaried GPs to be employed by community health trusts and for the development of so-called personal dental service contracts.
These new schemes should be particularly helpful in meeting some of the alarming gaps which exist today in inner city primary care, for example. I was told recently of one London health authority which has no applicants for its current GP traineeships. There are many others where practice vacancies are empty for long periods of time.
In dentistry the British Dental Association has pointed out that 70 health authorities have applied for the existing Government access fund, which is only available in areas where there are serious problems. Lack of access to NHS dental care is now spreading from poorer urban and rural areas to more affluent areas. If the proposed schemes go any of the way to restoring some kind of equity they are to be welcomed.
But there is another aspect of access—that of equity. The British Medical Association and the Medical Practices Committee are concerned that the Bill may make the situation worse rather than better. The Medical Practices Committee, which was established by the original 1946 NHS Act, exists to ensure that there is an adequate number of GPs in all parts of the country.
There is already disquiet, as I have described, about the inadequacy of services in inner cities and remote rural areas. Broader geographical disparities across the country have been well documented. For example, it has been calculated that 700 doctors would need to move to the north of England from the south to provide equitable distribution of GPs across the country. Better off areas tend, for obvious reasons, to have a higher proportion of

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general practitioners per head than poorer ones. Anglia and Oxford region have 9.4 per cent. above the norm compared to the north-west region which has 9.4 per cent. below the norm.
The best efforts of the Medical Practices Committee have failed to prevent this inequity but now they are legitimately concerned that the very broad provisions of the pilot schemes may make any strategic attempts at more equal distribution impossible. If all decisions about numbers and organisation of GPs are devolved to local initiatives and local health authorities, the role of the Medical Practices Committee must be bypassed. The only discretion will be left to the Secretary of State in agreeing and then reviewing proposals for new arrangements.
We will want to probe this further as there is clearly no point in seeking to improve equity of access by new individual employment agreements in areas where recruitment is difficult while at the same time diminishing the national strategic capacity to assess and meet local needs. It may be that the role of the MPC should be extended to pilot schemes. If, on the other hand, the Government intend deliberately to marginalise the committee and the new arrangements then that should be made clear and specific.
Finally, there is the usual vexed question of resources. My noble friend Lord Rea will raise some issues about the sources of overall funding for pilot and permanent schemes when he speaks later in the debate. My initial concern is that the sum of £6 million, which has been set aside to pay for setting up and evaluating new schemes, must surely be inadequate if the ambitions of these projects, as they have been described, are to be properly fulfilled.
More generally, the schemes are not intended to come fully into effect until 1998 to 1999 when, in spite of the post-Budget euphoria about NHS growth, we now learn from the Red Book, health service funding will at best be at a standstill and may be cut in real terms.
We will need to return to detailed questions of how the proposed broad spectrum of new services can be paid for within our tax-funded system. Does the lack of clarity about this in the Bill as it stands suggest that Ministers expect there to be a substantial private commercial investment?
Overall we support the intention of the Bill to improve primary care through a more flexible approach to local delivery of services. But we fear that total deregulation could lead to greater inequities, lower standards and easier privatisation. As the Bill progresses we will want to ensure that publicly financed diversity is structured in a way which brings benefits to all patients; in other words, that any changes there may be to primary care are true to the principles of the NHS.
4.08 p.m.
Baroness Robson of Kiddington: My Lords, I, too, should like to thank the noble Baroness, the Minister, for her clear and detailed introduction of the Bill. She clearly stated that there are two different parts of the Bill. The first part deals with the introduction of pilot schemes which might lead to changes across the board in the way in which the GP service is provided in this country. The
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second aspect of the Bill deals with parts of the primary care which require legislative change to make them work more appropriately.
There is a great difference between this Bill and previous National Health Service Bills. This one, if adopted, begins an evolutionary change which will be with us for many years. It will not happen overnight like some of the other "big bang" National Health Service Bills. I welcome that; but, on the other hand, we must also consider how an evolutionary change will affect the health service. It will take some time before people employed in the health service will feel that they know where they are.
As has been stated, it is essentially an enabling Bill. Most of it will be implemented by regulation. As I understand it, those regulations will be subject to negative resolution. I am certain that some details of these regulations will be vital to the future of primary care. Some of them might need affirmative resolution, so that a proper debate can take place in Parliament.
Part I of the Bill, which deals with changes in the general practitioner services in this country, is to be tested through setting up pilot schemes to enable GPs to develop a multi-disciplinary approach to primary healthcare. That has much to recommend it. However, we must ensure that any changes introduced do not jeopardise what is the most precious part of the National Health Service; namely, our general practitioner service, which every other country envies us.
I also feel that the further development of primary care will inevitably demand greater resources. We are concerned that changes flowing from the Bill must not be at the expense of the secondary sector, which already suffers from a shortage of resources. Every day we hear of one hospital after another having to reduce its services due to overspending. The extra £6 million being injected to cover additional costs in preparing, managing, monitoring and evaluating the pilot schemes seems to be the only additional finance available for this change.
If the proposed changes are to work, a thorough preparation of each pilot scheme will be necessary. The evaluation process will also demand extra cash. There are two important points about evaluating the pilot schemes. First, I ask the Government to make sure that schemes run for a reasonable length of time in order to ascertain that they are an improvement on the present system. It is no good having a pilot scheme where decisions are taken within four or six months because one is absolutely convinced that it is an improvement. A much longer time is needed.
Secondly, the evaluation process must be thoroughly completed before the scheme is given a permanent go-ahead. We must not have a repetition of the speed at which the nursery voucher scheme was given the go-ahead, even before the pilot scheme was finished. If we are to make sense of this legislation, it has to be implemented very carefully and patiently.
In the evaluation there must also be close liaison between general practitioners and local authorities. Primary care is the responsibility of both those parts of our community. I believe that co-operation between those two bodies should be included on the face of the Bill.

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The Bill also deals with changes to the contract between general practitioners and the National Health Service. The introduction of a salaried contract for general practitioners may be helpful in achieving equal cover of GP services throughout the country, in particular in inner city and rural areas which at present are often left with insufficient cover. It may also be of help for the group of doctors who opt for part-time work. They are, in the main, married women who are not able to take on a full-time job, so a salaried contract may be of great benefit to them.
However, these changes have implications for manpower planning. As the noble Baroness, Lady Jay, mentioned, the Medical Practices Committee will not cover GPs taking part in pilot schemes nor those doctors who are employed by hospital trusts on a salaried contract. The Medical Practices Committee will still be required to carry out the workforce planning for GPs working under the present arrangements. Existing GP practices would be affected adversely when they wished to replace a partner in an area where a pilot is in existence, boosting the number of GPs in that particular area.
Without a national overview of the medical workforce, there could be over-doctoring in some areas, which is bound to lead to under-doctoring in other areas. The need to maintain one overall body looking at workforce planning and distribution still remains.
Many of the pilot schemes will be dependent on the ability of nurses to prescribe, if they are to fulfil the aim to produce more flexible and appropriate services. It will be essential for nurse prescribing to be extended to include both more nurses than the limited number of appropriately qualified health visitors and nurses that is now allowed and a wider range of products. It is therefore important that nurse prescribing be extended in parallel with the implementation of this Bill.
The Minister mentioned the possibility of a change from individual GP contracts to practice-based contracts. Under a practice-based contract it is conceivable that a nurse could become a partner in a practice. Will the Minister say what happens to the list for that practice? Let us say that there are six partners and one partner retires and the practice decides to appoint a practice nurse as a partner instead of another general practitioner. What happens to the patients who were allocated to the GP who retired? Will nurses be allowed under those circumstances to have a list of patients as well? There are all kinds of questions that need to be answered if we are to know where we are going under the new system.
There is one aspect dealt with under Part II which will have everybody's approval. The proposal to change the regulations governing recruitment to single-handed practices surely must have our support. Currently, health authorities are responsible for appointing GPs to vacancies in single-handed practices. They have to advertise a minimum of three times and if, at the end of that process, there is not a suitable fully qualified candidate, they have to employ whoever is the best of the bad. I cannot understand how, ever since 1948, we have perpetuated that system. But now I am happy that under this Bill health authorities can freeze the vacancy until a suitable candidate can be found.
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I also very much welcome the recognition in the Bill of the tremendous services that the pharmacological profession can give to the NHS. In this country we are very lucky to have a large number of community pharmacists who act as advisers to the general public and are always helpful to their customers. But they face great problems in being able to keep going, particularly in rural areas and away from great concentrations of population. At the moment they are tremendously concerned about the removal of resale price maintenance in the pharmaceutical sector. They estimate that if RPM is removed at least 3,000 of those small community pharmacists will have to close through lack of funds. That is something we must consider deeply because pharmacies have the potential of taking tremendous pressures off the GP surgery and giving great service to the communities in which they function.
I said at the beginning of my speech that this is an enabling Bill; and that it will be many years before we see the final outcome of what it creates. It is, therefore, interesting that we are only a few months away from a general election and do not know who will implement the regulations in the Bill. In fact, we do not know if it will be implemented at all should there be a change of government. However, I hope that most of the good proposals in the Bill will be implemented by whichever party wins the election. The Bill has the potential to be a step forward in the provision of community care. But it must be done carefully and Parliament should retain some input into the discussions on the regulations which have yet to be introduced.
4.21 p.m.
Lord Walton of Detchant: My Lords, there can be little doubt that the drafting of parliamentary Bills is a unique art form. I confess that I have wrestled with the Bill being considered today at Second Reading in your Lordships' House and found some of its provisions complex and difficult to interpret, though the explanatory memorandum is helpful and explicit. The Bill cannot be recommended as light bedtime reading, but the Minister introduced it with commendable clarity.
When I graduated in medicine 51 years ago there were some outstandingly able general practitioners. Nevertheless, in many respects general practice was the weakest section of the medical profession. The quality and extent of its provision was exceptionally variable across the country. Indeed, before the NHS began there was a widespread feeling in many areas—not least in my native north-east—and especially among the less affluent members of society, that for a child with severe abdominal pain, for example, two-pennyworth of castor oil was cheaper than the doctor. Sadly, that perception resulted in an unacceptably high incidence, in the days when I was a paediatric house physician, of children being admitted to hospital with perforated appendixes.
The introduction of the National Health Service on the appointed day in July 1948 heralded a slow progressive improvement. But there were still many aspects of general medical practice which were far from satisfactory. In particular, the range of services provided from GP surgeries, often in converted houses, cramped annexes or otherwise inadequate premises, was very limited. The

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concept of the healthcare team involving nurses and other healthcare professionals working alongside GPs still lay far ahead into the future. And, with the rapidly escalating advance of medical science, doctors going into general practice immediately after graduation were often ill-equipped to deal with the wide range of illnesses and disabilities which came regularly to their attention.
The introduction in 1950 of a compulsory pre-registration year prior to full registration with the General Medical Council brought about some improvement. But a proper standard of training for doctors working in primary healthcare had to wait for the subsequent introduction of the compulsory period of three years of vocational training after full registration which is now required before any doctor can become a principal in general practice. That development, above all others, has resulted in a striking improvement in the standard of primary medical care, as have many other governmental and professional initiatives, leading to the establishment not just of health centres as originally envisaged in the NHS Act, but of surgeries in much improved premises capable of offering a very much wider range of services than was ever envisaged at the inception of the NHS.
It seems to me clear that this primary care Bill now before us represents another major step along the road towards an improved primary care led service. And it overcomes some current contractual arrangements which limit the ability of GPs to expand and develop services. Speaking as a former teacher of medical students and as one much involved some time ago in postgraduate medical education and in the work of the GMC and its education committee, I have been much impressed by the way in which the profession has come to terms, first, with the need for continual upgrading of knowledge, even after the completion of vocational training; and, secondly, with the necessity of collaborating with practice nurses, district nurses, health visitors, social workers, physiotherapists and occupational therapists and many other members of the caring professions so as to make the concept of the healthcare team a reality. Indeed, as pressures upon the primary care service have continued to escalate, as indeed they have with innumerable new initiatives imposing new responsibilities upon GPs, it has become abundantly clear that many of the tasks in which they were historically engaged could readily have been carried out, and are being carried out to an increasing extent, by other healthcare professionals with whom they work in close concert and collaboration.
One of the strengths of our NHS, which has enabled comprehensive medical care to be provided at a much lower cost than is the case in publicly-funded health services in many other countries, has been the crucial gatekeeper function of the GP. Patients in the UK do not, as a rule, consult specialists directly but first see their GP, who then advises them upon the best course of action and the best specialist opinion to be sought, if required. I earnestly hope that the recent decision of the GMC to allow specialists to advertise will not erode that vital gatekeeper function.
As a former consultant neurologist, I welcome the concept of a primary care led NHS, and I welcome also the flexibility inherent in this Bill, as well as the opportunities which it will offer to GPs, enabling them to
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offer an increasingly diverse range of services. Closer collaboration, for example, with pharmacists, optometrists, dentists and many others is to be greatly welcomed. But with the increasingly difficult problems now being faced by our hospitals across the length and breadth of the country, it is vital to recognise—as the noble Baroness, Lady Robson, pointed out—particularly in the light of the increased funding which is to be made available for the NHS following the recent Budget statement by the Chancellor in another place, that any increase in resources for the primary care service, inevitably required if this Bill becomes law, must not be at the cost of a reduction in the funding of our acute hospital services. Our hospitals are already under serious threat because of many factors, including the remorseless pressures of an ageing population, of major developments in medical science and technology, not least in drug development, but also, very properly, because of increasing public demand and expectation. It is particularly important that Her Majesty's Government should be aware of the present parlous state of clinical academic medicine, since it is the clinical academics, not just in hospital specialities but also in primary care, who are largely responsible, and will in future be increasingly responsible, for the training of future recruits into general practice.
There are at present 57 vacant clinical chairs in the United Kingdom which have failed to attract, on advertisement, suitable applicants, and the recent charade through which the universities were unable to find the funds to award the same very small annual salary increases to clinical academics as to their NHS counterparts not only breached a long-standing agreement between the Department for Education, on the one hand, and the Department of Health, on the other—an agreement which had existed since 1969—but added further flames to the fire of disenchantment in the clinical academic community; this has had a very serious adverse effect upon recruitment. Happily, this issue has at last been resolved, not before time, with a long-term agreement, which I trust will hold. Her Majesty's Government must also recognise that morale unfortunately is low in primary care itself; there has been a sharp decline in the number of young doctors applying for registrarships (formerly called traineeships) in general practice. Many parts of the country are finding great difficulty in recruiting appropriately qualified candidates.
May I, nevertheless, express a warm welcome for virtually all the provisions of this Bill. In particular, I believe that the BMA and the Medical Practices Committee, a statutory body controlling medical manpower distribution in primary care, welcome the proposal to introduce, where needed, salaried GPs, not least for the part-time women referred to by the noble Baroness, Lady Robson, but also because this option will help to retain doctors in and possibly to attract others to, areas of high need and deprivation, not least in our inner cities where there is still room for improvement. I also greatly welcome the proposal that appointments to single-handed vacancies in general practice should be made only where there is a suitable applicant. This provision will ensure that such GPs have the necessary qualities to meet the unique and often particularly

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demanding responsibilities of single-handed practice. It is also right that GP partnerships should be responsible for making appointments to vacancies within their own practices, but with the strict proviso that single-handed principals working in group practices which do not constitute partnerships must be excluded from that proposal.
It is, however, apparent that many of those in the medical profession and in the Medical Practices Committee—a body which has exceptional experience in the recruitment and appointment of doctors to primary care vacancies—are seriously concerned about the proposal that pilot projects should be established outside the existing national manpower distribution controls. The Medical Practices Committee, since its inception in 1948, has proved extremely successful in ensuring an even distribution of doctors delivering general medical services to patients. It has invariably adopted a very flexible approach, and its success in supporting the London Initiative Zone and other initiatives by individual health authorities has proved that within its existing framework flexibility to accommodate any pilots or other future schemes is possible.
The MPC is the only body which has a detailed overview of the national GP manpower situation at any one time. Health authorities feed in local details about each case to be considered, placing the MPC in a unique position to encourage local proposals in the context of the national situation. Hence, I think it is important that central workforce planning is essential for the continuing nationwide delivery of high quality care. The increasing shortage of GPs means that the maintenance of such an adaptable national mechanism controlling the distribution of GP manpower has never been more important. Indeed, the Government's own White Paper accepted that it would be necessary to ensure that there remained in existence a coherent national view of the overall GP workforce.
I hope, therefore, that pilot projects, which I welcome, as proposed in the Bill, will be embraced within existing national manpower distribution controls. These pilot projects are an extremely useful, important and innovative proposal. They are voluntary. They will enable unconventional groupings and partnerships to be achieved, as, for example, between doctors, dentists, pharmacists, nurses and others that seem to be appropriate in relation to local circumstances.
I must ask the Minister what plans are going to be made not just for the assessment of these partnerships and the valuation of these pilot projects before they are made permanent, but also the extent to which the local populations, who, after all, will be the consumers, will be consulted about their value. I would also ask whether it will be possible to achieve an unconventional (at present) partnership not allowed under present GP contracts; for example, between doctors and nurses. Is it then possible that that partnership, with contracts to provide health services, could be regarded and accepted as a health service body, as I believe is proposed as a possibility within the Bill?
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The present arrangements for admitting doctors to a medical list and checking their qualifications through the MPC means that the staff involved are highly expert in the necessary procedures. Is it then really necessary that health authorities should be responsible for adding GPs to the medical list? There is no evidence to suggest that the existing system is flawed in this regard. Any new method might result in dilution of existing expertise, more bureaucracy and an increased risk of doctors being admitted to medical lists when not properly qualified. The Medical Practices Committee takes the view that this proposed change is unnecessary and indeed would be unsatisfactory in the interests of quality. I look forward to hearing the noble Baroness's comments upon this particular concern.
Finally, I should also be interested to learn of the Minister's opinion about the Government's proposals, not so far as I can see on the face of the Bill, to target pro-actively high-list GPs with a view to aiming for an average whole-time equivalent practice list size of 1,800 or even 1,700. There is good evidence that some of the most able and effective GPs in this country who have been foremost in education, innovation and research, as well as in providing a high standard of primary care, have functioned very effectively with lists substantially larger than those proposed. I look forward to hearing the Minister's view upon the extent to which these proposals may be rigidly imposed—or are they simply suggestions and not decisions which are likely to be enshrined in regulations or in law?
Subject to these relatively minor criticisms, I welcome this far-sighted and original Bill, as I believe that in the longer term it will not just be to the benefit of those involved in the provision of primary care but also very greatly to the benefit of the population at large.

ECOFIN
4.37 p.m.
Lord Mackay of Ardbrecknish: My Lords, with the leave of the House, I would like to repeat a Statement made in another place by my right honourable friend the Chancellor of the Exchequer. The Statement is as follows:
"Madam Speaker, I would like to make a Statement about the Council of Finance Ministers Meeting in Brussels which I attended yesterday.
"The Council considered at some length a new lending remit for the European Investment Bank. We considered and approved a report on employment policy to be submitted jointly by ECOFIN and the Social Affairs Council to be considered by the forthcoming European Council at Dublin. We transacted a number of other items of routine business which I will report to the House in due course by Written Answer in the usual way.
"We carried forward political preparations for the anticipated discussion at Dublin of economic and monetary union. Finance Ministers have been charged by the last European Council at Florence to prepare a progress report on preparations for EMU. Progress was made but no final conclusions were reached, mainly

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because of outstanding issues which remain to be resolved on the operation of the proposed stability pact and, in particular, on the definition of an exceptional and temporary deficit for the purpose of Article 104(c).
"I made a constructive contribution to the debate in an effort to achieve the widest possible measure of political agreement in preparation for the summit meeting. I made it clear at the outset that my agreement, while in line with government policy, was subject to a parliamentary reserve and could not commit the Government until parliamentary discussions had been completed. The Irish President of the Council confirmed that my parliamentary reserve would be reported and printed on the face of any document laid before the Dublin Council.
"Only two of the texts of the draft regulations which are currently subject to parliamentary scrutiny and were the subject of my Statement last Monday featured in the discussions at ECOFIN yesterday. They were the regulations on the legal framework for the euro under Article 235 and under Article 109(1)4 of the treaty.
"There never had been any question of legislative decision on EMU being taken at yesterday's meeting. These two regulations were considered and drafts will probably be attached to the eventual report to Dublin.
"The Council is at present agreed that there will be no final agreement on the operation of EMU or the text of any regulations until all the negotiations are completed. ECOFIN and every member state are working on the basis that nothing is agreed until everything is agreed. I now anticipate that no final agreement on any binding legislation on EMU is likely before, at the earliest, the planned European Council meeting in Amsterdam in June of next year.
"The draft Article 235 regulation causes no problems to the British Government as it now stands. We would like to see it progressed as quickly as possible to give greater legal certainty to existing commercial contracts in English law denominated in ecus or in currencies which might go into the euro.
"The Article 109(1)(4) regulation might have caused concern in this country as some people might have claimed, mistakenly, that the legislation to be enacted in due course by the member states of the euro-zone might be directly applicable to all member states in a way which contradicted the British opt-out. This interpretation would have been incorrect. However, I was able to obtain agreement of the Council to amendments to Article 17 of the draft regulation and consequential changes to the recitals of the regulations which make the position clear and beyond doubt on the face of the document. The amendments make the application of the regulation subject to Protocol No. 11 of the treaty and the amendments also make clear that the protocol stipulates, among other things, that Article 109(1)4 shall not apply to the United Kingdom unless we move to the third stage.
"I have also obtained agreement to changes to any text of the report that ECOFIN may eventually submit to the Dublin Council on progress towards EMU. I have obtained clear statements that membership of the proposed ERM2 for states outside the Euro will be
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voluntary. I have obtained explicit statements that the council can only make non-binding recommendations under Article 103 to member states outside the euro and outside ERM2 when carrying out surveillance of economic policies. We have, of course, been committed to economic and monetary co-operation and convergence of economic and monetary policies which are necessary for the further development of the Community ever since we signed the Single European Act. The present treaty and practice only commit us to seek to ensure that our domestic policies are geared to price stability and sound public finances and to seek to avoid an excessive deficit. No sanctions can be applied to this country for any failure to take effective steps to achieve that unless and until we move to Stage 3.
"The report will deal with budgetary discipline in Stage 3. The draft now states that euro area member states will be obliged to submit programmes and will be subject to agreed sanctions for failure to act effectively on excessive deficits. In the surveillance procedure, other member states will be obliged to submit convergence programmes only. In the excessive deficit procedure, sanctions cannot be applied to them. I will ensure that such statements remain in any report which may eventually be submitted to the Dublin Council. They are not being challenged by any other member state or the Commission.
"The outstanding matters to be resolved relate to the circumstances in which a member state of the euro may not be subject to this excessive deficit procedure and possible sanctions if a deficit is only exceptional and temporary.
"The preparatory work in ECOFIN is therefore proceeding precisely on the legal and political basis which I and my honourable friend the Exchequer Secretary and others have frequently described to this House."
My Lords, that completes the Statement.
4.43 p.m.
Lord Peston: My Lords, I thank the Minister for repeating the Statement of his right honourable friend the Chancellor of the Exchequer. This is a particularly difficult Statement to deal with. One obvious reason is that your Lordships will be debating all these matters tomorrow under a Motion submitted by my noble friend. I believe that it would be trying the patience of the House too much if I were to make the same speech again within 24 hours.
Lord Graham of Edmonton: Go on!
Lord Peston: My Lords, perhaps within 48 hours, yes, but 24 hours is too soon. I hope therefore that noble Lords will allow me to concentrate on a few of the points in the Statement and elaborate further tomorrow.
There is also a more delicate matter. As I understand from this Statement, the views of the right honourable gentleman the Chancellor of the Exchequer and mine are very similar: his inclination is towards monetary union in principle, subject to all sorts of conditions being met. That is the way he leans and that is certainly the way I lean, but

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I gather that one or two of his right honourable friends do not quite see the matter that way. Since I wish to see this matter proceed rationally, I shall not make mischief on the subject today or for that matter tomorrow.
As regards the report, perhaps I may say how much I welcome the second paragraph. I look forward very much to seeing the report on employment policy. I take it that the Minister will confirm in a few minutes that, when the report on employment policy is submitted by the Council of Economic and Finance Ministers and the Social Affairs Council to the forthcoming European Council at Dublin, your Lordships and Members of the other place will be able to see it, because what happens in the employment field is enormously important.
The material dealing with economic and monetary union raises the most obvious question. Some progress has been made but no final conclusions have been reached according to the Statement. But has as much progress been made as was anticipated? My impression—I was not there, so I am relying on the Statement—is that things are going more slowly than we expected. In particular—this is a matter that I shall deal with tomorrow concerning the definition of an exceptional and temporary deficit—can the Minister tell us whether Ministers at the meeting ran into the technical problems that those of us who study this subject are well aware of but which we have as yet been unable to solve? In other words, did Ministers hope to make progress, but they have not done so? As I said, I shall enlarge on that tomorrow.
Although my views on the opt-out are different from those of the Government, I believe that the Chancellor of the Exchequer was entirely right in that the Statement makes it clear beyond peradventure—which I assume is more for his honourable friends than for the rest of us—that the opt-out is genuine. That is essentially my way of summarising the various aspects. The Chancellor of the Exchequer has asked for various statements to be included in any documents, and he was right to do so. It is not that I agree with the substance of the matter, but having made an agreement, I agree that it should be made clear. I do not criticise the Government for that in any way whatsoever.
The questions that I have already asked lead to another question, which is this. Can we now expect anything serious in this area to occur at the Dublin Summit? From reading the Statement, and in particular that binding legislation will arise at the earliest at the European Council meeting in Amsterdam next June, it is by no means obvious that anything of use will happen at the Dublin Summit. I cannot imagine that the Heads of State would dream of cancelling the Summit, even though that might save their time and a certain amount of taxpayers' money. But one wonders what they can do to occupy themselves at that time if full progress has not yet been made on EMU.
The Statement also contains remarks on ERM2 quite separate from the evidence given to my noble friend's sub-committee. In terms, the Government have made it clear, not that they are open-minded on ERM or ERM2, but that they have no intention of joining ERM2. I have asked this question several times and have been unhappy with the answers. Since the Maastricht Treaty—which is a solemn treaty ratified in all proper ways—says that for
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a country to join EMU it must have been in ERM for two years within the relevant bands, can the Minister say whether it is still the Government's view that that commitment is somehow solemn but not binding? It puzzles me enormously—I am not an expert on matters concerned with law or treaties—that the Government persist in the view that they have not decided whether to join EMU but they have decided never to join an exchange rate mechanism and that somehow they find that compatible. In particular, I should like to ask the Minister—this is relevant to the Statement—whether the Government have received legal advice that their position stands up. I understand that people in other countries say that it could not possibly be legally correct.
I have been as brief as I possibly can, not because the subject is unimportant and not because I wish in any way to be disrespectful to your Lordships, but because we shall have an opportunity to look at other matters in much more detail tomorrow. Therefore, I hope that the Minister will bear with me if I do not pursue those other matters today.
Lord Ezra: My Lords, I too thank the Minister for repeating the Statement. I was a little surprised that we should have it because we had a similar Statement on 25th November and we have a full-scale debate tomorrow. Although the importance of the subject perhaps merits two bites of the cherry, three may be a little excessive. Like the noble Lord, Lord Peston, I shall therefore limit my remarks to just a few questions.
Like the noble Lord, I got the impression that the work done at the ECOFIN meeting yesterday was of a fairly limited nature. Only two of the four texts in connection with EMU preparation were considered and apparently no final agreements were reached on those two. Furthermore, somewhat to my surprise, it seems that the Dublin European Council meeting will apparently transact very little business because it was made clear that effective decisions will not be reached until the Amsterdam meeting in June of next year, a point to which the noble Lord, Lord Peston, referred. Perhaps the Minister will be able to explain exactly what is going to happen at the Dublin meeting and whether all is going to be decided at Amsterdam, which is mentioned as being the earliest date for such decisions, so this could probably go on for another six months until the next meeting.
In view of the rather fanciful press speculation, perhaps I may also ask the Minister—it is important that he confirms this—whether it remains the intention that the Government will continue to play a positive and active role in the negotiations. I feel that that is probably the intention, but as virtually every newspaper from the Financial Times to the tabloids has doubted that, I think it is relevant to ask the Minister on this occasion, and in advance of our full debate tomorrow, whether it remains the Government's firm intention to continue to play an active role in those deliberations. Following on from that, would it still be the Government's intention to pursue without ambiguity, whether in or out, a policy for "price stability", "sound public finances" and the avoidance of an "excessive deficit"—I quote from the Statement—and to promote such policy objectives within the EU as a whole? Those may appear to be somewhat redundant

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questions, but in view of this morning's press speculation I am sure that it would help the House to have clear answers to them.
Lord Mackay of Ardbrecknish: My Lords, I am grateful to both noble Lords for what they have said and I shall try to join them in brevity as we shall be having a debate on this tomorrow. Indeed, we seem to be having a number of debates on the issue in fairly short order.
I turn first to the questions asked by the noble Lord, Lord Peston. I expect that the employment report will be attached to the conclusions of the Dublin Summit, so the noble Lord will be able to see it then.
The noble Lord asked me whether things were going slowly. I am not sure whether my right honourable friend the Chancellor has a timetable for such matters, but these are difficult decisions. The definition of "excessive and temporary deficits" is difficult because on that definition will hinge whether or not the procedures fall on top of the heads of any state which breaches the deficit—that is, if it is in the euro. Such definitions are difficult and, as I indicated a week ago on Monday, there is a view—this is clearly seen in the papers—that the Germans would like firm statements on these matters and are keener on "automaticity" (if that is the right word) while other countries think that there should be a little flexibility in case a member state gets into a deficit for purely temporary reasons which should be taken into account. As I have said, these are difficult issues.
The Dublin Summit will have plenty to do. It will consider the progress made so far in this area. As the Finance Ministers will be meeting a week come Thursday (before the heads of government meet), it is possible that more progress may have been made and they may have to consider that.
I think that I have answered questions on ERM and the treaty previously, but when the proposition was made that before one could join the single currency one had to be in the ERM, it was an ERM with narrow bands. No one has interpreted the treaty now that ERM is based on broad bands. As with other factors, it will eventually be for heads of state to decide whether any country joins the single currency. I think that I explained that last week and we shall no doubt return to the matter tomorrow.
I turn now to the points raised by the noble Lord, Lord Ezra. I think that the two matters under consideration yesterday were very important. The legal status of the euro is a very important issue for the continuity of contracts for those states which decide to join the euro. There needs to be a smooth transition between contracts delineated in their currency and contracts which would thereafter have to be delineated in the euro. I am sure that the noble Lord knows that the City of London is very keen that such matters are clearly resolved before there is any more towards the euro. As I have said, the legal status of the euro is a very important issue.
I can assure the noble Lord, Lord Ezra, as I have on a number of occasions, that we shall continue to play a full and active part in all negotiations and discussions. As on a number of occasions, I fully agree with the noble Lord that price stability and avoiding excessive deficits are not only good with regard to a possible single currency but are sensible and should be pursued in any sensible economy.
4.58 p.m.
Lord Harmar-Nicolls: My Lords, I am confused about the purpose of these various Statements. In my experience, Statements are given to keep Parliament informed of what the Executive are doing. This Statement—and one or two like it—does nothing of the sort. Indeed, the Statement itself said that no agreements were made. I can understand that because the final agreements will be made at the end and after Dublin. Although no agreements were made, the Statement went on to say that we had secured opt-out powers for this country. There has to be some sort of agreement by somebody if we are able to say that that has been re-established because there has been a lot of doubt. Furthermore, the Government say that no agreements have been made and yet progress has been achieved. Progress from where to where? In which direction was the progress? What does it mean?
I do not think that my noble friend or the Government should be easily satisfied with the comments made by those on the Labour and Liberal Democrat Benches. They will agree with whatever is done, provided that it is a move in one direction, which seems to me to lead to federalism or something like it. So their comments about wanting to know more about this can be disregarded. Their interpretation of "progress" is of progress in that direction. The Statement really should indicate in which direction we are progressing and how far we have got. I fully accept that the ultimate decision must be taken later.
Lord Mackay of Ardbrecknish: My Lords, the decisions about the legal basis of the euro and the stability pact are vitally important for the future of this country whether we are in or out. Their importance is obvious if we are in. They are equally important if we are out. The single market and the European Community will remain our single most important trading partner. It is essential to our economy that any single currency created by some member states is stable. That is why I have said on a number of occasions that the stability pact is very important. As I have explained to the noble Lord, Lord Ezra, the legal status of the euro is also important. If my noble friend doubts that, I invite him to ask those in the City of London whether these matters are of vital importance to them.
As regards Statements, when my ministerial colleagues return from Europe having discussed a variety of subjects they usually report to Parliament, in particular the House of Commons. This is done usually by Written Answer but sometimes by Statement. We believe that that is the right way to report these important issues to Parliament in order to keep Parliament informed so that it can express its views. I make no apology for this Statement. My right honourable friend the Chancellor has given Written Answers time without number on his return from ECOFIN meetings. On this occasion he has chosen to

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make an oral Statement because of the importance of these issues and the interest expressed in them in the other place and in your Lordships' House.
Lord Monkswell: My Lords, I, too, thank the Minister for repeating the Statement. I believe that all noble Lords recognise that whether this country is in or out of the common currency regime it is important that it succeeds. Nothing could be worse for Europe than for such a regime to be set up and within a short space of time to find it falling apart. I believe that that sentiment is shared all round the House and across Europe. We have heard from authoritative sources that the present method of setting it up is not viable. My noble friend Lord Desai said that a greater proportion of GDP should be available to the central budget than is currently the case. My noble friend Lord Healey has referred to social instability as a result of the implications of EMU. Perhaps I may ask the Minister whether any work is being done on the transfer of funds and the increase in the proportion of GDP available for budgetary purposes, in particular in terms of unemployment benefit or pension provision at European level, rather than that those matters should remain the sole responsibility of member states, the implication being that the European budget covers less than 2 per cent. of GDP.
Lord Mackay of Ardbrecknish: My Lords, over recent weeks I have dealt with a number of these issues. I hope that I have made the position of the Government abundantly clear. As far as concerns pension provision in other member states that have pay-as-you-go systems, I thought that I had made it abundantly clear that the Government were firmly of the view that there was no question of Britain having to pick up the tabs for any deficits in those schemes. That is clearly set out in the Maastricht Treaty which provides that one country will not be expected to take on the deficit of another. As far as concerns the budget of the Community, I believe that I have also made it clear on a number of occasions, as have the Government in another place, that Britain will not agree to any increase in the budget. In that we are now happily joined by a number of other countries who are either new entrants to the Community or are becoming budget donors (so to speak) and not budget recipients.
The Earl of Onslow: My Lords, can my noble friend confirm that the articles from which Britain can opt out are those referred to in paragraphs 3 to 9 of the Protocol to the Maastricht Treaty? Can he also confirm that under those articles we can be fined under the stability pact, and cannot opt out of any of them until we have specifically notified the Council under paragraph 2 that we do not intend to move to Stage 3? Therefore, we do not have an opt-out from any fine under the stability pact until we exercise our opt-out from Stage 3.
Lord Mackay of Ardbrecknish: My Lords, I am not entirely sure that I understand the thrust of my noble friend's question. We do not have an opt-out from the fines until we say that we intend to opt out. That seems to me to be logical. Our opt-out position is clearly
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delineated in the Protocol. It states clearly that we shall notify the Council that we do not intend to move to Stage 3, and we shall be under no obligation to move to Stage 3. If that happens, paragraph 5 of the Protocol delineates the articles that will not apply to the United Kingdom. I make clear yet again that if we decide to exercise our opt-out and formally notify the Council that we will not move to Stage 3, there is no possibility of our being fined under the excessive deficit procedure.
The Earl of Onslow: My Lords, is it not the case that we can be fined if we have not exercised the opt-out?
Lord Mackay of Ardbrecknish: My Lords, I find it difficult to understand my noble friend's question. If we have not exercised our opt-out but have decided to join up for the euro we shall have signed up for whatever stability pact arrangement is decided upon in order to keep the euro stable. I understand that my noble friend does not approve of the whole concept. However, I do not believe for a moment that he wishes it to be unstable, because that will damage our economy as well as our important markets on the Continent.
Lord Monson: My Lords, on the face of it there is some reassurance in the Statement repeated by the noble Lord, Lord Mackay. However, perhaps he would be kind enough to clarify one closely related matter. On "World at One" today the Deputy Prime Minister, Mr. Michael Heseltine, was asked why the Government were so determined to postpone any decision about joining EMU until June 1997 at the earliest. To paraphrase his reply, he said that in Britain's national interest it was essential to keep a seat at the negotiating table for as long as possible. Of course, one would not disagree with that. But is it not correct to say that in law we have an absolute legal right to remain at the negotiating table whether or not we announce shortly our intention to stay outside EMU for the time being?
Lord Mackay of Ardbrecknish: My Lords, I am not entirely sure whether or not in law we would be allowed to remain at the negotiating table if we said at this stage that we did not wish to enter the euro at any stage. But even if we were allowed to stay at the negotiating table I do not believe that our negotiating position would be very strong. It is important that we remain at the table and that we take a decision about whether Britain should join the euro currency scheme when that decision has to be made and when we see the results of the formal negotiations about the stability pact and how strictly the convergence factors are being obeyed. To paraphrase my right honourable friend the Chancellor (just as the noble Lord paraphrases my right honourable friend the Deputy Prime Minister), he said that if the convergence factors are fudged, brushed over and not obeyed at all, he will be doubtful about the value of joining in that kind of proposition. We are clear that we should be at the negotiating table and should ensure, whether we are in or out, that if the Euro comes about it is stable and

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sensible and that this major trading group to which we belong, and on which our prosperity heavily depends, is stable in future.
Lord Stoddart of Swindon: My Lords, if some noble Lords are sceptical about the copper-bottomed guarantees that the Chancellor has just given to the House of Commons, perhaps they will recall that the same kind of guarantees were given about our opt out from the social chapter. Yet, only two or three weeks ago we saw just how "copper-bottomed" they were when the 48-hour week and various other employment matters were imposed on this country over the head of Parliament by the European Court of Justice. As far as concerns ERM, we were told that the conditions would be agreed by the heads of state. Those conditions are already in the Treaty of Maastricht. They provide that to qualify member states must have been members of the ERM for two years. That seems to be explicit, or are heads of state, as the Commission has already done, prepared to have a creative accounting system, as they have in France, for example, over meeting the convergence criteria in relation also to the ERM? Those are serious matters.
Despite what was negotiated and agreed yesterday by the Chancellor, does Article 103 involve the intervention of the ECJ in the whole matter, and irrespective of what we agree will the decision of the ECJ just overrule what has been agreed, not just yesterday, but in any subsequent intergovernmental agreement? Was there any discussion at that meeting about the stresses and strains being caused in various countries by the restrictive nature of the convergence criteria? I am thinking of course of the lorry strikes which caused so much difficulty in France and elsewhere.
Finally, was the Chancellor helped at all in his negotiations by the intervention in our internal affairs by M. Santer when he said, as reported in the Financial Times yesterday, that pressure from the City and big business would force Britain into a single currency irrespective of any sceptical views?
Lord Mackay of Ardbrecknish: My Lords, I am not going to become involved in the internal affairs of other members states on matters of employment and the like. That we firmly believe is a matter for individual states. As I believe that to be right when they look at us, obviously it is right for us, when we look at them.
So far as concerns the ECJ, the court would be extraordinarily creative were it to overturn the clear specifications of the Maastricht Treaty, the protocol, and many of the agreements that have been made since. One cannot compare that with its decision about the 48-hour week. It would be of much greater significance than that as a legal precedent. Having read all the material, I believe that were the court to take the view, for example, that Britain did not have an opt out so far as concerns penalties, it would probably be more creative than any court has ever been, because the opt out is clear on the face of all the documents, and in all the agreements that my right honourable friend the Chancellor has reached. It is clear what it is an opt out from. It includes the fines.
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On the first part of the noble Lord's question, my understanding—all these matters are complex, but I am pretty certain that my memory is right on this—is that when a member decides that it wishes to join, it is not just its say so, there has to be a decision by the other 14 that it can join. That is the point to which I was referring earlier.
Lord Shaw of Northstead: My Lords, does my noble friend realise that we welcome the Statement specifically because it is the custom to have Statements whether or not there is much to say? There would have been severe criticism had that practice not been followed on this occasion. I welcome the fact that the negotiations show every appearance of taking longer and being more drawn out than first envisaged, because is it not true that the longer the negotiations go on the more the problems are teased out and the greater is the likelihood that a proper, long-term, satisfactory solution will be arrived at? Nothing could be worse than having a botched-up hasty decision. The longer the negotiations go on the more important it is that we in this country make our presence felt to ensure that all the problems are properly analysed and that proper solutions are found. To that end, will my noble friend take back the feelings—I hope from the whole House—that we are entirely behind the Prime Minister and the Chancellor of the Exchequer in the negotiations that they are at present conducting?
Lord Mackay of Ardbrecknish: My Lords, I am grateful to my noble friend for his support of my position here and, more importantly, the position of our right honourable friends the Chancellor and the Prime Minister. It is vital in this country's interests that we get right all the issues surrounding the euro. It is a huge step for the European Community to take, either in whole or in part, to move to a single currency. It is a step which, if it were not taken carefully and with many safeguards, could lead easily to disaster. That disaster would encompass the economies of us all, whether we are in or whether we are out. That is why we are certain that we must be in all these negotiations, ensuring that the conditions for the euro are commonsense and stable, and that Britain's voice, as an important player and contributor to the European budget, is heard throughout, and that our point of view is listened to. With my right honourable friend the Chancellor doing that, no one can have any doubt that our voice will be listened to.
Lord Bruce of Donington: My Lords, I have just one question for the Minister. Will the account of the proceedings at ECOFIN that the Chancellor of the Exchequer gave in his Statement be supplemented by an official communiqué as to what happened and to which we can refer? On the basis of experience it is not always the case that the Commission, for example, and some member states, agree with the versions of various conferences that we for our part, in good faith, have laid before Parliament. What means have we of verifying that other member states will agree with our Chancellor of the Exchequer's version of what happened?
Lord Mackay of Ardbrecknish: My Lords, as my right honourable friend said in the Statement, he will, in

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the usual way, be making a Written Answer giving more of the detail of various other aspects discussed and agreed to at the Council. So far as concerns a communiqué at the end of the Council, these are more in the nature of working meetings. The communiqué on these matters will come at the end of the Dublin Summit at the end of next week.

National Health Service (Primary Care) Bill [H.L.]
5.18 p.m.
Debate on Second Reading resumed.
Lord Dean of Harptree: My Lords, now that we return to the Bill, I should like to begin by paying a tribute to the men and women who work in the NHS and our private health services. The critics of the service are rarely silent. We are always being told that the NHS is in crisis; that it is starved of resources; and that morale is at rock bottom. Of course there are problems. There are bound to be problems in a service which is nationwide and extensive. Of course there are bound to be pressures. They are inevitable with a service which is open-ended but where resources are finite.
If one looks at the sensitive figures which most concern patients, there is a good story to tell. The number of treatments is substantially up. The trend of the waiting lists, although they fluctuate, is firmly down, particularly for those waiting for a year or more. Medical techniques are advancing all the time. There are more staff to carry out treatments, and all that is made possible by the Government's commitment to provide more money in real terms for the service each year. The announcement by my right honourable friend the Chancellor of the Exchequer only the other day of a further £1.6 billion for the service next year is most welcome. At the helm of course, we have my noble friend the Minister and her colleagues in the Department of Health who provide such effective leadership to the service. We can be justly proud of our health services and their achievements. I am only sorry that we do not hear more about the success stories and the men and women who are responsible for them.
When I heard it announced in the gracious Speech that legislation will be introduced to improve and develop primary care services my first thought was, "Oh dear, not another reorganisation". But as I studied more fully what was intended it become clear that this was not another reorganisation. It is, in fact, legislation catching up with the tremendous developments that have taken place in primary care during recent years. The emphasis which appears in the White Paper is of more choice, more opportunity and more flexibility, as mentioned by my noble friend in her introduction.
The Bill follows logically from legislation on GP fundholding, which now covers half the population of the country. I am glad to see that it has the support of most organisations involved, including the British Medical Association and the Royal College of Nursing.
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They have some reservations and need clarification on certain points, but their support is clear. That is a good start for the Bill.
Primary care is, of course, the base of the pyramid. It may not be as dramatic as major operations, spare-part surgery and so forth, but care starts with the family doctor and the practice nurse and their team. I very much welcome the team-based approach in which all involved in primary care can work together for the good of the patients without barriers or demarcation lines. I am glad to see that the BMA has emphasised that very important point.
I also welcome the concept of pilot schemes under which different ideas can be carried out in different parts of the country. The noble Baroness, Lady Jay, had some reservations about the schemes and referred to flowers and weeds. My experience in my garden is that where there are flowers there will always be weeds, but it is the job of those concerned to ensure that the weeds are eradicated.
Concern has been expressed by the BMA that the Medical Practices Committee will find it difficult to ensure an equitable distribution of GPs throughout the country as it has no say in the pilot scheme. That point was mentioned by the noble Lord, Lord Walton, and it is important. I hope that my noble friend the Minister will be able to reassure the House in her reply. I also welcome the fact that participation in any of the schemes will be purely voluntary. No doctor or anyone else will be forced to try out new ways unless he or she wishes to do so.
I should be grateful if my noble friend the Minister would give clarification on three points. She mentioned the possibility of services in supermarkets. That is all to the good if it brings services closer to the patients. But there are obvious risks. We must be very careful to do nothing to weaken the doctor-patient relationship, which is of such great importance in our health services and gives great reassurance to patients.
I suggest that we must also ensure that doctors and others providing services outside their health centres retain full independence and clinical freedom and that they cannot be leant on by the owners of supermarkets. I believe that in the pilot schemes it will be necessary to avoid the duplication of services and equipment, which could be wasteful. Then there is a whole series of detailed points which will need careful consideration; for example, whether the practice notes are in the right place at the right time. I feel sure that my noble friend will be able to give reassurances on those issues.
The second point to which I wish to refer for clarification is the concept of practice-based contracts as distinct from contracts for individual GPs. I can quite understand that they could make it easier for other professionals, such as nurses, to be full members of the primary care team. I notice that both the BMA and the Royal College of Nursing mention those points. However, I hope that the concept of practice-based contracts will in no way undermine the position of GPs as independent contractors if they wish to remain in that position.

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Finally, for clarification I refer to nurses. I must admit to your Lordships that I have a soft spot for nurses. And before that remark is misinterpreted, I should explain that my mother did VAD nursing during the First World War, after which she went up to Bart's to complete her training. She finished as a theatre sister before leaving to marry my father. I notice that the Royal College of Nursing welcomes practice-based contracts which it believes will allow nurses to become full partners in the primary care teams. It suggests that a senior nurse can be taken into a partnership where nurses are employed in a practice. The noble Baroness, Lady Robson, mentioned that matter too. But the college also makes the point that as nurses become increasingly important in the primary care team there should be access for senior nurses to the National Health Service superannuation scheme. I hope that Her Majesty's Government will give sympathetic consideration to those points, particularly in view of the growing importance of nursing in the primary care team.
With those reservations, I warmly welcome the Bill and I hope that it will receive a speedy passage through Parliament.
5.27 p.m.
Lord Campbell of Croy: My Lords, I, too, thank my noble friend Lady Cumberlege for her very clear explanation of the proposals in the Bill. The principles appear to have been agreed by the medical profession, dentists and pharmacists. They are also supported generally by organisations representing the public and consumers. I believe that all of them have some issues to raise and no doubt they will arise at a later stage of the Bill's passage.
I welcome the Bill because it will introduce more flexibility. Schemes will be voluntary. The status quo will still be an option and, as I understand it, GPs and others can revert to the existing arrangements if they do not wish to continue with a scheme.
I have a few general comments to make. The first relates to pilot schemes. Their effectiveness can be judged by a form of evaluation, which seems to be implicit in the Bill. Clause 5 requires the three Secretaries of State for England, Scotland and Wales to conduct at least one review of every pilot scheme. That may be a check on how the scheme is proceeding. Will there be an evaluation of a scheme after it has been operating for a significant period? If so, how will judgments be made and against what criteria, or will they simply be carried out by comparing one pilot scheme with another? Will there be a time limit—for example, several years—in which an evaluation has to be carried out? I do not expect my noble friend to reply to all these questions this evening; indeed, there will be plenty of time for her to let us know the answers in due course.
I turn now to another matter. The Bill aims to introduce more flexibility into the arrangement for recruitment and employment of GPs. GP partners will have more say in selecting candidates to fill vacancies in their group practices. It seems that flexibility is also to be introduced in the appointments of GPs to
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single-handed practices, ensuring that a suitable person is appointed. I am very glad of that. I am also glad to note that the British Medical Association, the BMA, welcomes the Bill and the proposed changes.
There is one point to which I should like to draw attention and it is one which I believe the noble Baroness, Lady Jay, mentioned. The BMA is concerned that the Medical Practices Committee (the MPC—a statutory body responsible for the distribution of GPs throughout the country) will no longer cover GPs taking part in these pilot schemes. That may distort recruitment and replacement patterns and lead to a high proportion of doctors in some areas and low proportions in others. Is there any reason why the MPC should not still consider the whole country, including the proposed pilot schemes?
When I was a Member of another place, I was informed in the 1960s by the BMA that there was a higher proportion of doctors in relation to the population in my constituency in Northern Scotland, where my home is, than anywhere else in the country. I should add that that was before, not after, I was responsible as Secretary of State for the reorganisation of the NHS in Scotland by putting through Parliament the Scottish Bill in 1971, a year before my late colleague, Lord Joseph, presented the reorganisation Bill for England and Wales.
However, it was not as a Secretary of State responsible for health, but as a patient that I have had my main contacts and experience with the health services for well over 50 years. I hope that the House will bear with some personal particulars. I am by no means the only Member of your Lordships' House who has had such experiences. I was wounded when I was 23 and I emerged from St. Bartholomew's Hospital when I was 25. I still could not walk but I was successful in the Foreign Office exam and the subsequent medical examination. I guessed that I had passed the medical when the chairman of its small board said, as I was leaving, that as a diplomat, of course, I would not need to walk or stand. That may have been so then, but it was not so in later years. An embellishment has been added since that time—an uncharitable one—that the Foreign Office would have expected me to lie, if not stand or walk.
However, I should make it clear that in the subsequent four years I worked personally at times for the then Foreign Secretary, Mr. Ernest Bevin, and the Minister of State (later Secretary of State for Scotland) Mr. Hector McNeil, in London and at the United Nations in New York. I had the greatest respect for both as men of integrity. I was not asked to dissemble in any way during my period of service.
When vesting day for the NHS arrived in March 1948, I was working in the Foreign Office and having to go for treatment early every day to Westminster Hospital. Both in my medical contacts then and in Whitehall, I heard a view being expressed that the cost of the new NHS would in time decrease because the nation's health would be so improved. Well, of course, the opposite has happened. But those who were making that prediction were not taking into account the advances to be made in medical science, new operations,

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new treatments and drugs. In addition, people have been living for longer and needing medical services in their old age. It is worth recording from those days that, from the very start of the NHS in the late 1940s, contracts have been made by the NHS with private contractors—indeed, that happened from the very beginning—for supplying services in primary care. There is nothing new in that.
I have been an NHS patient since 1948, in hospital operations and outside treatment, including periods when I was a Cabinet Minister and, before that, a junior Minister. I happen to be of an age to have been a continuing long-term patient of the health service since its inception. That is why I speak from my personal experience.
During the whole time that I spent as a patient in St. Bartholomew's, which was evacuated in wartime from Smithfield to the Home Counties, I was warned that various troubles would arise in later life. However, if you have had a bullet through the middle—in the front and out of the back—that is not surprising; indeed, one is simply lucky to be alive.
Lord Graham of Edmonton: Yes.
Lord Campbell of Croy: I know that the noble Lord had a similar experience.
However, those people were right. Troubles have arisen ever since. In fact, GPs, mostly in Scotland, have had to cope, usually at short notice; but, in direct touch with St. Bartholomew's and with copies of my hospital notes. They have instilled the greatest confidence. The fact that the GPs and the BMA welcome the Bill reinforces my support for it.
5.36 p.m.
Baroness Eccles of Moulton: My Lords, I warmly welcome the proposals in this Bill and would like to thank my noble friend Lady Cumberlege for her very clear introduction. First, I should apologise to the House in that, I am sorry to say, I shall have to leave before the end of the debate. I am meant to be attending a workshop on how to manage change in the NHS.
The Bill allows the primary sector of the NHS to develop in innovative ways and with the emphasis on voluntary choice according to local need rather than by prescriptive means. It has become increasingly obvious that communities benefit most from a primary care service which is tailored to reflect their needs and that these needs can differ widely. The way in which primary services can be provided most effectively in a rural area, a small town, a seaside resort or a large and complex urban setting varies enormously.
Even in the part of London that I am concerned with—the boroughs of Ealing, Hammersmith and Fulham, and Hounslow—where you could expect a degree of uniformity of need, there is great diversity. Nearly 30 per cent. of our population belong to ethnic minorities. Also, some practices have a quarter of all patients over the age of 65, while in other practices they represent about 10 per cent. or under. Other factors
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which place additional and complex demands on the primary care services are a highly mobile population, many homeless people and a large number of refugees. Some practices provide a very high level of care tailored to meet the needs of AIDS and HIV positive patients.
A single national contract for all 30,000 GPs has been the longstanding link between the independent contractor and the health service, and this has provided the mechanisms by which the GP can be paid for services rendered to the individual patient, who, in turn, receives these services free at the time of use. However, the National Health Service has now reached a point of maturity and experience in its 50 years of history where it can respond more accurately and effectively, through locally agreed contracts, to both the needs of our diverse population across the country and also to the different aspirations of GPs.
It is worth spending a moment on how it is that we have arrived at a time when we can be considering the changes that this Bill proposes. It is not a bolt from the blue, in three respects. First, if we go back six years, the 1990 legislation, which arose out of two White Papers (Better Health and Working for Patients), introduced changes to the GP contract. Principally this was a departure from payment received based on items of service to capitation and target payments, and also indicative budgets for drugs were introduced at that stage. The other very important factor was the introduction of fundholding.
Secondly, a keystone of the current health service strategy is the primary care led NHS. As the purpose of this strategy is to ensure that services are organised around the needs of patients, it is important that GPs are placed in the best position to be co-ordinators of their care.
Thirdly, the Government have gone through an exhaustive process of repeated consultation, before publishing the White Paper. The Minister has already spoken of this. To recap briefly, the listening exercise was mounted in the early spring of this year. Views were sought from a cross-section of those both working in and receiving services from the NHS, including patient representative groups, and in areas where change would or could improve service. After that first stage the Government produced a document entitled Primary Care: the Future which sets out the results of this listening exercise.
This document was in its turn widely consulted upon. Both consultations were supported by road shows which made sure that very many GPs and others in the NHS contributed their ideas about how best to develop services to meet future needs. Finally, distilling the views and opinions gathered, the White Paper with which we are so familiar entitled Choice and Opportunity, was published.
In making provision for a wider variety of ways of organising primary care than the current law permits, this Bill not only makes it possible to adapt to diverse needs, but it also helps to meet the aspirations of GPs and other professionals working in primary care better than the limited range of options available at present.

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Young doctors, whether male or female, like so many other young people, have more varied career aspirations than used to be the case, and are often not wanting to make the traditional commitment involved in joining a partnership which, whether it is of GPs or any other professional group, is a considerable legal and financial as well as day-to-day working commitment. The Bill recognises this change in outlook of GPs, and other professionals working in primary care. As the noble Baroness, Lady Robson, has already said, it will make general practice a much more attractive career for the highly regarded young female GP, who simply may not want to combine both bringing up her children and the 24 hour commitment that the national contract requires.
Another fundamental change that has occurred in recent years is that the range of staff working in primary care has significantly widened. That fact has already been mentioned by previous speakers. Many practices now have attached to them a practice nurse, nurse practitioners, midwives, health visitors, district nurses, community psychiatric nurses, physiotherapists and social workers. That is not an exhaustive list. With this wide range of skills many practices can provide far more comprehensive care for a community than used to be the case. The option of practice-based contracts proposed in the Bill allows such multi-professional groups to be formally recognised as providing an extended range of services for the community.
Another important aspect of the Bill is the voluntary nature of the proposals. It does not demand changes in the way in which primary care is provided at the moment, and in that sense the Bill poses no threats. In many localities the present system works well and does not need to change. However, through the "try it and see" pilot schemes there is scope for innovation and experimenting with different combinations of service to reflect local needs. Appropriate new ways of working will emerge through the pilot schemes, which have already been much discussed. These pilots will be thoroughly evaluated before they can become permanent. Of course, the necessary mechanisms are being put in place to make sure that primary care is properly managed and delivered while these local variations are being developed.
There are exciting and challenging prospects before us. In a sense the primary sector is being given its head and is being asked to find solutions in a non-prescriptive environment. However, expectations are high amongst those who set the ground rules, those who provide the service, and not least those who receive it—the patients. This is an opportunity not to be missed.
5.45 p.m.
Lord Ewing of Kirkford: My Lords, the noble Baroness, Lady Eccles of Moulton, apologised for the fact that she could not be present for the closing speeches of the debate. The noble Baroness made it clear that she should be attending a workshop on managing change in the NHS.
In this country a whole industry has grown up around managing change in the NHS, such is the pace and the constant nature of change in the NHS. Here I declare
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my interest as chairman of Fife Healthcare NHS Trust. If I were to attend every seminar and workshop to which I am invited I should be lucky to spend one weekend at home and perhaps Christmas Day and New Year's Day, such is the constant change that is taking place in the NHS. I am not by nature a sceptic. I like to think of myself—generously, I suppose—as a forward looking person. However, I hope your Lordships will forgive me if I bring to this debate a healthy helping of scepticism.
However, I shall relieve your Lordships of any anxiety that I shall regale the House with my experience of the NHS because most of my wounds were self-inflicted and recounting them harms me more than those listening to me. But I was interested to hear the comments of the noble Lord, Lord Campbell of Croy, as I recall having served, in 1971 and 1972, on the committees to which he referred on the reform of the National Health Service in Scotland, which was undertaken a year before the NHS was reformed in England and Wales. Since that day I have never ceased to wonder and gaze in amazement at health Ministers—I include myself because I was formerly a Minister responsible for health in Scotland—who stand at a government Dispatch Box and present a proposal on change in the NHS and say with absolute and firm conviction, "This is the way ahead". I have experienced so many ways ahead that I am beginning to long for the road back.
The noble Lord, Lord Campbell of Croy, mentioned a 1971 reorganisation. It is worth recalling that until 1971 the health service in the United Kingdom was fragmented. The hospital service was managed separately from the general practitioner service. The preventive medicine sector was not managed by the health service at all but by the education authorities of local authorities which were responsible for the immunisation programme. The effect of the noble Lord's reform was to bring all three wings together and introduce an integrated health service. That was the way ahead. That reform lasted for nine years. That is not bad. It was pretty much a record.
Then in 1980 there was a further reform. A bit of fragmentation was reintroduced. There were stand alone district general hospitals designated as directly managed units and funded directly by the health boards that had been set up under the 1971 reform. Directly managed units became the way ahead. That reform lasted three or four years and then we had another reform. NHS trusts and the internal market were then introduced.
Today I was delighted to hear my honourable friend in another place announce that an incoming Labour government would abolish the internal market. NHS trusts and the purchaser/provider principle were established. A whole industry of negotiating contracts has developed. It has become so complex that to add further negotiation and further contract activity through the powers proposed in this Bill seems to me to be complicating an already complicated situation. The introduction of trusts and the purchaser/provider arrangement was "the way ahead". Then we come to this new, primary care led initiative. We have gone through

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fashions in the National Health Service. Every new fashion is to be the future upon which we build the NHS. The fashion now is primary care led initiatives.
There is a very strong movement among general practitioners in this country—I address this point particularly to the noble Lord, Lord Walton—which believes that health boards and health authorities should be abolished, and that all the funds should go to general practitioners. The feeling is that the whole system in this country should be primary care led. That is very much how the American system works. In my view it would be a very dangerous road to follow.
I have never been a supporter of GP fundholding. I see a great many dangers in it. We may talk about a two-tier health service. In GP fundholding there lies the distinct possibility that a two-tier health service will be created. I am not at all certain that that is not the purpose in any case. If a two-tier health service is created, in all honesty, and realistically, it is very easy to move the top tier of such a service into the private sector and leave the bottom tier with the NHS. As Nye Bevan would have said, there are familiar echoes from the past. There could be a return to former conditions, to when those who could not afford treatment simply had to make do with a much reduced level of care when they were ill.
I enter the debate on these proposals because Part II of the Bill amends the 1978 Act in Scotland and applies the Bill's provisions to the health service in Scotland. It proposes that pilot schemes should be established and then be assessed. My plea to the Minister is that the pilot schemes should be allowed to run, not just for a few months but for at least 18 months, so that they can be properly assessed; and that there should be no thought at all of trying to apply this principle to every area throughout the country—I refer to Scotland in particular. Of all four countries in the United Kingdom Scotland has the greatest number of large rural areas. This principle cannot be applied in the same way in those rural communities as it would be in the inner cities.
Members of this House talk of flexibility, as does the Minister. That is an under-statement. These measures will require great flexibility in different parts of Scotland, and indeed in the rest of the United Kingdom. In rural areas in Scotland we already have what are called dispensing practices: the general practitioner will diagnose the illness and prescribe the medicine, and will then dispense the medicine. That already happens in parts of Scotland. It is a very good model which could be applied elsewhere.
In all honesty, the whole question of salaried GPs attracts me. As chairman of a healthcare trust I have given it considerable thought. I would certainly not object to employing salaried GPs in my trust. I am not sure that the Government have thought the issue through properly in relation to their view of the health service. When in a few weeks' time my noble friend Lady Jay is a health Minister with responsibility for this matter, I believe that she will find the prospect of trusts employing salary earning GPs to be a very attractive proposition. I certainly do, but I am not sure that the Government have thought it through. I say this in
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relation to the general practitioner service and the resources that are made available for primary care led medicine.
The Government will need to be more forthcoming on a proposal that is not contained in the Bill but, if implemented, would be devastating in terms of funding for NHS trusts. I refer to the idea that is being widely canvassed that general practitioners should have the right to buy health centres. If it were implemented, the impact on National Health Service funding in Scotland would be devastating because of the way in which such properties are valued. They are not valued by the district valuer or by any professional valuer. In Wales they are valued by the Welsh Office; in England by the Department of Health; and in Scotland by the Scottish Office. However, when they come to be sold, it is done under the value given by the district valuer employed by the local authorities. In our experience the difference between the value placed on the property by the Scottish Office and that placed on it by the district valuer is very, very substantial indeed. There is an impact on funding because the loss has to be borne by the NHS trust which owns the property. Sums of many millions of pounds are involved. If the Government believe for a minute that a primary care led service can be run while at the same time the assets are sold off in this way—in the same way as council houses were sold, with massive discounts—I can tell the Minister that those two ideas will not work together.
Finally, much has been said about the voluntary approach outlined in the Bill. All my experience is that we soon move from a voluntary to a compulsory approach. Over the years I have seen aspects of policy introduced on a voluntary basis and then, because the policy was not being adopted by people in line with the wishes of the government of the day, we soon moved from the voluntary approach to compulsory imposition.
These changes badly need to be piloted and assessed over a very long period. Not only do they need to be assessed over a long period, but the results and outcome of that assessment need to be reported to both Houses of Parliament, and a meaningful debate needs to take place on the assessment.
I leave these thoughts with the Minister and with your Lordships. I hope that my remarks have sounded a few warning notes and made a few welcoming sounds, but, above all, sounded a number of notes of caution.
5.58 p.m.
Lord Colwyn: My Lords, before starting my remarks I must apologise to the House on two counts: first, for not following the argument of the noble Lord, Lord Ewing—I wish to say something constructive about the Bill—and, secondly, for the fact that I missed the opening speeches of my noble friend the Minister and the noble Baroness, Lady Jay. I declare an interest as a practising dental surgeon. That was the reason that I was late.
Whoever was responsible for fixing the order of speakers for this debate has lumped the two dentists together. I have not discussed the debate with my noble

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friend Lady Gardner. She has wide experience of dentistry and other aspects of the health industry and I am quite glad that I speak before she does.
The Bill proposes that the piloting of local commissioning of dental and medical services will start in April 1998—almost 50 years since the National Health Service was born. Since then, dentists have been working within the general dental services and have seen considerable improvements in the oral health of the nation. Quality dentistry has been brought to the whole population. The number of people with no natural teeth has fallen consistently and it is predicted that in just over 10 years' time, only 10 per cent. of adults in the UK will have no natural teeth. There have been considerable improvements in decay rates for patients of all ages, but especially for children over recent years. Much of this improvement is due to the hard work of dentists and to successive governments who have found the money necessary to pay for the service.
Noble Lords will have seen the recent publicity that in some parts of the country there is now a worrying trend towards an increase in tooth decay in children, except where water supplies have been fluoridated. Now is not the time to debate fluoridation, but it is interesting to note that, for example, five year-old children in non-fluoridated Bolton have around four times more tooth decay than five year-olds living in fluoridated south Birmingham.
There are still areas of poor oral health. A recent survey by the British Fluoridation Society—of which I am a vice-president—showed a high proportion of children in the north west of England with dental disease. That pattern is repeated in parts of Wales, Scotland and Northern Ireland. There are also places, especially in the south of England, where no dentist is available. To address those problems, the Bill proposes to introduce local commissioning of dental services to be known as personal dental services. They will run alongside existing dental services but will address specific problems where they exist.
The White Paper which preceded the Bill was called Choice and Opportunity. There will be a choice for dentists in whether they stay in the present system or move into a new way of working.
Sadly, many NHS dentists are having to leave the health service and, as a result, an increasing number of patients are unable to find an NHS dentist. I know that my noble friend will have figures which show that there is an increasing number of treatments provided within the NHS, but dentists and patients know that in reality there is a worsening problem of lack of access to NHS dental treatment affecting patients in affluent parts of the country as well as in poorer rural areas and inner cities. Seventy health authorities have applied for the Government's Access Fund which is only available in areas where there are serious problems. Twenty-two authorities have been successful and I am informed that this fund will be more substantial to cover more authorities next year. Perhaps my noble friend could confirm that when she replies to the debate.
Many of my dental colleagues have a strong commitment to the health service, but the fees which (not allowing for inflation) have only just returned to
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1991 levels are inadequate to meet practice expenses. In real terms they are too low. Other healthcare professionals are provided with premises, equipment and staff. Only NHS dentists have to provide those personally at their own expense and although provision is made for the expenses within the fee scale, the costs of premises, equipment and staff are now at 1996 levels, funded by fees which are still at a 1991 level. NHS dental practices must be provided with more resources if NHS patients are to be provided with up-to-date technology and materials.
However, the Bill will certainly provide opportunities for dentists to develop new services with their patients and, despite the resource allocation, I hope that the profession will see these changes as opportunities rather than threats.
The Bill marks the start of a new chapter in NHS dentistry. Noble Lords will be aware that the past five years have not been happy ones for my colleagues. Late in 1991, the Government realised that the budget for dentistry was running out of control and that there would be a considerable overspend for dental services. Through no fault of the profession who had been encouraged by the department to register as many patients as possible, it was decided in July 1992 to cut fees by 7 per cent. That caused considerable distress and started a dispute which was only ended this summer.
In April 1995, the Minister for Health sent an invitation to representatives of the General Dental Services Committee of the British Dental Association, which represents all high street dentists, to take part in talks with a view to introducing short-term reforms within the general dental services. The negotiations were difficult and protracted, but it is to the credit of both sides that they came to an agreement which was announced by the Minister on 12th June this year.
Those reforms should bring considerable improvements to the dental care of children. The dispute with the profession was formally called off and the overspend which occurred between 1991 and 1993 was written off by the Government. The end of the dispute saw a welcome new spirit of co-operation with the profession which has led to the publication of the Bill.
During the period of the dispute, both the Government and the profession entered into a large consultation exercise, starting with the fundamental review of dental remuneration by Sir Kenneth Bloomfield which was published in January 1993. Dentistry was investigated by the health Select Committee in another place which reported in June 1993 and finally the Government published the Green Paper in July 1994.
All those proposed a solution to the problems of dentistry based on the local purchaser/provider approach initiated in the National Health Service in the early 1990s. The proposed change was not universally popular with the profession, indeed only a third of local dental committees expressed an interest in taking part in pilot studies. Many misgivings were voiced both about the proposed pilot studies and the final shape of a new local system. I am glad to see that the profession's misgivings have been addressed in the Bill.

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What the consultation period showed was that the loss of morale in the profession was not just about money but a perceived lack of security and stability. During the consultation, many dentists proposed improvements to the services they could offer their patients and new ways of being paid for providing them. The Bill gives them the opportunity to develop these new services while retaining the choice to provide dentistry for their patients within the general dental services, as they have done successfully over the past 50 years.
In conclusion, I had intended to say something in support of community pharmacies and urge the Government to resist the proposed abolition of resale price maintenance on over-the-counter medicines but it has been well covered by the noble Baroness, Lady Robson, and must wait until a further stage of the Bill. I welcome the Bill and the opportunities it gives for improving services to patients and providing stability and security for the dental profession.
6.7 p.m.
Baroness Gardner of Parkes: My Lords, I, too, formally welcome the Bill. I find it interesting that it is supposedly full of new ideas, particularly the voluntary basis attached to them. I have received briefs and comments which I shall mention rather than reading them to your Lordships. They come from medical, dental, pharmaceutical, county council and consumer organisations. There is a wealth of advice and information in all of them, and I agree with some points but there are some with which I strongly disagree. I therefore thought that I would pick out relevant points.
All the comments emphasise the need for consultation. Like my noble friend Lord Colwyn, another dentist, I believe that the whole national health dental system went wrong on consultation. The supposed consultation did not really result in what the dentists wanted. At the time of the introduction of the present contract, which has proved such a disaster, 63 per cent. of dentists voted against it but the elected members of the General Dental Services Committee of the British Dental Association agreed with the Government who introduced it that it was desirable for dentists. Yet 63 per cent. of dentists voted strongly against it. It is not surprising that it proved to be unsuccessful.
The points made about people's problems in obtaining national health dental treatment are real. When I was on the regional health authority, we had to introduce a salaried service in certain parts of Essex where no national health treatment at all was available. Yet we had an obligation under the national health regulations to provide dental treatment.
When people consult, whether in dentistry or other spheres, it is important to ensure that the consultation produces answers from the people who should be consulted. In dentistry the General Dental Practitioners Association represents a great body of dentists whose views are never considered because the British Dental Association seems to be treated as the only body to be considered.
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As to the pilots of new ideas, I ask the Minister to clarify one point. The noble Lord, Lord Walton, referred to the possibility of doctors and dentists providing services together, but as I read the Bill it seemed that the first clause prohibited that. Clause 1(2) states:
"A pilot scheme may not combine arrangements for the provision of personal medical services with arrangements for the provision of personal dental services".
I should like that point to be clarified because, like the noble Lord, Lord Walton, I believe it would be desirable to combine the services. I think the opposition to this goes back a very long way. When I started in practice, 35 or more years ago, I remember that you were not allowed, as a dentist, to have your surgery above or below a doctor. However, over the years that has been relaxed. Closer working between doctors and dentists would be very desirable.
Doctors in those days were pretty horrific. I remember phoning a local doctor to say that I had a patient in for an extraction who had a history of rheumatic fever and, of course, there was a great danger, in extracting a tooth, that this patient would develop a sub-acute bacterial endocarditis. Therefore, there should be penicillin cover for it. I was in the East End of London, and the doctor said, "Oh nonsense, nonsense. People in this area are tough and rheumatic fever is everywhere. Oh no, I would not consider that." I really was quite shocked. We ended up giving the penicillin to the patient ourselves because my Australian training was such that we would not have gone ahead without it.
Fortunately the standard of general practice—medical and dental—has improved over the years. We have heard many favourable references to the Medical Practices Committee but I think they should be looking into things more thoroughly than they do. I just offer this for consideration. There are many areas that are referred to as closed areas or intermediate areas and yet I keep meeting people who cannot get on to a doctor's list in these areas. In some of the smarter parts of London if you have a smart address they do not want you as a national health patient unless you can convince them that you are the housekeeper or the au pair. That is not good enough. There is also, I believe, a point at which it just pays a doctor to have a list of a certain size so that he has all the advantages without any of the unnecessary work. Certainly in dentistry I am told the same thing: there is rate support for your practice if you have a national health practice, so many practitioners just take enough patients to obtain rate support without making a proper and full input into the health service. These are abuses of the national health system which should not be continued.
In my day everyone was terrified of a salaried service for dentists but I think that times have changed and people are now willing to look at that. I am not at all in favour of the suggestion made by the Association of County Councils that they would like to run the health services. I would strongly oppose that because I believe that local authorities have more than enough to cope with. They have no understanding of the enormous task involved in taking on the running of the health service, which is a massive system. I would not like to see the day come when people have to choose between

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emptying the dustbins or providing better medical services. It is far better to have social services as they are now, run by the local authorities, and good consultation with those running the medical services, but I would certainly not support the view that has come from the county councils that there may be a role for them in running the health services. The primary care team is most important and the sole paymaster should be the National Health Service.
The pharmacists have put forward two points: the first relates to retail price maintenance, as mentioned by the noble Baroness, Lady Robson, and the second is their feeling that it is most surprising that the Bill allows everyone except the pharmacists and the opticians to produce and initiate a pilot scheme. They feel that this must be an oversight. They would like to be able to have this opportunity, particularly as the role of the community pharmacist has enlarged so greatly and pharmacists are often now the first stop for patients. They relieve the general practitioners of a great deal of work. They are often much more accessible at any hour of the day or night. Pharmacists suggest that perhaps pilot schemes might be considered under which they could visit people in their homes or could go to old people's homes to visit groups of people who might need medicines and to give advice. Again that might lift some burden from the doctors.
The position of general practitioners is already changing and there is an increasing collaboration between general practitioners and consultants. The noble Lord, Lord Ewing, mentioned that he would like to employ general practitioners. I would like to say, as Chairman of the Royal Free Trust, that we do that already. We have general practitioners who come to the accident and emergency department, on a salaried basis, a sessional basis. Of course this may be a central London problem because in central London so many people who should go to a general practitioner go instead to their local casualty or accident and emergency department. The doctors are invited in by the hospital to do work and fortunately many have taken this up. They take off some load by treating cases which are primary care cases but which have presented themselves at the hospital.
Then there is the other side where the consultant goes to the general practitioner's surgery. We have this in ENT, gynaecology and skin specialisms. This again is very beneficial because it is often much easier for the patient to be with the general practitioner than to have to go to the hospital.
A more recent development is tele-medicine, where the patient is with the doctor in his or her own surgery but has a consultation by modern technology through a screen. Digital imaging is so good. I saw this in Boston but it is in operation now in the UK.
In these ways, the traditional boundaries are gradually merging and being broken down. The days when a general practitioner had paper and a phone as his only tools have quite gone. We see more and more packages of care being formed around the individual. The aim is to have greater continuity of care and better care for the patient.
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I should like to comment briefly on some of the points that have been made. The noble Baroness, Lady Jay, spoke of fundholding and the fact that a statement had been made opposing fundholding. But I notice that the BMA, in their report, are very much in favour of fundholding. They say:
"We are proud of the key role played by enthusiastic and committed individual GPs in driving the NHS forward through commissioning groups, fundholding and total purchasing, or in providing enhanced care through a wide variety of innovative schemes and the development of team work and appropriate skill-mix".
So the BMA is in favour of fundholding and I think that should he pointed out.
Baroness Jay of Paddington: Would the noble Baroness allow me to intervene? I do think that there is a slight confusion in the terminology. There is a difference, is there not, between the individual fundholder and the groups which the noble Baroness has rightly referred to: commissioning groups, total purchasing groups in which GPs work together as consortia rather than as individuals who may purchase services on behalf of their patients which are to the detriment of other patients. If commissioning groups work on behalf of all the patients in a locality then that is certainly to be welcomed.
Baroness Gardner of Parkes: My Lords, I thank the noble Baroness for that but I think the difference is a very fine line. If you are a single practitioner, practising on your own, the only way you could be vying with other people is by joining a consortium. If you are a large group practice, there are enough of you there to form your own group fundholding nucleus and you do not need to be part of a consortium. People have taken this phrase "consortium" simply as a politically acceptable term to cover what everyone else calls GP fundholding. In my view, GP fundholding means that the GP controls the budget and controls where the money is spent for patient care. In that sense I completely support it. I would like to see much greater control over treatment and cost of treatment exercised by the general practitioners as opposed to any other way. The personal doctor and the health team know the needs of the patient better than anyone else. I believe that if, instead of adopting the attitude that we are against GP fundholding, we had universal GP fundholding, we should not have a problem at all.
I have spoken about dentistry and finding a dentist, which again were points raised by the noble Baroness. The noble Baroness, Lady Robson, spoke about the Medical Practices Committee, which I have mentioned also. The noble Lord, Lord Dean, spoke of nurses. I should like to pay tribute to the nursing profession. They are the backbone of the health service and have done marvellous work. But, in raising the profile of nurses, as we have done through Project 2000—I am all for raising their academic status and their personal status—I am concerned that we may now have such a high entry qualification that many people who might wish to be nurses feel that they cannot enter the profession. In these days of Calman, when there are new methods for training medical consultants, junior doctors

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and nurses, it is time to consider improving the status of care assistants and bringing in a new structure for them and for those people who may not qualify to enter full nursing training. Perhaps there should be graduate nurses and nurses; or perhaps there should be some other way of dealing with the matter. But, if we lose any of those people who are genuinely dedicated to caring for others, that is not in our interest and I should be very sorry to see it.
The noble Lord, Lord Ewing, also dealt with GP fundholding and the two-tier structure. I accept that if everyone were in it, it would not be two tiered. That is a different issue.
I should like to comment on one or two of the points which came to me in the briefs. The Royal College of General Practitioners made some interesting points. It said that it considered it very important that people who were going to set up pilot schemes should be actively working in general practice as part of a primary health care team. It thought that it was very important that there should be an input from active general practitioners. It is indeed important. We do not want people who have retired and think that they might dabble in some new idea or people who are not currently in touch with treating patients. That feature is desirable.
It is also important that we should have the medical workforce properly distributed. Everyone is concerned about areas which are unattractive. Years ago in certain parts of Wales one could have nothing done in dentistry except an extraction. The dentist ran a Rolls Royce on the fact that everyone came to him just to have a tooth out. No one ever received any more treatment than that. He was the only dentist in the area. People had to pay for whatever treatment they had and he did very well out of it but nobody received any comprehensive dental health treatment.
I believe that we could use the carrot and stick and produce some form of incentive. Over the years incentives have been used to encourage people to practise in less attractive or less profitable areas. There should be some equivalent of the higher pay for antisocial hours or antisocial work that we see in other professions. Something of that type would help ensure that people practised in areas which may at the moment look less attractive to them.
I have covered most of the points that I wish to make, with the exception of a mention of the Consumers' Association, on which I shall pass just the briefest comment. As I gave way to the noble Baroness, Lady Jay, perhaps I may speak for just one more second. The Consumers' Association report makes the point about access that people should be able to have their choice of GP or dentist and the doctor/dentist should be able to have his choice of patient. However, it is sometimes very difficult to reconcile those two choices. The consumer interest, which is very real and concerns us all, is sometimes misguided. Trying to force a doctor or dentist to accept a patient is no way to build up a good and close patient-doctor/dentist relationship. There has to be voluntary acceptance on both sides that they are suited to one another and the practice must be the one
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that the patient wants to be with. I believe that insistence on any dentist or any doctor taking any patient would be very counter-productive. I hope that it will not happen.
6.24 p.m.
Baroness McFarlane of Llandaff: My Lords, I add my voice to those who welcomed the Bill. It reflects very ably the White Paper, Choice and Opportunity, and the aspiration in that paper to make arrangements for the delivery of primary care services more flexible, so that they are better attuned to local needs and circumstances.
The Second Reading of this Bill provides us with an opportunity to restate what may appear to be two very self-evident truths. One is that primary health care services are the foundation of our healthcare system, a foundation on which all the superstructure is built. The noble Lord, Lord Dean, referred to primary care services as the base of a pyramid.
Episodes of acute illness and the need for acute care services may be very dramatic but relatively infrequent episodes in the normal healthcare trajectory of an individual. They call for expert services. But the day to day healthcare of the nation over a much broader spectrum of provision belongs to primary care. I believe that we cannot stress too much the need for health promotion, preventive services, treatment of early deviations from normal health and long-term care. Those form the bedrock of our health services.
It follows that the roles of nurses, midwives and health visitors are of absolutely paramount importance in achieving the objectives of the health service. I welcome the tribute from the Minister, the noble Baroness, Lady Cumberlege, in her introductory remarks, to the importance of nursing services. The White Paper itself pays tribute to them. It says:
"They have an equally important part to play in providing primary care and the changes proposed have implications for them both in their wider involvement in any pilots … [and] in the opportunities which different approaches may offer to develop further the team based approach which is essential to good quality primary care".
So I welcome the practice-based contracts which will allow nurses to become full partners in the primary healthcare team. It would be useful to have some clarification of how that might be worked out. I had not perhaps imagined it as had the noble Baroness, Lady Robson; namely, that a nurse might take the place of a practitioner in the team. Rather I thought that as a partner, she would offer services in line with her training and qualifications and as a full member of the team. But I welcome that opportunity.
Very briefly I shall deal with some of nurses' concerns about the Bill. Some of them relate to employment conditions. The more flexible employment opportunities would allow general practitioners to employ community nurses other than practice nurses—for example, health visitors. But in that event, issues of professional supervision and accountability need to be addressed. It is there that I believe that a senior nurse in partnership would commend itself as a solution. In terms of employment rights, the noble Baroness, Lady Robson, mentioned pension rights and having access to

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the National Health Service superannuation scheme. That is an element of employment rights that needs to be addressed as we go into this new era.
I welcome the pilot schemes and their evaluation. That seems to be a new trend in our way forward in the health service. But as we test those schemes, nurses will want to know what their employment rights will be if a pilot scheme fails. General practitioners and general dental practitioners are identified as qualified people to propose a pilot scheme. No mention is made of a nurse being able to propose such a scheme and it would be useful to have clarification on that point. Neither is there any indication that a nurse could apply to be a health service body, and that is another point on which nurses seek clarification.
The noble Baroness, Lady Robson, as always, spoke feelingly of the interests of nurses and raised the question of a need for the extension of prescribing rights. As we enter these experimental schemes it would be useful to know the extent to which any consideration has been given to the need to extend the prescribing rights of nurses.
Those are just some of the issues about which nurses have concern. I confess that I am watching the clock anxiously. I may be running out of the time I need to catch the last train to Manchester. I hope to stay until the end of the debate but, if I cannot, I ask the House to accept my apologies.
6.32 p.m.
Baroness Seccombe: My Lords, I wish to add my good wishes to this Bill which I welcome most warmly.
We are able to choose our doctor. Thankfully, most of us for practically all our lives only need treatment from the GP. The surgery is usually comparatively close to our home, so the more that can be achieved by local treatment the better. That can be of particular importance to those patients who are old and frail, to those unable to drive and to those whose condition is made worse by travel. We all know how a visit to a consultant can be a lengthy and tiring exercise.
So, under this Government, a primary care led NHS has moved from aspiration towards reality. Primary care professionals include GPs, dentists, community pharmacists, practice nurses and community nurses. Those professionals work in the community and are thus closest to patients and often know them well. That makes them best placed to meet patients' needs in the local setting.
This Bill will take forward primary care in the NHS. It follows extensive consultation within the NHS and enjoys the full support of the British Medical Association. As Dr. Sandy Macara, Chairman of the BMA, said on the "Today" programme on BBC Radio 4 on 15th October last:
"We, the BMA, are fully behind the Department of Health in exploring the possibilities for making the delivery of general practice and related services, family services, more readily available because that is bound, if we can find the right way of doing it, to give better value for money".
The success of GP fundholding, which gives GPs real budgets and thus real power to influence the pattern and quality of services, has fundamentally
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altered the balance of power within the NHS. It has improved the provision of local services and increased the decision-making power of professionals. It represents the most decisive shift of power in favour of medical professionals in the history of the health service. Today, over 50 per cent. of the population in England is served by a family doctor who is a GP fundholder. By next April, that will reach almost 60 per cent.—over 15,000 GPs.
A report on GP fundholding by the independent Audit Commission earlier this year concluded that all fundholders have secured some benefits for their patients and some have secured spectacular benefits. Fundholding allows GPs to be innovative in the way they plan services, allowing them, for example, to hold outreach clinics by consultants in their surgeries or, as has happened in various places, keeping or re-opening cottage hospitals. Since the scheme began in April 1991, it has been broadened by the Government. Community fundholding allows those GPs who wish to, to opt to buy a more limited range of services for their patients. Total purchasing allows those GPs who wish to, to purchase all services for their patients. A primary care led service is not about developing primary care to the detriment of other parts of the NHS; it is about improving the whole service in a way which reflects the needs of patients.
In October 1995 my right honourable friend Gerald Malone, Minister of State for Health, began an extensive series of consultative meetings across the country listening to primary care professionals. The purpose of those meetings was to identify obstacles to the further development of primary care and to agree a shared agenda for overcoming them. The result was the publication of Primary Care: The Future in June of this year. It summarised the results of Mr. Malone's meetings and set out an agenda for the way forward. A further round of consultations followed which culminated in the publication of the White Paper, Choice and Opportunity, which explained the Government's proposals.
The main aim of the general practice aspects of the legislation is to enable new approaches to contracting for general practice to be developed locally, piloted and then evaluated. That is intended to encourage local people to put forward proposals on different contractual arrangements which could better suit their circumstances and the needs of the service in their locality. Seizing the new opportunities presented by this legislation will be entirely voluntary—yes, "voluntary".
I was interested to hear what the noble Baroness, Lady Jay, said in relation to commissioning. It seemed as though we were talking about more regulation and making sure that groups of practices got together and became commissions. But some doctors do not wish to become fundholders; my doctor is not a fundholder. The Government are keen to create choice and opportunity for health professionals, which are lacking in the socialist approach. Labour appears to want to take away that opportunity by ruling out the popular option of fundholding.

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Additionally, there will be no disadvantages for GPs who remain in the current contractual arrangements. Legislation should enable local flexibility but also ensure that there are adequate safeguards for both patients and professionals. Patients will retain their right to be registered and to choose their GP.
The proposed legislative changes will allow health authorities more flexibility when contracting for community pharmacy services. It will also abolish the anomaly which prevents community pharmacists from providing some services to patients across a health authority's borders. Patients will still have the right to take NHS prescriptions to the community pharmacy of their choice.
The Opposition suggested that the changes the Bill will herald could lead to commercialisation of NHS general practice. That is wholly wrong. Since 1948 general practitioners have been private contractors providing NHS services, and NHS pharmacy, for example, is already provided within commercial premises such as Boots. The fact that it is provided within Boots does not change the fact that it is still an NHS pharmacy.
The Bill is not about supermarkets—or any other commercial concern—providing private general practice; it is about making the provision of NHS general practice more flexible. It will remain free at the point of use and available on the basis of medical need, not the ability to pay. The Bill is not about changing the nature of general practice in the NHS. It is about helping GPs to remove the obstacles they have encountered in providing better services for their patients.
With structural change now behind us, the Bill demonstrates how the Government are working with NHS professionals to produce a positive agenda of service improvement that we all wish to see go from strength to strength. I support this Bill wholeheartedly and look forward to it being on the statute book.
6.41 p.m.
Lord Harmsworth: My Lords, may I briefly welcome this Bill. It seems to me to do two things which are eminently worth while and which follow a strong trend in healthcare legislation, certainly in the past six years and earlier still so far as general governmental approach to administrative handling is concerned.
The first principle, which I thoroughly commend and which is anyway now a necessity, is the enabling of total flexibility in the ways in which professionals in primary care can organise themselves. The second principle is that decision-making continues to be devolved to the people at the sharp end: those who know exactly what their local community requires and are best able to supply it. I have always considered the NHS to be almost over-endowed with talent. The move away from central control is to be welcomed. Giving groups of primary care professionals the chance to crack their own problems for themselves is to be welcomed even more.
One of the aspects I particularly like about the Bill is the way in which both the providers and the purchasers effectively have to work together in the making of a
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proposal to the Secretary of State. Between them, there will be little doubt as to what the community needs and whether the structure proposed by the providers will do the job. I am instinctively against pilot schemes. So often they become a technique for procrastination, or, dare I say it, an excuse for not thinking things through. Nevertheless, I must allow that so far as the diverse kinds of association envisaged in this Bill are concerned, at least initially, there is no practical alternative. I suspect that the schemes put forward in the first instances will be various and that it may take some time before patterns emerge which could provide models for other schemes.
This is a Bill that I trust your Lordships will welcome. I wish it a fair wind.
6.43 p.m.
Baroness Anelay of St. Johns: My Lords, like so many other speakers this evening, I welcome the Bill because I believe that it gives health professionals the opportunity to increase still further the range of primary healthcare services so that they match even more closely the needs of the people who live in the area they serve.
As the National Health Service has developed and managed change, it has had to respond to the advances in medical science and to the increased expectations of the public about the extent and quality of the service which they should receive. Throughout that period of change my focus of concern has always been to examine whether those patients who are particularly vulnerable have the quality of their care at the very least maintained during the period of change, and then improved as a consequence of any changes which become part of normal practice.
If I have to describe the kind of patients I mean, I would say that I am thinking of those who do not or cannot choose to seek healthcare outside the National Health Service and those who find it difficult to negotiate the highways and byways of medical bureaucracy. It may be that they are too ill to be able to make judgments about the care which they should seek or about the care offered them; or perhaps they simply lack either the information or the ability to be effective advocates on their own behalf. With the greatest respect to those noble Lords who are medical practitioners, my experience of working with the citizens advice bureaux and as a past member of my local community health council means that I am not always convinced that the medical profession is the patient's best advocate.
When I combine all these factors together I think in particular of those who are elderly and frail. Community care policies have made it possible for them to live in the familiar and reassuring surroundings of their own homes rather than entering a residential care home or nursing home until it is absolutely necessary. For them, the GP is almost always their first recourse when seeking medical care, and of course community care policies mean that they will now have recourse to the GP rather than the health services within residential care. So it is even more important than ever to them that the GP services are centres of excellence. I therefore concentrate my remarks today upon the services offered by GPs.

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When changes to primary healthcare provision were proposed my litmus test was, "Will they be of benefit to the elderly frail and, above all, how will they be protected during the period of change?" Any change, however beneficial it is intended to be, can seem threatening and can undermine one's confidence. It is vital that the elderly frail remain confident in the services provided by their general practitioner service. So does this Bill pass my litmus test? Yes, I believe that it does, and for several reasons. First, it underlines the Government's commitment to NHS care free at the point of use. Secondly, I welcome Clause 19, which re-states the patient's right to he registered with a GP and their right to choose their GP, whether or not that doctor is taking part in a pilot scheme. Where patients cannot be registered with a doctor of their first choice, the Bill maintains their right to be allocated to a practice.
Clause 19 also includes a provision for the Secretary of State to give directions imposing a limit on the number of patients to be accepted by a medical practitioner who provides personal medical services in accordance with Section 28C arrangements. I note what my noble friend Lady Gardner of Parkes said about the practice of some doctors maintaining a limited list for their own advantage. However, I think that it is also important to have this regulation so that we can be sure that GPs do not extend their patient lists beyond their capacity to serve them properly.
It is important that patients who are in practices which take part in pilot schemes can have confidence in the quality of their treatment. This Bill meets that point because Clause 4(1) provides that when the Secretary of State has approved a pilot scheme it must be implemented in the format that has been approved. GPs cannot alter it thereafter just to suit themselves. In addition, Clause 6 includes provisions to enable the Secretary of State to vary or terminate pilot schemes if they prove to be unsatisfactory.
Much mention has been made already this evening about the value of evaluating pilot schemes. Clause 5 promises that pilot schemes will have evaluation. I shall be interested to hear from my noble friend the Minister what methods will be used to judge the schemes and whether and how the views of patients will be sought. The Bill also provides reassurance about the quality of work to be carried out by those within the range of services provided in the pilot schemes. Clause 21 enables regulations to be made covering the liabilities and obligations of Part II general medical practitioners who either deputise for medical practitioners working under Part I of the 1977 Act or engage medical practitioners working under Part I of the Act to deputise for them. Clause 9 specifies that medical practitioners who provide medical services under a pilot scheme must be suitably qualified within the terms of Section 31(2) and Section 32 of the 1977 Act.
All patients will benefit from the development of a primary care service within the National Health Service, which embraces non-medical professionals, including nurses, therapists and managers. The advantages to patients will be that the staff will be more motivated and their skills further developed. There is also another consequence which sounds mundane but which is
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equally important to those who are not easily mobile. If you have access to a variety of medically related services in one area that are being managed by people working together as a team, then you do not have to find your way through the maze of healthcare provision to find the services you need. The stress placed on the elderly frail of having to deal with different experts, each with different methods of recording information and working to different timescales, should not be underestimated. Change will be a continuing necessity in the development of the National Health Service. I believe that the Bill gives primary healthcare practitioners the flexibility to develop vital new services while maintaining the essential character of British general practice, which provides the continuity of care and personal service which we all value so much. That special feature of primary healthcare is not only of benefit to us all, but is particularly important to the elderly frail. I therefore welcome the Bill and wish it a speedy passage.
6.50 p.m.
Lord Rea: My Lords, it is good to hear from the noble Baroness, Lady Anelay, the first time for me. She obviously knows what she is talking about and I am sure that she will definitely be contributing to debates on health in future to the benefit of all of us. I must apologise for my voice, which has practically gone. I hope that it will just about last out for the next 10 minutes. It has been a very interesting debate. Almost all the points that I was going to make have been made by other speakers, but I shall just cover some of them and re-emphasise those which I believe to be the most important.
Any Bill which sets out to improve the effectiveness of primary healthcare should be welcomed. On these Benches we support moves in that direction. But as my noble friend Lady Jay and many others have pointed out, there are concerns about this Bill from a number of different directions. The noble Baroness, Lady Cumberlege, and her right honourable friend the Minister have tried to allay those concerns, but they persist. In summary, those concerns have the common theme that the proposed changes may undermine or damage the very features of British primary healthcare which makes it such a valuable and internationally admired institution. I refer to its improving coverage of the whole population. It is not perfect, as the noble Baroness, Lady Gardner of Parkes, and others have pointed out, but it is moving in the right direction.
There is also the right of patients to register with the doctor of their choice who will provide continuing care. The noble Baroness has reassured us about that a number of times, but we are still concerned about it. I refer also to the system of lifelong medical records which follow patients to all parts of the country wherever they move. As has been mentioned by a number of speakers, there is also the helpful gatekeeper role in which the hospital services are truly secondary care services with 90 per cent. of illness episodes dealt with in primary healthcare.

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Of course, everything in the garden is not as rosy as these principles might suggest. There is obviously need for continuous improvement, both to improve patient care and to maintain—and this is very important—morale and recruitment to the service. Some doctors do not provide care of the standard required—the noble Baroness, Lady Anelay, pointed that out—despite the very great improvement which the noble Lord, Lord Walton, mentioned, as a result of vocational training over the past 25 years. Many practices still do not have the additional staff or premises to allow the comprehensive team approach of the best practices.
While on that point, I would like to voice a worry of the Royal College of Nursing. Why is the Bill about primary care and not about primary healthcare? The noble Baroness knows that good primary healthcare provides an ideal opportunity for preventive medicine and health promotion, and internationally in the World Health Organisation frontline care is known as primary healthcare. I believe that the title of the Bill should reflect the wide scope that primary healthcare involves.
While on the subject of nurses, I believe that the Bill does not fully emphasise the central role that nurses will play in future, and which they are increasingly playing in primary healthcare. They should be able to be partners—that is fine. This Bill enables that to be done. But why cannot they initiate pilot schemes themselves or form themselves into what are called National Health Service bodies? At the moment nurses tend to be bodies to be kicked about in the National Health Service, particularly when it comes to nationally agreed norms of pay.
The concerns about the Bill that have been brought to my attention, which have been mentioned by many other speakers, include first, and perhaps most important, the role of the Medical Practices Committee. I quote from its statement:
"its ability to distribute GPs fairly"
as has been mentioned by many speakers as the main strength of the current system—
"will be seriously impaired by the Bill and that patients' equity of access to GPs will be lost".
In addition, checks that the MPC,
"currently makes on every GP's application for inclusion before approval will not be done by the MPC but by inevitably inexperienced staff"
for each project.
In her reply can the noble Baroness address these important points. Amendments, which could give the MPC a more central part in decisions about pilot schemes, may well be proposed at later stages of the Bill.
Another important concern is that of resources. The sum of £6 million has been promised for the pilot schemes although I am not quite sure exactly from which section of the health service that money is to come. There is also the question of costs of continuing to operate the successful pilot schemes. Part II of the 1977 Act covers hospital and community services and Part I the primary care services—or have I got it the wrong way round? My understanding is that money to
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pay for these schemes will come from that part of the National Health Service which funds the hospitals and not from that part which funds primary care.
As other speakers have pointed out, and as the noble Baroness well knows, hospital budgets are extremely tight. That was pointed out particularly by my noble friend and the noble Lord, Lord Walton. In many cases those budgets are overspent. Can the Minister give us some information about how the successful schemes are to be paid for and out of what part of the National Health Service budget?
Another point was mentioned by the noble Lord, Lord Campbell of Croy, and many other speakers: who will design and carry out the evaluation of pilot projects? For that to be properly done academic departments of health service research need to be involved at a very early stage. I believe that the thinking out of the scheme in the early stages was mentioned in particular by the noble Lord, Lord Campbell of Croy. I suggest that there needs to be an independent, well-qualified body to review all the proposals before they start. I hope that the Minister will be able to give us some information. Perhaps she will agree that such a body should be set up in order to advise Ministers.
The aims of each scheme need to be carefully stated so that their success or otherwise in improving care or professional morale can be properly measured. One of the criteria for acceptance of a pilot project should be that the services in that area are inadequate in some way at present. Such a scheme must augment, not detract from, the existing primary healthcare services in needy areas.
Other concerns have been mentioned. I refer to the need to include local authorities in the planning of pilot schemes. To answer the noble Baroness, Lady Gardner of Parkes, I do not think that local authorities have suggested taking over the running of parts of the National Health Service. That has certainly not been stated in any document that I have received. However, they do suggest that their departments of social services, housing, education and environmental services may all have important parts to play in the schemes that are to be evaluated. I hope that the schemes to augment the roles of pharmacists and optometrists and which seek to attract dentists to what perhaps I might call "under-dentisted" areas will be deemed possible. They would be very welcome from our point of view.
To take up the point raised by the Royal College of General Practitioners, I hope that at every stage the changes resulting from the Bill will build on what has been suggested by the experts—the doctors, nurses and dentists who are now working in primary healthcare and who know what the problems are. The White Paper states that consultations were held with a wide group of professionals concerned with primary healthcare. If that is the case, it is surprising that almost all of the relevant professions have serious reservations about the Bill. Under this Government, "consultation" tends to mean that plans are waved in front of people, but that those plans go ahead regardless of the suggestions made by those who have been "consulted".

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However, I agree that the Government have grasped one important point—the need to try out and to evaluate new schemes. We should be truly grateful for that, providing that the evaluations are carried out properly.
We can regard this House and the other place as a form of hatchery; the Bills that pass through being the eggs. Government Bills going through your Lordships' House can be thought of as a variety of different kinds of egg, ranging from good eggs, which are the necessary Bills which please most people, to rotten eggs, which are usually based on ideology and are to the detriment of many people. Your Lordships know that I am going to say that this Bill is a curate's egg—good in parts. Roget's Thesaurus provides an alternative meaning for the phrase "a curate's egg"—"room for improvement". In Committee, we shall try to bring about the improvements that are necessary.
As the noble Baroness, Lady Robson, said, this Bill will not come into force until after the election. I suggest that in the hands of a government run from this side of the House comprehensive primary healthcare will be safe and that this Bill, suitably amended of course, will be of use. In the unlikely event of the present Government being returned to office, we still have some serious doubts about the effects of the Bill.
7.4 p.m.
Baroness Cumberlege: My Lords, we have had a lively and informative debate. That bears witness to the importance which your Lordships attach to the future development of primary healthcare. It was encouraging to see a degree of consensus in your Lordships' House over the broad direction in which we should move.
The noble Baroness, Lady Jay of Paddington, said that she accepted the overall aims of the Bill and welcomed the principles underlying it. I was sad, however, to learn today that the Labour Party has stabbed primary healthcare in the back since it has stated its wish to end the individual practice of fundholding which has brought so many improvements not only to patients and to primary care but to the whole of the NHS, as it ties together primary healthcare and hospital services. This morning the Labour Party disenfranchised over 50 per cent. of GPs from holding budgets. According to the Labour Party, they are not fit to be trusted. The noble Baroness talked of low morale—a view with which I disagree. But nothing will lower morale more than disqualifying all those who have put so much time and effort into fundholding from holding budgets for their own practice population. The Labour Party seeks to take away their control, to ignore their judgment and to pressgang them into area committees. I say to fundholding GPs, "I warn you: New Labour, new danger".
Baroness Jay of Paddington: My Lords, I am afraid that I must intervene. I know that my honourable friend Mr. Smith spoke only this morning about our plans, and given the time that she had to spend preparing for this debate, I quite understand that it has not been possible for the Minister to read precisely what he said. However, there is certainly no question of fundholders—people who are now joining together to
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commission the new work that is being carried out by individuals—not being able to hold budgets. They will have financial responsibility, as collective bodies, for the collective interests of their patients. We on this side of the House feel that it is in the best interests of the health service—and in accordance with its best principles—for there to be collective responsibility for collective health rather than the individual queue-jumping, which is what individual fundholding has resulted in.
Baroness Cumberlege: My Lords, I am grateful to the noble Baroness, but perhaps she can enlighten me further by saying whether the Labour Party is giving a guarantee that individual fundholders will be able to continue having responsibility for the budgets that they hold for their practice population?
Baroness Jay of Paddington: My Lords, I am not sure that the House is particularly anxious for us to debate this matter in such detail. However, it is certainly the case that this morning my honourable friend referred to the possibility, in certain circumstances, of individual practices continuing to hold their own funds. He made very clear—we certainly support this—that the development of individual fundholding will not be encouraged. I suppose that I should say that it will be "frozen" after a Labour victory at the general election. I repeat that we believe that collective fundholding and the collective use of money under GP commissioning arrangements are more advantageous and more equitable for the population at large.
Baroness Cumberlege: My Lords, I do not find that at all reassuring because it means that in the future GP fundholders will not be able to have the responsibility that they currently have for holding funds for their particular practice. Whether they like it or not, they will have to work with other GPs and form committees to decide how to purchase services. One thing that comes through strongly in discussions on GP fundholding is that GPs are individuals. They run their own businesses and are successful in doing so. They have been innovative beyond all measure. They have done things of which we would never have dreamt and, because they are in control, they have been able to introduce services like physiotherapy and more complementary therapies. They now provide all sorts of different services. It is a tragedy that that development will not be allowed to continue if a Labour Government come to power.
Baroness Jay of Paddington: My Lords, I hesitate to intervene again, but I must answer the Minister's point, although it was an inappropriate one to raise when replying to such a debate. However, as the noble Baroness insists on developing these points, I shall respond. The fact of the matter is that, as the Audit Commission demonstrated, some GP fundholders have made innovations in their practices. They have often been those individual GP fundholders who have had advantages of locale, who have had specific government grants and who are working in areas where there is access to good DGH provision. We all know that. However, that system has also increased the inequities

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in the provision of care in the health service. We on this side regard the attempt to iron out inequities as more important than giving advantage to individuals.
Baroness Cumberlege: My Lords, the Audit Commission said that to some extent all GP fundholders had improved their services. Even if it is only to some extent, the Labour Party's policy launched today will ensure that those further improvements do not take place.
Referring to the question of equity, the first essential issue is whether there is equity of funding for the patients of fundholders and non-fundholders. As the noble Baroness is aware, the setting of budgets is not an exact science. However, the Government's guidance is clear: health authorities must seek equity of funding for all patients in their areas. From an equitable base fundholders may use their budgets differently, but they will reflect the different needs of their practice population, different priorities and management of funds throughout the year and service innovations which lead the way and so often spread to patients in other practices. My noble friend Lady Seccombe is right to say that a primary care led NHS brings decisions closer to patients. Fundholders have brought many benefits undreamt of when the schemes were introduced.
The noble Baroness, Lady Jay, also raised the prospect of the Bill opening the door to privatisation of primary care. This is primarily a measure to enable those who already provide NHS services—GPs, general dental practitioners and NHS trusts—to develop provision in new ways. We are confident that they will seize the opportunity. The Bill gives them a guarantee that their proposals will be forwarded to the Secretary of State. My noble friend Lord Dean is right to stress that in any new schemes the doctor-patient relationship is of prime importance. For that reason we are safeguarding the current registration system that sets the whole tone and nature of primary care in this country.
The noble Baroness, Lady Robson, asked about regulation by affirmative resolution. I understand her concerns. However, the Delegated Powers and Deregulation Select Committee of your Lordships' House has considered the Bill in detail and does not want to alter it. The proposals are on all fours with all the primary healthcare legislation passed since 1946.
My noble friend Lord Dean referred to the welcome given to this measure by the RCN. The noble Baroness, Lady Robson, asked whether new partnerships formed with a nurse if a GP retired would affect the patients' registration system. That issue was also raised by the noble Baroness, Lady McFarlane. If a patient is not on the list of a specific GP but is on the practice list there will be no change. A patient may always choose to be on an individual GP's list, in which case he or she can choose on which alternative GP's list to appear. The nurse may not have a separate list of patients but may undertake a wider range of work for patients within the practice.
The noble Baronesses, Lady Robson and Lady McFarlane, asked about nurse prescribing. There can be no one more convinced, no one more determined, no
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one who has worked longer and harder to make nurse prescribing a reality. For 10 years I have fought this cause. Progress has been slow. Initially, I believed that it would be accomplished in two years but I was naive. I was told that it did not require legislation, but it did. I was told that it would be easy to negotiate, but it was not. I was told that money would not be a problem, but money has been a problem. I was told that training would be minimal, but training has been problematical. I am pleased to inform your Lordships that I believe that most of the obstacles have been overcome. An announcement will be made shortly by my right honourable friend the Secretary of State.
The noble Baroness, Lady Robson, was concerned about the closure of pharmacies due to the possible abolition of resale price maintenance. I believe that my noble friend Lady Gardner also touched on that issue. There is an essential small pharmacy scheme under which financial support is provided to small pharmacies which are more than 1 kilometre from the next nearest pharmacy. That model can be developed further if it proves necessary. As far as resale price maintenance is concerned, that is a matter for the Department of Trade and Industry. I understand that RPM on medicines is with the Restrictive Practices Court, and therefore I do not want to go into that issue at the moment.
The noble Lord, Lord Walton, was right to chart the beginnings and progress of primary care. From his personal experience he left us in no doubt that primary care had never been stronger, training never more thorough and primary healthcare teams never more real. I am grateful to my noble friend Lord Dean of Harptree for highlighting the successes. I believe that it is right to remind ourselves that, compared with the rest of the world, we receive an outstanding service at relatively little cost to the nation through the present system of funding of the National Health Service. But we recognise the pressures to which my noble friend Lord Campbell of Croy so eloquently referred. Clearly, he has knowledge of this matter through personal experience (which I wish had not been necessary). We fund it very generously. We have the guarantee of my right honourable friend the Prime Minister that so long as the Conservative Party is in power there will be more money year on year for the National Health Service. The United Kingdom spends £4.8 million every hour on the National Health Service. Next year we plan to invest a further £100 million in primary care.
The noble Lord, Lord Rea, and other noble Lords referred to resources. The £6 million is for the pilot schemes. Clearly, that will not cover the cost of setting up the schemes on the ground. The whole of the £100 million is available for primary care and clearly some for the pilot schemes. The noble Lord, Lord Walton, asked whether a partnership of GPs and nurses would be accepted as health service bodies under the proposals. The Bill will allow nurses to put forward proposals in partnership with GPs. One of the key aims is to encourage greater integration of the work of different healthcare professions. To allow new forms of partnership in pilot schemes will help to achieve this.

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The noble Lord also addressed the issue of the shortage of doctors. It is true that the number of trainees has declined, but the number of GPs has increased. Eighty per cent. of vacancies are filled in a matter of months. On average, every vacancy attracts nine applicants to the post. Those who make appointments of general practitioners assure us that they do not have to compromise on quality.
The noble Baronesses, Lady Jay and Lady Robson, and the noble Lord, Lord Walton, dealt with evaluation. My noble friend Lord Campbell asked some probing questions in that regard. Perhaps I may seek to reassure my noble friend Lord Harmsworth, who I understand is sceptical about pilot schemes. The Bill requires that each pilot scheme should be reviewed and that such reviews take place before the pilots are spread more widely. The precise approach to evaluation has not yet been set out. We wish to discuss with the professions, health authorities, representatives of academic units and patients the best way to evaluate schemes. We will be establishing a representative group nationally to take this forward and to consider the application process for pilots and the criteria that govern their approval. I am sure that one of the issues that that group will wish to consider is the question of consultation, which was referred to you by my noble friend Lady Anelay. We have demonstrated our commitment to evaluation by ensuring that the requirement is on the face of the Bill. As yet, we have not set a period of time, but obviously it must be long enough to test the new arrangements properly.
A number of your Lordships referred to the Medical Practices Committee. The Government strongly endorse the principle of equity in medical services both in health authorities and nationally. We want to make further progress. I have talked at length to Mary Leigh, Chairman of the MPC, as have my honourable friend the Minister of Health and my right honourable friend the Secretary of State. We have discussed the MPC's role in relation to pilots and the more permanent arrangements which may follow pilots if they are successful. This issue is being discussed also with Dr. Bogle, Chairman of the BMA's General Medical Services Committee. Shortly, we will put forward proposals in the light of those discussions to take the issue forward and ensure that a coherent local and national approach is applied to both pilots and the existing arrangements. We want to continue to work with both parties.
My noble friend Lord Dean raised the question of GPs' responsibility for patient and practice records in a practice-based contract. I can assure him that GPs will continue to be responsible for the patients they treat. That is only to be expected given their status as professionals. That will be the case whether they are part of a team which has a practice-based contract or operate single handedly. Perhaps I may make it clear that under the new arrangements patients who want to be on a specified GP's list will be able to be.
My noble friend Lady Eccles of Moulton is right to point out that change in the 21st century is inevitable. As a health authority chairman, she knows well the benefits that recent changes have brought. The noble
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Lord, Lord Ewing, advocated change for industry and commerce but perhaps not quite so much change for the NHS, as he outlined all the reorganisations that have taken place since 1948. I should like to suggest to him that it is because the NHS has accepted change that it has survived to the 21st century. I look forward to the day when he will take me on one side and tell me exactly what is Labour Party health policy, because he said that the Labour Party has today announced its intention to abolish the internal market, but I understood that it was to keep trusts and the purchaser/provider split. No doubt we shall hear more in Committee.
The noble Lord was worried that voluntary schemes would become mandatory, but he will know as a member of a trust that trust status is always a voluntary initiative. He may be slightly disappointed that all units have chosen to become trusts and that through a voluntary approach we have now changed the whole system. GP fundholding—another voluntary scheme—has resulted in England, as my noble friend said, with 50 per cent. of GPs choosing fundholding. That is an honourable record in ensuring that voluntary schemes are treated as voluntary schemes. The noble Lord has no reason to question us on that.
I shall not disappoint my noble friend Lord Colwyn, who suggested that I might put forward some figures. This September there were 19,147 NHS dentists in Great Britain—an increase of 2,403 over 10 years and an all-time peak. The number of adult courses of treatment has also increased by 18 per cent. over 10 years, from 24.2 million in 1985 to 28.6 million in 1995. But I would agree with him and my noble friend Lady Gardner of Parkes that the national picture may mask buoyant services in some localities and an inadequacy of availability of NHS services in other areas. Patients have always had to travel to get to the dentist. We must ensure that they do not have to travel excessive distances.
We are taking action to tackle local problem areas. We encourage health authorities to make use of the community dental service to provide primary care services, and on 12th June we announced a package of reforms which we believe will do much to promote an atmosphere of stability and security for the dental profession.
One of the measures was an access fund to help finance local schemes to improve access to NHS dentistry. My noble friend Lord Colwyn is right that there are 22 grants to help authorities with innovative schemes. We have been encouraged by the range of schemes put forward by health authorities, and we shall want to evaluate them carefully before deciding whether and in what form to extend the scheme. Dentists' fees are set annually, as my noble friend realises, by the Doctors and Dentists Review Body, so as time is getting on I do not wish to get into the whole issue of expenses.
My noble friend Lady Gardner of Parkes asked about pharmacists initiating schemes. The Government are already funding a number of pilot schemes in pharmacy, and the Bill will enable health authorities to enter into NHS contracts to purchase those services. They will be informed by the existing pilots.

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The noble Lord, Lord Rea, asked about prevention. I agree with him that primary care is an effective and important tool in preventing disease, but he will know of our Health of the Nation strategy which is all-embracing and described by the WHO as a model for other countries to follow. The noble Lord also mentioned medical records. I can reassure him that the existing arrangements will continue under the pilot schemes.
The drive to innovate has always been the hallmark of good health professionals and our consultation with a broad range of people over the past year revealed a genuine enthusiasm for innovation. Primary care has been an area in which an already successful service has not rested on its laurels. We have only to witness the integration of teams involving doctors, nurses, therapists and others. We have seen the creation of primary healthcare teams. We have seen them strengthened. We have seen the success of fundholding. We have seen community pharmacists strengthen their role through the New Horizon: Pharmacy in the New Age—a document that shows all their determination to use their experience and skills within the profession. Dentistry has made huge strides, and our oral health has never been better.
We have made an encouraging start. We are building on the consensus which emerged from the primary care listing exercise. The main representative bodies have given a positive response to the White Paper, Choice and Opportunity, which sets out our proposals.
It has been an interesting debate. I am sure that there will be an even more robust debate when we come to Committee stage. At this point I should like to thank noble Lords for all the contributions that they have made and to ask them to give the Bill a Second Reading.
On Question, Bill read a second time, and committed to a Committee of the Whole House.

EU: Racial and Religious Discrimination
7.26 p.m.
Lord McNair Lord McNair rose to ask Her Majesty's Government whether they will support the proposal to incorporate a provision banning discrimination on the grounds of race and religion in the revised Treaty of European Union.
The noble Lord said: My Lords, it may seem rather late to be asking the Government to support the proposal, in a general sense, to incorporate a provision banning discrimination on the grounds of race and religion in the revised treaty at the next IGC on 14th December. It would indeed be late if others had not for some time now been asking the Government and other EU member governments a similar question.
I shall be looking separately at race and religion, although in the case of some groups, such as the North Africans in France or the Turks in Germany, the two identities of course overlap. Apart from such cases, the subjects need to be considered separately because they each raise different kinds of difficulties for the person who finds himself subjected to discrimination.
I shall discuss what has already been done to move this matter forward, and then, as far as I have been able to determine them, describe the stance on this issue of various member countries. First, however, I should like to make a general point about the pathways by which legislation appears on our statute book. We have directives which, whatever their provenance or genesis, become law in Britain by the official route, as it were, but there are other harmonising measures whose genesis is more informal and which could be said to constitute European legislation by the back door.
One may agree or disagree with individual pieces of legislation, but I am talking about the process. It is an unhealthy process, just because it is secret. I am thinking in particular of law and order measures which may have had their origin in one country, but which, possibly as a result of discussions within the secretive Justice and Home Affairs Committee, find their way on to the statute books of other countries. I shall come back to it, but I feel strongly that no good will come of that process of harmonisation by stealth, which circumvents and subverts those modest democratic processes which have so far evolved within the EU.
If we look at the moves which are already afoot in the direction of the Question I have put, we find that the Irish presidency is putting forward a range of options to amend the treaty in 1997 to deal with racial and religious discrimination. I shall look first at race. Amendment is long overdue. There is no mention of racism in the original Treaty of Rome of 1957. Perhaps it was too soon after a war where racism had figured so largely, and it was inconceivable that it could become a problem in Europe.
The European Commission urged in its White Paper on social policy of July 1994 that there should be such an amendment. The European Parliament has approved the idea on many occasions since 1991. The opportunity has come with the present Inter-governmental Conferences and the certainty that a new treaty will be ready for signing sometime next year.
I turn to the context in which the matter rests. The main aims of the IGCs are to deal with the enlargement of the Community, to reform the Community's own institutions and those of the European Union, which, though that includes the same countries as the Community, is a distinct entity, and to find common measures for dealing with unemployment and poverty.
At the same time, however, the existing workings of the Community and the Union are coming under review. The arguments for a race amendment which are put forward by the CRE and which I endorse include the fact that the EU's commitment to human rights for citizens is incomplete without a commitment to outlaw racial discrimination, and that free movement in European territory is impeded when there is a different standard of protection against racial discrimination in each country. In that respect, we must acknowledge that we, the British, are the leaders in the field. Our legislation—the Race Relations Act 1976—is far superior to anything that exists in the European Community. We can be very proud of that.
The next reason why the proposal is essential is that racial discrimination is economically inefficient because it wastes talent and increases spending on social welfare. Furthermore, racism, xenophobia and anti-Semitism are socially divisive and are a threat to peace and security.
In addition, resident third country nationals—that is, nationals of a non-EU country who are resident in an EU country—deserve the same standards of protection against discrimination as citizens. Our Race Relations Act has shown the importance of such protection in Britain. Women who are third country nationals are protected against discrimination on the grounds of their gender but they are not protected against racial discrimination if that occurs.
Proposals for exactly what form the treaty modifications should take are many and I do not propose to go into them in detail tonight. EPIC, the European Parliamentary Intercultural Committee, of which I am an executive committee member, and which is chaired by my noble friend Lady Seear—we all wish her a full and rapid recovery—has put forward several amendments. Perhaps the best known of the suggestions is the Starting Point, which was put forward by the Starting Line Group. This is an informal committee which includes legal experts from different European countries. The purpose was to draft a text which would be a model for a European Community directive prohibiting racial and religious discrimination. The group was concerned to test possible objections from representatives from different national legal systems and constitutions. The agreed text, therefore, does not represent any one national or religious point of view and it requires a treaty amendment because the Community is unable to propose such a directive without specific authorisation in the Community treaty.
For reference, the model amendment is called the Starting Point. It proposes, first, to add to Article 3a a new article which seeks:
"the elimination of discrimination against persons or groups of persons, whether of the European Union or not, on the grounds of race, colour, religion, or national, social or ethnic origin and the promotion of harmonious relations between such persons or groups of persons".
It also proposes a new Part la entitled Non-discrimination between the existing Part 1 and Part 2, but I do not expect the Minister to speak in detail about that. I mentioned it so that we know what we are talking about.
We should remember that current estimates of the ethnic minority population of the European Union as a whole suggest that approximately 16 million people would stand to gain from such a treaty amendment, considering only racial discrimination. That is more than the population of some of the smaller countries such as Belgium and Holland. It is a large number of people.
I turn to religious discrimination, as distinct from discrimination on the grounds of race. Those who are members of minority religions—I refer to traditional Christian denominations and others—are experiencing a growing sense of oppression. As the House will be aware, the noble Lord, Lord Hylton, and I went to Germany to investigate discrimination in that country. But it is not only in Germany that religious intolerance
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is becoming commonplace. It is fair to say that almost all the minority religious groups which were banned by the Nazis and which survived that era are now under threat not only from the German authorities but also from the French. The Jehovah's Witnesses in particular are having a rough time in France, but they are not alone. Last year the French Minister of the Interior, apparently in a bid for popular support, boasted that he would take measures against the sects and listed 172, including the Mormons, the Seventh Day Adventists and many other Christian denominations. The list also included a small Tibetan community in the south of France which is almost certainly Buddhist. He has described it as a dangerous sect. That is most puzzling.
The proposal has historical precedents. I think not only of the religious hysteria of the Crusades but, going back to European history of the 12th and 13th centuries, recall that the hysteria against those who were regarded as witches began in southern France. The European country which seemed to specialise in that was what is now western Germany. The problems which are being caused would be resolved if we had the kind of measure that I am asking the Government to endorse.
7.37 p.m.
The Lord Bishop of Coventry: My Lords, I hope that I can claim that the Church of England is firmly opposed to discrimination against a person on either racial or religious grounds. Of course, adding the religious dimension enriches and strengthens the noble Lord's proposal and makes it more complex. A significant amount of discrimination in this country and in Europe is experienced as religious discrimination. That is felt particularly by religious people of Asian origin in this country. A multi-faith forum which meets in my house in Coventry conveys that to me most vividly and strongly each time it meets.
Many young people are growing up in inner cities and identify themselves in religious terms. Research confirms that. The question which the noble Lord raises is crucial for us too. Many who suffer racial attack are abused by their assailants about their religion. The Inner Cities Religious Council, chaired by Sir Paul Beresford under the auspices of the Department of the Environment, recently produced a summary of existing remedies for those who believe that they are being discriminated against because of their faith. It is entitled Challenging Religious Discrimination and I commend it as a guide.
The Commission for Racial Equality has produced a leaflet on religious discrimination by employers. I should like to welcome its work. It is holding public meetings and receiving evidence on religious discrimination. We need to know more about the kind of discrimination that is being experienced and to consider a variety of ways of tackling it. For instance, in Northern Ireland an approach concerned with policy appraisal and fair treatment requires government agencies to consider whether any new policies or practice contain an element of religious bias. Within the Christian community, many of us are concerned that devout Christians should not suffer at work as a result of changes in legislation which previously protected

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Sunday as a day of shared rest. In letters and conversations, I hear of hardship experienced by many people. It is so important that Sundays should be preserved for the protection of family life.
I wish to support any appropriate and effective action to deal with the vital issue of religious discrimination throughout Europe. We would of course want to stand firmly on the side of human rights and religious freedom for all the citizens of the European Union member countries. Christian values demand that Europe should not define itself at this key moment in its history on the eve of a century in which Europeans will by sheer economic forces be compelled to co-operate more and more, not as fortress Europe, but as a richly multi-racial society committed to the Christian principles of hospitality, protection for the vulnerable and justice for the stranger. The European House should be an "open house", a home. That is why the Churches of this country have committed themselves to a Charter for Racial Justice.
The Churches of Europe played a key part in initiating the Starting Line—now the Starting Point to which the noble Lord referred—and a move towards possible ultimate amendment to the treaty of the European Community to place the elimination of all racial and religious discrimination in the midst of the guiding aims and principles of the Community and to ensure that its institutions are given power and direction in that area.
That is an essential aim. The only question is how it can best be realised. Actual legislation has its dangers. We need to be clearer as to what is the most sensitive and apt remedy for religious discrimination whether through training, through promotion of good practice, through codes of practice or by means of law itself. There may well be questions as to what is the most appropriate direction to take now, and, if that is by way of an amendment to the European Union treaty, then as to what form that amendment should take.
There is serious and growing concern on the issue throughout Europe. This is an urgent matter in our increasingly divided and passion-driven world. But we must not legislate in haste. One could envisage law suits within and between religious communities. There are tensions between, say, the existence of blasphemy laws and the case for legal redress for discrimination by the religious as well as against them. Even if the treaty were to be amended as proposed by the noble Lord, the amendment would need to be fleshed out with directives and the like, the precise terms of which could be contentious.
The position is not helped by the absence of any agreed definition of "religion", though that is certainly not an insuperable objection to legislation as has already been shown. But, in the religious sphere, I have to confess that the principle applies of corruptio optimi pessima—the corruption of the best is worst. What is noblest and most creative in human life can tragically become the most destructive of all.
That apart, in this country, with a Church established by law and all the legal implications that flow from that, the whole question of religious discrimination in the
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widest sense, beyond that which directly affects the individual, needs very careful handling. I firmly believe, with Professor Adrian Hastings, that the relation between Church and society that has emerged in the history of this country is something profoundly precious for us to bring into the European Community as a vital ingredient. I see it working out in my own city in a way which brings all faiths and religions together into its embrace.
Although I am no lawyer, I can understand that there could be many pitfalls in this kind of legislation. So, believing profoundly in the intention of the proposal made by the noble Lord, Lord McNair, I want now both eagerly and urgently to support a call to the Government to investigate the position and to come forward with carefully and effectively worked out concrete proposals.
7.43 p.m.
Lord Graham of Edmonton: My Lords, from these Benches I should like, first, to thank the noble Lord, Lord McNair, for giving the House an opportunity to debate this important matter. I should also like to express my appreciation for the fact that the Minister is present this evening. The noble Baroness has a very busy life, with very weighty problems, and yet she has managed to find time to give us the benefit of her views, together with those of her department, on such an important topic.
I was a little worried by the speech made by the right reverend Prelate. He started off with kind words, but then virtually repeated what I consider to be a ministerial speech advocating caution, consideration and reflection. Of course, those things are well understood. We understand that discrimination is a minefield; indeed, racial intolerance is not something to which the whole House or any decent-minded person would subscribe.
I hope, in response to the noble Lord's request, that the Minister will be able to express some sympathy with the thrust of his case. I hope that she will immediately acknowledge that there must be problems in ensuring that such a proposal is implemented. It is well understood that the Irish presidency of the European Community is putting forward a range of options for amending the treaty in 1997 so as to deal with racial and religious discrimination. One of the options includes outlawing other forms of unjust discrimination on grounds, for example, of age, sex, disability and other factors.
The case put forward by the noble Lord, Lord McNair, ably supported by the right reverend Prelate, will I am sure be well understood by the Minister. Quite frankly, I hope that we will hear kind words in response. The proposal under consideration was endorsed in a directive in April 1993. I am indebted to EPIC, like other speakers, for giving me such details. It was also endorsed by the European Parliament in December 1993. The proposals relate to race, colour, religion or national social or ethnic origin.
In a very busy life with so much for us to undertake, one could ask what in actual fact is the need for this House, this Parliament and this country to do more than

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simply acknowledge the situation. Quite frankly, I believe that the need is perfectly clear. There is no doubting the fact that there is an increase in racial violence and intolerance.
During the first three months of 1992, the number of attacks on foreigners in Germany increased by 400 per cent. over the same period in the preceding year. There were nearly 600 attacks, most of them carried out by people under 20 years of age. In April, a Jewish cemetery in Berlin was desecrated: there had been similar desecrations earlier in France and Britain. In France, too, racist attacks have increased, with North Africans the main targets. An opinion survey in France in November 1991 found that 49 per cent. of respondents had negative views of North Africans, while 62 per cent. wanted to reject immigrants from eastern and central Europe. In Spain, in June 1992, 30 Right-wing extremists attacked a group of North Africans, injuring some of them severely, and about 200 North Africans fled the town of Fraga in fear of further violence. (The Mayor resigned in protest against the failure of the central authorities to prevent the violence, which he had predicted).
In Italy, attacks on seasonal workers from many parts of Africa have been increasing in the south: some victims have been seriously injured by firearms. In Britain, Somalian refugees have suffered stone-throwing and physical assaults in Sheffield, while a mosque in Greenwich, east London, has been desecrated and many people in the area attacked. An Afghan refugee was murdered in the summer in what a police officer described as
"a racist attack with no possible provocation".
Arson attacks have increased in several countries: against African immigrants in north Italy; in Germany, where a refugee hostel in Rostock was set on fire; while in Britain, arson against the homes of south Asians has been happening for many years. These publicised examples represent only a fraction of the violence which occurs.
The Labour Government passed the Race Relations Act in 1976 and the Labour Party has consistently proposed, or supported, stronger penalties for aggravated offences of racial violence or discrimination. It would be of value if we could move the action to another higher, more prominent plane—that is, the European Union—and encourage measures by member states, which have not passed comparable legislation to our own Race Relations Act, perhaps setting time limits and offering patterns for legislation. I would certainly want to argue that Community action should necessarily be undertaken because of the Union's respect for fundamental rights: discrimination interferes with free movement of goods and services.
I noted the very strong component in both previous speeches concerning religion and also the quite legitimate points raised by the right reverend Prelate about the sensitivity of the action of lawyers and experts. I do not wish to become involved in that argument because I am not competent to do so, but there are precedents which exist in directives on equal treatment for men and women. Some will also insist that
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action should be taken using the third pillar on intergovernmental co-operation. However, in my view there is no need to get involved with that.
The Commission for Racial Equality understands that the Government are opposed to treaty amendment. The Government believe that each government should be encouraged to make its own laws. The Minister is, as always, well briefed and she is well able to deal with these matters. She should know that the intention to seek to amend the treaty is supported by the Runnymede Trust, the Law Society, the Bar Council and many others.
We should support the proposed amendment to the treaty on the grounds that it will extend the protection given to British people under the Race Relations Act to our people elsewhere in Europe, and to other Europeans, and others living in Europe. It does not mean imposing Brussels laws on Britain, but actively encouraging the elimination of discrimination throughout Europe. In 1997 we shall enter the European year against racism, xenophobia and anti-Semitism. I believe that the time is right to take those actions.
7.51 p.m.
The Minister of State, Home Office (Baroness Blatch): My Lords, I, too, am grateful for the opportunity to hold this debate. I thank the noble Lord, Lord McNair, for providing us with the opportunity. As has already been said, this is an important subject on which we have heard a range of views. As the noble Lord, Lord Graham of Edmonton, said, it has been a timely opportunity for us to do that, given that the Intergovernmental Conference is taking place now.
We all share the same goal: equality of opportunity regardless of racial origin and freedom from discrimination. I have to say though that we differ from those who have advocated a stronger role for the European Union on the most effective and appropriate way of reaching that goal.
The noble Lord in proposing this debate has raised two issues: whether the Treaty on European Union should be amended to include a provision banning discrimination; and whether such a provision should also cover discrimination on the grounds of religion. These seem like simple propositions, but there are a number of threads which run together here and a range of different considerations which affect the Government's approach.
I believe that the United Kingdom can be proud of its record on race relations, which is significantly better than that of most comparable countries. That point was made by the noble Lord, Lord McNair. The United Kingdom has one of the most comprehensive anti-discrimination laws in Europe. As the noble Lord said, we are leaders in the field. This legislation has been developed over many years. It strikes a delicate balance which is appropriate to the situation in the United Kingdom.
We need to recognise that the incidence of racism, discrimination and disadvantage reflects in some measure differences in history, geography, culture and of course the political situation. It is not self-evident that

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problems in one country will automatically be repeated in another, where the issues may be very different, or that the solutions will be the same.
The Government believe that the prime responsibility in this area rests with member states where action can be targeted at areas of real need. We do not support the idea that the European Community should have any general competence in the field of race relations. We noted that Sub-Committee E of the European Communities Committee of this House expressed similar concern at extending Community competence in relation to racism when it looked at the Commission's communication on racism and xenophobia earlier this year. Some of those difficulties were mentioned by the right reverend Prelate the Bishop of Birmingham.
Noble Lords: Oh!
Baroness Blatch: My Lords, I have made that mistake twice in two days. I apologise for referring to the right reverend Prelate the Bishop of Birmingham, who will be sitting on those Benches one day. Last night I referred to the right reverend Prelate the Bishop of Birmingham when the right reverend Prelate the Bishop of Lincoln was in the Chamber. I have made a mistake again today. I apologise to the right reverend Prelate the Bishop of Coventry. I have travelled through Coventry and Birmingham today. I have corrected my error for the record.
Turning to the question of religious discrimination, we do not accept that the European Community should have competence in this field either. The issues surrounding religious discrimination are extremely complex and sensitive. There is no specific legislation in Great Britain covering religious discrimination as such. As yet, there is no evidence of a real problem of discrimination on the grounds of a person's religious beliefs as opposed to his racial or ethnic background.
The Government would be prepared to look at any evidence in this area. But no one yet has presented us with evidence to suggest that existing legislation is inadequate to deal with any mischief which may occur. In the circumstances, we do not see a case for giving the European Community competence to act in that area.
Our strong doubts about European competence in these areas does not mean that we deny the importance of appropriate European level co-operation. On the contrary, I see a key role for co-operation with our European partners. We already work closely together in various fora going beyond the European Union and actively share experience and information.
In the area of tackling xenophobic criminal activity we were very pleased earlier this year to agree the Joint Action on Racism and Xenophobia which marks a significant step forward in tackling racism across Europe. Under the joint action member states will provide evidence to other member states to help convict and punish those committing racist acts; facilitate the search for racist material intended for dissemination in another member state; and provide powers to seize such material.
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As the Government have made clear, we are prepared to legislate to close a loophole in our law. That will enable us to seize racist material produced here which is intended for distribution in other member states. The United Kingdom has also agreed that 1997—as the noble Lord, Lord Graham, said—should be designated European Year Against Racism. The Government believe that the European year has the potential to make a valuable contribution to the fight against racism, xenophobia and anti-semitism and will help to highlight the benefits of a diverse society. Plans for the year are still being drawn up, but we are determined that the United Kingdom should play a full and constructive part. We have been greatly heartened by the enormous interest shown in the year by all sections of the community. Countless organisations, large and small, are already planning their own events to mark the year, and this is just as it should be, because tackling racism and prejudice is not just about legislation, important though that is. It is also about winning hearts and minds; promotional and awareness raising activities can make a significant contribution towards this.
The noble Lord, Lord McNair, referred to justice and home affairs. The justice and home affairs pillar of the European Union Treaty operates by unanimity and on an intergovernmental basis. It does not produce Community law but international law agreements or conventions. The Government have agreed to submit proposals, which would require United Kingdom legislation, to be scrutinised by Parliament before they are agreed.
Reference was also made to Starting Point. The Government are aware of the work done by the group of lawyers who produced the Starting Point. We are also aware of the fact that their proposal has been endorsed by certain non-governmental organisations in member states. The fact remains that we are not persuaded by their arguments for the reasons which I have already set out.
Reference was made to EPIC. We have also listened carefully to the arguments put forward by EPIC. Indeed my honourable friend the parliamentary Under-Secretary at the Home Office, Mr. Kirkhope, met a delegation from EPIC earlier in the summer of this year. The delegation included the noble Baroness, Lady Seear. My noble friends and myself wish the noble Baroness a speedy recovery. We miss her presence greatly in this House. EPIC's conclusions were presented to my honourable friend in another place. What was said at the meeting was taken careful note of. We kept that very much in mind while reflecting on this issue.
The noble Lord, Lord McNair, referred to experience in other countries, as did the noble Lord, Lord Graham of Edmonton. Nobody would seek to deny that discrimination and harassment exist in other member states. Our point is that those matters are best dealt with in the context in which they arise. That is why we believe it should be for each member state to deal with them.
I was asked: why is there reluctance on the part of the Government to introduce a specific law against incitement to religious hatred and against religious

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discrimination? As the right reverend Prelate the Bishop of Coventry said, the situation is extremely complex and sensitive. Of course it is important to explore the issue carefully with all those groups concerned in the matter. We already have comprehensive legislation on race, and the Race Relations Act 1976, again referred to by the noble Lord, Lord Graham, makes discrimination on grounds of race unlawful. The public order law prohibits incitement to racial hatred. We would be prepared to examine any evidence in this area, but nobody has yet presented us with evidence to suggest that the existing legislation is inadequate to deal with any mischief which may occur.
The noble Lord, Lord Graham, mentioned the 1993 directive. The European Union has no legislation on race discrimination. It does not have the power to make such a directive. There have been numerous condemnations of racism and xenophobia by the European Union, including by the European Council Heads of Government. The United Kingdom has joined in those declarations and condemnations.
The noble Lord, Lord Graham, also asked what the Government have done about racially motivated violence in the United Kingdom. Again, I say unequivocally that the Government are committed to providing strong protection for ethnic minorities against racial violence and harassment. Violent racial attacks are already well covered by the criminal law. In an appeal case, the then Lord Chief Justice, the noble and learned Lord, Lord Taylor—to whom we also send our very best wishes—stated:
"it is perfectly possible for the court to deal with any offence of violence which has a proven racial element in it, in a way which makes clear that that aspect invests the offence with added gravity and therefore must be regarded as an aggravating feature".
What is dealt with in that situation is the actual offence; however, if the motivation for the offence is racial hatred, that becomes an aggravating feature. We have found in relation to sentencing in the courts—and it has been very impressive—that that aspect has been taken into account and therefore the sentence has been all the more severe as a result of the aggravating feature.
Where there are gaps in the law, we have acted. The Criminal Justice and Public Order Act 1994 introduced an offence to tackle racial harassment and give the police greater powers to deal with racially inflammatory material. Our proposals on stalking may also help. They
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will provide protection in cases where victims are threatened or harassed. It will not be necessary to prove intention in those cases.
The noble Lord, Lord Graham, asked whether British citizens of ethnic minority origin are subjected to harassment and even violence when they travel in the European Union. This point is not about discrimination; it is about racially motivated criminal activity. That is completely unacceptable. We believe that the criminal law of the member states should be able to deal with it. This is an area in which a good deal of co-operation already takes place between the member states under the third pillar of the European Union: co-operation in the field of justice and home affairs. It is under that third pillar that we believe this issue belongs. It encourages the highest possible degree of co-operation between member states.
We should be wary of thinking that there are any easy answers in this area. The good community relations that we enjoy in the United Kingdom are very precious. They are the fruits of years of hard work. We owe much to the basic good sense and decency of the people of this country. If we wish to maintain and improve those relations, we should tread very carefully indeed.
This debate has been short but useful. This will go on record as another subject that this House addresses very seriously.
Lord Hylton: My Lords, before the Minister sits down, will she accept that Northern Ireland has legislation against religious discrimination and that there is in function there a Fair Employment Agency dealing with the employment aspects of religious discrimination? Is she also aware that in England many Moslem groups would like to see that kind of legislation extended to this jurisdiction?
Baroness Blatch: My Lords, I am certainly aware of what the noble Lord describes as pertaining in Northern Ireland. I am also aware that we have a raft of legislation which gives employees in this country of any race or background a good deal of protection. Given the shortness of the notice of the noble Lord's question, I need to reflect more on whether there is a lacuna about which we have not thought. However, I have referred to a good deal of legislation which is there to protect individuals in work and in their homes and communities.
House adjourned at four minutes past eight o'clock.