Lords Sitting of 17 December 1996

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

Ex-servicemen and women: Employment
Lord Molloy Lord Molloy asked Her Majesty's Government:
What measures exist to help ex-servicemen and ex-servicewomen to obtain gainful employment on leaving the services.
The Parliamentary Under-Secretary of State, Ministry of Defence (Earl Howe): My Lords, Her Majesty's Government recognize the invaluable contribution which service leavers can make to civilian life. Appropriate resettlement advice is available to all throughout their service. A programme of career and specialist briefings, training courses and elements of outplacement is also provided for eligible personnel. Training may be through in-house centres or by external providers. The Services Employment Network works with the Officers' Association and Regular Forces Employment Association to provide a free job-matching service for personnel and employers alike.
Lord Molloy: My Lords, I thank the noble Earl for that most encouraging reply. Is he aware that the Royal British Legion is now providing facilities at Tidworth Training College? Will the Government consider giving all the help that they can to the Royal British Legion in its further endeavour to assist ex-servicemen and women?
Earl Howe: My Lords, I am well aware of the excellent facilities provided by the Royal British Legion's joint services training and resettlement centre at Tidworth. Our own resettlement organisation in the MoD enjoys a close relationship with the Tidworth centre. As the noble Lord will know, eligible personnel can claim a grant for training courses. But we believe that the individual should be free to choose whether to train at an in-house centre or with an external provider such as the Royal British Legion. However, I shall take full note of the point raised by the noble Lord in the knowledge that he is the Royal British Legion's national vice-president.
Lord Gisborough: My Lords, is my noble friend aware that the expertise of highly experienced junior ranks in the services in one field or another is not compatible with, and not acceptable in, the civilian counterpart as regards NVQs? Can the Minister seek to make the NVQs and work in the Army more compatible?
Earl Howe: My Lords, I am grateful to my noble friend for the point that he raises. In fact in all three services an increasing emphasis is being placed on NVQs and on
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accreditation of service training and experience. Much of the formal training within the services develops skills which are directly transferable to civilian employment. These are relatively early days but I believe that we should see an increasing proportion of service leavers with NVQs to their credit over the years ahead.
Lord Mackie of Benshie: My Lords, in view of the effort involved, will the Minister tell us what percentage of ex-servicemen are in full-time employment within six months of leaving the service?
Earl Howe: My Lords, the figure that I have relates to those who have left the services within a period of three months. A post-exit survey conducted a few months ago indicates that around 80 per cent. of service leavers are employed or otherwise engaged in their chosen activity within three months of leaving the services.
Lord Williams of Elvel: My Lords, the Minister will be aware that certain ex-servicemen and women who served in the Gulf have not been able to retain employment. Indeed, there is some evidence that those who served in the Gulf have lost their jobs as a result of service. Is the noble Earl further aware that the noble Countess, Lady Mar, this morning issued a press release on the problems of Gulf War veterans and that I shall be putting down a Question for Written Answer to ensure that the Government give a considered response to that press release? Will the noble Earl tell the House how many of those who served in the Gulf and have now left the services are in gainful employment or have been sacked as a result of the Gulf War syndrome?
Earl Howe: My Lords, whenever a Question is tabled I always give a considered response. That will be the case with the noble Lord's Question or any that the noble Countess, Lady Mar, cares to table. I do not have the figures relating specifically to Gulf War veterans. If they are available, I shall write to the noble Lord.
Earl Jellicoe: My Lords, will my noble friend enlighten me as to the meaning of the three initials about which the noble Lord was inquiring?
Earl Howe: My Lords, they stand for national vocational qualifications.
Lord Monkswell: My Lords, the House will be very glad to hear that the Government are providing some training and retraining facilities for servicemen who are about to leave the forces. However, the House will be absolutely appalled to learn that there is a 20 per cent. level of unemployment three months after leaving the services. Bearing in mind that the Government have presided over twice the rate of unemployment that pertained during the 1970s throughout virtually their whole period of office, when will they change course and realise that full employment is a sensible object of government policy?
Earl Howe: My Lords, the noble Lord does not paint a very accurate picture. What the services offer in terms of advice, resettlement training, civilian work experience and job finding bears very favourable comparison with anything of the kind that is available in the commercial sector. They have done that for years. The services pride themselves on being good employers. They take resettlement extremely seriously. As I am sure the noble Lord will know, for that reason they are never complacent. They are always seeking ways to improve the package and introduce up-to-date best practice.
Baroness Young: My Lords, will my noble friend the Minister confirm that, as NVQs become increasingly important qualifications for all young people, he will make sure that they are compatible with the qualifications that servicemen may collect in the course of their service lives?
Earl Howe: My Lords, I give my noble friend that undertaking. There is an increasing emphasis in all the services on NVQs. As a qualification they provide an understandable skill level that is easily transferable to civilian employment. Throughout their service all personnel acquire a variety of personal skills: leadership, adaptability, self-motivation and so on. Those stand them in very good stead in the civilian job market.
Baroness Nicol: My Lords, since it is likely that service personnel have not been able to get a foot on the property ladder, is any particular help given to ex-servicemen with finding accommodation, either to rent or to buy?
Earl Howe: My Lords, when those personnel who occupy a married quarter leave the service, they are normally given discretion, should they ask for it, to stay on for a period. The services go to some trouble to liaise with the local housing association or local authority as the case may be to ensure that housing can be provided if it is required.
Lord Mayhew: My Lords, is it not a strange commentary that only a few years ago, despite the urgings on the Minister from all parts of the House, the Government insisted on making redundant so many first-class servicemen? Fewer servicemen would be unemployed today if the Government had followed the advice of this House.
Earl Howe: My Lords, as I indicated, a very high proportion of service leavers gain employment within a relatively short space of time. I do not believe that any side of this House disagreed with the principle that the services needed to be reduced in size following the end of the Cold War. The downsizing has been managed extremely successfully. Although inevitably there has been some pain along the way for those made redundant, it has been well managed and jobs have been found for the majority of those who left.

Police Inquiries: Use of Personal Information
2.47 p.m.
Lord Cornwallis Lord Cornwallis asked Her Majesty's Government:
To what use may the police service put personal information collected in the course of inquiries into offences committed by third parties.
The Minister of State, Home Office (Baroness Blatch): My Lords, the use of any information gathered by the police in the course of an investigation is a matter for the chief officer of the police force concerned, subject to the provisions of the Data Protection Act and any order of the court.
Lord Cornwallis: My Lords, I thank the Minister for that reply. Is she aware that I was recently visited by a police officer in the very laudable undertaking of checking on a firearms certificate and ascertaining that the firearms that it covered were in place and secured. Having ascertained that that was the case, he sat down at a table and asked me to fill in a form without which he said he could not get confirmation from the police computer that he had in fact made a visit to me. As somebody who served for 28 years in the special constabulary, I did not give the officer concerned a hard time. The form requested all my personal information: height, hair colour, eyes, any tattoos that I might have had, right down to the colour, make and registration numbers of my vehicles. Will the Minister tell the House who keeps that information and to what purpose it is put?
Baroness Blatch: My Lords, first, I understand the concern lying behind the noble Lord's Question. He described what is called HOLMES—or the Home Office Large Major Enquiry System—a system used by the police but only employed in pursuit of very serious crime. As he knows, the crime being investigated at that time was murder and the weapon used in the murder was a .38 revolver. Anyone owning a revolver of that calibre in the area was visited, as was the noble Lord. The information involved, as I understand it, was checking on the licence and security of guns. I know from what the noble Lord said that that was all in order, but the officer then went on to personal details, which is part of HOLMES.
In response to the question of what it is used for, the police can do a number of things. Having gone back to the force with the information, they can either deem it so irrelevant as not to be even remotely material to the case, whereupon it can be destroyed. It can be inserted on the computer because at some point it may become relevant. Alternatively, it may go on the schedule of non-relevant information which goes to the prosecution and is made available to the defence in the pursuit of the trial.
The system is for the pursuit of serious crimes and the information may well by now have been deemed wholly irrelevant or it may be on the computer, where it will lie as non-relevant information for the purposes of that case.
Lord Campbell of Alloway: My Lords, may I ask the Minister whether it is right that, the information having been found non-relevant on that schedule, it will be destroyed at the end of the trial? In such a situation with personal information which I gather was improperly obtained, has not the Home Secretary a discretion to order its destruction now?
Baroness Blatch: My Lords, whether or not the information is relevant must be a matter for the police. They are the people with operational responsibility for pursuing serious crime. My noble friend asked whether it would be destroyed. Yes, it would be at some point. That may not be until the trial is at an end and the appeal system is exhausted, but at some point it will be destroyed, consistent with the policy of the force.
In passing, my noble friend Lord Campbell said that the information had been "improperly obtained". I think that the noble Lord, Lord Cornwallis, would say that it was a proper investigation in the first place to check the licence and the security of the guns. What he objected to was that the detailed personal description of himself was systematically recorded and might then go on the computer. The noble Lord is concerned as to what will happen to the information and for what purpose it will be used. There is strict control of access to the computer and the purpose for which the information will be used is only in pursuit of particularly serious crime.
Lord McIntosh of Haringey: My Lords, is it not the case that in addition to the Data Protection Act, to which the Minister referred in her original Answer, there are also extensive controls on the retention of such information in Part IX of the Police and Criminal Evidence Act? Does not the fact that there are such controls point up the need for comparable controls over the retention of material obtained through intrusive surveillance under the Police Bill currently before the House?
Baroness Blatch: My Lords, that was a nice try! I shall not be drawn on intrusive surveillance because the noble Lord knows that we shall discuss the question in some detail at the next stage of the Police Bill. He is absolutely right to say that data protection is a good safeguard in the system. Not only does the noble Lord, Lord Cornwallis, have subject access to the material kept on the computer about him but there are strict limitations on the use to which the police can put that information. I believe that that is an important safeguard.
Lord Marsh: My Lords, is the Minister aware that many of us find it puzzling that anyone should take exception to such inquiries by the police in the course of a murder investigation?
Baroness Blatch: My Lords, I cannot account for the attitude that people take. The noble Lord, Lord Cornwallis, knows the police and their methods very well. He is merely concerned about this particular investigation.
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Perhaps I may say to the noble Lord, Lord Marsh, that in crimes such as serial killings, inconsequential and seemingly inoffensive or extremely trivial information gathered on to the computer with a facility for searching and matching information can result in interception more quickly. That may help to save lives. That is the rationale for the activity.
Lord Mackie of Benshie: My Lords, is it not true that successive governments have destroyed the bobby on the beat and the local information available? Therefore, the more information about respectable citizens the police have, the more chance they have of catching the bad citizens.
Baroness Blatch: My Lords, information and intelligence are a key part of what the police are about. I take exception to what the noble Lord said about destroying the bobby on the beat, there are many more bobbies on the beat. The marvellous service given to the Specials by the noble Lord, Lord Cornwallis, is responsible for putting many pairs of feet on the beat in the local communities, towns and villages in this country. They are important links in the chain for providing information to uncover crime.
Lord Hylton: My Lords, is there not a wider point about information reaching police stations? Is the noble Baroness aware that the possibility of that information getting to the local press is sometimes a deterrent to the full reporting of crimes, particularly theft?
Baroness Blatch: My Lords, the noble Lord raises an important point. It can be worrying. Information gratuitously given to the press is wrong and the police are as subject to the force of law as any other citizen. If information is gathered and improperly used, it is subject to the Data Protection Act, as I have said it is, so passing it gratuitously to the press would be in breach of the law.
Lord Cornwallis: My Lords, will the Minister confirm that the form concerned has no statutory authority and that the officer concerned should have advised me that I had no need to complete it?
Baroness Blatch: My Lords, I agree with that. It is part of the normal investigation of the police and HOLMES is one of the methods that they use. However, I believe that the noble Lord should have been told by the policeman not only why he required the information but also that he did not have to complete the form and that he was not compelled to give the information.

Church of Scientology
2.56 p.m.
Baroness Sharpies Baroness Sharpies asked Her Majesty's Government:
Whether they have any objections to the way in which the Church of Scientology conducts its operations in this country.
Baroness Blatch: My Lords, the Church of Scientology may follow its own doctrines and practices provided that it remains within the law. But the Government recognise that serious allegations have been made about some of its activities.
Baroness Sharpies: My Lords, I thank my noble friend for that reply. Is she aware that entrants to the church have to undergo a so-called "purification" process? Is it under qualified medical supervision? Is my noble friend further aware that a number of those who have left the cult have been both threatened and harassed and many have been made bankrupt by the church?
Baroness Blatch: My Lords, I am not in a position to help my noble friend or to comment on the detailed practices of the Church of Scientology. It is something which she may care to raise with the scientologists themselves because it must be for them to respond. Any evidence of the unethical or unlawful practice of medicine would be a matter of serious concern and could be in breach of the law. Therefore, it would require action.
As to my noble friend's second point, I know that serious allegations have been made and it is right that people should be warned of the potential dangers of becoming involved in organisations of that kind. Any evidence of harassment or threats which could amount to criminal activity should be reported to the police.
Lord McNair: My Lords, in asking this question I have to tell the House that I have an interest in it. I am a member of the Church of Scientology. If the noble Baroness has any problems or questions about scientology, I should be happy for her to come and ask me.
Will the Minister accept that I am pleased that the Government's policy remains as laid down by the noble Earl, Lord Ferrers, at the CESNUR Conference in 1993? Does she also agree that those who fail to meet and talk to members of such organisations are liable to form a biased or incomplete picture of the organisation?
Baroness Blatch: My Lords, I know how seriously the noble Lord feels on the issue. But if someone comes to me as a Minister, or to anyone else, and makes allegations and we simply refer the matter to a member of the Church of Scientology, or any other cult, it is unlikely that they will say: "Yes, of course we harass people and extort money from them", or whatever it is. Their natural reaction will simply be denial. I am not in a position to answer for that. But it seems to me to be important to persuade people so far as possible to produce evidence so that it can be properly responded to by the scientology movement. In the meantime, I can say that sometimes it is fear that prevents people from doing that and sometimes it is sheer distress, not only on the part of the individual but on the part of the individual's family.
Lord McIntosh of Haringey: My Lords, the Minister used the word "cult". The Church of Scientology calls itself a church. Is there a definition of the words "church" and "cult"? If so, does the Church of Scientology meet either of those definitions?
Baroness Blatch: My Lords, my understanding is that the Church of Scientology chapels do not conform to the legal definition of a church and certainly not a religion. I believe it was in 1969 that the scientologists appealed before the courts and were not regarded as a religion.
Baroness Sharples: My Lords, can my noble friend tell me the status of the Americans working at the Church of Scientology headquarters? Can she say whether the church has applied for charitable status?
Baroness Blatch: My Lords, I am sorry but I cannot help my noble friend about the status of the Americans. Coming to this country to work, they would of course need a work permit. They could not simply arrive and work in the scientology movement. In answer to the second question, my understanding is that the scientologists presented informally a hypothetical case to the Charity Commission; namely, should they apply for charitable status, would it be granted? The Charity Commission—it is a matter for the Charity Commission—investigated the matter thoroughly, came back to the scientologists and said that on the basis of the information provided to it it would not have granted charitable status. I also understand that the scientologists have now submitted a formal application to the Charity Commission. It must be for the Charity Commission to consider that application afresh.
Lord Avebury: My Lords, is the Minister aware that when the application was made to the Charity Commission it ruled that, in order to qualify as a religion, an organisation had to be theistic in character but that Buddhists, having existed for 2,500 years, were an exception to that principle? Does she feel that it would be appropriate for Parliament to frame a sensible definition of "religion" and "church", instead of leaving the matter to be determined by the Charity Commission and the courts?
Baroness Blatch: My Lords, wiser counsels than I have tried that one. We have set our face against a definition of religion. We have settled for there being no legal definition of religion. I have now found the date in my brief: it was 1969 when the scientologists appealed to be considered a religion and it was decided at that time that their chapels did not constitute a church and were not a religion.

Architects Bill [H.L.]
3.2 p.m.
The Lord Chancellor (Lord Mackay of Clashfern): My Lords, I beg to introduce a Bill to consolidate the enactments relating to architects. I beg to move that this Bill be now read a first time.
Moved, That the Bill be now read a first time.—(The Lord Chancellor.)
On Question, Bill read a first time, and to be printed.

Vehicles (Price Indication) Bill [H.L.]
The Earl of Bradford: My Lords, I beg to introduce a Bill to make provision concerning price indications of vehicles. I beg to move that this Bill be now read a first time.
Moved, That the Bill be now read a first time.—(The Earl of Bradford.)
On Question, Bill read a first time, and to be printed.

Overseas Domestic Workers (Protection) Bill [H.L.]
Lord Hylton: My Lords, I beg to introduce a Bill to amend the Immigration Act 1971, to confer protection on overseas domestic workers who are witnesses or plaintiffs in proceedings before a court or tribunal. I beg to move that this Bill be now read a first time.
Moved, That the Bill be now read a first time.—(Lord Hylton.)
On Question, Bill read a first time, and to be printed.

Business of the House: Debates this Day
The Lord Privy Seal (Viscount Cranborne): My Lords, I beg to move the Motion standing in my name on the Order Paper.
Moved, That Standing Order 38(4) (Arrangement of the Order Paper) be dispensed with this day to allow the Motion standing in the name of the Earl Russell to be taken before the Motion to approve the Child Support (Miscellaneous Amendments) (No. 2) Regulations 1996.—(Viscount Cranborne.)
On Question, Motion agreed to.

Consolidated Fund Bill
The Minister of State, Department of Social Security (Lord Mackay of Ardbrecknish): My Lords, I beg to move that this Bill be now read a second time.
Moved, That the Bill be now read a second time.—(Lord Mackay of Ardbrecknish.)
Lord Boyd-Carpenter: My Lords, does the prohibition on debating what is one of the most important Bills of the Session still continue or has the Procedure Committee at long last taken another look at it and decided to amend the provision?
Lord Mackay of Ardbrecknish: My Lords, I am not sure whether this is the most important Bill of the Session. I think that some of my other Bills are more important Bills of the Session, but I shall leave that point to one side. In fact, the Procedure Committee has looked at this matter. I am sure that
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my noble friend Lord Boyd-Carpenter knows that in the Companion on page 148 the guidance endorsed by the Procedure Committee is that:
"It is now a convention that proceedings upon [Consolidated Fund Bills] are taken formally".
On Question, Bill read a second time; Committee negatived. Then, Standing Order No. 44 having been dispensed with (pursuant to Resolution of 12th December), Bill read a third time, and passed.

National Health Service (Primary Care) Bill [H.L.]
3.5 p.m.
The Parliamentary Under-Secretary of State, Department of Health (Baroness Cumberlege): My Lords, I beg to move that the House do now resolve itself into Committee on this Bill.
Moved, That the House do now resolve itself into Committee.—(Baroness Cumberlege.)
On Question, Motion agreed to.
House in Committee accordingly.
[The CHAIRMAN OF COMMITTEES in the Chair.]
Baroness Jay of Paddington Baroness Jay of Paddington moved Amendment No. 1:
Before Clause 1, insert the following new clause—
PILOT SCHEMES: EXCLUDED BODIES
(".—(1) Nothing in this Act shall permit the Secretary of State to approve any proposal for a pilot scheme submitted to him by an authority if that proposal includes the provision of personal medical services by—

(a) a company as defined in section 735 of the Companies Act 1985, or

(b) a body corporate incorporated outside Great Britain, which has paid, or has the power to pay, a dividend to its shareholders or which is part of a group of companies, any of which has paid, or has the power to pay, a dividend to its shareholders.

(2) In this section, "provision" includes the employment of persons providing personal medical services or any other contractual arrangement with such a person, including sponsorship and other forms of assistance in money or in kind.").
The noble Baroness said: The purpose of this amendment is simple. It is to prevent the family doctor service in this country being taken over by private commercial interests. General practitioners have always been the cornerstone of our publicly funded National Health Service. For 50 years they and the community nurses, health visitors and other professionals who work with them have provided the excellent primary care on which all our families rely. Although there have been recent concerns about the development of a two-tier system in the new NHS internal market, the local surgery has continued to be the place to which people turn for skilled, objective advice, health service prescriptions, referrals to hospitals and most of the medical care that we need from the cradle to the grave.
The Bill before us contains opportunities to develop those services and make them more flexible. But it also contains a major threat. Deregulation can lead to privatisation. This Bill is an enabling Bill. The first

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part—the first 16 clauses—allows a variety of pilot schemes to change the delivery of primary care at the local level. There are very few specifications about the nature of those pilots on the face of the Bill.
New Clause 1 is designed to ensure that commercial companies who pay dividends to their shareholders are explicitly excluded from promoting those pilot schemes. They cannot become even indirectly the providers of personal medical services within the National Health Service. At Second Reading the Minister explained that GPs, dentists and NHS trusts, provided that they prepared the proposals correctly, could automatically submit pilot schemes for approval to the Secretary of State. But the noble Baroness also said that proposals from other bodies would be considered.
In the Second Reading debate the Minister dismissed as "chatter" the concern that the "other bodies" might be commercial companies and that supermarkets, for example, might get involved in providing or sponsoring medical services. That, the noble Baroness said,
"is no doubt a good story, but it is time to bring speculation down to earth".—[Official Report, 3/12/96; co1.592.]
But, as I am sure many Members of the Committee have seen reported since the Second Reading debate, the "chatter" has been openly confirmed by company spokesmen. For example, the supermarket chain ASDA, which is one of the largest of our successful grocery retailers, has said that it is considering introducing doctors' services on contract to the NHS in some of its stores if the Bill before us becomes law unamended.
Boots, with its countrywide network of chemist shops, is also interested, while Unichem, one of the largest pharmaceutical wholesalers, which runs more than 400 chemist shops, states that it will be pursuing its proposals immediately if the Bill before the Committee becomes law. I hope therefore that the Committee will realise that by introducing Amendment No. 1—new Clause 1—we on these Benches are not dealing in the realm of fanciful speculation or scaremongering but in the possibilities of practical reality.
There seem to be three essential reasons for supporting the new clause which, as I say, excludes commercial companies from the pilot schemes. The first is obvious: the commercial companies provide a threat, under the arrangements that might be proposed, to the basic principles of a publicly-funded NHS and to its public service values. The British Medical Association has already spoken of its grave concern that the proposal suggested specifically by Unichem will bring the privatisation of personal medical services nearer.
We are also concerned, as indeed is the British Medical Association, with the provisions for the sale of goodwill which appear in the Bill and which could lead to the sale of goodwill within general practice to commercial interests. That is the subject of subsequent amendments which we shall be discussing later today.
I am pleased that the General Practitioner magazine conducted a rapid survey of its readership about the possible proposals in the past two weeks. It found that 71 per cent. of general practitioners surveyed were against commercial companies being involved in
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sponsoring their services. Perhaps there will not be any takers therefore; but that does not obviate the necessity to try to prevent the possibility being put on the face of the Bill.
The second fundamental reason for supporting new Clause 1 is that, from the individual patient's point of view, the essential nature of a trusting relationship between a patient and his or her GP is a relationship based on the understanding that everyone is acting from no personal self-interest. That must surely be open to question if the doctor is an employee of a dominant commercial organisation. For example, it may be convenient to me as a shopper and a patient to visit my GP in an annexe of Asda. But I would be doubtful of his or her objectivity if I found his pharmaceutical products offered at discounts by the sponsoring Unichem chain and my healthy eating encouraged by special deals from the resident supermarket. The doctor's role as an independent advocate must be undermined if he is inextricably linked to a commercial company whose interest in that association is clearly to increase its profits.
A speaker at the conference of the Institute of Health Service Management in November put it bluntly. He was talking about similar proposals being made for employing people within individual trust hospitals, not in primary but in secondary care. He said,
"You could be the chief executive officer of a trust hospital but employed by Tarmac. These people will still be health service managers in the public sector but they will be working for a private sector company with a different bottom line".
It is precisely that question of the "different bottom line" that concerns us and caused us to table Amendment No. 1.
My third basic reason for asking the Committee to support the new clause is the issue of equity. The National Health Service is intended to provide equity in healthcare. The Government told us at Second Reading and in background briefings that the purpose of the Bill was to extend and improve primary care services. Those improvements are most needed, as we all know, in deprived communities whether they are inner cities or remote rural areas. It is unlikely that commercial companies will wish to be involved in extending services in those areas, precisely because they are not likely to improve their own profits there. Realistically, we are far more likely to see commercial general practice in a prosperous suburban supermarket than in an inner city corner shop.
We already have great inequities in our healthcare provision, and commercial schemes will exacerbate them. I hope that the Government will accept new Clause 1. It specifically excludes the possibility of those potential developments which are a threat to the essential character of NHS primary care. It is a threat which the Government have previously denied and described as fanciful speculation. If that is so, there is certainly no cause to oppose the amendment. If the Minister responds today that these concerns can be met by regulation rather than by primary statute, that may be sufficient, provided Parliament is given an early opportunity to consider any regulations.
The Secretary of State for Health has spoken, in the context of this Bill, about enabling a thousand different blooms of different primary care to flourish. But a potential bloom of commercial privatised primary care must be doused with weed-killer at this early opportunity before it spreads. I beg to move.
3.15 p.m.
Baroness Robson of Kiddington: We on these Benches very much support the amendment. I consider it to be, in many ways, one of the most important amendments before us today. There are many good things in this new primary care Bill but without Amendment No. 1 the dangers of which the noble Baroness, Lady Jay, spoke are very great.
At Second Reading the Minister stated that she had not seen or heard of any specific interest by supermarkets in the possibility of setting up a health centre on their premises. We now know without doubt that they are interested. If we take that, together with the fact that they could employ salaried doctors only and not bring in a health service practice already in existence, we can see how the relationship between the GP and his patient may be destroyed. The trust would no longer exist between them.
A general practitioner is an unusual person within the health service today. He is not only a provider; he is also a commissioner of services on behalf of his patient. I am therefore slightly worried about hospital and community trusts setting up new health centres. If they used salaried doctors—or even if they did not—there would arise a clash of interests between the doctor and his patient in the commissioning part of the duty to the patient.
I cannot see how we can retain the trust of the patient in the doctor, a trust of which we are so proud in this country and which has carried our health service through all its troubles. It is the basis of the general practitioner services that has helped us through the many difficulties that we have encountered. I sincerely hope that the Government will accept the amendment.
Lord Walton of Detchant: At Second Reading I gave considerable support to the spirit underlying the Bill now being considered in Committee. However, I support in principle the spirit underlying Amendment No. 1. Having said that, perhaps I may make clear that I have long believed in the importance of a partnership between public and private medical care. I have certainly appreciated such developments in our hospitals. The efforts made 20 years ago by a former Labour Government to try to remove all private beds from our NHS hospitals did irreparable harm to the service and, at the same time, gave an enormous impetus to the development of private medical care outside NHS hospitals. Happily, many NHS hospitals now provide private medical care and derive a considerable income from doing so.
However, general practice is different. There is nothing to prevent a private company from employing salaried general practitioners who are offering private
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primary care. That can surely not be an objection. But for many years it has been the case that private commercial companies have employed occupational health physicians. They are employees of the company. They are there in the interests of the company to examine and report on employees relating to their fitness to practice and also relating to issues that may arise in consequence of disorders or diseases resulting from their respective occupations. But if an occupational health physician detects evidence of an illness in someone whom the company has asked him or her to examine, then it is not up to that occupational health physician to prescribe or offer treatment. But, with the permission of the patient, that physician should report to the patient's general practitioner who would then offer treatment to that individual.
The problem that I foresee if private commercial companies were able to employ general practitioners is that there would be a real or perceived conflict of interest between the commercial interests of the company on the one hand and the general practitioner services on the other. Many GPs have worked part-time as occupational health doctors, but in doing so they have separate contracts: one as an independent contractor with the NHS and the other on a sessional basis with the commercial company. The duties under those two contracts are totally separate and distinct. It is a possibility, as the noble Baroness, Lady Jay, said, that a doctor employed to give general medical services through a commercial company might feel under pressure to prescribe the products of that company and might not therefore be able to function properly and independently, as every general practitioner should, in the interests of his patient and in the interests of the community. For those reasons, I support the principle underlying this amendment.
Baroness Gardner of Parkes: I find the amendment rather complicated and I believe that a number of points have not been thought through. The amendment refers to "personal medical services". Does that mean medical services only or does it include dental services? If the term medical services includes dental services, perhaps I should point out that dental companies and companies that provide treatment already exist. British Petroleum employs a dentist within its building. He is paid by the company but operates on national health dental forms and claims fees from the National Health Service. I refer to British Petroleum because it was near my surgery. It took that course because it had many people—British citizens—coming in from different parts of the world who had to be seen rapidly and could not be sure of getting an appointment elsewhere. If that same firm wanted to have a general medical practitioner, would it be precluded from doing so under this amendment?
As a dentist I practised for years as one of the directors of a dental company. A number of dental companies are registered under the General Dental

1401
Register. I do not know whether medical companies exist. I do not know whether dental companies are still registered, but they certainly are a fact of life.
Baroness Jay of Paddington: I agree with the noble Baroness. The question of the nature of the company is very difficult. That is why we used the terms in the amendment. They may not be precise but, as we know, if the principle of an amendment is accepted, the Government are always willing to help with that. Where a company pays dividends, that is different from a practice. We took the example of one in Dorset where a group of general practitioners working together form a company. However, they do not pay out dividends. That is the distinction which one can make in broad terms between the type of company we would wish to see excluded and a broad collection of professionals in practice, which I think is what the noble Baroness is speaking about.
Baroness Gardner of Parkes: I am interested in that comment. The General Dental Council had strict rules on what proportion of dentists had to be directors of the company. It was not an open matter and no new companies could be created. It was only companies created prior to 1957.
The noble Baroness referred to whether dividends are paid. Whether a number of practitioners working together share remuneration or whether payments are classified as dividends, are taxation matters. If tomorrow, or at some later stage, a new Chancellor said that it was more advantageous to be paid dividends than a salary, one would rapidly find practitioners wanting to pay themselves dividends. Therefore, I have doubts about that argument.
The noble Baroness, Lady Robson, was concerned about trusts employing people. At Second Reading I said that the trust of which I am chairman, which is a large teaching hospital, has general practitioners who come in on a salaried basis for so many sessions. They come into the accident and emergency department and are enormously valuable. So many patients, particularly in London, who should go to a general practitioner do not do so. They present themselves at the accident and emergency or casualty department. They take time and attention away from the proper treatment of emergencies. Therefore, I think it is important that we should be able to employ these people.
Baroness Robson of Kiddington: I am aware that hospitals do that. I was talking about health authorities setting up complete health service centres in some other part of the area in which they function.
Baroness Gardner of Parkes: When I was vice-chairman of the North-East Thames Regional Health Authority, there was such a scarcity of dentists in some parts of Essex that we had to consider setting up salaried practices there in health centres. All those situations exist. It is quite impossible to predict when and where these needs will arise.
1402
Another point has been overlooked. A number of doctors, particularly younger doctors, quite like the idea of working as salaried practitioners. Many do not want the burden of practice management and would prefer to be salaried. Therefore, we want to leave open some flexibility for such a situation.
The noble Baroness, Lady Robson, referred to the trust between doctor and patient. Where that exists, it is marvellous. There could not be a better relationship. Sadly, however, although it works in the very best practices, it does not work everywhere. There would hardly be a practice in this country which did not have at least one disagreeable patient that it found difficult to get along with. Health authorities would say that they often have to allocate patients to doctors because no doctor wants to take the patients voluntarily. It is an idealistic and desirable thing for this trust to be continuing at the highest level; but, sadly, it is not always so.
I am opposed to any amendment which might limit possibilities for patients. We should be putting patients first. We tend—I say this as a dentist—to have a degree of self-interest as to what suits us as practitioners. That is not good enough. We have to put patients first. The walk-in private medical service at Victoria Station is a great success. The idea is such a success that centres will be set up elsewhere. It is clear that many patients would like to have that walk-in service. The system of a company setting up a practice would enable patients to have the right to walk in when they felt like it.
I would not want to insert anything into the Bill that would prevent that happening. We have to leave open our options—we are always hearing that expression in another context—because we do not know what good and innovative schemes will be brought forward. The amendment might well preclude schemes that would be of the greatest benefit to patients. I oppose the amendment.
Baroness Masham of Ilton: I wish to ask the Minister about the pilot schemes. Where will the patients' records be kept? If a practice sets up in a supermarket, will the records be kept in the supermarket? The noble Baroness, Lady Gardner, referred to the walk-in centre at Victoria Station, which I have heard is very popular. What happens there with the patients' records? Records take up quite a lot of space.
Baroness Gardner of Parkes: Perhaps I may reply to that point. I do not know what happens to the records at Victoria Station. I do know that we are now reaching the point where records can be available on line by computer much more readily. Therefore, they could be held at the original base and then be made available. However, we get into this tremendously complex situation regarding patient confidentiality. The patient would have to release the right for the records to be obtained from the original source, and you would have to be quite sure that when the original source received your request, it was satisfied that you were the legitimate person. I believe

1403
that it might be a very complicated issue as regards patient confidentiality and computer records. But in technical terms it is possible to do that. The other aspect is that many people who use the service at Victoria Station just have an anxiety about something and want to see a doctor then and there at the moment of their choice.
3.30 p.m.
Baroness Cumberlege: This amendment implies that GPs will find it hard to hold their own in the new system; that they will struggle to come up with proposals that will win approval as pilot schemes and that they need protecting. We strongly believe that none of those is the case. GPs have shown time and time again that they are innovative, imaginative and able to deliver better services to patients in new ways. GPs, dentists, NHS trusts and other frontline NHS staff are closest to patients and we look to them to bring forward proposals about how we can improve services for local people. That is why we have given GPs, dentists and NHS trusts, and only those groups, the automatic right for their proposals to be put forward to the Secretary of State for approval as pilot schemes. We are confident that they will seize the opportunity. We are sure that they do not need to fear competition, let alone be protected from it.
As well as being unnecessary, we believe that this amendment will be damaging to the NHS. The prime purpose of our proposals is to enable existing GP practices to do more and to do it better. But there may be circumstances, as my noble friend Lady Gardner said, where a salaried GP service would be the best option. We all know of the difficulties that arise in filling practice vacancies in some inner city areas. We are serious about tackling these difficulties and do not want to rule out any sensible opportunities, including a GP being employed by a commercial organisation. After all, what is piloting for if not to see if innovation works?
I should like to make this very clear: the Secretary of State will only countenance new arrangements if there are obvious gains attached to them. New services will be subject to NHS rules and standards. In particular, we will want to be absolutely sure that there is no potential for conflicts of interest before allowing any specific proposal to go ahead—a point made by the noble Lord, Lord Walton.
Talk of commercialisation in this context is a nonsense. GPs have always been in the private sector in that they are private contractors. Indeed, it might be practically impossible to differentiate between, say, a group of GPs and other healthcare workers who formed a limited company and a company already operating in the commercial sector with suitable experience of providing medical or dental services. To differentiate in this way would be unjust and unfair. Why rule out companies which pay dividends and not private companies? If private companies, why not partnerships? The point is that no one can draw firm lines between these bodies. What is important is that the services that they might offer should be NHS services for NHS patients to NHS standards.
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The noble Baroness, Lady Jay, ignores the fact that schemes put forward by commercial organisations will have to be endorsed by health authorities and then approved by the Secretary of State. One of their concerns will be to ensure that pilot schemes meet local needs including, in particular, improving services in areas which are not currently well served. The example that I have already given is the inner cities. Our proposals open the way to greater equity and better access to NHS services for all.
Our commitment to NHS primary care is beyond doubt. We believe that this amendment will do nothing for primary care, nothing for professionals and nothing for patients. Therefore, I urge the Committee not to support it.
Baroness Jay of Paddington: I am grateful to the Minister for that reply. I thought that the particularly illuminating sentence in her reply was that in which she said there was no way that the Government would rule out a private organisation being involved in these pilot schemes, which is precisely what was being denied as speculation in previous debates on this subject both in your Lordships' House and in another place.
If it is really the Government's policy that they do not rule out private companies being involved we have at least achieved clarity about the intent of part of this Bill. It is a clarity that we on these Benches find extremely disturbing. It is disturbing because although the Minister may argue that there are forms and ways in which this may help local services, the fact is that they are involving commercial organisations and the problems about conflicts of interest which the noble Lord, Lord Walton, so eloquently described in his contribution to the debate, cannot be ruled out.
I am surprised that the Minister used the words "protecting GPs". Indeed, one would wish to see GPs protected from that sort of conflict of interest, which would be difficult for their professional practice as well as doing nothing, as the Minister said, to enhance the well-being or, indeed, the useful healthcare of patients.
I believe that the point is that what has been revealed in this short debate, and most specifically by the Minister's reply, is that all of the points made at Second Reading about the potential for diversity, which we all welcome—we on these Benches underline our welcome for diversity in extending primary care—did not lead to the kind of deregulation, competition and privatisation, which precisely would undermine the basic principles of the health service in the way that I described in my opening remarks in moving the amendment.
What we have learnt this afternoon is that, despite all the warm words of the Government and their plethora of White Papers about their determination to support and extend primary care within the NHS, they are quite content to see commercial organisations involved whose basic profit bottom line is their basic guiding principle. The Government are willing to see that kind of element introduced into the essential

1405
nature of our primary care system, which is GP services. On the basis of that very clear distinction of principle and understanding of what NHS primary care should be delivering in this country, I will have to seek the opinion of the Committee.
Baroness Cumberlege: Perhaps I may just explain to the noble Baroness that I said that no scheme could be ruled out from being considered by a health authority. As the noble Baroness is a member of a health authority she will know how diligent members are in seeking to ensure that the services that are provided for their populations are to a high standard and that they comply with the NHS rules.
These are the very principles that we are putting forward for these schemes. It is the health authority who will say, perhaps, "No, we do not believe that this is value for money because, after all, it is still public money. No, we do not believe that this scheme is going to serve patients, and we do not believe that it is going to serve staff'.
That is twisting what I actually said. I believe that the noble Baroness will realise that if patients have to be registered with their GP, with public money and NHS standards and rules, then the health authority will weigh all that up. If it is then in the interests of the population served, the health authority has the prerogative to put that forward to the Secretary of State. He will then make a judgment on the criteria that I have laid out as to whether these schemes are going to benefit the local people.
To merely imply that the commercial sector is always a brigand; is always ready to waste resources and is evil in any way, is plagiarising the situation. We know that sometimes the private sector helps the health service. We have only to consider hospital doctors sponsored by the private sector through research programmes to know that they contribute enormously to the National Health Service. The noble Baroness said that she will seek the opinion of the Committee. I am convinced that it will want to oppose this amendment.
Baroness Jay of Paddington: I am bound to return to the Minister's points. She accuses me of twisting her words. I said nothing in my reply to her response to the amendment that implied that I regarded commercial companies as evil. That would be inappropriate. Before I seek the opinion of the House, can the Minister say whether in principle pilot schemes proposed by commercial companies will be looked at favourably or otherwise on the grounds considered by the Secretary of State? The bottom line question is whether the proposals for pilot schemes by commercial companies will be considered by the Secretary of State.
Baroness Cumberlege: The noble Baroness misunderstands the Bill. The Secretary of State will consider these proposals only if they are forwarded by the health authority. It is the health authority that acts as a sieve and has the right of veto if it believes that the proposals are not in the interests of the local population or the taxpayer.
3.40 p.m.
On Question, Whether the said amendment (No. 1) shall be agreed to?
Their Lordships divided: Contents, 122; Not-Contents, 145.

Division No. 1

CONTENTS

Addington, L. [Teller.]

Kinloss, Ly.

Alderdice, L.

Longford, E.

Allenby of Megiddo, V.

Lovell-Davis, L.

Archer of Sandwell, L.

McFarlane of Llandaff, B.

Ashley of Stoke, L.

Mackie of Benshie, L.

Avebury, L.

McNair, L.

Beaumont of Whitley, L.

McNally, L.

Berkeley, L.

Mar, C.

Borne, L.

Mar and Kellie, E.

Brooks of Tremorfa, L.

Masham of Ilton, B.

Bruce of Donington, L.

Mason of Barnsley, L.

Callaghan of Cardiff, L.

Mayhew, L.

Carmichael of Kelvingrove, L.

Milner of Leeds, L.

Carter, L.

Molloy, L.

Castle of Blackburn, B.

Monckton of Brenchley, V.

Chandos, V.

Monkswell, L.

Cledwyn of Penrhos, L.

Morris of Castle Morris, L.

Clifford of Chudleigh, L.

Murray of Epping Forest, L.

Clinton-Davis, L.

Nathan, L.

Cocks of Hartcliffe, L.

Nicol, B.

Currie of Marylebone, L.

Ogmore, L.

David, B.

Paul, L.

Dean of Beswick, L.

Peny of Walton, L.

Dean of Thomton-le-Fylde, B.

Peston, L.

Desai, L.

Plant of Highfield, L.

Diamond, L.

Prys-Davies, L.

Dormand of Easington, L.

Ramsay of Cartvale, B.

Dubs, L.

Rea, L.

Exmouth, V.

Ritchie of Dundee, L.

Ezra, L.

Rix, L.

Falkender, B.

Robson of Kiddington, B.

Farrington of Ribblcton, B.

Rochester, L.

Fisher of Rednal, B.

Rodgers of Quarry Bank, L.

Fitt, L.

Sainsbury, L.

Gallacher, L.

Sandwich, E.

Geraint, L.

Scanlon, L.

Gladwin of Clee, L.

Serota, B.

Gould of Pottemewton, B.

Sewel, L.

Graham of Edmonton, L. [Teller.]

Simon, V.

Gregson, L.

Smith, L.

Grey, E.

Smith of Gilmorehill, B.

Hampton, L.

Stallard, L.

Hanworth, V.

Stoddart of Swindon, L.

Harris of Greenwich, L.

Strabolgi, L.

Haskel, L.

Strafford, E.

Hayman, B.

Symons of Vernham Dean, B.

Healey, L.

Taverne, L.

Hilton of Eggardon, B.

Taylor of Blackburn, L.

Hollick, L.

Tenby, V.

Hooson, L.

Thurso, V.

Howell, L.

Tope, L.

Howie of Troon, L.

Tordoff, L.

Hughes, L.

Turner of Camden, B.

Hutchinson of Lullington, L.

Varley, L.

Hylton-Foster, B.

Wallace of Coslany, L.

Ilchester, E.

Walton of Detchant, L.

Jay of Paddington, B.

Warnock, B.

Jenkins of Hillhead, L.

White, B.

Jenkins of Putney, L.

Whiny, L.

Kilbracken, L.

Williams of Elvel, L.

Kilpatrick of Kincraig, L.

Winston, L.

1407

NOT-CONTENTS

Aberdare, L.

Inglewood, L.

Addison, V.

Ironside, L.

Ailesbury, M.

Johnston of Rockport, L.

Aldington, L.

Keyes, L.

Alexander of Tunis, E.

Kingsland, L.

Alport, L.

Kinnoull, E.

Ampthill, L.

Knollys, V.

Archer of Weston-Super-Mare, L.

Lawson of Blaby, L.

Arran, E.

Long, V.

Ashboume, L.

Lucas, L.

Astor of Hever, L.

Lucas of Chilworth, L.

Balfour, E.

Lyell, L.

Belhaven and Stenton, L.

McColl of Dulwich, L.

Birdwood, L.

McConnell, L.

Blake, L.

Mackay of Ardbrecknish, L.

Blaker, L.

Mackay of Clashfem, L. [Lord Chancellor.]

Blatch, B.

Mackay of Drumadoon, L.

Boyd-Carpenter, L.

Macleod of Borve, B.

Brabazon of Tara, L.

Marlesford, L.

Brentford, V.

Merrivale, L.

Bridgeman, V.

Mersey, V.

Brougham and Vaux, L.

Middleton, L.

Butterworth, L.

Miller of Hendon, B.

Byford, B.

Montgomery of Alamein, V.

Cadman, L.

Mountevans, L.

Campbell of Alloway, L.

Munster, E.

Campbell of Croy, L.

Murton of Lindisfame, L.

Camegy of Lour, B.

Napier and Ettrick, L.

Charteris of Amisfield, L.

Noel-Buxton, L.

Chelmsford, V.

Northesk, E.

Chesham, L. [Teller.]

Onslow, E.

Clark of Kempston, L.

Oppenheim-Barnes, B.

Cochrane of Cults, L.

Orr-Ewing, L.

Cornwallis, L.

Oxfuird, V.

Courtown, E.

Palmer, L.

Craig of Radley, L.

Park of Monmouth, B.

Cranbome, V. [Lord Privy Seal.]

Pender, L.

Cranworth, L.

Peyton of Yeovil, L.

Crickhowell, L.

Pilkington of Oxenford, L

Cross, V.

Pym, L.

Cuckney, L.

Quinton, L.

Cullen of Ashboume, L.

Reay, L.

Cumberlege, B.

Renton, L.

Dacre of Glanton, L.

Renwick, L.

Davidson, V.

Richardson, L.

Dean of Harptree, L.

St. Davids, V.

Denbigh, E.

Saltoun of Abernethy, Ly.

Derwent, L.

Sandford, L.

Dilhome, V.

Seccombe, B.

Dixon-Smith, L.

Sharples, B.

Eccles of Moulton, B.

Skelmersdale, L.

Ellenborough, L.

Soulsby of Swaffham Prior, L.

Elles, B.

Stodart of Leaston, L.

Elliott of Morpeth, L.

Strange, B.

Erne, E.

Strathcarron, L.

Flather, B.

Strathclyde, L. [Teller.]

Fraser of Carmyllie, L.

Strathcona and Mount Royal, L.

Gainford, L.

Swinfen, L.

Gardner of Parkes, B.

Terrington, L.

Geddes, L.

Thomas of Gwydir, L.

Gerard, L.

Thurlow, L.

Gisborough, L.

Trumpington, B.

Glentoran, L.

Ullswater, V.

Goschen, V.

Vivian, L.

Gray of Contin, L.

Whitelaw, V.

Greenway, L.

Wilberforce, L.

Haddington, E.

Wilcox, B.

Hailsham of Saint Marylebone, L.

Willoughby de Broke, L.

Harding of Petherton, L.

Wynford, L.

Hannsworth, L.

Young, B.

Hemphill, L.

Henley, L.

HolmPatrick, L.

Hothfield, L.

Howe, E.

Resolved in the negative, and amendment disagreed to accordingly.
3.49 p.m.
Clause 1 [Pilot schemes]:
Baroness McFarlane of Llandaff Baroness McFarlane of Llandaff moved Amendment No. 2:
Page I. line 14, at end insert ("or
(c) services are provided which are not personal medical services or personal dental services but which may be provided under Part I of the National Health Service Act 1977 or (as the case may be) Part 1 of the National Health Service (Scotland) Act 1978.").
The noble Baroness said: I beg to move Amendment No. 2. In doing so I shall speak to Amendments Nos. 9 and 29 in addition. The purpose of the amendment is to clarify that nurses may propose pilot schemes in their own right rather than via a doctor or NHS trust. Amendment No. 9 seeks to ensure that health authorities will prepare proposals for any pilot scheme put forward by nurses; and Amendment No. 29 seeks to allow nurses providing nursing services in pilot schemes to apply to become health service bodies.
At Second Reading the Minister paid tribute to the important contribution of nurses in primary care. She said (at col. 591 of Hansard):
"The nursing profession already plays a major and growing part in the delivery of primary care. We want to encourage that trend and also greater integration of the different primary healthcare professions. Our proposals will enable nurses to develop proposals with GPs which include a range of services in which they take a lead, such as child health clinics or monitoring of asthma".
Questions were asked at Second Reading about the nature of the ability of nurses to submit pilot schemes in the terms of the Bill. If nurses are to be full partners in the multi-disciplinary team in primary care and if, as the White Paper Choice and Opportunity states, they have an equally important part to play with other professionals, the Bill needs to give expression to this equality. As it stands, it presents barriers to the nurse acting independently of GPs or trusts in proposing pilot schemes. Subsection (3) of Clause 1 implies that a pilot scheme could include nursing services only as part of a wider pilot but nurses acting alone could not propose a pilot scheme. Amendments Nos. 2 and 3 seek to rewrite this subsection to define pilot schemes as covering all nursing and other services which may be provided.
Clause 2 presents a further barrier. It sets out the duties of health authorities to consider pilot schemes submitted to them by "a qualified person" and to prepare proposals for submission to the Secretary of State. Subsection (7) defines "a qualified person" as either an NHS trust or a medical or dental practitioner.
Amendment No. 9 adds nurses to the list of qualified persons, thus allowing nurse-promoted pilots the same status as other pilots. This would allow nurses to maximise the potential of the Bill.
Amendment No. 29 to Clause 13 allows nurses providing services under a pilot scheme to apply to become a health service body rather than restricting that status to persons providing personal medical or personal dental services. Not all primary healthcare services can

1409
be subsumed under the description "personal medical or personal dental services". Nurses and other healthcare professionals provide services which are complementary to medical and dental services and the multi-disciplinary team needs to work in a partnership.
Nurses, midwives and health visitors provide a wide range of specialised services in primary healthcare. They make a major contribution to health promotion through health education and a range of preventive services. The health visitor, for instance, is well trained in epidemiological analysis.
The amendments before the Committee would liberate nurses to develop a range of services for vulnerable client groups who fail to engage with and remain untouched by GP services which exist at the moment on a so-called "come and get it" basis. Pilot schemes in health education, screening programmes and epidemiological services would be eminently suitable as pilot schemes, as well as the child health clinics and monitoring of asthma mentioned by the noble Baroness at Second Reading.
The contribution of community psychiatric nurses has been well acknowledged. It is the view of the Royal College of Nursing that, in partnership with a medical practitioner in mental health, nurses could contract with a health authority to provide a 24-hour emergency mental health service for a locality. Similarly, in partnership a team of nurse practitioners could contract to deliver a wide range of services for homeless people not registered with a GP.
The NHS Executive report published in June of this year, Primary Care: the Future, paid tribute to the role of the nursing services in primary healthcare. It drew attention to their many strengths: the work they do in health needs assessment, health promotion and illness prevention, as well as nursing care of patients with acute long-term illnesses. It said that their services are readily accessible and available in a variety of settings and that nurses are already well qualified and have many postgraduate qualifications and some have degrees.
The nursing contribution to clinical audit and research is increasingly strong. The report drew attention to the fact that nurses play a leading role in the provision of immunisation, clinical cytology and disease management through practice nurses, child health surveillance, nurse-led minor injuries clinics, nurse-led home care schemes and nurse-led specialist services such as parenting skills, dermatology, leg ulcer and palliative care.
In looking for areas of development, the NHS Executive report saw scope for nurses to widen their role but said that there should be a change in the way teams worked and the structures underpinning them. We believe that community nurses are in a prime position to lead and co-ordinate such services with their existing links in the community. For example, an integrated team of community nurses could provide local people with access to acute mental health and community medical services through the nurses themselves and through referral and joint working with GPs and professional
1410
sallied to medicine. A senior nurse in full partnership could be instrumental in leading such a team and maximising the contribution of community nurses.
The amendment before your Lordships' Committee is an essential step in providing the structural arrangements necessary for nurses to be maximised in their contribution to healthcare.
4 p.m.
Baroness Jay of Paddington: I would like to support the noble Baroness, Lady McFarlane, in moving Amendment No. 2 and the other amendments in this group. As she has rightly stressed, there are many other professions who contribute greatly to the important overall care that we receive in the primary healthcare setting. The noble Baroness rightly stressed the important role of nurses in this and the need that they have, and professionally feel would be appropriate, to become leading partners and not just supporters in the new experimental pilots which the Bill will allow. It is obvious that nurses are in an advantageous position to put forward ideas and to manage any pilot scheme.
I should like to mention some other professions allied to medicine and working in the primary health care field which equally feel that they could take a lead in forming pilots and delivering services. For example, health visitors are among the other well-qualified people. in the commonsense meaning of the term, who would be able to do that, as are pharmacists, occupational therapists, clinical psychologists and, of course, midwives. As the noble Baroness said, nurses and community nurses are already working independently in organisations such as minor injuries units.
It is clear that the work of those other professionals is often done independently. Indeed, one example has been given of a primary care team where the nurses employ a general practitioner. It seems that it would be legitimate, within the meaning of the Bill and the pilots as they were described by the Minister in introducing the Bill on Second Reading, to give nurses and the other professionals I have mentioned a lead role in the pilots.
The Royal College of Midwives is especially keen that midwives should take a lead in some of the pilots. As it says, maternity care provides an ideal opportunity. It could become a model service. It could move pregnancy and childbirth out of hospital and back into family-centred community services. It feels that that is in line with the spirit of the Government's changing childbirth initiative, with which we know the Minister has had a leading and influential role.
All those people bring their skills and professional backgrounds to the concept of the team approach to primary care which we all welcome and which is clearly an important way of dealing with the needs of the community. My noble friend Lord Rea emphasised at Second Reading the need for the team to be seen as a body of equals rather than as one partner taking the lead over other professionals. In that context it would be interesting to know whether any group of professionals—whether or not the amendment stands—will be able to put forward pilot schemes if they are not formally incorporated into a partnership at the moment.

1411
For example, would a group of GPs who are not already in partnership together within the technical meaning of the words within the Bill qualify as "qualified people"?
The Government have today produced a further White Paper on developing partnerships in care entitled Primary Care: Delivering the Future in which they emphasise the notion of the team approach to primary care, specifically include the proposal to extend the existing nurse prescribing pilot scheme and make other proposals which show that they regard nurses, in particular, and other professionals working within the community as equal partners in the delivery of health care in the community. It therefore seems appropriate, as the noble Baroness, Lady McFarlane, said, to include those people specifically on the face of the Bill as people who can lead on the pilot schemes which are proposed. I support the amendment.
Baroness Robson of Kiddington: We on these Benches support the amendment. We have for many years tried to achieve greater recognition of the contribution that nurses make to our health service. It seems to me, as it does to the noble Baronesses, Lady McFarlane and Lady Jay, wrong, when nurses can now be a full partner in a general practice, that they should not be able together to put forward a pilot scheme which might be of the most tremendous use in the community.
One suggestion was that nurses could propose a pilot scheme of 24-hour emergency mental health services. There is nothing we need more in our health service at the moment than an improvement in mental health care in the community. It is difficult to understand why nursing services are not personal medical services—I know why they are not personal dental services—which may be provided under Part I of the NHS Act. It is long overdue for nurses to be given the recognition they deserve. I support the amendment.
Lord Campbell of Croy: It is appropriate that the amendment should be moved by the noble Baroness, Lady McFarlane, who has immense experience in the nursing profession and as a leader of it. I, too, received the text of the amendment, and two others in the group, from the Royal College of Nursing.
As noble Lords will be aware, my main experience of nurses is as a hospital patient over long periods, including a year and two months at the end of World War II. I have tremendous admiration for their dedication and the contributions they make to different parts of the NHS. I am glad that nurses nowadays are authorised to do a good deal more than they were 50 years ago. I shall listen closely to what my noble friend the Minister has to say about the amendments.
Baroness Gardner of Parkes: I, too, am a great supporter of the nursing profession, and, indeed, of all the people involved in the primary care delivered to patients. It will be a pity if they are not all equally entitled to bring forward a pilot scheme. As my noble friend the Minister told us on the previous amendment,
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the pilots will all be sifted by the DHA. So we are not committing anyone to accepting any scheme that is not appropriate and suitable.
It is wrong to stifle the initiation of schemes by excluding a number of different branches of the caring professions. I include pharmacists who are great innovators within their own practices and who are doing more and more all the time towards helping patients and removing the burden from GPs. We have had no mention of opticians. It would be desirable for any people with a health qualification—I am not saying that any member of the public could come forward with a scheme, because that would make the provision too wide—and any member of the caring professions, allied to medicine, or who are part of the primary care team, to be able to bring forward a scheme.
I support the principle behind this group of amendments. However, when it comes to practicalities, I notice that the noble Baroness, Lady McFarlane, referred to Clause 2(7) which sets out the two lists of medical practitioners and dental practitioners. I wonder whether, rather than produce a list of other qualifications—we should need to include them all—there could be an amendment to the effect of "all other approved qualified people" or some more general phrase. Because even within the caring professions, modifications, changes and new terminologies are coming all the time for people doing different jobs. I would rather see the provision sufficiently wide to cover those people who might be branching into a new form of medical care as well as those who are involved at present. I support the principle of the amendment.
Lord Walton of Detchant: I, too, support the principles underlying the amendments. The past 25 years have seen a veritable revolution in the range and quality of services provided by nurses, health visitors, midwives and others. Indeed, within the NHS itself there are many circumstances in our hospital service when nurses have been appointed as managers of various hospital trusts.
The purpose, I think, underlying the amendments is to acknowledge the fact that nurses, working in collaboration with, and in future perhaps in partnership with, doctors are capable of providing a wide range of services and of relieving the GP of certain duties and responsibilities that he or she may, in the past, have carried. It is a very important principle that we should accept. There have been circumstances, particularly in our inner cities, where the most impoverished section of the population and the homeless have found themselves being looked after by nurse practitioners; people who have not registered with general practitioners.
When I heard the Minister reply to the debate on the first amendment I was almost persuaded by her argument that pilot studies must be approved by the health authorities and the Secretary of State on the advice of those authorities. Surely, if we are to give the same responsibilities for the initiation of pilot schemes to members of the nursing and allied professions, only those examples which are regarded by the health authorities and

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the Secretary of State as being suitable will be approved. For that reason I believe that this group of amendments has considerable strength. I support them.
Baroness Eccles of Moulton: There is an aspect of the amendment which we should consider. It follows from the comments of the noble Lord, Lord Walton. In the early stages pilot schemes will require a heavy workload of assessment and monitoring by the health authorities. It would be helpful if in reply the Minister could indicate the effect on the monitoring and pilot process of widening the range of individuals and bodies which can enter into pilot schemes. We must bear in mind that health authorities are continually under pressure to reduce their management activities. Although they will be taking on the extra work of monitoring the pilot schemes, we must be mindful of other tasks which must be performed at the same time.
Baroness Gardner of Parkes: As this is the Committee stage, I am sure that I am allowed to intervene again. I wish to follow the point made by the noble Baroness, Lady Eccles. Of course it might create too great a burden for the district health authorities, but surely through local medical committees and equivalent pharmacy and nursing committees there must be some way of setting up an earlier filtration system in order to avoid that burden. I understand the argument that we would not wish to make the system totally unpracticable.
Baroness Cumberlege: I strongly support the views expressed by many Members today concerning the role of nurses. The noble Baroness, Lady McFarlane, could not be a better champion for the cause, knowing more about the nursing profession than anyone in the Chamber today.
I too have strongly supported the role of community nursing. When I carried out the review, Neighbourhood Nursing: A focus for care, I recognised very strongly in the report that the role of nurses is fast developing and that there is plenty of potential for them to take on more duties and responsibilities and to use their full range of skills. That report recognises the services provided by nurses, midwives and health visitors in their totality of primary healthcare and that primary care was at its best when provided by a range of professional staff working together as members of a primary healthcare team. The Bill before the House and the White Paper, Primary Care: Delivering the Future, which was published today, also significantly support those objectives.
I have given these amendments a great deal of consideration. I am very clear that nothing should stand in the way of nurses, midwives and health visitors playing a full part in using the flexibility provided in this legislation to develop not only their professional skills but to use opportunities. I am convinced that this can be achieved within the Bill.
Amendment No. 2 would allow the services currently provided under Part I of the 1977 Act to be provided through pilot arrangements. These are the services which we usually describe as hospital and community
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health services and are currently provided through health authorities or GP fundholders who may purchase hospital and community health services on behalf of their patients.
The amendment seeks to enable the piloting of community nursing services and others in addition to the pilots for personal medical services and personal dental services. I believe that this Bill already provides a significant opportunity for nurses through the development of their skills as members of the primary care team either in partnership with GPs or through taking on a more significant role in a trust that provides primary care services.
Amendment No. 9 aims to provide an automatic right to have proposals submitted to the Secretary of State to ensure that where, for example, a health authority has reservations about a proposal it may not block its scrutiny and potential approval at national level. Of course, we would not expect this to happen in the normal course of events. We are very confident that health authorities would want the widest range of proposals to be examined. But nevertheless we felt it was important to enshrine the principle of unfettered access to the Secretary of State within the legislation.
The health authority would need to be satisfied that any scheme not proposed by a suitably qualified doctor or dentist, or led by an NHS trust as proposer, could deliver the services proposed and had sufficient merit to warrant submission. Where a proposal was put before the health authority by any other professionals—and a good example might be of a nursing led proposal—it would look at the soundness of the proposal and use its discretion in deciding whether to prepare the proposals and submit them to the Secretary of State.
The proposed amendment does not add to the existing legislation. The health authority can already use its discretion in the way that the amendment provides. A similar line of argument applies to Amendment No. 10 which seeks to add UKCC registered nurses, midwives and health visitors to those persons who would have an automatic right to have their proposal for a pilot scheme passed to the Secretary of State for consideration.
As the Bill stands, nurses, midwives or health visitors putting together a proposal would need to secure health authority support for their proposal to be submitted to the Secretary of State. I believe this is reasonable since a health authority would have to be convinced that a pilot scheme which replaces general medical services with personal medical services would satisfactorily cover those areas of care which explicitly have to be provided by doctors. If doctors are co-initiators of the scheme, which would be the normal model for a pilot with substantial or even majority nursing interest, then the doctor can formally put the proposal to the health authority and automatic submission of the proposal would apply. If doctors are not involved in the proposal then it will need to be clearly set out how the medical practitioner input to the pilot will be made.
It is in everyone's interest that prior to the proposal going to the Secretary of State there is the opportunity for the proposers and the health authority to discuss fully the arrangements. My noble friend Lady Eccles

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spoke of the workload, which is a serious consideration. I am sure that if the health authority believed that a proposal merited support it would want to see it go forward to the Secretary of State.
Amendment No. 28 would seek to take nursing beyond the scope set out during our year long consultation on the future of primary care. What it envisages is that nurses will be able to provide medical services in the place of a doctor; that a nurse, or a midwife or a health professional, would deputise fully for a GP.
Our consultation has made it clear beyond doubt that we need to move to make more of the great potential there is for nursing professionals; but we do not want to turn nurses into doctors. Indeed, this Bill will allow nurses to play a full role as equal partners in the primary care team by allowing more explicit account to be taken of their skills. It is not appropriate that they will do the same job as doctors. I am sure nurses would agree.
The pilots will be replacing general medical services with personal medical services. In doing so, pilots will need satisfactorily to cover those areas of care which need to be covered by doctors. Doctors' vocational training and the particular role that they play in providing services to those on a patient list emphasises the rather different and discrete role that they play. The point is that GPs have spent at least nine years learning about the breadth and depth of the art and science of medicine and diagnosis; which conditions they can treat themselves; and which require the expertise of hospital care or primary health care colleagues, including nurses, midwives and health visitors who themselves possess skills unique to their professions. Doctors do not have all the skills of nurses and neither can nurses stand wholly in the place of doctors.
Amendment No. 48 goes wider than the proposals for pilots or for permanent schemes and is making a separate point about midwives in general. Midwives play a central role in line with Changing Childbirth, as the noble Baroness, Lady Jay, said, and in many cases the midwife is the lead professional providing maternity care across hospital and community settings. Our consultations on primary care reiterated and endorsed many of the points put forward in Changing Childbirth. There was continuing demand for more appropriate use of the skills and experience of midwives and the importance of maternity care professionals working together in a complementary way to give the best care for women.
Midwives of course already have autonomy in the care of women in normal pregnancy and childbirth. I understand that the move towards a primary care-led NHS has led midwives to look at new ways of working. I understand that a very small number have been looking at ways that they might contract through NHS contracts with health authorities and fundholders. The proposed amendment would enable them to contract through NHS contracts.
This Bill would already allow midwives working with GPs or NHS trusts to be innovative. They might, for example, look at new ways of delivering maternity care in the community in partnership with a community trust
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or a GP. This would achieve the aims of midwives who wish to further the aims of Changing Childbirth. Moreover, it would enable them to place NHS contracts with other NHS bodies.
Baroness Hayman: I am grateful to the Minister for giving way. She has spoken of midwives being lead professionals in some areas and of nurses being equal partners in others. In that case, why are proposals that are put forward by nurses, midwives or other professionals dealt with not through the system that applies to doctors and dentists where there is an automatic referral to the Secretary of State but through what was described earlier as a sifting system reserved for the Asdas, the supermarkets and commercial organisations? Surely, that is not sending the right message regarding the esteem and value which we are placing on those professionals.
Baroness Cumberlege: The difference is that the majority of health visitors, district nurses and midwives are already employed by NHS trusts, whereas doctors and dentists are private contractors who choose to have a contract with the health service for part of their activities. Certainly that is the case for dentists and that covers the vast majority of GPs' activities. That is the difference.
The noble Baroness, Lady Jay, asked whether a group of GPs who are not in partnership will be able to put forward a proposal. Yes, they will. There is no reason why individual GPs not in a formal partnership should not be able to put forward a proposal.
The noble Baroness, Lady Robson, cited a scheme where mental health services could be improved and the majority of the work would be done by community psychiatric nurses. That is a scheme which I am sure the health authority would wish to consider and there would be no objection to that being put forward to the Secretary of State if it was felt that that would improve services locally. The same applies to the point made by the noble Lord, Lord Walton, in relation to health visitors working with the homeless. I believe that in every scheme that I have seen, the health visitor was employed by the trust and of course, the trust would have a fast track, as it were, to the Secretary of State.
Therefore, we feel that these amendments are unnecessary. We believe that the Bill meets the aspirations which are being sought, and we hope that the noble Baroness will not seek to press the amendment.
Baroness Masham of Ilton: Before the Minister sits down, perhaps I may ask her (or perhaps I should ask the noble Baroness, Lady McFarlane) what would happen about insurance if midwives and nurses were taking full responsibility for patients? Is it not the case that insurance costs for doctors have gone sky high? Would nurses and midwives be able to afford that? I just ask that as a question.
Baroness McFarlane of Llandaff: I feel tremendously encouraged by the support that I have received from all sides of the Committee. It is

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encouraging to have the tributes to the professions other than medicine and dentistry which we are thinking about here.
To turn to the independent practice of nurses and midwives to which the noble Baroness, Lady Masham, referred, nurses, midwives and health visitors are practitioners in their own right and they are insured for their full professional indemnity through various agencies, although they hold joint liability as an individual, with the trusts employing them and with the medical staff who may be involved in a case. Therefore, nurses, midwives and health visitors have professional liability for their actions.
I have tried to follow the Minister's arguments in the case. I have difficulty in understanding her inability to accept the amendments and to allow access by nurses, midwives and health visitors in particular, and some other professions, to this right to submit pilot schemes in their own right. Nevertheless, I wish to consider very carefully what the Minister said on this occasion, and I should like an opportunity to study the White Paper that has been published today and perhaps return to this matter on another occasion. I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Lord Rea Lord Rea moved Amendment No.3:
Page 1, line 15, leave out subsection (2).
The noble Lord said: This amendment would remove subsection (2) of Clause 1. It would remove the words:
"A pilot scheme may not combine arrangements for the provision of personal medical services with arrangements for the provision of personal dental services".
When the Minister replies to the amendment, she will probably tell me that there are good technical reasons why medical and dental services cannot both be included in a single pilot scheme. If so, I hope that she will spell those out for our benefit.
I have personal experience of working in a health centre which housed both medical and dental practitioners providing National Health Service general medical services and general dental services. That was very much appreciated by the patients of the health centre, the GPs and the dentists. It was a convenient and professionally fruitful arrangement. Several times a week there would be cross-referrals between the dentists and the doctors. As the noble Lord, Lord Walton, will know only too well as a neurologist (although I am sorry that he is not in his seat) a headache can sometimes be due to dental pain. Dentists often found that it was useful to ask GPs about the health or allergic status of particular patients which concerned them. As the records were on the premises, it made it easy to obtain that information.
Sadly, that arrangement terminated because the dental practice felt that the health authority was overcharging it for the premises, quite apart from the fact that it did not feel that the NHS was paying dentists enough for their services either.
If a scheme were to be proposed which provided needed dental and medical services in, for example, a deprived area, would two separate but perhaps
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co-operating pilot schemes have to be put forward simultaneously—one for dentists and one for doctors? That seems rather cumbersome.
This is a probing amendment to find out what this prohibition on merging the two services in one scheme is all about. I beg to move.
4.30 p.m.
Baroness Cumberlege: We support wholeheartedly the objective behind this amendment—that of encouraging better integration of services provided by different professions. This has been one of our aims in primary care for some time and we have made good progress. Primary health care teams are stronger than ever and there is co-operation between GPs and dentists in some of the total purchasing pilot schemes.
The provision in the Bill, which the amendment seeks to remove, will not hinder further progress. On the contrary, the provision in the Bill helps to provide a framework of rules within which innovation and integration can flourish and without which we might in future face unnecessary complications. The provision rules out the option of a single scheme—and a single contract—covering both personal medical and dental services. General practice and dentistry are very distinct services, as I am sure the noble Lord will agree, with very different financial and practical arrangements. The Bill maintains this distinction and avoids the complexities that could arise if the services were covered by the same contract.
The provision serves a useful purpose, but it will certainly not prevent co-operation between doctors and dentists in a range of different ways. Indeed, we will encourage such developments which in some locations, though probably not generally, will be the best way to provide both services. Co-operation may involve the sharing of premises or planning services together. It may well involve examining local health needs together and co-operating over the preparation of pilot proposals which tackle these. The main constraint is that the contracts which emerge from successful proposals will be separate. I hope that I have made the reasons clear as to why we would not want to pursue this line. I hope that the noble Lord, in his probing amendment, has received a sufficient reply.
Baroness Gardner of Parkes: I am quite baffled by my noble friend's explanation. I do not understand the clause. I sat here quietly to listen to the explanation in the hope that it might make it clear to me. Unfortunately, it has not; indeed, I am still quite confused. There was a time—I mentioned this on Second Reading—when doctors and dentists were not allowed to practise in the same building, but that went a long time ago.
I can understand that the provision for payment, and so on, might be different and that, for example, one might be on a different contract from the other. However, the wording in the Bill seems to me to be most specific. Subsection (2) says:
"A pilot scheme may not combine arrangements for the provision of personal medical services with arrangements for the provision of personal dental services".

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That appears to be very limiting, and unnecessarily so. I do not understand the reason for having that provision in the Bill. If it were to be removed from the legislation, surely there would at least be the option to consider whether in a given area it was suitable. However, when such a provision is in the Bill it specifically precludes any such consideration. That seems to me to be contrary to the purposes of the Bill as a whole; namely, to bring forward innovatory ideas.
Lord Rea: I agree with the noble Baroness. The Minister's explanation did not satisfy me; in fact, it increased my bewilderment rather than decreasing it. Surely it is less complicated to have the two types of practitioner working in a pilot scheme, and, although they are paid from different sources, to make the arrangements within that scheme, than it is to have two entirely separate pilot schemes. I am still at a loss to know why the provision is in the Bill. I wonder whether the Minister will agree to think about it before the next stage. If she will agree to do so, I shall not press the amendment.
Baroness Cumberlege: I believe both the noble Lord and my noble friend will agree that the contracts are very different. When one looks at how general practitioners work, it is clear that the vast majority in this country are wholly contracted to the NHS; that is where they choose to place their contract. However, when one looks at dentistry, the situation is very different. Many dentists amalgamate private practice and NHS practice: they spend some of their time doing one and some of their time practising the other. In no way do we want to stop co-operation between those two great professions. Indeed, I am sure that many schemes will come forward. However, we would find it very difficult to have a single contract with two professions which are organised and paid extremely differently. I can see that Members of the Committee are not satisfied with my reply. Therefore, I shall take the matter away and come back to it after further thought.
Lord Rea: In that case, I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Baroness McFarlane of Llandaff Baroness McFarlane of Llandaff had given notice of her intention to move Amendment No. 4:
Page 1, line 18, leave out subsection (3).
The noble Baroness said: I believe that this amendment falls in the light of the withdrawal of Amendment No. 2. I shall, therefore, not move the amendment.
[Amendment No. 4 not moved.]
Clause 1 agreed to.
Clause 2 [Proposals for pilot schemes]:
Baroness Hayman Baroness Hayman moved Amendment No. 5:
Page 2, line 37, at end insert—
("( ) consult the appropriate local representative committee on the proposals, and").
The noble Baroness said: In moving the above amendment, I shall, with the leave of the Committee, speak also to Amendments Nos. 6, 8, 20, 21, 24, 32, 34,
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35, 37, 38, 39 and 41, but not, I trust, at great length. In view of the earlier discussion about the potential of trusts for initiating pilot schemes under the Bill, I begin by declaring a potential interest as I am the chairman of an acute trust in an area where primary care is in much need of support and where we might, indeed, be interested in submitting such a scheme.
The purpose of this group of amendments, large though it is, is all of a piece. The amendments seek to strengthen and clarify the procedures for consultation about pilot schemes at all stages. It must be said that within the Bill the details of what consultation is envisaged are skeletal in the extreme. In initiating such schemes, it is extremely important—and to be hoped—that they should have support and that at the very least those assessing them, including the Secretary of State, should know and take into account the views of local professional bodies, local public representatives and patients' representatives.
Perhaps I may clarify the group further. Amendments Nos. 5, 6 and 8 deal with the procedures for consultation when pilot schemes are proposed. Amendments Nos. 20 and 21 deal with the arrangements for consultation at the stage of review of pilot schemes, and Amendment No. 32 deals with the arrangements for consultation at the stage when the Secretary of State has a view to giving permanent approval to what has in the past been a pilot scheme. Amendments Nos. 34, 35, 37, 38, 39 and 41 deal with additional "pharmaceutical services" which will be provided under the Bill and seek to make explicit on the face of the legislation the arrangements for consultation, which are contained within the 1977 Act, both nationally and with local pharmacy committees. Finally, Amendment No. 24 deals with the provision of an annual report to Parliament by the Secretary of State on decisions taken under Clause 3 on,
"the findings of all reviews of pilot schemes carried out under [Clause 5]",
and on the "variation" and "termination" of pilot schemes under Clause 6.
We envisage substantial change; and we believe that it is essential that local people understand and are consulted about the changes to the basic structures of the NHS on which patients depend locally. We therefore propose that we consult with representatives of local patients including, but not exclusively with, community health councils.
Many organisations in different localities represent patients. Many organisations speak for patients with a specific illness or disability. It is important that health authorities consult the most appropriate organisations in their area. In some areas we have seen developments as regards public consultation; for example, in the use of citizens' juries. If such schemes were up and running, there is no reason why they should not be utilised in order to test the proposals.
The case for ensuring robust procedures for public consultation is strengthened by our earlier discussions. We are talking about serious innovations and the

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possibility of commercial organisations providing personal medical services for the first time. It becomes, therefore, more crucial that we secure the views of local people and patients' representatives on the proposals.
Amendments Nos. 5, 6, 21 and 32 ensure that local professional bodies for doctors and dentists are consulted. It is obvious that innovation and diversity in those areas are to be welcomed. That is the whole purpose of the Bill. On that basis the Bill's commitment to pilot schemes is welcome on this side of the Committee. It is equally important that we take an overall view and ensure that not only the opinions of the enthusiasts for a specific scheme in a small locality are made known but also that the wider views from professional organisations are taken into account.
Amendment No. 8 puts an obligation on health authorities to take account of the consultation with local authorities in their areas. In areas of primary care we are all aware how important it is to have proper consultation between local authorities and health authorities on the provision made for patients. As we see the blurring of the dividing line between health and social care, one provided by the local authority and the other by the health service, it makes even more important the liaison between those organisations and bodies. It is important that the local authority is given the opportunity to comment on pilot schemes, the review of pilot schemes and the possibility of making permanent those pilot schemes.
Amendments Nos. 34, 35, 37 to 39 and 41 bring in the provisions of the 1977 Act regarding consultation on changes to pharmacy schemes. I shall be interested to hear from the Minister why it was not felt necessary to put such local and national consultation on to the face of the Bill.
Amendment No. 24 deals with the annual report to Parliament. The Committee will be aware that we are encouraging diversity and innovation. Many different schemes up and down the country will be brought into effect. It is important that we are able to take an overall view of the effects of the legislation as regards those schemes which have gone ahead, those which have been amended, and those which have been made permanent. It is important to take a national perspective of the effect of the many different schemes introduced by different groups. I beg to move.
4.45 p.m.
Lord Alderdice: I speak to Amendments Nos. 5, 8 and 21. In so doing, I declare a potential interest were the legislation to be applied by order to Northern Ireland. I am the medical director of a health and social services trust in Belfast. It is that experience which leads me to speak on these matters.
I have drawn to the attention of the Minister that, in essence, Northern Ireland has had a pilot scheme of considerable proportions in that health and social services have been entirely integrated for more than two decades. In my judgment and that of most objective observers, the pilot scheme has proved most successful. There are two components of the scheme to which the
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amendments refer and to which I wish to draw the Committee's attention. There is tremendous co-operation between members of the medical profession, whether in hospital or in the community, and between consultants in hospitals and general practitioners. It seems clear that if pilot schemes are to be drawn up, consultation and co-operation among all medical professionals will be important. Hence it seems appropriate that if any pilot schemes are to go forward, there should be consultation with appropriate local representative committees. In the case of doctors it would be the medical committee; with regard to other professionals it would be the relevant committee.
However, we must also try to bring the community along with us. That seems obvious, but I draw the Committee's attention to the experience in Northern Ireland. It is a matter of continual surprise to those who visit us that social workers, doctors, nurses, psychologists and others work remarkably well together when they operate within the same organisation. In this part of the United Kingdom social services operate in local authorities whereas doctors and nurses and others operate separately.
That leads me to be strongly supportive of the notion that as we move, I trust, to greater co-operation between health service and social services professionals we should open the door in this part of the United Kingdom by encouraging—indeed requiring—consultation and co-operation with the relevant local authority. In particular one would wish to see the social services department of those authorities being consulted and thus encouraged to work more closely with health professionals.
In our experience progress in many fields has been remarkable. I refer in particular to the care of the mentally ill, those with learning disability, the elderly in the community, and children. In those areas co-operation between social services and health and social services and primary care has been remarkable and impressive. I ask the Minister to consider seriously encouraging and indeed requiring proper consultation and co-operation with local representative committees of doctors and other professionals, and especially with the relevant local authorities and their social services department.
Baroness Eccles of Moulton: There is a great tradition of consultation between health authorities and the local community. It is hard to believe that anything as serious as these pilot schemes could be contemplated without wide consultation between the first point in the process—the health authority, the local community and the bodies most affected by the proposals. Certainly in my experience the CHCs are most assiduous in requesting a consultation over what sometimes seems to us relatively minor service changes. It is rather surprising to me that it is so important to have this process featured so frequently on the face of the Bill in view of the practice I have experienced so far.
Another point is worth making. Once there are requirements in primary legislation, they place a very weighty sense of responsibility on those who are required to carry them out. That can sometimes have the

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effect of delaying very important changes and important progress in carrying out improvements to the way the health service is delivered. I should not like to think that the imposition of a very strict regime of consultation on those responsible could have an overly delaying effect. I should be very surprised if anywhere in the country changes of the sort that are proposed could possibly go ahead without thorough consultation and without that having to be on the face of the Bill.
Baroness Gardner of Parkes: I, too, think that this is rather a mixed idea. Consultation has become so accepted within the health service that I do not for one moment think that there would be any lack of consultation. However, given the way that the requirement is set out, in amendment after amendment, a very long and slow process is envisaged which could be quite self-defeating. The whole idea is to have people coming forward with innovative schemes for possible consideration as pilots and then to have them approved, as pilots only. I believe that full consultation would go on.
In introducing the amendment, the noble Baroness referred to changing local NHS structures and attached great weight to that. I did not envisage these powers as changing NHS structures, and I hope that they would not do so. I hope that NHS structures would continue to exist as they are and that these changes would be possible improvements, subject to the success of the pilot scheme, which might eventually at a later stage change NHS structures, but not at the pilot stage. There is a great tendency for people to give negative judgments in consultations.
The NIMBY theory that we see in planning, where everything is fine provided that it does not affect you, is very much the same in every field. Have Members of the Committee met anyone who wanted to do away with anything that they already had? However, if you suggest putting a mental home or a new fire station next to people, no one wants it. If it is there already, they do not want to lose it. It is very strange, but that is the human reaction. I believe that consultation would happen in any event.
Community health councils are very valuable bodies. Had I been asked 20 years ago, I should have said how appalling I thought they were. That was my belief 20 years ago. I thought that they were so destructive that the idea was hard to believe. I never saw them becoming the valuable bodies that they now are. I am very impressed by how well they work and how closely they follow every event that takes place. Therefore I agree with my noble friend Lady Eccles on community health councils.
The noble Lord, Lord Alderdice, spoke about greater co-operation between health and local authorities. I believe that is happening, and it is very good. However, the crunch point comes in relation to budgets. If the health budget were ever to be submerged in the local authority budget, then health would suffer. For that reason we must keep the two separate. But there should be consultation.
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Although I am mildly against most of these amendments, I am very much against Amendment No. 24 on grounds of sheer impracticality. I understood that the whole idea of the Bill was to bring forward not just the odd scheme here or there but lots of new ideas to be tried in all parts of the country. Amendment No. 24 insists on an annual report to Parliament on each decision taken, the findings of all reviews carried out, and,
"each variation and each termination".
In my experience, whenever people have to be notified of each variation, a variation can be the most minor thing imaginable. If the annual report to Parliament is to cover each variation and each termination—I shall not go through all the words, but they are all set down in the amendment—we shall have something like an encyclopaedia presented to Parliament every year if the Bill produces the number of innovative ideas that are being suggested. It is not a case of having to report the ones that are implemented; it is a matter of each decision, and why an idea was rejected. All the emphasis in the earlier part of our debate today was on encouraging people, nurses, pharmacists and others, to bring forward schemes. That will make any annual report bigger and bigger. As I say, it is not just a matter of schemes that are accepted; it is a matter of each decision. Amendment No. 24 is totally impractical. I oppose these amendments.
Lord Harmsworth: Perhaps the Minister can help the Committee on this point, following the remarks of the two previous speakers. Would flexibility be lost if these amendments were adopted? Would it not be the case that greater precision could be had as the Bill presently stands in so far as, presumably, the numbers and different types of consultee are large and very varied?
Baroness Masham of Ilion: In the past few years there has been a tremendous number of changes in the National Health Service. The public get confused. Therefore it is very wise to write in on the face of the Bill that there should be consultation with various bodies representing the public and different organisations representing the mentally ill, paraplegics and all sorts of different people. Perhaps there is no need for so many amendments; they could be consolidated. However, it is very important to have the goodwill of the community supporting any health issues. If people understand what is going on, they are far more likely to support it. I hope the Minister will be able to bring forward a proposal before the next stage of the Bill.
Baroness Cumberlege: This is a very large group of amendments. I shall take them in the order in which they appear in the Bill. The amendments would require health authorities and boards or, in some cases, the Secretary of State, to consult patients' representatives, the professions and local representative committees on proposals for pilots and reviews.
We welcome the objective behind the amendments. Primary care is the first port of call, as the noble Baroness, Lady Jay, said earlier, when medical or dental

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treatment is needed. If the provision in an area is to change, there should be an opportunity for people to make known their hopes and concerns. Similarly, it is essential that in taking forward this new approach to family health services we keep in close touch and take the views of health professionals, who know more than anyone how those services can best be delivered. In some cases, as the noble Baroness, Lady Hayman, said, it may also be appropriate for there to be discussions with local authority services, such as housing and social services.
The legislation and the arrangements to enable us to achieve this co-operative approach are already in place. So far as concerns patient representation, it is the role of health authorities and boards to secure local services that meet the health needs of local people in the way they want. As my noble friends Lady Eccles and Lady Gardner said, that process must include appropriate consultation with patient organisations and we will want to satisfy ourselves when considering authorities' approach to piloting that that has been thoroughly undertaken. Similarly, we will expect health authorities to take account of patients' views in the input they provide to evaluations. Community health councils, which represent patients' interests, already have a right to be consulted on major service developments and this will ensure that their voice is heard in discussions on piloting and more permanent arrangements.
Turning to the input of the health professionals, it is worth reminding ourselves of the characteristics of the arrangements the Bill will allow. Those arrangements will not be imposed on anyone. They are for volunteers, and will only happen if GPs, dentists and trusts come forward with innovative proposals which promise improvements in services for local people.
More than that, we will want proposals to mesh reasonably well with other services provided locally. We do not want to push through piloting at the cost of destabilising existing services. That is precisely why we are committed to considering carefully the proposals for pilots that come forward and to proceeding cautiously. That is why the Bill provides for the Secretary of State to require health authorities and boards to carry out appropriate local consultation on proposals. So appropriate consultation will be central to the drawing up of proposals. It will also be crucial when we want to evaluate schemes. That is why the Bill explicitly gives those GPs and dentists involved in providing services under a pilot the right to contribute to the evaluation.
I hope that this demonstrates our commitment to a consultative approach. The amendments under discussion would not add to this, but they would risk imposing inflexible rules. The hallmark of our initiative is diversity. We need to ensure local consultation can be adapted to the types of scheme, and type of situation that will arise. We agree with my noble friend Lord Harmsworth that there is a danger that rigid consultation would inhibit flexibility. That is why we do not want prescription on the face of the Bill. We are setting up broadly based consultative groups to consider the detailed implementation arrangements for piloting
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and it will be for these to recommend how we can best ensure that the professions' and patients' voices are heard.
The noble Lord, Lord Alderdice, sought reassurance on consultation with local professional bodies. We are committed to working with representatives of the professions at national level on matters such as detailed operational arrangements and general criteria for evaluation of schemes. Locally we will expect health authorities, GPs and dentists to work together on proposals. Local representative committees have a role, particularly in considering the implications of the proposed pilot schemes on existing arrangements. They are already able to do that under their powers in the National Health Service Act 1977. We shall certainly want their views, both on proposals and on their impact when it comes to evaluation.
It is right that there should be appropriate parliamentary scrutiny of government policy on the NHS. It is equally right that there should be reporting to Parliament on the performance of the NHS and the use of public funds. There are well established mechanisms for doing this and we see one of them in operation today. Scrutiny of secondary legislation and the work of Select Committees also ensures that the Executive is properly accountable.
This amendment would take us much further than that. It would involve Parliament in the detail of NHS operations in an unprecedented way. We have no targets for the number of pilot schemes we intend to run. If the early pilots are successful, and there are sufficient volunteers, we may be looking at a fairly rapid expansion of schemes after a year or two. As my noble friend Lady Gardner said, we wonder whether it is appropriate that Parliament should have a report on each scheme and on each review. The same point applies with still greater force in relation to variations of schemes.
The Bill sets two conditions which must be met before the Secretary of State may make an order bringing Clause 17 into force, and with it the legal framework for permanent arrangements. The first is that he must have regard to reviews of pilot schemes which have been conducted. In other words, there are to be no permanent arrangements unless pilot schemes have been tested and found to be successful. The second is that the Secretary of State must be satisfied that it would be in the interests of the health service to set up permanent arrangements.
For something to be in the interests of the health service it seems plain that it must be in the interests of patients. That, after all, is the group that the NHS exists to serve. For something to be in the interests of the health service it must also be in the interests of the NHS as an organisation—by serving to build it up and by promoting the interests of its staff, its greatest asset. Those, surely, are the tests which the Secretary of State would have to satisfy if he were ever to be called to account for the way he had interpreted this provision. It follows from this that in reaching his decision on whether to make an order bringing Clause 17 into force the Secretary of State will have to take into account the interests of patients and of NHS staff. The ways in

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which he may do this are various and it would, again, be premature and risky to try to prescribe them now. I would rather have openness and a genuine commitment to the interests of the NHS than any number of ringing, declaratory statements in primary legislation. The true test of the Secretary of State's actions is already there, in the Bill. We do not believe that the amendments would add to it.
We agree with the noble Baroness that it is important for representatives of the providers of pharmaceutical services to be consulted about the directions to health authorities or boards for the provision of additional pharmaceutical services. However, this is already done in connection with any proposed changes to the pharmaceutical services regulations. In the Government's view this would apply equally to the directions envisaged in Clause 23. To put the matter beyond doubt, however, I am quite happy to give the noble Baroness an assurance that the same consultation process would apply to directions under Section 41A of the 1977 Act and Section 27A of the 1978 Act, as now applies to regulations made under Sections 41 and 27 at present.
I also understand the concerns of the noble Baroness, Lady Hayman, about the need for consultation at local level with persons or bodies representing potential providers of additional pharmaceutical services. Our belief is that sufficient consultation provisions are already contained within Section 43B of the NHS Act 1977 and its Scottish equivalent. This provides that before a health authority or board makes a determination about remuneration for any service, it shall consult either a prescribed body established to provide advice on such matters or an organisation appearing to the Secretary of State to be representative of persons to whose remuneration the determination would relate. Our belief is that, with national consultation on the services covered by the directions, this would provide a fair measure of discussion with representative bodies. While we would expect health authorities and boards to consult widely about the range of additional pharmaceutical services which their populations need, we do not believe that a specific provision for consulting the representative body of the potential providers is right. Consultation with representatives of the population served would be as important, if not more important. I invite the Committee to reject the amendments.
5 p.m.
Baroness Hayman: I thank the noble Baroness for those assurances, which are extremely helpful, regarding the changes in pharmacy services. I am not sure that Members of the Committee can have it both ways in arguing against putting provisions for consultation on the face of the Bill. Either the consultations would take place in all that detail anyway—in which case there is no need to put them on the face of the Bill and it would not take extra time—or they would not take place and if we had to put them in place there would be great unnecessary bureaucracy and extension of time. But Members of the Committee cannot argue both cases at the same time.
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My argument is that it is essential to put them on the face of the Bill. I believe that in the past few years we have seen a profound breakdown in trust in decision-making processes within the NHS. That has been a damaging breakdown because it has ended in an almost automatic opposition to any change, however justified it might be. That is because of a basic distrust of the motivation and direction of health policy. I fear that we could get into exactly the same situation here regarding the potential commercialisation of general practice in primary care through the introduction of commercial companies into providing it.
That is why I believe that it is important that, in the difficult process of rebuilding public confidence in decision-making processes, in taking people through the reasons why "not in my backyard" might not be the best response, the answer is not simply to plonk it in their backyard and tell them that they have to lump it. It is to argue one's case through, to listen to what people are saying and to be prepared to let them have a judgment on what you are saying.
Amendment No. 8 was specifically designed not to be inflexible, not to give a list of everyone who had to be consulted in every possible situation. Perhaps I am more suspicious than noble Baronesses opposite who spoke. We should not leave everything to the assumption that it would be done properly, but should give the commitment on the face of the Bill that consultation would be properly undertaken.
Much has been said about the "encyclopaedia" that would occur if Amendment No. 24 were accepted. Within the health service many professionals are deeply disillusioned, being lectured by politicians and managers about evidence-based medicine and how they should be initiating it but not seeing a great deal of evidence-based policy coming forward from people like ourselves. I believe that somebody should assess all the information in the annual report that we suggest in Amendment No. 24 and if that assessment, the evaluation of the experiments is done at the Department of Health—it would be inconceivable and irresponsible for it not to be done there—it ought to be shared nationally.
These are important issues and I fear that we may have to return to them at another point. I beg to leave to withdraw the amendment.
Amendment, by leave, withdrawn.
[Amendment No. 6 not moved.]
Baroness Robson of Kiddington Baroness Robson of Kiddington moved Amendment No. 7:
Page 2, line 46, at end insert ("and such matters shall include provision for the transfer of employment rights, including pension rights.").
The noble Baroness said: I am sure that everybody in this Chamber will agree with this amendment, including the noble Baroness the Minister, because it puts right an anomaly which has existed for some time; an anomaly whereby a nurse working in a general practice is not entitled to join the NHS superannuation scheme. Even though, over a number of years while working in the main part of the health service, she has contributed to

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the scheme she has to leave it. It is frozen and, if she wants to assure her pension at a later stage in her life, she has to start with a separate scheme.
That seems absolutely iniquitous, considering the fact that the general practitioners working in the service are entitled to be part of the NHS superannuation scheme. First of all, it is unfair that the nurses are discriminated against; but it might also militate against them wanting to join any of the new pilot schemes initiated by general practitioner services. It is important to treat all employees in the service in the same way.
If I had received somewhat earlier than about an hour before this debate started the new White Paper Primary Care: Delivering the Future, I should not have had to "speed read" in order to discover whether it said anything relevant to this amendment. On page 44, the Government admit that the situation was wrong and state:
"The Government therefore intends to open the NHS Pension Scheme to staff employed by GPs. The new arrangements will take effect from September 1997".
The paper goes on to say:
"The detail of how the Government intends to introduce these arrangements will he discussed with the profession's representatives".
That sounds very fine. It is in the White Paper. But I should still like this amendment to be on the face of the Bill to ensure that it is not forgotten over the coming months. If it is in the Bill, we should all feel satisfied that we were going to treat our nurses in exactly the same way that we treat the GPs in general practice.
In view of the statement in the White paper, I hope that the Minister will approve this amendment. I beg to move.
5.15 p.m.
Lord Rea: We very much endorse the views put forward by the noble Baroness, Lady Robson. It would seem as though the Government have conceded the principle embodied in the amendment. As the noble Baroness said, if the White Paper had come out at the same time as the White Paper which preceded the Bill, many things would have been clearer. But I agree with her that the amendment should still go into the Bill. After all, it is only a White Paper. The arrangements are to take effect from September 1997 and there may—there will certainly—be a change of government by then. It is very likely that the Government will be run by my noble friends on this side of the Chamber, although of course sitting on the other side of the Chamber. Would not the Government like to see their successors also bound to follow these excellent suggestions in the White Paper?
Baroness Gardner of Parkes: Without arguing the last point—I hope that we shall still be sitting here at that time—I should like to support the principle of the amendment. But I must query its wording. When I have on my other hat and sitting as a member of an industrial tribunal, I am very aware of continuing employment regulations or transfer of undertakings regulations. But
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from what the noble Baroness said, these people are not currently employees of the health service because they work for a general practitioner. If that is so, and they are not currently in the health service, the transfer of undertakings would not cover them. It would only cover people who are currently National Health Service employees. It may be that different wording is needed. I feel that one needs to create continuity of employment within the National Health Service or something of that kind.
I strongly approve of the noble Baroness's point about pensions. In the case of my husband and myself, we each paid 6 per cent. of our earnings into the National Health Service pension scheme. Yet if I die, he does not receive a penny from my pension; but if he dies, I get 50 per cent. from his. I understand that that anomaly has now been corrected. But I felt very bitter about the situation for a number of years. I believe that it is very important to ensure that pension rights are protected. But we might have to go into the legal technicalities of the employment situation and I am not sure that these words would do what the noble Baroness intends.
Baroness McFarlane of Llandaff: I too support the intention of the amendment put forward by the noble Baroness. In any other setting this kind of anomaly would lead to inflexibility and lack of mobility in the workforce. That is the very thing that we want to try to avoid in the National Health Service. I support the amendment.
Baroness Cumberlege: My noble friend Lady Gardner is right. Practice nurses have been employed directly by GPs in the past and therefore the Government felt it right that the employers should take on the responsibility of the pension scheme. But we have listened to nurses and recognise their concerns about this particular issue. So the Government are committed to widening the NHS pension scheme to practice nurses.
I think the Committee will agree that we need to discuss the matter with the profession's representatives. It would not be right just to go ahead without having discussed it with them. Therefore, we feel that it would be premature to put this amendment on the face of the Bill.
Baroness Robson of Kiddington: Of all the amendments that appear today on the Marshalled List, I felt that this was one to which the Government would agree. I can see the point in regard to nurses who are already outside the NHS scheme because they are working for a general practitioner; but I cannot understand why it is not possible to include this provision on the face of the Bill. I should very much like to see it included. I shall not press the matter today but will come back to it at a later stage. I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
[Amendments Nos. 8 to 10 not moved.]
Clause 2 agreed to.
Clause 3 [Approval of pilot schemes]:
Baroness Jay of Paddington Baroness Jay of Paddington moved Amendment No. 11:
Page 3, line 20, at end insert ("(if the pilot scheme is for personal medical services) ask the Medical Practices Committee for its assessment of the adequacy of medical services in the area likely to be affected by the proposed pilot scheme and its assessment of the likely effect of the pilot scheme on the adequacy of those services and, having taken into account those assessments, he shall").
The noble Baroness said: In moving Amendment No. 11, I shall speak also to Amendments Nos. 13, 14, 31, 54 and 62 and to Clauses 10, 11 and 12. I hope that that is in order. It may sound somewhat sweeping but, as we are in Committee and as the amendments and those short clauses are relevant to the status and position of the Medical Practices Committee—which all the other amendments address—I suggest that it may be appropriate to discuss them all together.
As the Committee will recall, when we spoke about this issue on Second Reading many Members on different sides of the Chamber raised concerns about the Medical Practices Committee and the position it would have under the new pilot schemes. The Minister, in reply, explained to us at that stage that she had already talked at length to members of the Medical Practices Committee and discussed its position in relation to the Bill or in relation to the pilots and further permanent schemes. At that stage she was not able to report any conclusion to the Chamber. However, she did say that she would be putting forward proposals in the light of those discussions. I hope that today the noble Baroness will be able to give us some report on the progress of those discussions and to say that these amendments as they stand will provide a stimulus to some of the solutions which we on this side of the Chamber and others who support the amendments feel may deal with the problem.
The purpose of the amendments is to ensure that the Medical Practices Committee continues to fulfil its statutory responsibility to ensure that as far as possible primary care services delivered by general practitioners are equitably distributed within a national framework. As I said, several noble Lords at Second Reading raised the concern that, by establishing the pilot schemes in the way that they are presently drafted in the Bill, that would mean that the Medical Practices Committee was effectively bypassed. There is anxiety in that committee that provisions in the Bill are designed to sideline it and make it irrelevant to the processes it justifiably and rightly feels are important.
I remind the Committee that at present the Medical Practices Committee, as a national body, has the duty which it has had since the NHS was instituted in 1948 to assess whether various areas are served by an adequate number of GPs; to exercise its discretionary power to refuse, where they are so served; and to ensure that as many areas as possible are so served. That is an essential function in the struggle to improve equity of access in the health service.
As I and other noble Lords who spoke at Second Reading described, there are large inequalities in the provision of services throughout the country. For example, it has been calculated that 700 doctors would
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have to move to the north from the south of England to provide a reasonably equitable distribution of general practitioners across the country. And, as I said in an earlier debate this afternoon on new Clause 1 and as my noble friend Lady Hayman emphasised in relation to the consultation process, we are fearful that some of the new proposals that could come forward under the pilot schemes, particularly those introducing commercial interests into primary care, may serve only to increase services for the better off and do nothing to improve overall equity, and indeed may work against it.
It is therefore extremely important that in a more deregulated system which this Bill opens up, the Medical Practices Committee should retain its power to act on a national overview of needs. Amendments Nos. 11 and 14 are specifically designed to ensure that that takes place. I prefer those two amendments to Amendment No. 13, which I feel is less stringent in its understanding and less precise in its demands on the regulations that the Medical Practices Committee should carry out.
The British Medical Association, as well as the Medical Practices Committee, is concerned that under the Bill as it stands there will be two different workforce planning systems—one where, through the Secretary of State, with prior agreement of health authorities and boards, decisions are made in relation to doctors entering pilot schemes and another where the Medical Practices Committee retains the remit for determining recruitment or replacement of GPs who are working under the present contract. Both the British Medical Association and the Medical Practices Committee feel that it is inappropriate, given the long experience of the Medical Practices Committee and its extremely extensive national database, that they should not be involved in assessing and agreeing to the involvement of GPs in the pilot that will take place under a rather different scheme.
The question also arises as to whether the way in which the approval of the pilots is obtained may adversely affect the ability of existing practices to recruit additional or replacement partners. That again relates to the matter of equity. It is suggested, for example, that if a local health authority agrees to pilots which are attractive to general practitioners, that may unfairly diminish the possibility of other GPs practising in that area gaining new partners or replacing old partners in a way which maintains the equity of the service.
The point overall is that there should not be two different systems for assessing and evaluating the way in which doctors are contracted and may be employed under the pilot schemes to provide services; that we have in existence the effective Medical Practices Committee which makes that provision possible within a national framework, and to make it more complicated by having a dual system may simply exacerbate inequities and do little to make it easier to establish a national picture of the way in which the workforce should be agreed.
There are also complications—referred to in the clauses we feel should not stand part of the Bill—in relation to why it is that the dual arrangements for

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contracting general practitioners and making them part of the pilots will have an inhibiting effect on the ways in which the general system is agreed. For example, under Clause 10, GPs entering into pilot arrangements are required to leave the medical list under Part II of the NHS Act. They would not be allowed to work under both parts of the Act or to hold lists of patients under both parts. If that was deleted it would mean there had to be special arrangements, as Clause 10 allows, for medical practitioners who provide medical services in pilot schemes to be separately looked at and assessed. They could stay on the medical list. They would be part of the original system and would not be required to resign.
Clause 11 is another area where the same problem arises in relation to treating general practitioners within a pilot scheme in a different way from the system nationally understood and already working which is arranged through the Medical Practices Committee. For example, if Amendment No. 31 is accepted, a doctor who was included in the medical list under Clause 17 (if that were amended) would be included on the local list by the Medical Practices Committee. If the pilot scheme failed, the doctor would still be on the list and would not need to be given preferential treatment to return to the list.
In other words—I know this sounds extremely complicated—the basic point is to maintain one unified system for dealing with all general practice and for allowing all general practitioners to be assessed under an effective and well managed national scheme which takes into account both local and national needs and is able under the scheme which has been working since 1948 to make assessments on the basis of long experience and with an invaluable database. Indeed, if Clause 12 was deleted, the difference between "personal medical services" and "general medical services" would be effectively eliminated by bringing all the personal medical services into the control exercised by the Medical Practices Committee (that would be under Amendment No. 31) and this clause would also not be necessary.
This is an extremely complicated area and there may well be different points to which the Minister will want to reply when she responds to this group of amendments. However, the basic point is that in the Medical Practices Committee there is a well organised and long established national body which has a statutory responsibility. It is unclear from the discussion we had at Second Reading why its remit should not be extended to cover pilot schemes. It seems important that the MPC should be included. If it is not to be included—if it is to be excluded—that should be made more specific.
At Second Reading the Minister said that she and other colleagues were engaged in discussions with the Medical Practices Committee. Noble Lords will recall that in many debates in your Lordships' House we have spoken of the need to maintain a national framework for the National Health Service. We have also expressed fears from these Benches about recent fragmentation. In her reply to the Second Reading debate when speaking about the Medical Practices Committee the Minister was
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specific. At col. 649 of the Official Report of 3rd December 1996 she said that she wished to ensure that a coherent local and national approach was applied to new proposals. I hope she will accept that these are in a sense probing amendments, because we want to establish the role of the Medical Practices Committee will have in future, but we are trying to seek to ensure a continuing role for the MPC and we are seeking to ensure that the aspiration which the Minister expressed at Second Reading for a coherent local and national approach becomes a reality. I beg to move.
5.30 p.m.
Lord Alderdice: In supporting Amendment No. 11, I should like also to refer to Amendment No. 13, which stands in my name, Amendment No. 31 and the proposition that Clauses 10, 11 and 12 be excluded from the Bill. The concern that I represent on behalf of my colleagues on these Benches is not merely about the continued existence and satisfactory functioning of the Medical Practices Committee, now almost at its 50th anniversary, but a much more fundamental one about whether a health service continues to be a truly national health service.
We strongly welcome the notion that local sensitivity and local creativity might be expressed in the development of pilot schemes in order that new ideas come forward which might be properly evaluated and then taken up by practices in other parts of the country. That is exactly what one would want to see in best practice. However, if things work out as described by the Minister and there is, in her words earlier today, "a rapid expansion of schemes", it is much more likely that, rather than a number of well constructed pilot schemes being embarked upon, reviewed, adopted widely and continuing to develop and to benefit a national health service, we shall see a rapid expansion of very different pilot schemes throughout the country which will lead to a fragmentation of service. Unless there are bodies which will properly monitor what is going on we shall undoubtedly see our health service no longer national but even more different and less coherent than is the case at present.
In supporting these amendments we express our serious concern that if the excellent idea of pilot schemes is not properly monitored, it could be the beginning of an even further fragmentation of the National Health Service, which is one of the most prized commodities and institutions of our country.
Baroness Eccles of Moulton: In considering the proposals put forward with regard to the Medical Practices Committee it is important that we accept the current situation in terms of equity of service across the country. The noble Baroness, Lady Jay, said that a certain number of GPs will have to move from the south to the north in order to achieve that. The Medical Practices Committee has only the power of veto and therefore it seems difficult to accept that pilot schemes going forward under the form of approvals we have already discussed will necessarily exacerbate the inequities. Unless it is given a try it will be difficult to know whether this is the right was forward.

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Another point is worth making. It has been said that the Medical Practices Committee is the repository of a great deal of knowledge about GPs' qualifications and their records of service. It is not the only repository of that information. The committees that sit to appoint GPs also have that information. I should have thought that GPs themselves, when applying for a new practice or for a first practice, would be well able to supply that information.
I do not think it will be at all helpful to the success of the pilot schemes if they are not established in the most unfettered way possible.
Baroness Cumberlege: The Government are committed to fairness in the distribution of services. That was a fundamental principle underpinning Primary Care: the Future and restated in the White Paper Choice and Opportunity. It is because we want to ensure equity that we presented the Bill.
The existing mechanisms have worked well in many places in the past but not everywhere. We need to be extremely careful about imposing constraints on decisions concerning pilots. The Government believe that pilot schemes should improve fairness both within health authority areas and between health authorities. That will be a key consideration when pilots are considered and before approval is given. We wish to have full discussions with the profession and others before determining how this can best be achieved. We have already started these discussions with the chairman of the Medical Practices Committee and my right honourable friend the Secretary of State, Stephen Dorrell, has written to the General Medical Services Committee. It would be wrong and potentially damaging to sensible development to pre-empt these discussions in the way the amendments seek to do.
Perhaps I may now deal with each specific amendment. Amendment No. 11 would require the Secretary of State to involve the Medical Practices Committee in the decision to approve a pilot. In particular it would place a requirement on the Secretary of State to obtain an assessment from the Medical Practices Committee about the adequacy of medical services in the area likely to be affected by the scheme and the likely effects of the pilot scheme on the adequacy of those services. Assessments would have to be taken into account in reaching a decision.
The amendment refers to medical services and not to adequacy of general medical practitioners. An important distinction needs to be made here. The distribution of general medical practitioners, by using negative direction, is quite a different role from that of assessing the health needs of populations and planning service provision to meet them. The former is about the input of a specific resource, albeit a crucial one, while the latter goes much wider, involving other considerations, including the part other professions have to play in the provision of family doctor services.
Health authorities have to assess the health needs of their populations and to judge the nature and extent of services required across primary and secondary care. They must make judgments about the balance between
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primary and secondary care and the priority to be afforded to particular services to best suit the needs of patients. They must also make judgments about the inputs into services—human and financial—balanced against outcomes. It is for this reason that health authorities will produce workforce plans for general medical services which are consulted on locally.
Plans will take account of all professional groups—medical practitioners, nurses, professions supplementary to medicine and administrative and clerical staff. These plans will be consequential upon careful planning of services to meet needs and will inform decisions about recruitment, education, training and development of the workforce. It is crucial to success that health authorities' plans for services and consequential workforce plans form a single point of reference to inform other decisions. That is what we intend to achieve.
Decisions by the Medical Practices Committee and decisions by the Secretary of State on pilots must be fully informed by these plans. This amendment would mean that the Medical Practices Committee not only second-guessed health authorities' decisions about the health needs of its population and the services required, but also the Secretary of State in the process of approving pilots. It would result in needless bureaucracy and take decisions about services further away from the patient.
As I have tried to make clear, I do understand the concerns which have been expressed about pilots leading to an inequitable distribution of services. I too would be concerned. But this will not be the case. Areas of high need will be targeted where perhaps the more traditional ways of providing general medical services has not delivered the quality or range of services required.
Pilots will cover a diverse range of services provided through a variety of professions. While for the most part they will be led by a family doctor, the emphasis will be on team working with other professionals—nurses, physiotherapists and others. The aim is to provide an environment which encourages innovation and flexibility.
In general medical services, resources have tended to follow general practitioners who themselves are not distributed entirely equitably in relation to population. The distribution of GPs per head of population varies across the country. Some health authorities have average patient list sizes which are 50 per cent. higher than in others. In some parts of the country expenditure is almost two-thirds higher than elsewhere. Recently published papers and articles have pointed to similar inequities. While it is probable that this may be overstating the case, because we need to develop better measures of need for general medical services, we do accept that there is an underlying problem.
It is not surprising that such inequities have occurred. As the noble Lord, Lord Walton, said in the Second Reading debate, the Medical Practices Committee has had considerable experience in ensuring an even distribution of general medical practitioners. But this is based on the distribution of GP principals through negative direction. In other words, while they can only

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prevent a doctor practising in over-doctored areas they cannot stimulate a doctor to work in an area. The provision of services in areas which are less desirable are best achieved if health authorities, GPs and other service providers are together able to explore ways in which services might be provided. Pilot schemes will provide new opportunities for such development.
The noble Lord, Lord Walton, also said that the Medical Practices Committee is the only body which has a detailed overview of the national GP manpower situation at any one time. But this understates the position. National manpower planning is a key task of the Department of Health. It is an essential component of financial planning and distribution of resources and providing the trained workforce for the future. Information is collected from health authorities at regular intervals to feed into this work, which is highly detailed and requires particular skills and abilities. This is a proper role for the department, which will continue to be taken forward. It is for this reason we have asked health authorities to undertake workforce planning for general medical services so that local needs and difficulties can be better understood and fed into the national picture.
This is not the role of the Medical Practices Committee nor would it be appropriate that it should be. The committee comprises of nine people, working part-time, dealing with applications from doctors to join medical lists. I am not questioning their expertise in this area; but it is wrong to believe that their role goes wider or indeed that it would be appropriate for it to be so widened. I repeat, we shall be discussing with the Medical Practices Committee ways in which its knowledge and expertise might usefully feed into the work on national workforce planning in collaboration with the profession and others who have an interest in this area.
As I said, we are committed to achieving equity and this is fundamental to our aims. We have already taken forward work within the department which has looked at the distribution of resources for general medical services. We need to develop this work further, in particular how to measure need and discuss with those who have an interest.
Amendment No. 13 is intended to complement the earlier amendment giving an inappropriate role, we believe, to the Medical Practices Committee. The amendment would mean that the Secretary of State may not approve proposals for a pilot scheme for personal medical services unless he is satisfied that the proposals have proper regard to the needs of other areas and the assessments made by the Medical Practices Committee. Thus, the Medical Practices Committee would be required to make an assessment of the impact of any pilot schemes for personal medical services on areas other than those in which the pilot is intending to operate.
As I hope I have already made clear, it is health authorities who must judge the health needs of their populations and determine how services should be provided to best meet those needs. Pilot schemes will be reflected in any plans, as will the more traditional
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ways of providing family doctor services. I expect health authorities to consult locally with LMCs and other interested groups about their plans for general medical services and the effect of any pilots on those services. Similarly, health authorities will be expected to consult the Medical Practices Committee about their plans for general medical services so that a coherent view can be formed over the number of general medical practitioners required to deliver services. These discussions will include any plans for pilots to enable the Medical Practices Committee to take these into account when carrying out its statutory role in relation to general medical services. It is totally inappropriate for the Secretary of State to have to seek any reassurances from the MPC about pilots.
Amendment No. 14 also seeks to ensure that, in approving pilot schemes, the Secretary of State has to have paid due regard to an assessment made by the MPC about the need for those services. In making such an assessment, the MPC would assess whether or not there is already adequate provision of general medical services in the area likely to be affected by the pilot scheme compared with the needs of other areas. That assessment would then have largely to determine whether or not the Secretary of State approved the scheme.
As with earlier amendments, this places a responsibility on the MPC well beyond its current statutory duty and provides for it to second-guess health authorities in their strategic, financial and human resource planning role. Perhaps even more importantly, it would fetter the discretion of the Secretary of State. In accepting such amendments he would no longer be responding to the clear messages received from the profession, public and health service managers through our listening exercise that the biggest need which currently exists is for primary care services to be provided in flexible ways to meet the needs of patients and the professionals working within those services. Instead we would be tying ourselves into a bureaucratic process, which would confound robust and clear decision-making processes and confuse lines of accountability and responsibility. Therefore, we do not support this amendment.
Amendment No. 31 is connected to earlier amendments which attempted to provide a role for the MPC in agreeing pilot schemes for personal medical services. This amendment is intended to provide a process whereby any permanent schemes which followed from successful pilots were considered by the MPC.
However, the amendment is defective. Decisions currently made by the MPC are concerned with the distribution of doctors providing general medical services and only that.
That is carried out by a process of negative direction whereby the committee does not admit a doctor to a health authority's list if the area is over-doctored.
The second part of this amendment confuses two quite different processes, which are in place for two different types of service provision: the process of admission to a list by the MPC so that a doctor can

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provide general medical services in a particular area, and decisions made by health authorities to provide personal medical services which do not involve admitting a doctor to a list. We cannot therefore agree to such an amendment.
Amendments Nos. 54 and 62 deal with our revised appointment procedures for doctors providing general medical services. These new procedures are required to remove anomalies and provide a sound basis for GP appointments. In particular, it is intended to reduce bureaucracy. These amendments would leave in place Section 30 of the Act, which requires the names of all doctors wishing to provide general medical services to be submitted to the Medical Practices Committee for approval and inclusion in the health authority's list. The section would remain alongside the clause we have drafted as a replacement. This confuses the roles and responsibilities of the MPC and those of health authorities. I am sure that that cannot have been the intention. I hope that these amendments will not be pursued by the Committee.
I should like to address the Question that Clause 10 stand part. This clause will ensure that medical practitioners who provide care for their patients under pilot schemes may not also provide services under the national arrangements. This should bring clarity to the arrangements under which services are provided for patients. It is important that GPs and health authorities are clear as to whether the services provided by a particular GP are provided under one arrangement or the other. To allow a mix and match arrangement, with a patient receiving some treatment under one system and other treatment under the other, could lead to confusion.
However, the clause provides for regulations to allow exceptions to this rule. There may be circumstances where such exceptions are sensible and necessary. For example, it may be necessary to allow GPs who provide a specialist obstetric service to the patients of other GPs to provide such a service to patients of medical practitioners working in pilot schemes. It is hoped that your Lordships will agree that Clause 10 should stand part of the Bill.
Clause 11 underpins the voluntary approach to pilot arrangements by ensuring that GPs can be given the right to transfer to the medical list and to the existing national arrangements if and when they leave pilot schemes. When a doctor sets himself up in general practice he is setting himself up in business and he takes the commitments that go with that. Whether he is a single-handed GP or a partner in a practice, he will have premises that need to be paid for, staff to pay and overheads to bear. GPs who work in pilot schemes will need the security of knowing that they can, if they want, transfer from pilots to the national arrangements with ease. It is particularly important that they should not have to go through the whole application procedure as if they were not yet practising GPs, especially since in most cases they are likely to bring lists of patients with them.
The clause provides that before a health authority or board makes a pilot scheme the Secretary of State will publish criteria dealing with such transfer arrangements.
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He will decide whether a particular GP should be given preferential treatment if, once he has ceased to provide services under a pilot scheme, he makes an application to a health authority or board asking for his name to be included in the health authority's or board's medical list. Naturally the GP would need to meet the eligibility criteria in force for the time being, for example those on age. The Government believe that this is a central plank of the Bill, and we ask the Committee to support the clause.
Clause 12 is important in safeguarding the quality of the services that patients receive when they are treated by a deputising GP. It will enable regulations to be made which will set out clearly the liabilities and obligations of GPs working in the existing system in circumstances where doctors working in a pilot either act as deputies for them or else use them as deputies. The situations that arise under the current arrangements are provided for by regulations made under the 1977 Act. Until now there has been only one arrangement around which to regulate. Under the pilots doctors will work under contracts that will differ from place to place and from circumstance to circumstance. Their arrangements will vary from the national terms of service. However, it is important that arrangements regarding liabilities and obligations are consistent and fair. This is the aim of these provisions. This clause will provide for a seamless primary care medical service where deputising services are used. I invite your Lordships to agree that Clause 12 should stand part of the Bill.
Baroness Jay of Paddington: I am grateful to the Minister for her detailed response to this series of amendments and the Question whether the clauses under discussion should stand part of the Bill. I am tempted to follow the response of my noble friend Lady Hayman to the earlier debate on Amendment No. 5 and the related group of amendments. This afternoon there have been a number of double arguments that attempt to make the same point. For example, in this debate each time we try to put in place a safeguard to protect standards, or in this case to protect the way in which general practice is developed in different parts of the country, we are told that it is needless bureaucracy. However, we are always assured that detailed planning will be carried out and enormously elaborate systems put in place before any pilot scheme is agreed, let alone determined to be a permanent change of service.
The more one discusses the Bill, the more it appears that what we are considering are good intentions rather than safeguards or exact provisions on the face of the Bill. In response to this group of amendments the noble Baroness referred to the Government's commitment to equity as being a basic plank of the Bill, but when in this and in an earlier debate on another group of amendments we have tried to ensure that equity is explicitly required on the face of the Bill, that is denied. In her response to this series of amendments the noble Baroness speaks of the central role of health authorities and their ability to assess local needs in a much more significant way than the Medical Practices Committee, which would look at the matter on the basis of only GP services. We are led to suppose that GPs are not

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absolutely central and that a wider provision of services is looked for under the Bill. That was exactly our understanding. We understood that the idea behind the Bill was to improve and increase the flexibility of local services. However, earlier this afternoon when the noble Baroness, Lady McFarlane, sought to introduce an amendment to enable other professionals to become the lead proposers of alternative arrangements under pilot schemes, it was rejected by the Government.
As we progress further with the Bill, it is difficult to understand precisely who are the principal instigators of the new schemes, who is to have the controlling influence in ensuring that they provide equity, together with the other principles that we are told are essential to the changes, and who is to assess the overall standards and framework within which we have always believed that the National Health Service operates.
The noble Baroness in her reply also said that she and her honourable and right honourable friends in another place, the Minister for Health and the Secretary of State, continued to discuss with the Medical Practices Committee the contribution that it could make under the new pilot schemes. However, if I were a member of the MPC, on the basis of the remarks of the Minister I would be extremely pessimistic.
The British Medical Association is also in tune with the Medical Practices Committee in agreeing that there should be a means of looking at the overall doctor workforce, whether or not they are regarded as central to the new pilot schemes. I agree with that. I believe that in the interests of equity—which the Minister emphasises is the primary aim of the Bill—there must be an organisation to do precisely that. I also agree with the noble Lord, Lord Alderdice—I am sorry that he feels that I have not emphasised it sufficiently—that the main principle behind all of these amendments is to try to avoid further fragmentation of the National Health Service. All of us are concerned about that. Within the Medical Practices Committee there is a national body that has some remit to try to prevent that fragmentation. However, from what the Minister has said—she has left the door slightly open—the Government do not see the role and overall perspective of the workforce as being particularly important in the development of the new pilot schemes. As we have feared, this is all about deregulation rather than the equitable organisation of services.
I am disappointed by the Minister's reply, but at this stage I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
6 p.m.
Baroness Jay of Paddington Baroness Jay of Paddington moved Amendment No. 12:
Page 3, line 24, at end insert—
("( ) The Secretary of State may not approve proposals for a pilot scheme unless he is satisfied that the scheme meets nationally agreed criteria for the quality of services provided to patients.").
The noble Baroness said: I beg to move Amendment No. 12 and speak also to Amendments Nos. 18, 22 and 23. All four amendments are designed to ensure that the
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pilot schemes for new primary care are not simply approved and evaluated on the basis of a described local need or comparative cost but will also meet nationally agreed criteria to ensure that the care that is offered is of the highest national standard of practice. To an extent, this is a continuation of the debate on the previous group of amendments. It is an attempt to prevent the fragmentation and disorganisation of services simply in the interests of diversity.
If this amendment is accepted we hope that agreed criteria are published before the machinery of establishing the pilots gets under way. On these Benches we accept that the increased flexibility in local practice arrangements may well extend the types of primary care services to be offered, something which we have already discussed this afternoon. For example, we discussed under earlier amendments that we welcomed the possibility that nurses and others would have a wider responsibility in health care promotion. Indeed, if the amendments of the noble Baroness, Lady McFarlane, had been accepted we would have liked to see them as lead partners in pilot schemes, but we are also concerned to ensure that increased diversity does not lead to reduced overall quality.
At Second Reading the Minister emphasised the need for quality controls in these pilots—also mentioned in the White Paper Choice and Opportunity, which spoke of promoting consistently high quality across the country. In introducing the Bill at Second Reading the Minister said, at col. 591 of the Official Report that local flexibility should be balanced by national safeguards for patients and practitioners. However, she did seem to see this more in terms of the professional relationship between individuals and their general practitioners rather than protecting or, even more importantly, promoting the quality of services to be offered under the new schemes.
I realise that the question of evaluating and standardising quality in medical care is extremely complex and very delicate. Doctors rightly resist what they now call recipe book clinical practice. However, one of the positive changes in the health service in the recent past has been the overall professional acceptance that evidence-based practice, peer group review and the general bench-marking techniques widely used in business and industry can play a role in health care. My noble friend Baroness Hayman has already referred to the scepticism which has grown up in some places within the health service about the fact that they are constantly asked to deliver evidence-based care without any reference to evidence-based policy. That lack of evidence-based policy has been very apparent in the fact that the Government have so far resisted developing what I suppose one might call NHS gold standards for the quality of service.
It is true that today we have the almost unenforceable aspirations of the Patients Charter, but there also seems to be very little official enthusiasm for producing and agreeing national workable criteria for assessing high quality care; criteria which presumably should be based (at least in the first instance) on comparative research and measuring outcomes. This Bill is a golden opportunity to initiate such research and agree such a

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system. Basically our concern, which has been expressed in several of the groups of amendments, is that unless the pilot schemes are developed and evaluated within a national framework of standards then more may simply mean worse. Clearly evaluation of these schemes, once they have been established, is absolutely crucial and we would hope to see that done on the same kind of previously published criteria as those which are agreed for setting up the pilots in the first place.
At the Second Reading debate the Minister said that the evaluation process would be determined following discussions with professions, health authorities, academic units and patients. However, it seemed to leave a great deal open in terms of the different types of review processes which might be applied to different schemes and it seems to us important that those proposing pilot schemes should know that there are at least some nationally agreed criteria which will be involved in determining the review process. Such criteria could again be very similar to those which were agreed on a national basis for setting up a pilot in the first place. They might, indeed, include all of the things about quality of outcome as well as responsiveness to local needs, which would be strengthened if the amendments which my noble friend Baroness Hayman introduced about local consultation had been agreed as well as, of course, cost effectiveness.
When the noble Baroness introduced the Bill at Second Reading she gave assurances about maintaining standards, as did the White Paper which preceded the Bill. We are back to this question of goodwill and assumptions about people's intentions which I referred to when I was summing up on the previous group of amendments. Assurances have been given but the Bill as it stands really gives no indication as to how maintaining standards will be achieved. The purpose of Amendment No. 12, and the others in this group, is to enable a national system of criteria to be developed against which pilots can be established and tested in terms of the broad overall quality of services to patients. I beg to move.
Baroness Robson of Kiddington: We on these Benches support this amendment. There is really nothing much to be said after that introduction by the noble Baroness, Lady Jay. However, we are concerned, as are most people, that although the idea of flexibility in the type of scheme that is introduced locally is appealing and basically good, the pilot schemes should be based on a national standard which everybody can understand and judge them against.
We suffer already, and have done for some time, from a lack of national standards of care over the whole of the National Health Service. In many parts of the country the standards vary enormously. We do not want the flexibility of the pilot schemes to add to that difference. We want them based on carefully considered national standards so that we are certain that they are an improvement on what is happening at the moment and
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that they will not endanger some of the undoubted benefits which we get from the present primary health care system.
Lord Winston: I should like to echo what my noble friend Baroness Jay said about the Government missing what is essentially a very important opportunity.
It must be recognised that general practice is among the most difficult of all medical specialties. That may seem a very odd thing to say, but this must be considered in the context of the general practitioner seeing a huge range of different medical problems and consequently having to spot among those medical problems the very occasional problem; for example, the one cancer of the colon that he might see once every three or four years in a typical general practice. He must be alert to such eventualities. That makes his responsibility a very grave one.
It seems to me that one of the key issues which has already been mentioned by the noble Baroness, Lady Robson, is the very great variability in the United Kingdom in the standards of general practice. Of course, most general practitioners in this country are excellent. They are among the best available anywhere in the world, but we do have a great variability of practice. Certainly many of us who work in the cities see that in the inner city areas general practice is often very poorly conducted. It troubles me that we might see a worsening of the position unless there is vigorous inspection of these pilot schemes. After all, this is not a new idea. It was this Government who instituted the notion of peer review, for example, of fertility units, which has been an important part of the inspectorate system, in order to make sure that adequate patient care and quality is maintained.
One of the aspects that concern me is that a general practitioner must ensure that he keeps a proper watching brief over a patient after referral to a hospital rather than simply losing that patient, that he maintains proper family care afterwards, and to ensure that he is actually referring the patient to the right place to get the best treatment. These are often omissions widely seen in general practice in this country. He must also make certain that there is adequate referral communication. I saw a patient only a week ago in my unit who had the most complex medical history with some five or six abdominal operations, and the referral letter simply said, "Please see and advise", with no recognition that the patient had this complex history which bore extreme elements to the nature of the referral.
Another issue is that when GPs decide to do investigations they do them adequately and at the right time. I have just seen a member of my family who, as it happened, turned up at my hospital, having been sent by a GP with the wrong forms, for a series of investigations. The investigations were not going to be done because they were on the wrong forms. However, those investigations were done over 10 days ago. As far as I know, the GP has never bothered to pick up the results, so he cannot act on them. It fortunately happens that that relative has a medical person in the family who can sort that out.
Finally, one of the issues that is troublesome is the variability in primary care medicine of how GPs pick up or attend post-graduate education. That is an area which

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could also be monitored in these schemes. It is important that the Government consider the implications of the amendment to see whether something could be done about that area.
Baroness Cumberlege: We are committed to introducing pilots only where there are demonstrable potential gains to be made in the quality of services delivered. As indicated in the document Primary Care: the Future and in the White Paper Primary Care: Delivering the Future, published today, we have identified the need to take action to bring up the standards of service in some areas to meet the overall high standard of primary care. The introduction of this Bill is one arm of our strategy to do this.
We are currently setting up arrangements to underpin our commitment to ensuring that pilots set up under this legislation deliver service improvements. We wish to discuss with the professions, with representatives of academic units and patients and with health authorities how standards might be identified in schemes for approval and subsequent evaluation of how successfully the aims and objectives of the pilots have been met. We do not underestimate the difficulties in doing this or the importance of getting it right. We will be establishing a representative group nationally to take this forward and have written out today on this matter to individuals. This will include discussion of what criteria should govern the approval of pilots.
We do not believe that in advance of that detailed work we can on the face of this legislation circumscribe the Secretary of State's decision-making powers in quite the way these amendments imply. We do not know to what extent the group will be able to come up with criteria which might be applied across the board in looking at prospective pilots. Pilots will inevitably vary considerably and it may be quite difficult to find criteria which are both generally applicable and sufficiently challenging to provide the assurances that both we and the noble Lords believe are needed. We have within the Bill in Clause 2 the powers for the Secretary of State to direct health authorities on what matters must be dealt with and what information included in preparing the proposals for any scheme.
We have within Clause 5 the powers for the Secretary of State to determine what procedures on any review should apply. It is within these powers that we intend to reflect the results of the representative national group's conclusions on both scheme specific and general criteria on the quality of services to be provided to patients. It could be positively harmful to prescribe a common procedure and criteria if this meant producing standards which met only the lowest common denominator and distracted attention from the vital quality and procedural issues specific to the pilot in question.
We would therefore ask the noble Baroness to withdraw Amendment No. 12 and not to move Amendment No. 23, as we think their intentions are better served by the provisions already within the Bill.
In looking at Amendment No. 18 we acknowledge the need to be open about pilots and the criteria on which reviews will be based, but I am not sure that this
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amendment is the best way to achieve this. Clause 4(4) is about providing useful information to local people about services being provided under schemes. What local people what to know is what services they can get where. Mixing up this information with details of what is being piloted and what the criteria for evaluation will be could cause confusion rather than be helpful.
I can assure the Committee that the criteria against which pilot schemes will be evaluated will be established prior to the scheme being implemented. In the main these are likely to be to what extent the pilot scheme has met the service objectives set out in the proposal. But there may be others. We certainly have no reason to keep the criteria secret. We want the evaluation to be open, thorough and credible.
Perhaps I may take up the points made by the noble Lord, Lord Winston, about inner city areas. We had a discussion about that earlier this afternoon. It is because we are so concerned about those areas that we have sought new ways of providing services. In the past we have been convinced that it is the rigidity of the NHS Acts that has prevented some imaginative proposals. If we do not improve primary care in those difficult and challenging areas, the Bill, if it becomes an Act, will have failed.
Training is an issue that has been taken up today in the White Paper. I hope that when the noble Lord has had a chance to see it he will come back to me if he feels that there are issues that need further exploration.
6.15 p.m.
Baroness Jay of Paddington: I am grateful to the Minister for that helpful and in some ways encouraging reply. Especially encouraging is the news she gave of the establishment of a national body to look at national criteria in relation to those pilots. We of course look forward to hearing a progress report on how that group develops. If it is possible, perhaps before the Bill leaves another place, for those criteria to be explained to Members of another place, I am sure that that will give us greater confidence about the exact terms by which the pilots will be judged. If that proposal is within the White Paper, I am afraid that I must plead, as did the noble Baroness, Lady Robson, earlier, that speed reading has not enabled me to find it.
I would say also—this is something which my noble friend Lord Rea mentioned in an earlier debate—that it seems a little unhelpful, to put it at its mildest, that the White Paper, which is relevant to the progress and understanding of the Bill, has been produced only today when we have reached Committee stage. If it had been published with the earlier White Paper, some of the things which we have said—the Minister has rightly responded by saying that some of the points have already been met—would not have been necessary, and we should not have wasted everyone's time in making them. However, that does not affect the status of this group of amendments, to which, as I said, there was an encouraging reply from the Minister. I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
[Amendments Nos. 13 and 14 not moved.]
Lord Rea Lord Rea moved Amendment No. 15:
Page 3, line 28, after ("authority") insert ("and the applying qualified person").
The noble Lord said: The amendment asks that reasons be given by the Secretary of State for his decision to modify or reject a pilot scheme. As drafted, the Bill allows the Secretary of State to come to a decision about the suitability of a proposal for a pilot scheme without stating the reasons for his decision. We agree with the Royal College of Nursing that for reasons of openness it would be beneficial for those involved in drawing up a proposal to know why that proposal had been rejected or modified by the Secretary of state.
In the case of a rejection, that might allow a suitably modified proposal to be put forward which would be acceptable. We should like the Minister to expand a little on whether the Secretary of State will give full reasons for decisions taken in order to guide the people who put forward the proposal. I beg to move.
Baroness Robson of Kiddington: We support the amendment. It is important in particular that where a pilot scheme has been rejected, the proposers should discover the real reason for rejection so as to be able to decide whether to reapply.
Baroness Cumberlege: In a spirit of helpfulness—the noble Baroness, Lady Jay, is not in her place! I shall be helpful when she returns to the Chamber.
The proposals for pilot schemes will be put to the Secretary of State by health authorities and boards. Where the proposal has been made by a provider who is a "qualified person" within the meaning of the Bill—a GP, general dental practitioner or NHS trust—the health authority must put it forward. The reason for the health authority or board involvement is to encourage discussion of proposals between authorities and potential providers and to ensure that the proposal is set out in a format which is in line with the Secretary of State's directions.
It seems sensible to maintain the link between health authorities or boards and the Secretary of State once the decision on an application has been taken. But the reasons for this are above all practical. The Secretary of State may need to take decisions on a large number of proposals. In the case of some proposals, there may be a significant number of potential providers of services. If the Secretary of State has to inform each of them in turn of his decision we could end up with a huge mailing exercise at the Department of Health, unnecessary bureaucracy and greater potential for mistakes. Some providers could end up finding out about the decision before others, which is clearly a state of affairs to avoid. Far better for the decision to be passed to the relevant health authority or board and for it then to have to inform the providers of the outcome as a matter of priority. Where the proposal has been approved, this will be just the first of many contacts between the health authority or board and providers as they will then need to finalise contracts and other operational details.
I hope that the Committee will agree that we should avoid needless centralisation of the piloting process. The arrangements set out in the Bill will secure this and also
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provide a quick and efficient way of disseminating information about approvals of pilots. We believe that the amendment could threaten this, and I hope that the noble Baroness and the noble Lord will not press it.
Lord Rea: I listened carefully to the Minister, but do not believe that she has covered the point which the noble Baroness, Lady Robson, and I made about the bodies whose proposals are rejected. Surely, it is very important for them to know in some detail why they have been rejected. That can be transmitted to them by the health authority concerned but I believe that the provision should be included in the Bill so that applicants for pilot schemes know why their proposals have not found favour.
Baroness Cumberlege: The noble Lord is right in saying that we want a great deal of discussion between the health authorities and those proposing pilots. We do not believe that putting forward a proposal for a pilot scheme is like an exam which is marked and is either right or wrong. We believe that there will be a long iterative process with a number of pilots. Certain aspects will need to be tested out, particularly if the Secretary of State has questions or seeks further information.
The situation is ongoing in terms of agreeing the schemes and therefore we believe that it would be unhelpful to have to say at a single point that a decision must be made and put in writing. The discussion may well go on for longer.
Lord Rea: The Minister's last remark was helpful. I am speaking as one who has put forward proposals for research projects which have been rejected. I know that sometimes the body which has been approached helpfully gives referees' reports showing why they did not believe the project was worth funding.
However, I believe that the Minister has said enough and we shall look at that carefully. In the meantime, I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
[Amendment No. 16 not moved.]
Clause 3 agreed to.
Clause 4 [Making of pilot schemes]:
Baroness Hayman Baroness Hayman moved Amendment No. 17:
Page 3, line 44, leave out ("implementing proposals") and insert ("receiving notification of approval from the Secretary of State").
The noble Baroness said: This is a straightforward amendment. It follows from the previous amendments in that it deals with the procedure when the Secretary of State has approved proposals for a pilot scheme. As the Bill stands, the details of the scheme are to be published only upon its implementation. If the schemes are to be successful, as we would all wish, and as they change the nature of the services and the way in which they are provided, we believe that it will be sensible if the details of the approved scheme are made immediately available to those who might be affected by it rather than on implementation.
There is always a timelag in such matters until the public and the patients become used to changed services. It will help no one if a scheme is up and

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running before its details are made known locally. The purpose of the amendment is to ensure that such details are published as soon as the health authority receives approval from the Secretary of State. Following from what the Minister said earlier, I assume that will be when the scheme and its details have been decided and will no longer be for negotiation between the parties. The appropriate point for details to be published locally is when the scheme has been firmed up and not later at the point of implementation. I beg to move.
Baroness Cumberlege: Clause 4(4) is intended to ensure that the system is open and above board, which all noble Lords believe to be right. What people need is good quality information about the services that are available now. We drafted the clause with this in mind. Our aim is that people should be able to find out about the scheme and would be aware of the system they were being treated under and the service that they could expect.
We have two difficulties with the amendment set against these criteria. First, it is possible that the Secretary of State may give approval for a scheme six months or more before it is implemented. Yet at this point some of the contractual details of schemes may still have to be tied down through negotiations between health authorities and boards and providers. There could also be changes to a scheme in the period between approval and implementation. Most such changes will require the Secretary of State's agreement, but authorities may be permitted to make some themselves by agreement with providers. It would not be very helpful if information about schemes was published and then had to be revised, even before the scheme was operational. Generally, people want up-to-date information about the services they can obtain now, rather than about long-term plans for the future. Putting information that may change into the public domain ahead of time could lead to confusion. For that reason, we cannot support the amendment.
Baroness Hayman: I am grateful for the Minister's comments and I understand the difficulties that she outlined. However, a balance must be struck. There will be some approved schemes which are about to be implemented by the Secretary of State and I do not believe that it will be helpful for their details to be held back necessarily to the date of implementation. As I said previously, there is a timelag during which patients become used to a new pattern of services. It might be helpful if in guidance given to health authorities it was stressed that the earliest point at which a scheme is definite in its detail is the appropriate time at which to make that known, in the sense that there should be no constraint to wait until implementation if there is a possibility of doing that sensibly earlier.
6.30 p.m.
Baroness Cumberlege: That is a suggestion that we should wish to consider carefully. But it must be seen
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in the context of all the consultation which we discussed earlier in the day. My experience of the National Health Service is that nothing is ever secret.
Baroness Hayman: It is not always totally clear. There are often many versions of what is going on. But on the basis of what the Minister said, I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
[Amendment No. 18 not moved.]
Clause 4 agreed to.
Clause 5 [Reviews of pilot schemes]:
Baroness Robson of Kiddington Baroness Robson of Kiddington moved Amendment No. 19:
Page 4, line 3, at end insert ("not less than eighteen months and not more than three years after the date on which the pilot scheme comes into operation.").
The noble Baroness said: I shall not take long in moving this amendment. It is a necessary amendment because it deals with two aspects of a pilot scheme. It seeks to provide that no pilot scheme should be implemented for less than 18 months before the evaluation takes place.
The primary health care service is extremely complicated and it is necessary that a scheme should run for at least 18 months before it is evaluated. But it is necessary also that it does not run for ever and ever without being evaluated. That is why the amendment provides a maximum of three years.
We feel that it is necessary to have this amendment in the Bill because of what we consider were the unfortunate circumstances in relation to the pilot scheme for the nursery voucher scheme. We do not want that treatment to face the people who are working with the implementation of the pilot scheme. I hope that the Minister will be able to grant us the approval of this amendment that we seek. I beg to move.
Lord Rea: I support the amendment. By time limiting the pilot schemes, the amendment would stimulate the evaluation team to clarify the criteria on which the evaluation of the scheme would be based. I believe that the evaluation should be in the minds of those who are running the scheme right from the inception of the scheme, even before it starts. To have a set limit for the scheme helps very much to concentrate the minds of those who are to carry out the evaluation. Therefore, I support the amendment.
Lord Harmsworth: Does the Minister agree that when a large number of pilot schemes are set in place, it may well be possible to evaluate some of those which fall into a pattern before the 18 months have expired?
Baroness Cumberlege: We are committed to thorough reviews of pilot schemes because we wish to ensure that we learn from experience and establish what works well and what works less well. However, the variety of schemes that we hope will emerge makes it difficult to prescribe a fixed timescale for the operation and evaluation of all schemes—a point made by my noble friend Lord Harmsworth. We believe that, as we

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learn from experience, we shall not have to go through the full panoply of a thorough evaluation with every single scheme if it follows the model of one that has already been successful.
Some schemes are likely to become established more quickly than others and will therefore be ready for evaluation more quickly. More ambitious schemes may need a longer period to settle down and demonstrate their effectiveness. We must ensure that schemes are given enough time to become established before they are evaluated so that we can get a good idea of how the pilot scheme is performing. The Secretary of State will set a timescale for each pilot that he approves with that in mind. Therefore, there will be flexibility, which is important, but also we shall ensure that each scheme has a regular plan to it.
It is likely that the vast majority of pilot schemes will be evaluated within the timescale specified in this amendment, but there may be exceptional cases where the timescale will be inappropriate. For example, where several of the individual GPs providing services under the pilot change, perhaps because of personal circumstances unrelated to their work, more time may be needed for the pilot to become established and to demonstrate its effectiveness. A three-year review could be premature and perhaps of little value. Conversely, it is possible that some pilots involving very small changes in existing arrangements could be ready for an earlier evaluation.
Therefore, we agree with the timescales set out in the amendment as general rules but we believe that it would restrict unnecessarily our initiative if we were to try to set those timescales on the face of the Bill. Therefore, we do not support the amendment.
Baroness Robson of Kiddington: I thank the Minister for that reply. I am glad that she believes in the principle. I thought that I was providing sufficient flexibility by specifying between 18 months and three years. I want to prevent a pilot scheme running on indefinitely without evaluation. The noble Baroness gave an example which may need a time extension, but that could almost be considered to be a new pilot scheme because the people involved would be different. Therefore, I should like to see a maximum of three years.
I can see also that when a scheme is running—and some pilot schemes are already in existence—there may be similar pilot schemes which are not quite the same thing but would need perhaps a shorter evaluation timescale. However, I am determined that pilot schemes should not run indefinitely. I shall read what the Minister said and perhaps return to this matter at a later stage. I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
[Amendments Nos. 20 to 23 not moved.]
Clause 5 agreed to.
Clause 6 agreed to.
[Amendment No. 24 not moved.]
Clauses 7 to 9 agreed to.
Clause 10 [Leaving medical lists]:
Baroness Hayman Baroness Hayman moved Amendment No. 25:
Page 5, line 27, leave out ("not").
The noble Baroness said: In moving this amendment, I seek clarification in relation to Clause 10, which I must admit I found rather difficult to understand. As I read it, personal medical services are those provided under pilot schemes and schemes that then become permanent schemes under this legislation. General medical services are provided by family practitioners under Part II of the 1977 Act or Part II of the 1978 Act.
Clause 10 appears to separate those two functions and to ensure that a medical practitioner who is undertaking a pilot scheme under this Bill should not be a medical practitioner who is receiving remuneration under Part II of the 1977 Act. I seek clarification as to why someone who is providing GMS under the 1977 Act should be debarred from providing also PMS, which may be different and involve different services, under this Bill.
I should also like to probe a little into the exceptional circumstances, or the "prescribed" circumstances, where there would be exceptions to the rule. There is a reference in Clause 10(1) to there being "prescribed" circumstances and their extent, to the effect that there might be exceptions from the barring of people performing both sorts of medical services, both personal and general. I should be most grateful to receive some clarification from the Minister about what those circumstances might be. I beg to move.
Lord Alderdice: We certainly support the amendment. We have some concern because we want to see some creativity; indeed, we want to see people coming forward with pilot schemes. However, we are worried that this may actually deter general practitioners because it will be asking them to move out from a circumstance to which they are accustomed and with which, in many cases, they are very happy, into a very unknown field. We do not feel that is a particularly helpful approach. We heard the earlier advice from the Minister in that regard, but we are still rather puzzled as to why there is the need to split things in quite this way. As I said, we support the amendment.
Baroness Cumberlege: We believe that the national arrangements which have formed the link between GPs and the NHS have served us well. They date mainly from 1948. But our wide-ranging discussion on primary care has also made it clear that the services these arrangements deliver—for some patient groups and in some areas—are not always of the highest quality. It has also become clear that we need to consider new ways of addressing those problems.
The proposals set out in Choice and Opportunity are not forcing GPs to move into a completely different system. What we are proposing is that where GPs wish to test out a wide range of contractual options to see what benefits they will bring, this legislation will allow that to happen. The overriding aim must be to deliver high quality primary care from well-motivated professionals.

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Considerable flexibility is required in this legislation to provide the scope to enable the potentially wide variety of arrangements that are likely to be proposed to take place. Part II of the 1977 Act does not provide the flexibility to allow these broad ranging changes to be put into effect. The Bill will provide a base which will enable a wide and diverse range of arrangements to be brought about.
It is important that it is clear under which arrangements GPs provide services. They should provide them either under the existing Part II arrangements or under the proposed pilot arrangements. It would be a bureaucratic nightmare to have GPs who provided services under both arrangements. It would be difficult for GPs and health authorities and potentially confusing for patients. What we want is a coherent and seamless service from our GPs. This amendment would not further that aim. Because a GP who takes part in the new arrangements will no longer be participating in the Part II arrangements they no longer need to be on the health authorities' medical list, the list being a list of the GPs in each area who are providing Part II services.
We made a commitment in Choice and Opportunity that GPs should not be disadvantaged by taking part in the new arrangements. We have also made a firm and solid undertaking that participation should be voluntary. These pledges are backed up by the provisions in Clause 11 which will allow for a GP to transfer to a medical list where a pilot ends for any reason, and which we shall debate in due course.
The MPC will of course continue to have an important role, particularly in relation to existing arrangements where it will continue to approve vacancies. But one of the reasons for the pilots is to improve the distribution of GPs which remains uneven because the MPC only has powers of negative direction. Both locally and nationally we need to discuss with the professions what a fair distribution of services would be. Then Part II general practice, pilots and permanent schemes will all need to develop in a way which is consistent with fairness. We shall be discussing with the GMSC how best to achieve that aim. I hope that that is a sufficient explanation for the noble Baroness.
6.45 p.m.
Baroness Hayman: I am grateful to the Minister. We are on technical territory here. The Minister talked about the bureaucratic implications as regards the people involved in both sets of services. There are also implications about the funding streams, together with difficulties about the two sets of funding. I listened to the Minister's response, but I have residual concerns that we may in fact be stifling innovation—a point made by the noble Lord, Lord Alderdice. There are potential circumstances in which someone who is delivering most of his services as mainstream services under GMS might still wish to be involved in an innovative project, which was not a full time one, and in providing services that were very specific and more innovatory. However, I shall read with care what the Minister said on that point. I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Clause 10 agreed to.
Clause 11 agreed to.
Schedule 1 agreed to.
Clause 12 [Liabilities and obligations in relation to deputies]:
Lord Rea Lord Rea moved Amendment No. 26:
Page 6, line 17, leave out ("perform") and insert ("provide").
The noble Lord said: In moving the amendment, I shall, with the leave of the Committee, speak also to Amendment No. 27. The amendment seeks simply to improve the Bill by inserting rather more appropriate language. I feel that the use of the word "perform" is wrong because of its double meaning. We are more inclined to think of a performance as involving someone who is executing some tricks in front of an audience or, indeed, putting on a musical recital. I believe that the word "provide" is better; in fact, the Shorter Oxford English Dictionary defines it as to "supply or furnish" whereas the word "perform" refers to something corning into effect or being "the agent of" something. While speaking to the two amendments, I should point out that there is another part of the Bill—namely, Clause 11(4)—where the word "performing" appears. I also believe that that word should be altered to "providing". With those short remarks, I beg to move.
Baroness Cumberlege: GMS services are delivered through the personal relationship of the GP with the patients on his list. It is the GP who must see to it that GMS are delivered and he remains responsible for this delivery. However, when a GMS (or Part II GP) engages a deputy and, for example, that deputy is on the health authority's medical list, then that deputy, through the existing regulations, will be responsible for his own acts and omissions under the terms of service for doctors. That is because as a professional in his own right of the same standing as the GP he deputises for, it is right and reasonable for him to take responsibility for his acts and omissions while he provides services under a deputising arrangement.
Under the proposed pilot arrangements, the word "provide" has a very specific meaning. A pilot GP might enter into an agreement with a health authority to "provide" services. This means that while the GP may enter into an agreement to "provide" services, he may then actually arrange for the performance of these services by someone else. That is likely to happen when, for example, the GP has agreed to provide chiropody services or the services that are provided by an NHS trust. It then becomes another person's duty to provide those services.
If the word "perform" were replaced by "provide" it would suggest that the regulations would be about more than merely deputising for a pilot scheme GP. It would suggest that the Part II GP would be taking on all of the pilot scheme GP's obligations to provide services under his contract with the health authority (including, for example, arranging for subcontracting of the services to be provided by the pilot scheme GP), whereas the clause

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as currently drafted is only about deputising for the actual performance of medical duties. It is therefore right to talk about "perform" rather than "provide".
Lord Rea: I thank the noble Baroness for her explanation. I do not like the word "perform". I would almost prefer the word "undertake". However, that does not appear in the amendment before us. I undertake to read the noble Baroness's remarks and beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
[Amendments Nos. 27 and 28 not moved.]
Clause 12 agreed to.
Clause 21 agreed to.
Clause 13 [NHS contracts]:
[Amendment No. 29 not moved.]
Lord Rea Lord Rea moved Amendment No. 30:
Page 7, line 21, after ("circumstances") insert ("including cessation at that person's request").
The noble Lord said: The amendment seeks clarification. We note that all the pilot schemes are to be conducted on a voluntary basis. However, having agreed to participate it is not clear whether the person concerned has to carry on to the conclusion of the pilot scheme, or whether for personal or other reasons he can leave the scheme before it is finished. In the prescribed circumstances when a person ceases to be such a body, the amendment includes the personal decision of such a person. I beg to move.
Baroness Cumberlege: The effect of Clause 13 is to give providers of personal medical and dental services a choice of whether the contracts they make with health authorities and boards should be ordinary contracts, or NHS contracts. The advantage of the latter is that they provide for dispute resolution by the Secretary of State, thus avoiding time-consuming and expensive recourse to the courts.
Under existing law only so-called "health service bodies" are eligible to make NHS contracts for certain purposes. Clause 13 enables providers to apply to the Secretary of State to become health service bodies. They will then be able to make NHS contracts. The whole arrangement is purely voluntary. We believe that NHS contracts are a sensible, cost-effective arrangement and will encourage GPs, dentists and NHS trusts to opt for them. But there will be no compulsion.
If achieving health service body status is entirely voluntary, then leaving it should also be at the discretion of the person concerned. There would be no point in allowing choice in one respect but not in the other. The purpose of Clause 13(8), to which this amendment relates, is to enable the Secretary of State to make regulations setting out arrangements by which someone can stop being a health service body in certain circumstances. It stands to reason that a request by a volunteer health service body to stop being one is a circumstance that will be covered. The regulations will simply set out the arrangements for this to happen, including dealing with any obligations under existing NHS contracts. Just as a
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GP will need to approach the Secretary of State to become a health service body, so he will need to approach him again to stop being one.
The freedom for GPs and dentists to stop being health service bodies is inherent in the logic of this clause. We will certainly provide for it. But we see no need to spell it out on the face of the Bill. I hope that the noble Lord will withdraw the amendment.
Baroness Gardner of Parkes: My noble friend stated that there would be provision to meet any obligations. If someone seeks to withdraw, is there any cover to ensure that others are not left with heavy obligations afterwards?
Baroness Cumberlege: That is an issue which would have to be explored when the pilot scheme was being proposed.
Lord Rea: I thank the noble Baroness for her detailed answer to a small amendment. I believe that the answer justified the moving of the amendment. We now have something to go on. We shall read Hansard in order fully to understand the answer and its implications. In the meantime, I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Clause 13 agreed to.
Clauses 14 to 16 agreed to.
Clause 22 agreed to.
[Amendments Nos. 31 and 32 not moved.]
Baroness Hayman Baroness Hayman moved Amendment No. 33:
Page 11, line 35, at end insert ("and unless the order has been approved by a resolution of each House of Parliament.").
The noble Baroness said: In moving Amendment No. 33, I speak also to Amendment No. 56, which is consequential upon it.
At Second Reading of the Bill, the noble Baroness, Lady Robson, flagged up the issue of the procedures to be used when certain provisions of the Bill came into force. She argued that it would be necessary to have positive rather than negative procedures in order to ensure parliamentary debate. The amendment seeks to ensure that there has to be positive agreement to provisions under Clause 17 of the Bill.
Clause 17 provides for permanent schemes to be set up. Bringing that provision into force will change permanently the way in which primary health care is delivered.
We believe that the change is important enough to merit another parliamentary debate before schemes are made permanent. It would provide an opportunity for full parliamentary scrutiny of whether the pilot schemes so far evaluated had worked well—that is a question to which the Secretary of State must have regard—and, if so, whether it would be,
"in the interests of any part of the health service to bring this [new] section into force".
I beg to move.
Baroness Robson of Kiddington: The Minister will know that I support the amendment because I mentioned

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the issue at Second Reading. Before a scheme becomes a permanent part of the National Health Service, in the sense that the schemes can be implemented in other parts of the country, it is important that Parliament should debate the matter. It should not go through on a negative instrument. I prefer it to be an affirmative instrument. I support the amendment.
Baroness Cumberlege: The aim of these amendments is to introduce a more rigorous parliamentary test for the commencement order triggering the provisions on permanent arrangements which may follow piloting.
I understand the thinking behind this—the wish to ensure that permanent arrangements are not introduced until pilot schemes have been properly tested and found to be successful. However, I believe firmly that the safeguards necessary to secure this are already in place in the Bill.
First, there is the voluntary nature of both piloting and permanent arrangements, set out explicitly on the face of the Bill in several places. If pilots fail to deliver, nobody will be able to force GPs and dentists to enter either further pilots of the same kind, or permanent arrangements based on them. They will continue to provide services under existing arrangements. Nor will trusts or other providers be able to take over from them. The skills and experience to provide primary care services rest with GPs and dentists who provide those services at the moment.
Secondly, there is our commitment to a thorough review of pilot schemes, involving the relevant health authorities or boards and providers of services. This will not be an attempt to gloss over difficulties but a frank analysis. We will learn from them. If they show that certain schemes are ineffective, we will not repeat them. We will certainly not attempt to give them the status of permanent arrangements.
Finally, there are the conditions attached to the commencement of permanent arrangements which already appear in the Bill. The two tests that are set are crucial: no permanent arrangements without taking account of the views of pilot schemes—which is why thorough and honest evaluation is so important—and no such arrangements unless the Secretary of State is satisfied that these would be in the interests of the NHS. That surely must be the acid test of any scheme. No scheme that does not work well, and work for patients, could be interpreted as being in the interests of the health service. In today's climate it would be a foolhardy Secretary of State who attempted to introduce permanent arrangements which did not demonstrably meet those strict criteria.
So we are not trying to mask some masterplan with a thin layer of piloting. If schemes work, we will allow them to develop to the point where the Secretary of State's direct approval is not necessary and permanent arrangements can be introduced. If they do not work, we will not hesitate to drop them. I hope that I have demonstrated that the Bill backs that approach with the force of law. The further hurdle proposed by
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these amendments—affirmative resolution—would be without parallel in current NHS legislation. It would also be unnecessary. I hope that the noble Baroness will agree to withdraw the amendment.
7 p.m.
Baroness Hayman: I am grateful for the Minister's comments. I understand that the Secretary of State has to take into account what is in the interests of any part of the health service. However, after the experience of the past seven years at least, we have to conclude that what is in the interests of the health service can be a matter of both dispute and honest disagreement. I am rather saddened that on the issue of the annual report and on this amendment there seems to be a reluctance to have parliamentary scrutiny of what are quite far-ranging changes to the structure of primary care. However, I will read the Minister's remarks. For the moment, I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Clause 17 agreed to.
Clauses 18 to 20 agreed to.
Clause 23 [Provision of additional pharmaceutical services]:
[Amendments Nos. 34 and 35 not moved.]
Baroness Masham of Ilion Baroness Masham of Ilion moved Amendment No. 36:
Page 19, line 3. at end insert—
("( ) In giving any directions under this section the Secretary of State shall ensure that there is no diminution in the range of additional pharmaceutical services in an area.").
The noble Baroness said: In moving this amendment and speaking to Amendment No. 40, I seek to improve the present situation for patients. The Government have for some time been encouraging a primary healthcare-led NHS, as all noble Lords will know. Patients are now staying in hospital usually for far shorter periods of time than they did a few years ago and many more are being treated for serious conditions in the community.
It has been brought to my attention by the Tissue Viability Society, with which I have been associated in a voluntary capacity since its inception, that there is a problem, which these amendments seek to rectify.
In recent years there has been an explosion in the range of dressings available to manage wounds. There has also been much research activity to determine the efficacy of many of these products. Many of the modern products have been demonstrated to be considerably more effective than the traditional dressings such as gauze.
One area where there has been a great improvement is in the management of cavity wounds. Cavity wounds are deep wounds which may be caused by drainage of an abscess or a surgical operation or be chronic wounds such as pressure sores. They take time to heal and can cause much discomfort to the sufferer. Several products have been developed specifically for this type of wound.

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They are easier to apply and much less painful to remove than ribbon gauze, the traditional type of dressing, as well as being more effective.
As patients are discharged earlier from hospital, more and more patients with cavity wounds are being cared for by district nurses. Unfortunately, their task is made more difficult by the fact that there are no modern dressings for cavity wounds available on general practitioner prescriptions.
At a recent meeting between the Surgical Dressings Manufacturers' Association and the drug tariff team from the Department of Health, it was announced that there was no need for cavity wound dressings to be added to the drug tariff as district nurses are already obtaining them.
Anecdotal evidence supports the view that many district nurses do manage to obtain cavity wound dressings. However, that is said to be through "doing swaps" with their local pharmacists. That is, a prescription is obtained for a product listed on the drug tariff and that is exchanged for a different dressing of equal price value. Although it is purely for the good of the patient, it is an illegal practice. The Department of Health could be seen to be encouraging such actions. At present there is insufficient evidence to determine the extent of the practice; however, it was found that about one-fifth of dressings used in cavity wounds were obtained by illegal means. There are also problems in obtaining a selection of bandages for the treatment of leg ulcers in the community.
I am sure that the Minister and the Committee will agree with me that the most cost-effective procedure is getting the patient back to full health as quickly as possible. The greatest expense is in nurses' time treating patients whose wounds or ulcers will not heal. Different patients respond to different medication and dressings. There needs to be a choice and the drug tariff needs to be kept up to date as better and more effective products come on the market.
I hope that the Committee will support this amendment, and the one for Scotland, which ensures that the Secretary of State sees that there is no difference in the range of pharmaceutical products to treat patients wherever they may be, either in hospital or in the community. I beg to move.
Lord Rea: The Minister will have heard the plea of the noble Baroness, Lady Masham. I hope that she will be able to say that not only will there be no diminution in the range of additional pharmaceutical services but that there will in fact be an augmentation along the lines suggested. I shall be interested to hear the Minister's response.
Baroness McFarlane of Llandaff: I support the noble Baroness, Lady Masham. It has been my experience in the past that district nurses have been unable to obtain the specific kinds of dressings in the community that have been used in hospital for the patient. When a patient is discharged he or she sometimes has a temporary supply from the hospital;
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then in the interest of cost that source dries up and they are unable to obtain suitable dressings in the community. I support the amendment.
Baroness Gardner of Parkes: I was very interested to hear the comments of the noble Baroness, Lady Masham. However, I was slightly puzzled. I could not quite see how the amendment reflected what she said. That slightly confused me. For example, it refers to no diminution in "additional" pharmaceutical services. That seemed difficult to follow. I wondered whether the noble Baroness meant pharmaceutical suppliers rather than services. I was a little lost. I completely agree with her about the need for special dressings and so on. However, I was not sure whether this amendment quite said what she intended. I shall be interested to hear the Minister's reply.
Baroness Miller of Hendon: The Government favour a wider role for pharmacists. We have, for example, introduced a scheme whereby pharmacists provide advice on the safe keeping and correct administration of medicines to residential homes and to nursing homes. Community pharmacists are also among those who take part in syringe and needle exchange schemes for drug misusers.
We also support local management of services. Health authorities are best placed to fit services to the needs of their population. Some services provided by pharmacists will be required throughout all geographical areas of all health authorities. Others may be a priority in some areas only. Syringe and needle exchange is a good example of this type of service--it is only in some places that there is a need for it.
Therefore, while we support an increase in the choice of services which can be purchased from pharmacists, we believe that health authorities should, wherever possible, be left to decide which services are needed in their area. They should not be obliged to spend public money on a service which is not a priority for their patients. The proposed amendment would hinder health authorities from tailoring services to local needs, and therefore the Government cannot support it.
I understand the noble Baroness's serious concerns about the availability of dressings on GP prescription. I can reassure her that the list of dressings available through this route can be extended without new legislation. I understand that community trusts already provide dressings through the district nurses whom they employ and that there is no legislative reason for the amendment. It would not help in any way to add the amendment to the Bill. I hope that the Committee will reject it.
Baroness Masham of Ilion: I thank all Members of the Committee who have spoken. I wish first to say to the noble Baroness, Lady Gardner, that I am in the hands of the excellent Clerks to the House of Lords. Perhaps they will consider what she said and correct the wording so that I may bring it back at the next stage.
I wish to say to the Minister that I am told that the drug tariff list needs to be changed because district nurses are obtaining some of these products and dressings through the back way, illegally. I hope that the

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Minister will take the matter back and discuss it with her department. I can put her in touch with the Tissue Viability Association and we shall see what happens at the next stage. Therefore, I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
7.15 p.m.
[Amendments Nos. 37 to 41 not moved.]
Clause 23 agreed to.
Clause 24 [Terms and conditions etc.]:
Baroness Jay of Paddington Baroness Jay of Paddington moved Amendment No. 42:
Page 20, line 9, at end insert—
("( ) In deciding on any standards relating to quality of service to be included in the terms or conditions specified in any direction, the Secretary of State shall, in relation to any additional pharmaceutical service included in the direction, have regard to any standards for that service promulgated by the professional body representing pharmacists.").
The noble Baroness said: I apologise for my loss of voice. Amendment No. 42 deals again with the issue of trying to establish consistent national and local standards of quality for pilot schemes, this time in the pharmaceutical area.
We have debated the whole issue in relation to several amendments this afternoon in general terms and we return now to the issue of pharmacists and pharmaceutical standards. The Royal Pharmaceutical Society, which promulgates and maintains national standards for the profession at a personal and professional level, is concerned that there should be national minimum standards for any additional pharmaceutical service which is provided under one of the pilot schemes.
As the registering body for pharmacists, the society already publishes standards for many aspects of professional practice with which all registered pharmacists are required to comply. But there is concern that the Bill as drafted at present would appear to permit a health authority to contract for a specific additional pharmaceutical service with different contractors and to have different standards for the services provided by those individual contractors.
The Royal Pharmaceutical Society has pointed out that already in existing legislation there is a recognition of the standards which it promulgates and which are the guiding force in the professional bodies. They would like to see an amendment such as the one now before the Committee which would provide similar criteria for the additional pharmaceutical services which could be provided under the pilot schemes.
The NHS pharmaceutical services regulations for 1992 require a pharmacist whose name is on the pharmaceutical list to provide pharmaceutical services and exercise any professional judgment in connection with the provision of such services in conformity with the standards generally accepted in the pharmaceutical profession.
This amendment, if it were adopted, would simply extend that understanding about the standards that are generally accepted to the pharmacy services which could be provided under pilot schemes. Indeed, it does not require any new development of criteria, as we discussed earlier in the afternoon, but simply the extension of existing criteria to the new pilot schemes. I beg to move.
Baroness Miller of Hendon: We fully understand the aim of this amendment in seeking to ensure that directions given to health authorities do not cut across professional standards already extant within the pharmacy profession. However, a Secretary of State in making such directions would need to consider any existing code of practice before making any such decision and would not wish to undermine professional standards in the way contemplated. We therefore think this amendment is not necessary. While we want health authorities to have flexibility in how much of a service to purchase and the features it contains, I can assure the noble Baroness that professional standards—for example, those laid down by the Royal Pharmaceutical Society of Great Britain—would certainly be something that the Secretary of State would wish to consider when issuing directions for additional pharmaceutical services. I therefore hope that the noble Baroness will be able to withdraw her amendment.
Baroness Jay of Paddington: I am grateful to the Minister for that reply. Again, it seems to fall into the category which I described earlier as being good intentions rather than precise regulation and understanding on the face of the Bill. However, I understand that she says that nothing which is to be regarded as a successful pilot scheme would go outside the understandings about professional standards that have already been agreed. For the moment at least, I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Baroness Jay of Paddington Baroness Jay of Paddington moved Amendment No. 43:
Page 20, line 12, at end insert ("hut may not add the name of any person to such a list whose name is not on any such list").
The noble Baroness said: With Amendment No. 43, I wish to speak to Amendments Nos. 44, 45, 46,49 and 50. All the amendments are designed to improve the mechanics of maintaining quality at a local level in new pharmaceutical provisions under the pilot schemes and to ensure that pharmacists, who, as we have agreed in several debates this afternoon, play an enormously important part in primary care services, are dealt with—to use the awful cliché—on a level playing field with other primary care professionals who operate in the pilot schemes.
Amendments Nos. 43 and 44 deal with the issue of pharmacists on a pharmaceutical list and how narrowly or broadly the conditions are drawn to include people on that list. The situation at the moment is that in order for pharmacists to practice within a health authority, that authority must keep a list of registered pharmacists. Only someone on that pharmaceutical list can practice

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within the health authority area. In fact, this is a somewhat narrowing provision in the existing legislation which is changed by Clause 24. It can enable the Secretary of State to alter the definition of the pharmaceutical list. That means, for example, that someone could be on a pharmaceutical list but not necessarily on the pharmaceutical list for any particular health authority. He could therefore, for example, provide a service between London boroughs in a health authority borough or area which was not the primary area of his pharmaceutical registration.
That seems to be precisely the kind of flexibility that the Bill seeks to encourage and it is indeed welcome. But the additional problem about extending that definition of the way in which the list should be organised is that it could include people who are not on the pharmaceutical list and who are not pharmacy contractors appearing on an existing list. It could go beyond that to other people whom the health authority might decide to include within the list as it exists.
That would mean that people other than persons who are already initially included as NHS pharmacy contractors could, under the pilot schemes, be contracted to provide services. It is well understood within the profession that, although happy with the idea that there will be additional flexibility around the lists based on a geographical qualification, it is less happy that it is drawn so widely that it might make it possible for health authorities in pilot schemes to include people who were not already on a pharmaceutical list within that health authority.
Amendments Nos. 45 and 46 deal with the issue—a vexed issue between the professions—of the relative authority of doctors and pharmacists in prescribing. One matter which concerns many pharmacists is that GP dispensing is on the increase. In view of many of the professionals involved in pharmacy that does not necessarily provide the best service. The amendments as they stand would have a simple effect. At the moment health authority lists of registered pharmacists are required to include the address from which the pharmacists dispense their services. In a sense that keeps some kind of regulatory control on the way in which pharmacies are distributed within a health authority area. The purpose of the amendments would be simply to include doctors who are also dispensing, in the sense of having to include their address on a pharmaceutical list. It is to extend the requirement at present made to pharmacists to GPs who are prescribing within a particular health authority area.
The purpose of Amendments Nos. 49 and 50 is equally mechanical but, in the view of many pharmacists practising at a local level, equally important. Again, it tries to establish a level playing field between doctors and pharmacists in these areas. As it stands at the moment, Clause 26 requires pharmacists providing Part I services to be the subject of an NHS contract. The amendments would give the pharmacists a choice of whether to be subject to an NHS contract or a so-called ordinary contract. That again would put them on a par with doctors and dentists under the pilot schemes. In the Second Reading debate the Minister spoke of the advantage of that choice. Although she was
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more happy with the idea of people being under NHS contracts, she said that the option of ordinary contracts would be available for those providers who preferred them. The object of those two amendments is simply to include pharmacists with GPs and dentists in having that choice. I beg to move.
Baroness Miller of Hendon: We do not believe that Amendments Nos. 43 and 44 are necessary. The existing draft of Section 41B(2) makes it perfectly clear that additional pharmaceutical services can only be provided by someone whose name is already included in a pharmaceutical list. The noble Baroness may be concerned that the Secretary of State's power of direction in Sections 41B(6) and 27B(6) might be used to redefine a pharmaceutical list more broadly. If so, I am happy to reassure her that we have no intention of using this new power to extend the definition of a pharmaceutical list, even were it possible to do so. The power of direction is necessary so that we can limit the pharmaceutical lists from which a health authority or board can draw when making an arrangement for additional pharmaceutical services. For example, we might wish an individual health authority or board to be able to arrange such provision only with people on its own or adjacent health authorities' or boards' lists. We would perhaps do this so that patients could conveniently access the pharmacy closest to their homes, in which case there would be no need to open the service to providers from further afield.
The noble Baroness suggested that perhaps the Secretary of State could alter the definition of a pharmaceutical list to include new people. That is certainly not our understanding. I am very happy to reassure the noble Baroness that that would just be National Health Service pharmacy contractors.
So far as concerns Amendments Nos. 45 and 46, we have considered them carefully. I have to say that the Government cannot accept them. I should point out that the main purpose of the clause as drafted is to ensure that all dispensing doctors, including those who in future elect to provide personal medical services under our new Part I arrangements, who continue to provide dispensing services under Part II, will be subject as far as their dispensing activities go to the National Health Service tribunal arrangements. The suggested amendment is not relevant to that position in any way.
Doctors are allowed to dispense medicines to their patients in limited circumstances, the most common of which is where their patients are living in a rural area more than a mile from the nearest community pharmacy. The health authority in allowing the doctor to dispense makes no specification as to where the dispensing should take place—it may be from the main surgery or a branch surgery, and in some instances the medicines will be handed over in the patient's home—and we consider that not only would it be impractical, but irrelevant, to include addresses in the proposed list. The jurisdiction of the National Health Service tribunal will apply so long as the doctor is included on the list. That is what we want.

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As for Amendments Nos. 49 and 50, I understand why the noble Baroness wishes to create flexibility here. Our view at present is that effectively making National Health Service contracts for the additional services which pharmacists and optometrists might provide would be more attractive to health authorities and boards. Indeed, we thought it might be overcomplicated to open up a new question on the type of contract for health authorities or boards and their potential providers to consider when negotiating. We certainly would not wish this to be a point of dispute, over which service opportunities might be missed. However, we are sensitive to the professions' views. If, in light of what I have said, their general feeling is that the advantages of flexibility outweigh the disadvantages, we are willing to reconsider this provided we can find a simple mechanism for deciding what sort of contract is to be used.
Baroness Jay of Paddington: I am very grateful indeed to the noble Baroness for her replies. I am sorry that both she and I seem to need the attentions of a pharmacist—I shall try not to cough during my brief remarks. I am grateful that she seems to be very encouraging to the professional concerns of some of the pharmacy people with whom we have been talking about these two specific areas. I understand her difficulties about GP prescribing. Perhaps I may take away her replies and consult on them with the profession. But, for the moment, I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
[Amendment No. 44 not moved.]
Clause 24 agreed to.
Clause 25 [Authorised provision of pharmaceutical services by medical practitioners]:
[Amendments Nos. 45 and 46 not moved.]
Clause 25 agreed to.
7.30 p.m.
Baroness Flather Baroness Flather moved Amendment No. 47:
After Clause 25, insert the following new clause—
(".—(1) The Pharmacy Act 1954 is amended as follows.
(2) In section 10(1), after "eight" insert "or 11(4)".
(3) In section 11—

(a) at the beginning of subsection (1) insert "Subject to subsection (4) below,"; and

(b) after subsection (3) insert—

"(4) Where the Committee makes a direction under section 8(I)(ii) in respect of a registered pharmaceutical chemist providing pharmaceutical services or additional pharmaceutical services under or pursuant to—

(a) section 41 or 41A of the National Health Service Act 1977; or

(b) section 27 or 27A of the National Health Service (Scotland) Act 1978,

and the Committee is satisfied that it is necessary for the protection of members of the public or that it would be in the best interests of that registered pharmaceutical chemist, it may order that his registration in the register shall be suspended forthwith.".").
The noble Baroness said: I shall speak to both amendments standing in my name as they are closely connected. Amendment No. 47 will bring the powers of the professional misconduct committee of the Royal Pharmaceutical Society in line with the other professional misconduct committees of doctors and dentists.
It may surprise the Committee to know that at present an erring pharmacist cannot immediately be stopped from dispensing. At the very least, he can continue working normally for three months, in which time he may lodge an appeal. It is also possible that an appeal may be lodged to give him still more time to continue practising.
I wish to declare an interest. My husband has been chairman of the statutory committee—the professional misconduct committee of the Royal Pharmaceutical Society—for seven years, during which time, on a regular basis, there have been cases where he and others felt strongly that this power should be available to that committee in line with other professional bodies. There was a call for the society to seek the power of suspension from the register by the branches, as set out in the pharmaceutical journal, which stated:
"A Motion urging the Royal Pharmaceutical Society to seek power to suspend convicted pharmacists from the Register of Pharmaceutical Chemists was among nine 'non-controversial' motions referred to the Council from the branch representatives' meeting without debate, on the assumption that they would have been carried. The motion had been put forward by the Society's Bristol branch, which wanted the power of suspension to be used for pharmacists convicted of offences involving drug misuse and/or theft from an employer. The branch was concerned at the length of time that could elapse before such a pharmacist could be struck off under the current Statutory Committee procedure. The branch believed that the Society should emulate the dental and medical professions, which had mechanisms for temporary suspension, pending a full hearing".
There have been many cases of pharmacists stealing cocaine from their employer; of dispensing drugs to addicts without prescription; and of stealing cocaine to feed the habit of a partner—those are examples of actual cases—yet all the pharmacists involved can continue dispensing in the normal way for a minimum of three months, and longer if they lodge an appeal, however spurious that may be. We have been talking of level playing fields. Surely, with a profession that will become more important under present legislation, it is necessary that it be regulated in the same way as the other professions.
I should mention to the Committee that a Private Member's Bill recently had its First Reading in the Commons. It proposes to establish a health committee for pharmacists who have been found to be suffering from alcoholism or other kinds of mental illness. But it is not clear at the present time, because the Bill has not yet been published, whether that committee will have the power of immediate suspension. Even if it has such powers, and that Bill is passed, cases will still arise which are not due to illness but to sheer wickedness on the part of the pharmacist.
The amendment seeks to fill a gap in the armoury of the statutory committee to protect the public from the worst people in the profession; it is only the worst

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people who will need to be suspended forthwith and not those who commit minor infringements which can be dealt with by fines or by other means. I hope that the Committee will consider it seriously and that my noble friend the Minister will see its virtue. Pharmacists are still covered by an Act of 1954, which the provision seeks to amend. Also, it is some time since 1954 and no doubt the Pharmacy Act itself is due for revision. Until then, steps should be taken to protect the public as and when the opportunity arises. I beg to move.
Baroness Miller of Hendon: While I understand the concerns of my noble friend and I welcome the spirit of public protection in which she tabled these amendments, there are reasons of equity why the Government cannot accept them.
It seems unfair to us that some pharmacists working in what is generally known as community pharmacy should be subject to the immediate suspension of their registration by their professional regulatory body, while their colleagues working in hospitals or the private sector face no such sanction. For that reason alone I must invite the Committee to resist these amendments.
However, I hope my noble friend will be encouraged by the provisions we introduced early this year to give the NHS tribunal power of interim and immediate suspension from a pharmaceutical list. Matters of misconduct likely to prejudice the efficiency of the service can be brought before the tribunal which, if it considers it necessary, may effectively prevent the person on the list from providing any NHS pharmaceutical service.
Lord Winston: Before the Minister sits down, as a matter of clarification can she explain in the case of an NHS pharmacy whether it is right that a health trust cannot immediately suspend a pharmacist if serious misconduct occurs.
Baroness Miller of Hendon: My understanding is that if the committee finds that the pharmacist is unfit to practice, the name can be removed from the register but the pharmacist has three months in which to lodge an appeal.
Baroness Gardner of Parkes: My view is that a trust directly employing a pharmacist would have employment rights by which it could immediately suspend its employee. However, that could not be done if the pharmacist was a direct contractor in his own pharmacy. Only the registering body could do that and apparently it does not have the power.
Baroness Flather: I was interested to hear the Minister's comments. The distinction is quite spurious. The amendment increasing the powers of the statutory committee will apply to all practising pharmacists. It may not apply to people in employment because there will be other means by which they can be suspended. To prevent a pharmacist found guilty by the statutory committee of serious misconduct from dealing with the public for three months does not make the pharmacist less equal. It brings him in line with the other medical
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professions of doctors and dentists. Pharmacists can cause just as much damage to members of the public with who they are in direct contact.
I shall not press the amendment today but will take the opportunity of discussing the matter further with my noble friend the Minister. I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
[Amendment No. 48 not moved.]
Clause 26 [Provision of certain services under NHS contracts]:
[Amendments Nos. 49 and 50 not moved.]
Clause 26 agreed to.
Clause 27 [Medical lists and vacancies: England and Wales]:
[Amendments Nos. 51 to 54 not moved.]
Clause 27 agreed to.
Clauses 28 and 29 agreed to.
Baroness Hayman Baroness Hayman moved Amendment No. 55:
Before Clause 30, insert the following new clause—
POSITION OF HEALTH AUTHORITIES
(". Nothing in this Act shall prevent the direct employment by a Health Authority of a medical practitioner who provides personal medical services.").
The noble Baroness said: The purpose of this amendment is to introduce an extra degree of flexibility into the pilot schemes that may come into force under the Bill. As the Bill now stands, a wide variety of people may put forward pilot schemes. They may be medical practitioners, they may be dental practitioners, they may be NHS trusts and they may—we probed this point earlier today—be commercial organisations. The one group that seemingly cannot put forward pilot schemes is health authorities.
I understand, and the Committee will be aware from earlier discussions, that difficult issues are involved here. If a health authority were directly to employ medical practitioners to provide personal medical services it would be blurring the line between being a provider and a commissioner of services. However, as we discussed earlier, general practitioners are already in that position. There is also the issue of the scrutiny of proposals, but I think that is covered by the fact that the Secretary of State has to scrutinise and approve proposals.
We on this side of the Committee are keen that health authorities should be able directly to employ medical practitioners because we are concerned that in some areas there may be needs which are clear to the health authority but for which there is no taker for a pilot scheme from among local general practitioners or local trusts. I think particularly of areas of great deprivation: the provision of primary health care and personal medical services for homeless people, for a drug addict population and—this is an area to which we shall have to give greater attention in the future—for residents of long-term residential homes and nursing homes. That area needs to be addressed.
The purpose of the amendment is simply to introduce a greater degree of flexibility and to allow that in those circumstances where the health authority, with its epidemiological and overview of the health needs of the population, has identified a need that has not been met by someone coming forward with a pilot scheme, it would be able directly to employ a medical practitioner. I beg to move.
Baroness Cumberlege: As the noble Baroness said, these are difficult issues. When we were considering the content of the Bill we considered carefully whether we wished health authorities directly to employ medical practitioners. The present position under existing legislation is that health authorities can only employ medical practitioners to provide general medical services in exceptional circumstances where other arrangements are unable to secure adequate provision of services in the area. In effect, it is to deal with a crisis in local services.
In the new piloted arrangements which the Bill seeks to introduce there is a clear distinction between the role of health authorities and potential providers of personal medical services. That is crystallised in the contractual nature of their relationship. The health authorities are on one side of the contracted purchasing services; medical practitioners are on the other providing those services. We decided that the virtues of this arrangement and giving both sides a context in which they can discuss and agree what services are specifically required and how most effectively they are delivered were best served by maintaining that distinction in all circumstances. We foresaw difficulties for both health authorities and potential providers under piloted arrangements if health authorities could in effect become both purchasers and providers. It would be difficult for them to appear even handed in the process of allocating contracts if they were one of the potential providers. But even more seriously, if successful, it would compromise the health authority role in monitoring the contract and ensuring that patients got the best deal out of the arrangements.
The current capacity for direct health authority involvement under existing legislation would remain. If a pilot got into serious trouble, for example, and an adequate provision of services could not be maintained, a health authority could protect the interests of patients by employing GPs directly. We believe that it provides for clearer lines of management and accountability for services if direct health authority employment remains, as now, in a fall-back capacity.
Baroness Hayman: I am grateful to the Minister for those helpful remarks. It is helpful to know that in exceptional circumstances it would be possible for a health authority to take up these schemes. It would be a shame if we excluded the possibility of these more imaginative schemes being covered while the more basic and straitjacketed schemes under general medical services were covered. I shall look at what the noble Baroness has said. For the moment, I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Clauses 30 and 31 agreed to.
Clause 32 [Regulations and directions]:
[Amendments Nos. 56 and 57 not moved.]
Clause 32 agreed to.
Clause 33 agreed to.
Clause 34 [Short title, commencement and extent, etc.]: [Amendment No. 58 not moved.]
Clause 34 agreed to.
Schedule 2 [Minor and Consequential Amendments]:
[Amendments Nos. 59 to 61 not moved.]
Schedule 2 agreed to.
Schedule 3 [Repeals and Revocations]:
[Amendments Nos. 62 to 64 not moved.]
Schedule 3 agreed to.
In the Title:
[Amendment No. 65 not moved.]
House resumed: Bill reported without amendment.

Child Support (Miscellaneous Amendments) (No. 2) Regulations 1996
7.47 p.m.
Earl Russell Earl Russell rose to move to resolve, 0054hat this House calls on Her Majesty's Government to withdraw the Child Support (Miscellaneous Amendments) (No. 2) Regulations and lay amended regulations omitting Regulation 9.
The noble Earl said: My Lords, this Motion, if carried, would request the Government to delete Regulation 9 from the Child Support (Miscellaneous Amendments) (No. 2) Regulations. I have two different reasons for moving the deletion of Regulation 9. First, I believe that what the Government are doing is in itself quite seriously mistaken. Secondly, I believe that in terms of normal procedure in this House what they are doing is—and I choose my words carefully—unusual.
The previous law provided that when a benefit penalty—now 40 per cent. of benefit—was imposed on a woman who did not co-operate with the Child Support Agency, that penalty, which is itself heavy enough, could be suspended—and I say suspended, not remitted—if that person was already subject to a large and serious number of deductions from benefit. That is what is now withdrawn. I think the Government are mistaken because they are creating a very heavy burden on the women concerned and therefore also on their children. They are in fact in danger of infringing the basic principle of social security, which is, "Don't let poor Nellie starve".
In November 1996, 1.7 million people had more than one deduction from benefit. I shall run through some figures which may be familiar to the Minister because they have been quoted in the other place; but they are good figures and they bear repeating. The average—I am not dealing in exceptional cases, this is the average—deduction from benefit is 11.99 for electricity; f10.49 for gas; £4.90 for rent arrears and

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other housing costs; £5.83 for water—I fear we may expect that to go up—and £6.37 for social fund payments. That makes a total of £39.58. There are various figures that that omits such as deductions for court fines, which may on occasion be quite heavy. The noble Lord, Lord Gisborough, drew attention to these in the House very recently.
Put on top of a deduction like that—an extra 40 per cent. deduction from gross benefit—one is not going to be left with very much. I do not understand how people are meant to make a honest living on that figure. The Minister is in fact leading them into temptation. We know whose office that is and it ought not to be the office of the Government. So my first objection is simply that this is too heavy: it infringes the basic principle of social security that people ought to be able to live.
If I know the Minister's line of argument he is going to come back to this with a fairly standard set of arguments about why is this the business of the taxpayer. It is the business of the taxpayer because if any taxpayer is that badly off he ought not to be paying taxes at all. It is in the interests of the taxpayer that those who go out of work—I believe that that has happened to 8 million people since the last election—should not waste away, but should be able to resume work at some future date. So I believe that the taxpayer has a concern for keeping his fellows alive. He has that concern as a matter of self-interest as well as of altruism. So I believe that the taxpayer, if he refrains from starving women and children, may be doing so in his own interest.
I come to the circumstances of this change. The old system, the provision for suspension whose disappearance I so much regret, was first agreed to by the Government in response to an amendment moved by the noble Lord, Lord Carter—and I have given him notice of what I am doing today—to the Child Support Act 1995. The Minister's acceptance of that provision introduced this power to suspend in order to reduce benefit directions in cases of hardship.
On that occasion the noble Lord, Lord Carter, remarked, perhaps just a little smugly that it shows what one can do when one sets out to improve a Bill rather than mortally to wound it. Yes, it does. Appeasement does not work and it has not worked on this occasion either.
That measure was brought into effect by regulations introduced in December 1995 and came into force as recently as January 1996. So this concession has been withdrawn after merely 10 months in operation. It is that which I describe as "unusual". If one is to withdraw a concession that quickly, without casting doubt on the original concession itself, one needs to have a pretty strong reason. I have looked carefully at what Mr. Mitchell said in another place on 11 th December. If I have understood him correctly, he says that he is withdrawing the concession simply because a lot of people used it. It is not open to abuse, but open to use.
If the Government had understood the reasons why this concession was asked of them and when they so generously agreed to it, they would have expected that a lot of people would take advantage of it. They would
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have known that the extent of the deduction from benefit was very wide indeed and that the amount of hardship with which we are dealing was very widespread. The number of people who took advantage of this concession seems to me to show exactly how right the noble Lord, Lord Carter, was to move the amendment in the first place. It is really not a sufficient excuse. The Minister needs a better one.
The Government are also getting themselves into a real moral panic about people not collaborating with the agency. But I explained to them in 1991—and everything that has happened since confirms it—that one simply cannot find an economic incentive which is strong enough to make a woman co-operate when she is determined not to do so. I told the Government in 1991 that by believing that they could do it all by economic incentives they were missing so much. The repugnance in many cases to resuming negotiations is an emotional one. One might starve them before one makes them overcome it. So I believe that attempting to make life more difficult for the women concerned is not going to achieve the desired effect however severely it is done. I warned the Government of that and I believe that experience bears me out.
It may be that they have good reasons for this. I know the Minister of old as an honourable opponent and I am pleased to be opposite him. But when future historians read these exchanges—
Baroness Hollis of Heigham: They won't!
Earl Russell: They may: one will, at least. There is no subject so obscure that it cannot be the subject of a Ph.D, as I am sure the noble Baroness knows very well. They may think that the concession made in 1995 followed hard on the vehement reproaches from the noble and learned Lord, Lord Simon of Glaisdale, because the Minister was conceding nothing. Therefore, it may look as though it were done for show and not for substance. I believe that that impression would be unfortunate especially since I believe it to be untrue. Some response might help to take that bad taste away. I shall listen to advice from the Opposition Benches because it is the Opposition's honour which has here been wounded. If it were my honour I would know what to do, but since it is their honour I must listen to what they say about it. I beg to move.
Moved, That this House calls on Her Majesty's Government to withdraw the Child Support (Miscellaneous Amendments) (No. 2) Regulations and lay amended regulations omitting Regulation 9.—(Earl Russell.)
7.57 p.m.
Baroness Hollis of Heigham: My Lords, if I should trespass on the conventions of the House because I misunderstand the order of procedure, I apologise. Perhaps I am a little confused about what we are doing. I wish to register some concern about this matter. A Starred Question was changed at the last moment. This Motion was inserted today, thus requiring a

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re-ordering of our debate speakers' agenda without prior notice and consultation. I cannot believe that that is the best way to get the most helpful and constructive debate.
I cannot and will not suggest to my noble friends on these Benches that we support any such Motion in the Lobby. We do not do so although I support many of the sentiments and share many of the concerns of the noble Earl. As I said, this might have been a more effective contribution had we had more than a few hours' notice that the order of today's agenda was going to be reshaped.
Like the Government, we believe that absent parents should pay proper child maintenance and, like them, we do not believe that one should condone collusion between the parent with care and the absent parent, although I would add that I share with the noble Earl the belief that a proper maintenance disregard and not just the job bonus would encourage more voluntary co-operation from lone parents.
However, this might be the place to pay tribute to the agency. In no case, as far as I know, has the CSA erred in requiring a parent with care to disclose information where that parent is in fear of violence. I hope very much that the CSA will continue to have such an honourable track record. I am sure that if it did make such a grievous error and a lone parent was assaulted that would severely damage the credibility of the agency, which needs to ensure that on this issue, above all, it is protected. The CSA is absolutely right to be very careful indeed.
To come more substantively to the point of Regulation No. 2, since January 1996 the Government decently suspended the imposition of benefit penalties where the lone parent already has deduction from her—I shall use the word "her" throughout for this purpose—benefit for arrears of rent and utilities. Now, less than one year later, that suspension of the Government is being overturned—and why? The Government insisted in the other place that lone parents were using weekly deductions for rent and utilities from benefit as a way of avoiding incurring benefit penalties for failure to disclose relevant information; in other words, lone parents were manipulating their direct deductions to avoid the benefit penalty.
I am neither so sanguine about the ability of lone parents to do that, given the complexity of their finances, nor so cynical that they would do that as the Government's remarks appear to suggest. Essentially, the Government say that lone parents are doing conjuring tricks with their income to avoid having to pay a penalty. In one of two cases that may be the case. However, in my experience it is also true that lone parents give priority to the most urgent and pressing bills. For most of them, that means a home to live in for themselves and their children; that is, their rent payment, followed by payments for their utilities so that they can cook and stay warm, especially as many will be in poor housing and their children may be in poor health.
As the noble Earl said, the simple truth is that benefit levels are so low that 1.7 million claimants are in debt and in arrears and therefore have deductions from
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benefit. That situation existed long before the Child Support Agency existed. Debt and deductions are a feature of poverty, not a response to the Child Support Agency or a manipulation of its rules. For the Government to believe otherwise indicates cynicism of a very high order. The Government support that contention by saying that among lone parents as a group there is a high percentage of benefit fraud.
I should like to press the Government on this matter. It is known that, whereas the typical male benefit fraud is for a man to claim unemployment benefit or JSA while doing jobs on the side—any man must know that moonlighting is cheating and wrong—the "typical" fraud perpetrated by a lone parent is to have a boyfriend living in while continuing to claim benefit as a lone parent. I do not condone that financial arrangement, but in no sense is that an offence of equal magnitude as the man who claims JSA and works on the side. Why not? Often, the boyfriend is temporary, feckless and fails to contribute financially to her maintenance and the maintenance of the children, whatever the benefits agency may believe about the bedroom arrangements. He may judge that as the children are not his he should not have to contribute to the household budget for their support. She may have taken him into her bed but it does not mean that she has taken him into her family or that he contributes to the family budget. Understandably, she may believe after her experience that in financial terms she is indeed on her own and is entitled to claim benefit as if she were on her own. That reflects the realities of the world in which she lives. I do not condone fraud. However, to insist that among lone parents there is a high incidence of fraud, and that that is the type of fraud exhibited, is to misunderstand and misread the domestic and financial situation in which lone parents, in good faith, regularly find themselves.
When the draconian 40 per cent. penalty was introduced we argued that instead of increasing the penalties the correct response was greatly to increase the number of home visits to see the true home situation; for example, whether the lone parent had good reason not to reveal information. If the lone parent was not truly "lone" but falsely claimed benefit when she was in a proper and sustained partnership, obviously that would be wrong. However, as that is not always or necessarily the case lone parents should not be abused by treating all of them as fraudulent. That is what the Government do.
My fear, which I am sure other noble Lords share, is that the end result of the Government's draconian policy will not be improved child support but increased child poverty. A lone parent with a child under 11 in the current year will receive income support of about £80 per week. A benefit penalty will leave her with £61 per week. If on top of that she suffers the average level of deductions for arrears on electricity, gas, water and the social fund she and her child will have just £26.26 per week on which to live for all their food, clothes, travel and household costs. That is a sum of money that one of us might spend on one meal in the Barry Room tonight.

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Already one child in three in this country is born into poverty. There is no doubt that by adding to the financial pressures on the parent with care the regulations will add to the poverty of the child who is cared for. When we punish the mother we punish the child. To say that the mother should behave differently is all very well, but the child will still suffer. They are without our support and protection. The Government are wrong in what they are doing. I hope that even at this late stage they will consider reverting to their original position and suspend the benefit penalty where other deductions are in place.
8.5 p.m.
Lord Mackay of Ardbrecknish: My Lords, in responding to the Motion of the noble Earl, I shall also address the two draft regulations standing in my name on the Order Paper which were laid before the House on 25th November.
Baroness Hollis of Heigham: My Lords, perhaps the noble Lord will allow me to intervene. It is for that reason that I am confused about the procedure. Is the Minister saying that at this point he is to speak to the regulations dealing with the child maintenance bonus? I tried to discover the answer to that question by a hasty exchange of notes. I intended to speak to them but I did not do so. I believed that it was ruled out because the House was dealing with a Motion only on the first set of regulations. This confirms my concern that there should not be a re-arrangement of the agenda at such short notice, as that means that at some stage we are talking at cross-purposes. I do not quite know what we should do now.
Earl Russell: My Lords, I too would find it easier to take the other regulations separately, if the Minister was agreeable to that course.
Lord Mackay of Ardbrecknish: My Lords, I am happy to help both the noble Baroness and the noble Earl by re-phrasing what I said. I shall respond to the Motion of the noble Earl and speak to the Child Support (Miscellaneous Amendments) (No. 2) Regulations. After we have dealt with that, I shall deal with the Social Security (Child Maintenance Bonus) Regulations.
This is not the first time on which we have discussed the benefit penalty for those parents with care who claim benefit but refuse to co-operate in seeking maintenance for their children. I am sure that your Lordships are well aware of the background. That is especially true of the noble Baroness and the noble Earl, because we have discussed this together on a number of occasions. The penalty known as a reduced benefit direction is intended to make clear to the parent with care the seriousness of her decision not to co-operate with the Child Support Agency. It is important to remember that a reduced benefit direction is imposed only on those parents with care who have no good reason for failing to co-operate.
The Child Support Act rightly places an obligation on both parents to support their children wherever they can afford to do so. This principle would be seriously undermined if the incentive effect of the reduced benefit
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direction were to be weakened in any way. One of the regulations before the House today, which is the subject of the Motion of the noble Earl, removes a provision that has been shown to have exactly that effect. Regulation 9 of the Child Support (Miscellaneous Amendments) (No. 2) Regulations, which has already been approved in another place, removes a provision that currently allows a reduced benefit direction to be suspended when, at the same time as that direction is imposed by the child support officer, other deductions are already in place from her income support; for example, to cover repayment of a Social Fund loan or arrears of fuel and rent. Reduced benefit directions are suspended where arrears deductions are made, not deductions for current consumption. The maximum arrears deduction is £7.20. Payment for current consumption will have to be met by the parent, whether she pays by deduction or directly to the supplier, if it is electricity or gas or whatever. It is also true to say that the RBD is suspended where there is any deduction for arrears, so there is not, so to speak, a threshold. If there were any reduction for arrears, the RBD would be suspended.
That provision was introduced in January of this year following a government amendment which I announced at the Report stage of the Child Support Bill. At that stage I was persuaded by the noble Lord, Lord Carter, of two things. One was that the benefit direction should be suspended if either the parent with care or the child was disabled, and nothing we are doing in these regulations changes that.
It is the second part of my remarks that evening that we are now addressing, because during the Report stage I announced that we would suspend the benefit direction if the parent with care had other deductions made directly from her income support. I said at the time that, if we were to suspend reduced benefit directions in these circumstances, we would be discriminating against those parents who were better able to budget or who chose to pay off loans themselves without involving the benefits system. I stand by that view today. I did however agree to put down an amendment to do exactly what the noble Baroness and the noble Earl approve of, although I put in a caveat that I was not at all sure of it. That remains my position, but more so.
I shall come to the reason why we decided to change our minds on that. Since the suspension was introduced, a clear picture has emerged of a pattern of behaviour being adopted by increasing numbers of parents with care who set out not to co-operate with the Child Support Agency. I want to emphasise that again. We are actually talking about parents with care who decide not to co-operate with the agency.
The proportion of parents with care who have their reduced benefit direction suspended because they have deductions for arrears from their income support in place has been steadily increasing, and reached more than 50 per cent. in October. The indications are that this trend may well continue over the coming months. The evidence from Child Support Agency staff is that parents with care who set out not to co-operate with the agency are well aware of this loophole and are not, I am afraid, slow to exploit it. They do this by making sure

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they have a deduction in place from their income support as quickly as possible so that when the reduced benefit direction is imposed it is immediately suspended. This behaviour nullifies the incentive effect of the reduced benefit direction, and the numbers involved now make the situation unacceptable.
Our suspicions are further aroused when we consider that only 14 per cent. of all lone parents with a child under five have any deductions from their income support, and 27 per cent. where the child is over five. We already know from the Child Support Agency's own review of "good cause" published earlier this year that 45 per cent.—nearly half—of all parents with care who have a reduced benefit direction imposed fail to contact the Child Support Agency throughout the whole of the good cause process. Your Lordships will recall that this is quite a lengthy process, with a number of different steps in it, yet nearly half simply do not make any contact with the CSA during the procedure, which they must know is going to end up with a reduced benefit direction. Surprisingly, more than half make sure they contact the Benefits Agency in order to obtain a deduction from their benefit before that reduced benefit direction is imposed.
We should also bear in mind that the Benefits Agency's comprehensive and statistically valid review, published last year, showed that nearly 20 per cent. of lone parents were claiming or suspected of claiming benefit fraudulently—the highest proportion of any single client group. Allowing such large numbers of parents with care to have their reduced benefit direction suspended cannot be allowed to continue.
The noble Earl has expressed concerns about the levels of benefit that will be available to a parent with care who has a reduced benefit direction on top of other income support deductions. Indeed, the noble Baroness also expressed her concern about that. The answer to this potential problem lies fairly and squarely in the parent with care's own hands. She can choose to co-operate with the agency and, instead of actually checking with the Benefit Agency that there is a deduction in place, she ought to be checking with the CSA to explain to it what her position is and why she does not wish to co-operate. Of course, if she does that, and if she has a genuine reason for not co-operating and makes representations to the agency, her case will be treated sympathetically. I am pleased to say, and indeed confirm what the noble Baroness said in her speech, that the CSA has a very good record in this area of taking on board the representations of a parent with care and, where it sees that the reasons are genuine, it will not ask the parent with care to continue to work with them and to move to get benefit from the absent parent.
I believe it is simply not fair to the taxpayer or to the majority of parents with care who want the CSA to pursue child maintenance on their behalf to continue to allow others to dodge the penalty of the reduced benefit direction when they have no good cause for refusing to co-operate, and of course letting the absent parent get away without facing up to the responsibilities of the child. The requirement for a parent with care to co-operate with the CSA, unless she has good cause not
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to do so, is a founding principle behind the child support scheme, and I believe it has the support of the two main political parties and the vast majority of the British public.
I hope, therefore, with that explanation—an explanation which shows that we have not come to this conclusion lightly; that these are actually the statistics that are coming through from our work—that the noble Earl can see why we have come to the conclusion that we have in order to deal with the issue in this way. Any parent with care who has a genuine reason for not co-operating because she is fearful of the absent parent and how he might react only has to approach the agency to explain and it will take that on board very sympathetically. It has a good track record on this. I am afraid, however, that there is increasing evidence that the only agency they actually contact is the Benefit Agency to make sure that a deduction is in place, which of course blocks any reduced benefit direction. It simply suggests that this concession, made by us and agreed by us all in good faith, is being abused, and I do not believe that that can continue.
On the remainder of the regulations in this miscellaneous amendments package, there are various child support measures which simplify and speed up the handling of applications, together with a number of minor and technical changes. I do not believe that either the noble Earl or the noble Baroness has raised any of these matters and I need not dwell on them further. I hope that the noble Earl can withdraw his Motion, see the good sense of the proposal I am putting this evening and perhaps join us in encouraging parents with care who have a problem to contact the agency to seek its advice and help.
Baroness Hollis of Heigham: My Lords, before the Minister sits down, and given that he has spilled over into some of the other issues caught up by the regulations as opposed to the benefit deduction, may I ask him whether he will be kind enough to answer two points which, because I was confused about the procedure, I failed to make in my remarks. As I understand it, under the regulations on the proposed changes, the Government intend to give parents who are not on benefit in court orders dating back to 1993 the right to apply to the CSA for collection, but this was deferred while the CSA caught up with the backlog. When might we expect them to be brought within the remit of the CSA?
The second question is this. Given that we continue to have unacceptably poor levels of accuracy from the CSA—and I do not think even the Minister will doubt that; it has been regularly drawn to our attention by the National Audit Office—will he confirm that nonetheless the CSA expects to face a cut in its budget for running costs of about a quarter in the year 1998-99? How will that improve the efficiency of the CSA?
Lord Mackay of Ardbrecknish: My Lords, I am sure that the noble Baroness will appreciate that I am not able immediately to give her a detailed response. Of course we accept that the CSA has had, and indeed continues to have, accuracy problems, although they are

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improving. It is a difficult field, with some pretty unwilling participants. We mentioned parents with care earlier when referring to the subject of this discussion. There are also some pretty unwilling absent parents. Obtaining the right information is sometimes difficult. I believe that we are making progress. Perhaps I may answer the noble Baroness in writing or in the next debate when I move the next set of regulations.
8.20 p.m.
Earl Russell: My Lords, before I disappoint the Minister, I must make my apologies to the noble Baroness about the timetable. I understand that was inconvenient, and I regret it. The reason is that I had a severe cold over the weekend and my business has been put rather behindhand. I shall try not to cause that sort of inconvenience again, but we all do it to one another sometimes.
I was a little surprised by what the noble Baroness said about the CSA having never erred in a case involving domestic violence. I remember well one that came to me from Todmorden CAB where the woman who had been alleging domestic violence was told—I paraphrase from memory—to run away and stop making a fuss. I have had at least a dozen other such cases through my hands, most of which came to rest in the files of the Minister's honourable friend, Mr. Burt, who dealt with them expeditiously and effectively. If he checks his files, he will find that that is not true.
It is an unwise way of dealing with intimidation to assume that it does not matter because it has not actually been carried out. It is like the famous case of the asylum seeker from Bosnia who was told that the death threats against him must not have been genuine since they had not been carried out. It is an unwise way of dealing with it.
The Minister says that no one suffers a benefit penalty unless they refuse to collaborate for no good reason. How on earth can the Minister know that? He can know that he has not discovered a good reason. He can know that he has not been persuaded by the reason that has been alleged. But how can the Minister know in all the private history of a dead marriage that none of the reasons is good? People do also—this has survival value—act upon impressions.
I recall evidence given once by a woman who said, "It is difficult to describe. He had a strange and odd effect on me. It was the way he looked at me". I am sure that the Minister would not accept that as good cause. The man of whom the woman was speaking was Thomas Hamilton. We are unwise to ignore that sort of impression.
The Minister says that it would be discriminatory to relax rules in favour of people with a particular load of debt. The Minister would not do very well in banking. That is bad banking practice. He says that there is a pattern of behaviour involving non-co-operation. He would do well to study the various reports on the subject by Professor Gary Craig of the Children's Society. He has found a great many reasons for non-co-operation with the CSA, some of
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them extremely good ones. The Minister is also unwise always to assume the worst possible motives. It is like a certain sort of hellfire preacher. As a limerick addict I quote:
"Said the Reverend Jahez McCotten
Of the devil the foxtrot's begotten!
Said Jones to Miss Bly,
Never mind the old guy.
To the pure almost everything's rotten!"
I cannot help but think that that is the attitude of the DSS where it thinks that it can find collusion.
We have been at these arguments a long time. We shall he at them a long time longer. The Minister has not got an inch nearer persuading me that he is right and that the CSA will last, but we will not settle that tonight. So I beg leave to withdraw the Motion.
Motion to resolve, by leave, withdrawn.

Child Support (Miscellaneous Amendments) (No. 2) Regulations 1996
8.24 p.m.
Lord Mackay of Ardbrecknish Lord Mackay of Ardbrecknish rose to move, That the draft regulations laid before the House on 25th November be approved [5th Report from the Joint Committee].
The noble Lord said: My Lords, I have already spoken to this Motion. I beg to move.
Moved, That the draft regulations laid before the House on 25th November be approved [5th Report from the Joint Committee].—(Lord Mackay of Ardbrecknish.)
On Question, Motion agreed to.

Social Security (Child Maintenance Bonus) Regulations 1996
Lord Mackay of Ardbrecknish Lord Mackay of Ardbrecknish rose to move, That the draft regulations laid before the House on 25th November be approved [5th Report front the Joint Committee].
The noble Lord said: My Lords, these regulations provide for the introduction of child maintenance bonus, provision for which was contained in the Child Support Act 1995. I do not intend to go over the detail of all the regulations, so perhaps I can give a brief outline of the main points of the scheme.
Basic entitlement to a child maintenance bonus rests on the claimant satisfying three main conditions. First, the parent with care or her partner must be entitled to either income support or income-based jobseeker's allowance; secondly, child maintenance must be in payment, whether it be paid direct to the parent with care or collected by the Secretary of State on her behalf; and, thirdly, the parent with care or her partner must start work, or increase their hours if they already work part time, so that they stop claiming the qualifying benefit.
The child maintenance bonus will be paid to the parent with care as a tax-free cash lump sum when she leaves benefits. As long as the parent with care has a

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maintenance assessment of £5 or more, the bonus will build up at a rate of £5 for each week she has been on benefit and receiving child maintenance. The maximum bonus will be £1,000.
This scheme has been designed with two important goals in mind. The first relates to getting people back to work, the second to encouraging co-operation with the Child Support Agency. We do not require parents with care to seek work if they have no wish to do so. However, we do wish to give every encouragement to those parents with care who do wish to improve their family's standard of living by returning to work. The tax-free cash lump sum which this scheme will provide for parents with care when they return to work will go a long way towards both encouraging them to look for work, and helping them make the transition from benefit to work as successfully as possible.
The second goal of the scheme is to encourage co-operation with the Child Support Agency. I repeat that it is a widely accepted principle that parents should maintain their children wherever they have the means to do so, and not pass financial responsibility for their children on to the taxpayer. And that means co-operating with the Child Support Agency in the assessment and collection of maintenance.
By linking the amount of bonus which a parent with care can receive to child maintenance in payment, we have ensured that the scheme will act as an incentive for all parents to co-operate with the agency—parents with care will receive a direct cash benefit from maintenance paid for their child, and absent parents will see their child benefiting from the maintenance they pay.
We discussed the child maintenance bonus at some length in Committee. There was general agreement, although I know that the noble Baroness, Lady Hollis, would like to go further with disregards, and I am sure that she may return to that, but I believe that the child maintenance bonus represents a major step forward in trying to help those parents with care who want to go into work. So far as concerns the collection of pre-April 1993 cases, we have no plans at this stage to bring on those cases, so that may help the noble Baroness. I have perhaps been on my feet long enough, and I beg to move.
Moved, That the draft Regulations laid before the House on 25th November be approved [5th Report from the Joint Committee].—(Lord Mackay of Ardbrecknish.)
Baroness Hollis of Heigham: My Lords, we obviously welcome the bonus which the Minister has explained means that from April 1997 there is effectively a £5 a week disregard for up to four years which is then paid to lone parents entering work. May I press the Minister? When he says that the bonus will be paid to lone parents who no longer qualify for benefit, is he saying that lone parents who are on family credit would not be eligible for the work bonus, because that would suggest a problem with issues such as childcare disregard? The Minister talked about benefit; he did not confine himself to income support. Perhaps
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the Minister can help me on that point. That was not my understanding of it, but his remarks suggested some possibility of confusion. Perhaps the Minister can help me.
Lord Mackay of Ardbrecknish: My Lords, I am happy to help the noble Baroness on this point. I think I said at one stage that I was talking about moving off income support or jobseekers' allowance. Perhaps I did not repeat that later, but that is the position.
Baroness Hollis of Heigham: My Lords, I am happy to have the Minister's reassurance. It is clear that a lone parent entering work has additional costs and worries from clothing to transport to childcare, as well as the worries of coming off a low but reliable income. To that extent, the bonus is of considerable help.
We also welcome the fact that the bonus signals that the parent with care is receiving the equivalent of a modest disregard. However, we regret that it is not a proper, true maintenance disregard, however modest, which is payable to all lone parents with care, including those with very young children who not unreasonably put their parenting responsibilities first. We also regret that it is tied to child maintenance paid. We understand the thinking behind that but it means that the bonus of a lone parent returning to work will depend not on her returning to work but on whether the absent parent is himself in work and has therefore paid child maintenance. Otherwise it means that his poverty will reinforce hers; if he is on benefit there will be no bonus for her. I would love to be wrong about that, but I understand that if he is on income support and therefore paying only a relatively small disregard—in other words, the top-slicing of his income support far below £5 per week at £2.50—I do not see how that can roll up to the job bonus which the Minister indicated. Therefore, whether she receives the bonus depends not on whether she is in work but on whether he is in work. That turns the whole job bonus into a lottery, which is regrettable. I do not have an easy answer but it presents a genuine problem to which I hope the Minister can respond in reply.
My second point relates to the Minister's remarks about work incentive. He is right in saying that we should help lone parents with transitional costs to encourage them with the risks of taking up a job. We welcome that. However, given that philosophy which I entirely share, why in the Budget did the Government first choose to freeze and then propose to abolish the lone parent benefit, which, because it is not means tested can be carried by the lone parent into work? It is therefore a positive incentive for her to find work knowing that benefit—in other words, a platform—is securely in place. Why are the Government producing a child support bonus on the one hand while taking away a similar well established benefit which is doing a similar job—that is, the lone parent benefit—on the other hand? Give with one hand and take away with the other—apparently nowhere is that more true than in child support. The three cap trick is a good trick for conjurers at a children's party but it is not a sound basis for Government policy as regards the children of lone

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parents. It sends out a signal that government value a lone parent who works more highly than a lone parent who parents properly. As the Social Security Advisory Committee stated:
"We believe in looking a work incentives for lone parents. The legitimate need to support the parenting role rather than encouraging the parent to work should be given due weight".
Potentially the welfare of 2.7 million children depends on the conclusions which the Government reach about benefit provision for lone parents. I repeat that we welcome the bonus but we wish that it were more widely extended and that it did not appear to be the lottery that it apparently is.
8.30 p.m.
Earl Russell: My Lords, the Minister made one quite serious mistake in the course of introducing his regulations. He said that the noble Baroness and I wished to go further and have a maintenance disregard. He is right that we wish to have a maintenance disregard but he is wrong to suppose that that is going further. It is travelling in a quite different direction.
We on these Benches are strongly in favour of incentives to return to work. But that is a second priority. The first priority is to ensure adequate levels of support so that people can eat. That is the problem to which we were addressing the maintenance disregard.
As was pointed out in 1991, the problem is that, because of the operation of passported benefits, receiving maintenance puts the women below income support level. The back-to-work bonus has never done one thing to meet that and therefore it is addressing the wrong problem. I have one or two more points to make about it.
First, it takes four years to reach a bonus of £1,000. I wonder whether that is a very realistic incentive. Secondly, it applies only to full-time work, whereas more and more jobs are part-time. Is the Minister prepared to consider doing anything for people who get part-time work? Thirdly, it provides only for getting into work. What happens to the person who gets into work, banks the bonus and leaves after a week? With the Minister's attitude to sin, he might have foreseen that possibility. I am surprised that he has not. Fourthly, I agree with the noble Baroness, Lady Hollis, about the burden on the CSA of budget cuts during the changed programme. Does the Minister really believe that giving the CSA a large extra job of work at the moment is expedient?
Lord Mackay of Ardbrecknish: My Lords, the noble Baroness described the disregard as modest. Indeed, it certainly starts off as modest but it builds up, as the noble Earl pointed out, over quite a long period of time to £1,000. The point is that it builds up, so at any stage between the first week and after almost four years it will be between £5 and £1,000. It depends on how long the parent with care is receiving maintenance payment and building up the bonus before she goes back to work. That is entirely her decision, but we all know and have agreed that one of the best ways to improve the living standards of parents with care and their children is for them to find and return to work. We are also agreed that sometimes the most difficult part of that operation is the transition. That is why we have devised a number of ways of helping
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people to get back into work. This is one of them, together with the other bonus in the jobseeker's allowance which helps people who work part-time while on benefit and allows them to put aside some money and have up to £1,000 when they move into full-time work.
I believe that the key to the problem is coming off income support or jobseeker's allowance. I do not believe that it is so much the definition of work but I will check that. I believe that I am right in saying that it is coming off either of those benefits.
We are tying the bonus to child maintenance paid. We are doing so because, as I said, we want to give incentives to both parties. By tying the bonus to child maintenance paid we hope to give an incentive to the absent parent to encourage him, usually, to adopt a regular pattern of maintenance payments in the interests of the parent with care and of the child, so that if the parent with care goes into work some of the money which the absent parent has paid over will be available for that bonus. Therefore, we see this as a double incentive. It will help and provide an incentive to a parent with care moving off benefit and into work. We also hope that it will act as an incentive to an absent parent to ensure that he pays the maintenance and that it is not assumed to be notional, whether paid or not. It does have to be paid—
Baroness Hollis of Heigham: My Lords, perhaps I may ask the Minister to clarify the point. Does it mean that if the absent parent is on benefit it does not count as child maintenance paid and therefore, for that period of time, the mother though going back into work will not be eligible for any job bonus?
Lord Mackay of Ardbrecknish: My Lords, I was just coming to that point. I was trying to be as logical as possible. The noble Baroness asked about the absent parent who was on benefit. Of course, that absent parent will normally pay a contribution to maintenance of £4.80 a week. While that may not be £5, it will build up towards the bonus. I hope that that is a satisfactory answer.
I hope that I have answered all the points arising in respect of the child maintenance bonus regulations. I commend them to the House.
On Question, Motion agreed to.

Social Security (Incapacity for Work and Miscellaneous Amendments) Regulations 1996
8.40 p.m.
Lord Mackay of Ardbrecknish Lord Mackay of Ardbrecknish rose to move, That the draft regulations laid before the House on 2nd December be approved [5th Report from the Joint Committee].
The noble Lord said: My Lords, the new structure of benefits for people who are incapable of work have been in place for over 18 months now. These amendments introduce a number of tidying up measures and points of clarification. In addition they address the effects of a recent decision of the High Court which concerned the

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beneficial provision which allows people who would otherwise fail the all work test to be treated as incapable of work in exceptional medical circumstances.
The introduction of incapacity benefit was an important reform of a major area of benefit provision. With any reform of this magnitude it is inevitable that there will be the need for some fine-tuning in the light of practical experience. These amendments affect three sets of the regulations which contain the detailed rules for determining entitlement to benefits for incapacity. None, however, introduces any significant changes to the Government's established policy in this area.
Most of the amendments before us are aimed at achieving greater clarity, and a more consistent application of the all work test. Some are directly beneficial; for example, we are widening the provision which prevents incapacity benefit recipients being excluded from benefit solely because they are caring for a close relative. The definition of close relative is being expanded to include, among others, grandparents and grandchildren.
The new all work test of incapacity is the key to the reforms that we introduced last year. Our experience of the procedures so far has shown that, in a few areas, the wording of some of these activities and descriptors needs to be more precise.
In improving the wording of these provisions our aim has been to ensure that they reflect more accurately the original policy intention. I assure noble Lords that none of these improvements tightens the test beyond this original policy intention, which was set out in a report, The Medical Assessment for Incapacity Benefit, published before the new arrangements came into force in April 1995.
It might be useful if I illustrate this with an example. One of the functional areas assessed under the all work test is manual dexterity. The activities specified measure a person's ability to perform various tasks with his hands. We want to make it clear that the ability to turn a tap refers to an ordinary sink tap; and the word "control", in the phrase "control knobs on a cooker", is intended to be an adjective, not a verb.
The High Court decision which we are addressing concerned the provision which allows a person who fails the all work test still to be treated as incapable of work if the examining doctor considers that exceptional medical circumstances exist. This is, of course, a medical question. The High Court decided it was wrong to make the doctor's opinion binding on the adjudication officer, with the result that lay adjudication officers and appeal tribunals must apply the criteria. We are therefore amending the provision to define more clearly the circumstances in which it should apply; and to ensure that, while the opinion of the examining doctor is not binding, decisions are still based on medical evidence. We believe this is essential, given that we are talking about a specialist medical question. But an additional safeguard has been built in. Adjudication officers will now be able to consider other medical evidence—for example from the claimant's own doctor—when applying the provisions.
Finally I should like to remind the House that the Government's reforms in this area were introduced against the background of a rapid and unexplained growth in numbers receiving the former invalidity benefit. We believe the measures we have introduced address these developments in a fair and balanced way. The regulations before us today introduce some important improvements, and I commend them to the House.
Moved, That the draft regulations laid before the House on 2nd December be approved [5th Report from the Joint Committee].—(Lord Mackay of Ardbrecknish.)
Baroness Hollis of Heigham: My Lords, most of these regulations are tidying up and we welcome some aspects of them. We welcome Regulation 2(11)(b), involving a test of sitting in a chair comfortably. We welcome also Regulation 2(3)(a), which allows medical evidence other than from one's own doctor to be relevant, which may perhaps save the disabled person from seeking a judicial review.
However, I should like to ask the Minister about the implication of Regulation 27, which the Minister has suggested was merely fine tuning. That is not the understanding of the disability organisations, which consider that is an extremely damaging change. Their understanding of what this regulation does is at odds with what the Minister said in his introduction it was intended to achieve. Therefore, perhaps I may explain to the Minister how that regulation is being understood outside this House. If he can allay those fears and worries, that would be extremely welcome because at present, those organisations are extremely concerned about the implications of that regulation.
The current situation is that there are four exceptional circumstances in which a disabled person who does not pass the all work test can nevertheless be deemed still to be incapable of work. We understand that this regulation reduces that to three exceptional circumstances, therefore eliminating the condition that the person:
"suffers from some specific disease, bodily or mental disablement and by reason of such disease or disablement, there would be a substantial risk to the mental or physical health of any person if he were found capable of work".
In everyday life, that means there are many disabling conditions which would not allow a person to score the sufficient 15 points on the all work test but would nevertheless have the practical effect of making it impossible for him to work without his health being seriously at risk.
In addition, we understand that a previously undiagnosed potentially life-threatening condition now has to be discovered by a BAMS doctor if that is to come into play. That really strains credibility. Perhaps the Government would give us an example. One wonders whether, if the GP has not discovered that condition, the sick person might have a claim for legal action against the GP should the BAMS doctor discover such a condition.

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We are particularly worried because the all work test was drawn up after careful evaluation. It was found to be essential to have those four safety nets in place simply because the Government have insisted, for the incapacity benefit, that there should be a test which is dependent on current functioning physical capacity—lifting a hat, walking upstairs, walking along a road, bending, carrying a sack of potatoes and so on. Therefore, such current functioning capacity cannot take into account such considerations as the effect of work on continuing health.
Older people, especially those aged over 55, are vulnerable under this provision where the effects of ageing interlock with a deteriorating condition. The disability organisations fear that the Government may be reacting hastily and that they may be acting vindictively because of the Moule case, and they are worried. The Minister will know that in that case, a young man with a very severe skin condition failed the all work test and would have been judged capable of work except that the adjudication officer decided under Regulation 27 that a severe skin condition meant that his mental and physical health might be affected adversely if he were required to work. The BAMS doctor decided that Mr. Moule did not qualify under Regulation 27 and the adjudication officer felt obliged to follow the doctor's opinion, given the wording of the regulation.
Mr. Moule challenged that in the High Court by judicial review. Mr. Justice Collins found that the regulation was indeed ultra vires because it displaced the role of the adjudication officer with that of the BAMS doctor and that that ran contrary to statutory procedure.
I understand that the Government are appealing the decision, but it is right that the law should be clarified on that point. Nevertheless, we believe firmly that the Government must either change the functional capacity all work test or allow all the exceptional grounds to remain, including the exception in relation to the effect of work on a deteriorating health condition; otherwise, we warn the Government that they will face a series of embarrassing judicial reviews and court cases which, I am advised, they may well lose.
More generally, it cannot be right that the position of someone who is already in poor health should be substantially worsened by their being required to work simply because they cannot pass an incapacity test which most of us regard as being both inappropriate and inadequate but which the Government have persisted in despite much evidence to the contrary.
Earl Russell: My Lords, as regards Regulation 27 and related matters, the noble Baroness has spoken for both of us. The only other comment I have to make is to welcome the change in the definition of "a close relative", which pretty well exactly repeats the terms of an amendment I moved during the passage of the Bill a long time ago. You never know when you are going to be lucky!
Lord Mackay of Ardbrecknish: My Lords, I wish that I had the noble Earl's depth of historical stories in order to top the expression, "You never know when you
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are going to be lucky". Nevertheless, I hope that I can persuade the noble Baroness and the noble Earl that their fears and those of outside organisations regarding Regulation 27 are ill founded. As I said earlier, the reason we have had to take the steps outlined in Regulation 27 relates to a recent decision of the High Court. That ruling means that the exceptional medical circumstances provision must now be applied by lay adjudicators where we previously thought it should be applied by the BAMS doctors. That lay adjudication can be applied without any need for medical input, yet the judgments themselves, as the noble Baroness clearly explained, require medical judgment. Therefore, it is important to ensure that such judgments are based on medical evidence.
We should not lose sight of the fact that the provisions need to be considered only where people have failed to satisfy the all-work test. They are intended to cover "exceptional circumstances". The provisions were intended to be applied by qualified medical experts. We now feel that they need to be more precisely defined in the light of the court's ruling that an adjudication officer, a lay adjudicator, ought to make the decision.
The regulations previously referred to a,
"severe uncontrolled or uncontrollable disease".
Medically, such a disease would have potentially life threatening consequences. That was reflected in the guidance for examining doctors. The amendment defines this "exceptional circumstance" provision more precisely in the light of the High Court judgment. But we are satisfied that it will not exclude anyone whom we originally intended to be covered. We are redefining the provision more precisely in the light of the court's decision. But, as I said, it is not our intention that anyone who would have been covered originally should now be excluded.
In the case of a physical disease, the substantial risk criteria applies to people with a life-threatening uncontrolled or uncontrollable disease. As a further safeguard in mental health cases, the new definition of "severe mental illness" for the purpose of the exempt categories means that doctors will need to consider carefully whether the criteria for exemption are met. The possibility of exemption will need to be considered again during the all-work test examination. In particular, the doctor will consider whether a person's mood or behaviour is so adversely affected that his ability to function socially is severely restricted or that he is very likely to pose a real danger or a threat to others such as work colleagues or members of the public. In such cases, the doctor will consider advising that the client meets the criteria for exemption on the grounds of severe mental illness.
Where a person has recently been receiving treatment and there is evidence that he has a mental disease which is at present uncontrolled to a degree that he might represent a substantial risk to his own life, an exceptional circumstance would apply. I should stress that the risk could arise either from self-harm or self-neglect.
As originally drafted, the exceptional circumstance criteria could be applied only on the recommendation of a BAMS doctor. While the adjudication officer must still take account of the opinion of the BAMS doctor, he

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will in future be able to consider other medical evidence, including any provided by the claimant's GP. He may prefer such evidence if he considers that it outweighs that of the BAMS doctor.
I hope that I can assure the noble Baroness that we are satisfied that the people who were intended to be covered by the original position will still be covered. The IB handbook has been amended to take account of the changes to the detailed wordings of the regulations, but the advice is entirely consistent with the original intended coverage. The consideration is essentially a medical one and the approved doctor will be required to consider for every client examined whether the individual circumstances justify the application of these criteria.
The department issues detailed guidance to approved doctors on this area of the IB regulations. There it is. The BAMS doctor will still need to consider the individual clinical circumstances and the treatment in order to judge whether a person's disease is likely to remain controlled for the foreseeable future. In giving that advice, the doctor will assume that the person will be found capable of work because the exceptional circumstances are considered only where people fail the test. If the doctor considers that the disease would be uncontrolled in such circumstances, he should advise the AO that an exceptional circumstance applies. I know that we are discussing a complicated issue, but I hope that the assurance that I have given allays the fears which the noble Baroness expressed on behalf of some outside bodies.
Baroness Hollis of Heigham: My Lords, before the Minister sits down, I should like further clarification. If the adjudication officer receives from the BAMS doctor a statement saying that he does not believe that the claimant falls into the exceptional circumstances category and the adjudication officer is not persuaded by that opinion, does that mean that the AO may invite a second medical opinion and may indeed be bound by or follow that second opinion? In other words, I wish to know where the initiative lies for making the final judgment.
Lord Mackay of Ardbrecknish: My Lords, as a result of a court judgment, the initiative obviously lies with the adjudication officer. That is why we are here this evening. Therefore, if the BAMS doctor does not make the observation but the adjudication officer has other evidence presented by the client—perhaps, as I mentioned earlier, from the client's own GP—then the adjudication officer has to make a judgment. He is not bound by the judgment of the BAMS doctor.
Baroness Hollis of Heigham: My Lords, I thank the Minister.
On Question, Motion agreed to.

Local Authorities (Contracting Out of Allocation of Housing and Homelessness Functions) Order 1996
8.57 p.m.
The Minister of State, Department of the Environment (Earl Ferrers)The Minister of State, Department of the Environment (Earl Ferrers) rose to move, That the draft order laid before the House on 28th November be approved [6th Report from the Joint Committee].
The noble Earl said: My Lords, the order will enable local authorities to contract out their executive functions under Parts VI and VII of the 1996 Housing Act. Where an authority does so it will have to set out exactly how the allocation scheme should be operated and it will have to decide which classes of person are, or are not, qualifying persons who would be entitled to appear on the register. The authorities will remain ultimately responsible for any functions which are carried out on their behalf by contractors.
We consulted the local authority associations in England and Wales in October and we received no objections on the proposals which are set out in the order. The order is welcomed by local government and is needed by local authorities which have transferred stock. I commend the order to your Lordships.
Moved, That the draft order laid before the House on 28th November be approved [6th Report from the Joint Committee].—(Earl Ferrers.)
Baroness Hollis of Heigham: My Lords, I am not sure that all is well in the best of all possible worlds as the noble Earl seemed to indicate in his introduction. The order gives local authorities the power to delegate to other bodies the exercise of most of their allocation and homelessness functions under Parts VI and VII of the 1996 Housing Act. It particularly applies to local authorities which have transferred their council housing stock to private companies under large-scale voluntary transfer arrangements and validates their work, excluding only certain listed functions set out in Schedule 1.
While it is right to allow local authorities as much discretion as possible as to how they operate this law, consistent with their legal responsibilities—and we therefore have no objection to that aspect of the order which insists that certain functions, especially the financial ones, cannot be delegated—we nonetheless believe that the order is far too narrowly drawn. In our view, other responsibilities should also have been ring-fenced and should not be available for delegation.
We believe that the order permits a local authority to delegate functions to another body so far as concerns homelessness which should not be so delegated. For example, I refer to such decisions as to whether an applicant is homeless, in priority need, is not intentionally homeless, and has a local connection. We believe that those key policy decisions should be determined by the local authority because it is held responsible for that under the law and is accountable in the courts for its actions.

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We believe, therefore, that the order fails to ring-fence enough of those functions. First, it allows the local authority to delegate the assessment of homelessness to an agent even though the local authority will remain responsible in law. I believe that any local authority which delegated such a function would be acting unwisely, putting itself and its council taxpayers at risk of a legal action on the lines of fiduciary responsibility. The Minister will be well advised to consider that issue. I believe that a local authority will put itself and its taxpayers at risk.
Secondly, I believe that the Government, to a degree, are acting somewhat in bad faith. I and the noble Earl were involved in handling this section of the Bill when it went through the House, as was the Minister. At no point that I recall did the Minister indicate that private companies should be allowed to exercise and determine these pivotal functions and decisions. Throughout the debates during the Bill the Minister emphasised that local authorities retained their responsibility under the law. We were led to believe that that meant that as a function they could not be delegated.
When at any stage during the passage of the Bill did the Minister clarify the distinction between delegation and responsibility, as he now does? We believe that it was inappropriate. These regulations were not encompassed by debate when the Bill was passed. It was not our understanding, and had the Government indicated that that was their intention, I for one, and I am certain the noble Earl too, would have moved amendments to exclude that possibility and to get on record in Hansard our concern about such a possibility. We did not do so because we did not understand that the Minister had that in mind. At no point did he make clear that that was his intention. I believe that that was not in good faith.
Thirdly—it is perhaps the point that really matters—these regulations will now make homeless people even more vulnerable than they are currently. The work in determining whether someone is homeless, and the right response to their homelessness, is highly sensitive work. Such homeless people may now find that private companies rather than their elected local authority and councillors will determine their rights to perhaps the most important asset in their life—a decent and stable home. We may find that private bodies, not necessarily working within the professional codes of local government, will be handling highly confidential material supplied by a general practitioner on physical and mental health, issues of domestic violence and abuse, immigration status, and the like.
Such matters should not be handled by private companies not controlled by the proper ethical standards of local government. It is quite improper, particularly as private companies and private landlords are not exactly well known for compliance with the law on such issues as race and sexual harassment. After all, increasingly people are homeless because the private sector has evicted them. The Government expect the private sector to rehouse them. On top of that they ask the private sector to lay down the rules and determine who shall be housed by whom and when. We think that that is unreasonable, inappropriate and unfair.
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The Government are effectively releasing local government from its statutory duties but not from its legal responsibility. We warn local authorities now to take the advice of the local authority associations not to go down that road because trouble lies at the end of it.
Earl Russell: My Lords, I, too, have misgivings about these regulations, to put it no stronger. I confirm what the noble Baroness said about there being no mention of this point at any stage during the passage of the Bill. It is not impossible—I choose words carefully—that at least one Division might have gone a different way had that information been available. It surprises me very much that there is no restriction in the regulations in terms of the competence of the body to which functions are delegated. For all we know it might be a body such as Group 4. There are no clear provisions about avoiding conflict of interest; and there are many chances of that.
While I was pleased to hear what the Minister said about the local authority being ultimately responsible, there are some quite big problems here. I am not convinced that they have been thought through. The local authority will be liable to judicial review because it is its duty. But how far can we answer for the conduct of people other than ourselves? Can we have a categoric assurance that the company to whom all functions are delegated will not be allowed to plead commercial confidentiality when the local authority's duty is at stake?
Can we be told whether the local government ombudsman will retain jurisdiction over functions carried out by a contracted body? Can we be told whether a review under Section 204 of the Act may be delegated? If so, we should remember that it is the basic principle of natural justice that a body may not be judge and party in its own cause. I should have thought that the risk of that principle being broken was perfectly obvious.
The Minister may not be able to answer all the points tonight. If not, I hope that he will write to me because these are serious questions and I am worried about them.
Earl Ferrers: My Lords, I am sorry that the noble Baroness did not find it in her mind to approve the regulations in the way that I had hoped she would. It was made perfectly clear throughout the Housing Bill that that was what was intended. We consulted local authorities in October and received no objections to the proposals.
The noble Baroness said that it would be quite wrong for the private sector to lay down rules as to who should be housed and when. That is where the noble Baroness is greatly mistaken. It is for the local authority to lay down the rules under which the contractor, for want of a better expression, will operate. It is up to the person who takes that responsibility on to abide by the contract. It will be for the local authority to determine who shall or shall not be a suitable person to be housed. It is only the executive function that will be carried out by the other body. I do not think that there is anything wrong or particularly unique in that. We have seen it in many other cases.

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Perhaps I might ask the noble Baroness to address her mind to a different sort of case, but one which caused all the fuss to start with; namely, when prisons were contracted out. The fact is that it depends on what is written in the contract. There is no reason to think that this will not be done just as well under the present system.
Baroness Hollis of Heigham: My Lords, perhaps the Minister will give way. The difference in his analogy is that Group 4 does not decide who is a prisoner. The point here is that, although the local authority may lay down the rules as to what counts as homelessness, it will be for the private company to determine whether an individual conforms to the criteria—in other words whether they are "Guilty, M'lord, as pleaded". That is why the case is not analogous with Group 4.
Earl Ferrers: My Lords, I do not know why the noble Baroness keeps talking about Group 4; I did not even mention Group 4. The fact is that the local authority will determine what are the criteria by which a person will be determined to be homeless. That is the position.
I remind the noble Baroness that all the actions of a contractor are, by virtue of Section 72 of the 1994 Act, to be treated as actions of the authority; and the authority therefore remains the one who is responsible. If anything is wrong in that action, the local authority will be responsible.
The noble Baroness said that private companies exercise these functions. That is perfectly true. However, we made it clear throughout the passage of the Bill that in large scale voluntary transfer we would expect to see the registered social landlord carrying out the functions. Registered social landlords are private companies in this sense, and they are responsible bodies. We consulted local authorities about this matter and no objections were raised.
The noble Earl, Lord Russell, referred to conflict of interest. Most contracts would be let to a registered social landlord, possibly a housing association. Those bodies are required by the Act to co-operate with local authorities in discharging their functions. They share the same objectives in meeting housing need.
The noble Earl also asked whether, after contracting out the homelessness functions, they would be subject to the local government ombudsman. The answer is that they will be. The noble Earl also asked how far an authority can answer for the actions of others. The authority will need to make arrangements with its contractors, who will usually be a responsible registered social landlord. That will ensure that if there is a successful challenge in the courts the authority can require the contractor to respect the decisions of the courts.
I shall certainly look at what the noble Earl said. If I have not covered all the points that he mentioned, I shall write to him. I hope that the House will agree the passage of this order. I commend it to the House.
On Question, Motion agreed to.

Non-Domestic Rating (Chargeable Amounts for Small Hereditaments) Regulations 1996
9.12 p.m.
Earl Ferrers Earl Ferrers rose to move, That the draft regulations laid before the House on 9th December be approved [6th Report from the Joint Committee].
The noble Earl said: My Lords, as the regulations implement the measures outlined in the Budget which will reduce the rate bills of small business properties, I cannot believe that they can be in any way controversial. If it is for the convenience of the House, I will move them formally. If, on the other hand, your Lordships wish me to go into any explanation about them, I shall be happy to do so. I beg to move.
Moved, That the draft regulations laid before the House on 9th December be approved [6th Report from the Joint Committee].—(Earl Ferrers.)
Baroness Hollis of Heigham: My Lords, I realise that we are keeping the noble Earl from his dinner, so I apologise. Nevertheless, these are important regulations, and this one is no less important.
In these regulations the Government are freezing small business rates for this forthcoming year rather than allowing them to rise by inflation. As primary legislation requires them to rise by inflation, we need regulations to "do a Henry VIII". That will clearly benefit 1.1 million small businesses. As the Government, rather than local government, are picking up the Bill, it would be churlish to oppose this measure—though, given the pressures on government spending and the recent cuts in benefit and the like, the fact that the Government can find £100 million in additional relief for small businesses comes as some surprise, especially as it will absorb all the savings to be found apparently from the cuts in the notorious housing benefit regulations which we anticipate. Those regulations will force middle-aged men and women under 60 into bed-sit accommodation. The savings on the change in housing benefit will generate £105 million, of which, so far as I can see, every penny will go to ease and freeze the rate increase on small businesses.
That was an additional surprise to these Benches because the Government had insisted that, given the feel-good factor, local businesses would now be in a position to pay the proper input. Or do the Government accept that small businesses are so desperately in need that they require additional relief above and beyond what they would incur? It is a further surprise to these Benches because the Government have limited the revenue support grant to fund their tax cuts of one penny in the pound, thus forcing the council tax rate up by an average of 6 per cent.—double the rate of inflation. Or do the Government hope that the council tax rises will be blamed on Labour and Liberal local government while the freezing of the non-domestic rate will be to the benefit of the Government?
It is worth pointing out that the Government's timetable is short and local authorities will experience some costs in billing. If the Government can help us on

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the point, that would be welcome. Will they tell us whether the proposals require changes to the demand notice or to the accompanying explanatory notes?
What all this shows is the absurdity of the current arrangements for the business rate. Some areas are rather more prosperous than others and it is appropriate for businesses there to pay a higher non-domestic rate. In some areas business enjoys a higher level of services and it is appropriate that they should pay a higher level of non-domestic rate. It is also clear that small firms agree with that point of view. In the Department of Employment research of 1994 on the impact of rates on business, only 20 per cent. of firms thought that the current arrangements for the non-domestic rate had improved the system by removing variations in poundage between different local authorities. Three-quarters of firms agreed with the statement that business should pay rates according to the extent to which they benefited from local services.
Soon, I hope, we shall restore the business rate to local communities while ensuring that local authorities work in partnership with their local businesses to rebuild local economies which have been decimated over the past decade.
Earl Ferrers: My Lords, I always thought that the noble Baroness was fairly difficult to satisfy. Now she has shown that to be a fact. The festive spirit of good will does not seem to have entered her Benches. The Government are actually reducing liability for tax, freezing any increases in certain respects and reducing liability in other respects. All the noble Baroness can say is: "Oh well, if you used that money you would be able to help those in bed-sits".
The two are not comparable. As the noble Baroness knows, we must look at each facet and deal with it in the right way as an individual issue. What she said inferred that small businesses were in a bad way. Then she asked whether they needed the help. All I can tell the noble Baroness is that we on this side feel that small businesses and the part that they play in the economy are very important. It is interesting to note from her reply that the party opposite does not set such store by small businesses.
Baroness Hollis of Heigham: My Lords, will the Minister give way?
Earl Ferrers: My Lords, I shall give way in a minute. The noble Baroness is persistent and always tries to intervene. I gave way on the previous occasion and I will give way now.
Baroness Hollis of Heigham: My Lords, I thank the Minister for demonstrating the usual courtesies of the
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House. I did not object to the freezing of the benefit for local businesses because it is being funded by central government. However, I was making the point not that we were not anxious to assist small businesses but why the Government should think that small businesses needed assistance if the words of the Chancellor in his Budget speech that we have never had it so good were to be believed.
Earl Ferrers: My Lords, the noble Baroness cannot avoid bringing party politics into everything. That is her style. However, research has shown that small businesses pay a greater proportion of their outgoings in non-domestic rates and have been calling for action. We have taken that action. I should have thought that that would satisfy most people, even if we cannot satisfy the noble Baroness.
The noble Baroness referred to the changes in the billing regulations. We shall change the regulations in early January and have been consulting local authorities. I hope that the noble Baroness is in a minority of one in not rejoicing in the regulations. Nevertheless, I commend them to the House.
On Question, Motion agreed to.

King's College, London Bill [H.L.]
A message was brought from the Commons that they have come to the following resolution to which they desire the concurrence of this House—
That the Promoters of the King's College London Bill [Lords] may, notwithstanding anything in the Standing Orders or practice of this House, proceed with the Bill in the present Session; and the Petition for the Bill shall be deemed to have been deposited and all Standing Orders applicable thereto shall be deemed to have been complied with;
That if the Bill is brought from the Lords in the present Session, the Agents for the Bill shall deposit in the Private Bill Office a declaration signed by them stating that the Bill is the same, in every respect, as the Bill which was brought from the Lords in the last session;
That, as soon as a certificate by one of the Clerks in the Private Bill Office, that such a declaration has been so deposited, has been laid upon the Table of the House, the Bill shall be read the first and second time (and shall be recorded in the Journal of this House as having been so read) and shall be ordered to be read the third time;
That no further Fees shall be charged in respect of any proceedings on the Bill in respect of which Fees have already been incurred during any previous session.
House adjourned at twenty minutes past nine o'clock.