§ 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.
590 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 591 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.
592 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.
593 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 594 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.
595 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 596 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.
597 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 598 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 599 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 600 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 601 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 602 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.
603 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.
604 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 605 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 606 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 607 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?
608 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.