§ 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. 620 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.
621 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 622 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, 623 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 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 624 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.
625 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 626 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 627 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 628 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 629 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 630 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.
631 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.
632 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 633 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.
634 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 635 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 636 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 637 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 638 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.
639 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 640 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.
641 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 642 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.
643 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 fairlyas 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 stafffor 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 644 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".
645 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 646 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 647 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 648 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.
649 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 650 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.
651 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.