§ 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 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—
§ (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 1397 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 1398 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.1399
§ 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 1400 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.
1404 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, 145.1407
|Division No. 1|
|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.|
|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.|
§ Resolved in the negative, and amendment disagreed to accordingly.
§ 3.49 p.m.
§ Clause 1 [Pilot schemes]:
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, 1412 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 1413 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 1414 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 1415 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 1416 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 1417 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 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 1418 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".1419 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.
§ Amendment, by leave, withdrawn.
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 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, 1420 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 1421 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 1422 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 1423 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.
1424 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 1425 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 1426 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 1427 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.
1428 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 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 1429 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 1430 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.1431
§ Clause 3 [Approval of pilot schemes]:
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 1432 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 1433 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 1434 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.
1435 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 1436 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 1437 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 1438 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 1439 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.
1440 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 1441 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 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 1442 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 1443 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 1444 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 1445 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 1446 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.]1447
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 1448 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 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 1449 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 1450 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 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 1451 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.1452
§ Clause 10 [Leaving medical lists]:
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.
1453 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 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 1455 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".
§ 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 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 1456 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 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 1457 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 1458 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 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.
1459 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; 1460 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 1461 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 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.1462
§ 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 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 1463 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 1464 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.
1465 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 moved Amendment No. 47:
After Clause 25, insert the following new clause—
§ (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.".").1466
§ 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 1467 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 1468 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 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.1469
§ 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.1470
§ 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.