National Health Service (Primary Care) Bill [H.L.]

HL Deb 23 January 1997 vol 577 cc804-58

3.37 p.m.

Report received.

Clause 1 [Pilot schemes]:

Baroness McFarlane of Llandaff moved Amendment No. 1: Page 1, 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 I of the National Health Service (Scotland) Act 1978.").

The noble Baroness said: My Lords, in moving Amendment No. 1, I wish to speak also to Amendments Nos. 3, 8 and 19 which are related. The purpose of these amendments, as stated at Committee stage, is to allow nurses to propose pilot schemes in their own right, to ensure that health authorities must prepare proposals put forward by nurses, and to allow nurses providing nursing services under pilot schemes to become health service bodies.

The key reasons for bringing these amendments again are that nurses are often best placed to provide certain primary healthcare services for patients and to bring pilot schemes in respect of them. Justice demands that nurses should receive equitable treatment with doctors. Failure to make the change could undermine the success of the legislation.

I do not wish to be tedious or to weary the House in bringing back a group of amendments considered in detail in Committee and, by leave, withdrawn. However, the amendments attracted a considerable amount of support from all parts of the Chamber. I was surprised that the Minister was unable to accept the arguments. Following her very full and generous reply, I indicated that I wished to consider carefully what she had said, to study the White Paper Delivering the Future which had been published that day, and to have the opportunity to return to the issue at another stage.

The interest shown by the Minister in nursing, and in particular in community nursing, over the years has been considerable. The review, Neighbourhood Nursing, for which she chaired the committee, made her a redoubtable champion of community nurses. It must be a cause for particular personal gratification that 10 years on from what the profession calls the Cumberlege Report, and five years after the Nurse Prescribing Act, the roll-out of nurse prescribing was announced in the White Paper Delivering the Future. Nurses everywhere applaud that and the tenacity of the Baroness in keeping the issue on the political agenda.

I am all the more regretful, therefore, to return to these amendments and to the reply given by the Minister at Committee stage. One concern expressed was that nurse-led pilots should not replace general medical services with personal medical services; and that nurses should not provide services in the place of general practitioner services. Nurses would agree with that and with the importance of it. They appreciate their role and do not wish to encroach on medical roles.

However, there are a number of areas of healthcare which are not covered by general practitioners where nurses are best placed to provide services. Examples include services for homeless people or for those not registered with general practitioners, family planning services, midwifery services, health promotion and public health services. A community based programme was devised by the nurses in one deprived area to help families on low incomes eat a healthy diet. In another area, nurse-led community action saw the introduction of traffic calming schemes resulting in a reduction in child mortality and morbidity from road traffic actions on an estate. In inner London an initiative was established to deliver healthcare to the homeless population by nurse practitioners assessing needs and delivering care in hostels and treating conditions such as asthma, chronic lung infection, leg ulcers and foot conditions.

One could continue with many examples. I was impressed with the words of the general secretary of the Royal College of Nursing as she addressed the Conservative Medical Society on Monday this week. She said: 'When the Government launched Delivering the Future, press reports talked of the birth of 'supernurse'. The white paper maps out the crucial role that nurses will play in the delivery of a primary health-led NHS but for most community nurses the supernurse of the newspaper reports already exists. For years community nurses—district nurses, community midwives and health visitors—have delivered the largest component of primary healthcare. But the roles that nurses have always taken on in the community, are now also part of general practice. The explosion in the number of practice nurses in the UK"—

from, I believe, 1,500 in 1977 to 18,000 now— has meant that nurse-led asthma and diabetes clinics, nurse-run outreach projects for the homeless people and well woman clinics run by nurses are commonplace in many GP practices".

The nurse's role in health education is well recognised and research shows the benefits of nursing inputs in reducing costs and saving waiting time for patients. I believe that because of all those factors it is right and proper that nurses should be able to instigate their own pilot schemes.

Principles of justice and equity are involved. In Committee, at col. 1413 of the Official Report of 17th December 1996, the noble Baroness, Lady Cumberlege, said: 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".

But she argued that nurses could exploit those opportunities only through partnerships with general practitioners or through taking a more significant role in a trust.

At col. 1414, the noble Baroness said that the health authority receiving a proposal from a group of nurses 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".

However, no such requirement is made should a doctor propose a pilot scheme. The onus is simply on the health authority to consider any scheme submitted by a trust, doctor or dentist. Thus, if a nurse in partnership proposed to provide a 24-hour emergency mental health service for a locality and to employ a medical practitioner to undertake specific medical activities where necessary or appropriate, the scheme would not receive automatic consideration by the health authority. Yet if a doctor were to submit the proposal the health authority would be obliged to consider it even though the same services would be provided and the same questions would arise as to the nature of the areas of work covered.

If the crucial issue is that the health authority needs to satisfy itself that the pilot covers particular areas of care, then that should apply to any proposal regardless of its source. The question of equity is at stake. There is no question that nurses wish to usurp the role of doctors. They wish to work collaboratively and in a relationship of equality. However, without the changes embodied in the amendments the role that nurses could and should be playing in primary care—with the importance of the added expertise that their roles now have—will be limited because the widest range of innovative schemes will not be put forward.

It is argued that as the Bill stands, there is nothing that a nurse, midwife or health visitor could not put forward through a doctor or a trust. But there is a considerable difference between initiating a pilot scheme at first hand, directly, and having to do so at one remove. Of course, all pilots must be scrutinised with the needs of patients foremost. But to suggest that the paperwork would become intolerable is to suggest that nurses would be irresponsible in submitting schemes and that their schemes were less important than doctors' or dentists' schemes.

I have worked most of my life in a different setting, in a university. It would be unthinkable in that setting that any one discipline would be treated differently from another in putting forward research proposals or innovative schemes of any kind. It is hurtful to nurses to think that they would be treated differently.

As the Bill stands, it inhibits nurses, midwives and health visitors from being able to play a full part in submitting pilot schemes. In tabling these amendments again, I seek some reassurance that, at least at a later stage of the Bill, these important amendments relating to nurses will receive consideration. I beg to move.

Baroness Jay of Paddington

My Lords, I support the noble Baroness in this group of amendments, to which my name is also attached. As she explained so fully, the Bill as it stands offers unnecessary restrictions which run counter to what we have understood to be the more widespread approach to general practice and primary care in which the Bill seeks to engage and which we have generally supported from these Benches. As the noble Baroness said, it unnecessarily limits the potential for innovation.

In her reply in Committee (at col. 1415 of Hansard), the Minister said that some of these amendments seemed to suggest that the intention was to turn nurses into doctors. As the noble Baroness, Lady McFarlane, explained, that is clearly not the intention. She gave the House some vivid examples of the ways in which nurses already take a primary role in primary care. I shall mention just one example that is very well known to me, of a senior nurse running a local minor injuries unit who recently became a very successful chief executive of an acute trust. She would find very odd any suggestion that she was incapable of being the lead proposer or organiser of the type of pilot scheme that is proposed in the Bill.

As the noble Baroness said, the White Paper referred to the equally important role of nurses, although at Committee stage the Minister seemed to feel that that could be well achieved within the meaning of the Bill as it now stands. She seemed to develop the argument to which the noble Baroness, Lady McFarlane, referred that the sifting system of the health authority would enable good schemes by nurses possibly to be included in those forwarded to the Secretary of State.

The point was very well made. If we are to encourage the equal role of the nurse, midwife, health visitor or other professionals mentioned in the noble Baroness's amendments, some positive national lead needs to be given of the type that would be created were the amendments to be accepted. As the noble Baroness, Lady McFarlane, said, the Minister has a very well-deserved reputation for supporting and improving the role of nurses within the profession and within community care. She could do a good deal to enhance that reputation if she were to accept these amendments. I support them.

Baroness Masham of Ilton

My Lords, I wonder what doctors and the Royal College of General Practitioners think about these amendments. Could it mean that the doctors would opt out of some of their responsibilities?

As matters stand, understanding and training in relation to many disabilities and the attitude of many doctors to disabled patients should be improved. Doctors might try to pass that sort of work in relation to disability on to the nurses, as that would save them time. However, the nurse has different responsibilities and training. The doctors have longer training and should be better at dealing with some of the very complex matters. I should be very interested to know the doctors' opinion on these amendments.

Baroness Cumberlege

My Lords, I am grateful to the noble Baroness, Lady McFarlane, first, for giving me notice of a number of the amendments tabled, and also for her very generous and fulsome remarks. I am also grateful for the remarks of the noble Baroness, Lady Jay.

Any proposals put forward by the noble Baroness, Lady McFarlane, have to be taken with the deepest seriousness. She is one of the country's most distinguished nurses. I believe that she was the first nurse ever to get a chair in nursing at a university.

I have no doubt whatever that nurses are often the very best people to provide primary care services for particular groups of patients. As the noble Baronesses, Lady McFarlane and Lady Jay, said, there are some excellent examples of innovative primary care services which are not only provided by nurses but were inspired by them. I, too, have seen many of them. I can think of specific schemes to help homeless people where nurse practitioners have been providing the service without a GP being involved; those people particularly did not want to see a doctor, but they would accept a nurse. Many other examples given this afternoon are pertinent and inspiring.

Indeed, many other initiatives are happening now. They all fall within Part I of the National Health Service Act 1977, which is the subject of one of the amendments. So there is nothing now to prevent nurses from putting forward proposals like this to their local health authority. Arrangements for the provision of services under Part I are very flexible. There is no need for this Bill to enable such ideas to be taken forward.

The pilots that we propose relate to services currently delivered under Part II of the Act; namely, general medical and dental services. These are the concerns of the Bill. Up to now, the provision of services has been very tightly regulated. That is why we need primary legislation to allow for new opportunities.

The pilots we propose will cover the delivery of general medical and dental services. Those services will need doctors or dentists. Only suitably experienced doctors can legally provide the medical services received in general practice. That point is reiterated in the Bill.

I continue to think it right that where a proposal is put forward not involving doctors, dentists or NHS trusts, the health authority should be able to consider whether it satisfactorily covers those areas of care that have to be provided by doctors or dentists before it is submitted to the Secretary of State. Where a GP is not involved in the proposal, it will need to be clearly set out how GP input will be provided. That seems to me to be an essential screen at local level.

That does not prevent nurses putting forward proposals. Indeed, I hope they will continue to do so. However, I must also emphasise that I certainly look forward to seeing nurses continue to develop their unique roles through pilots with practices and trusts and to seeing them taking forward the proposals that we set out in Primary Care: Delivering the Future.

I wish to make two further points about the amendment. First, in most cases the proposals will be put forward by nurses employed by a trust. Unless those proposing a scheme wish to leave their current employment, it seems right that their proposals should have the support of their employer, who will have to hold the contract with the health authority should the proposal be accepted as a pilot. They are in a very different situation from that of general practitioners and dentists, who are independent contractors.

If a pilot receives such support it will have a direct route to the Secretary of State under the terms of the Bill, because it will be sponsored by the trust that employs the nurses. Secondly, if the nurses are part of an independent organisation then in line with other similar proposals it seems right that the health authority should decide whether or not it should proceed.

I have been through a number of examples given to me by the nursing profession. I have yet to find one that stands up in terms of those other two aspects. I share the aspirations of noble Lords. I wish to see nursing develop and become an even greater profession than it is. However, I really do not think that in the context of the Bill these amendments are pertinent.

To respond to the point made by the noble Baroness, Lady Masham, I cannot tell her what the Royal College of Practitioners thinks about these particular amendments. However, I assure her that the medical profession very strongly supports the Bill and the concepts behind it. I do not believe that there is any intention that doctors should opt out of their current responsibilities.

I hope that the noble Baroness will not press the amendment.

Baroness MacFarlane of Llandaff

My Lords, let me first thank the noble Baroness for her kindness to me personally in what she said. When there is such mutual respect it is all the harder to disagree. I know that her motives are of the highest and that she shows the greatest support for nurses. Nonetheless I believe that the Bill is discriminatory in the way it is drafted and that we should clear that discrimination from the face of the Bill.

At Committee stage there was considerable support from all sides of the House, including from many medical Lords. That encourages me to go forward with these amendments. In the intervening period between Committee and this stage I have sounded out views on the amendments with all the nurses whom I have met. With the exception of one, their view was unanimous that the amendments are necessary if nursing is to play its full role.

Because of the support at Committee stage and the importance of the amendments to the nursing profession, I feel that I should test the opinion of the House.

4.1 p.m.

On Question, Whether the said amendment (No. 1) shall be agreed to?

Their Lordships divided: Contents, 99; Not-Contents, 130.

Division No. 1
CONTENTS
Acton, L.	Judd, L.
Addington, L.	Kennet, L.
Archer of Sandwell, L.	Kilpatrick of Kincraig, L.
Ashley of Stoke. L.	Kirkhill,L.
Berkeley, L.	Lester of Herne Hill, L.
Blease, L.	Lockwood, B.
Borrie, L.	McFarlane of Llandaff, B.
Bruce of Donington, L.	McNair, L.
Butterfield, L.	McNally, L.
Callaghan of Cardiff, L.	Mar and Kellie, E.
Calverley, L.	Mason of Barnsley, L.
Carlisle, E.	Merlyn-Rees, L.
Carmichael of Kelvingrove, L.	Methuen, L.
Carter, L.	Monkswell, L.
Chapple, L.	Morris of Castle Morris, L.
Clancarty, E.	Murray of Epping Forest, L.
Cledwyn of Penrhos, L.	Nelson, E.
Clinton-Davis, L.	Nicol, B.
Cocks of Hartcliffe, L.	Ogmore, L.
Craigavon, V.	Palmer, L.
Dahrendorf, L.	Paul, L.
David, B.	Peston, L.
Donoughue, L.	Plant of Highfield,L.
Dormand of Easington, L.	Prys-Davies, L.
Dubs,L.	Ramsay of Cartvale, B.
Eatwell, L.	Rea, L.
Exmouth, V.	Richard, L.
Ezra, L.	Robson of Kiddington, B.
Falkland, V.	Sainsbury, L.
Gallacher, L.	Sandwich, E.
Geraint, L.	Serota, B.
Gould of Pottemewton, B. [Teller.]	Stoddart of Swindon, L.
	Strabolgi, L.
Graham of Edmonton, L. (Teller.)	Symons of Vernham Dean, B.
Grenfell, L.	Tenby, V.
Halsbury, E.	Tope, L.
Hanworth, V.	Tordoff, L
Harris of Greenwich, L.	Turner of Camden, B.
Haskel, L.	Wallace of Coslany, L.
Hayman, B.	Walton of Detchant, L.
Hayter, L.	Warnock, B.
Hilton of Eggardon, B.	Weatherill, L.
Hollis of Heigham,B.	Wharton, B.
Hughes, L.	White, B.
Hylton-Fbster, B.	Wigoder, L.
Ilchester, E.	Williams of Crosby, B.
Jay of Paddington, B.	Williams of Elvel,L.
Jeger, B.	Williams of Mostyn, L.
Jenkins of Hillhead, L.	Winchilsea and Nottingham, E.
Jenkins of Putney, L.	Winston, L.

NOT-CONTENTS
Aberdare, L.	Brabazon of Tara, L.
Addison, V.	Brentford, V.
Ailsa, M.	Bridgeman, V.
Alexander of Tunis, E.	Brookes, L.
Anelay of St. Johns, B.	Byford, B.
Astor of Hever, L.	Cadman, L.
Balfour, E.	Campbell of Alloway, L.
Barber of Tewkesbury, L.	Campbell of Croy. L.
Belhaven and Stenton, L.	Carnarvon, E.
Beloff, L.	Carnegy of Lour, B.
Birdwood, L.	Carnock, L.
Blake, L.	Carr of Hadley, L.
Blaker,L.	Chesham, L. [Teller.]
Blatch, B.	Coleraine, L.
Blyth, L.	Coleridge, L.

Courtown, E.	Mackay of Drumadoon, L.
Cranbourne, V. (Lord Privy Seal)	Macleod of Borve, B.
Cumberlege, B.	Marlesford, L.
Davidson, V.	Merrivale, L.
Dean of Harptree, L.	Mersey, V.
Denbigh, E	Miller of Hendon,B.
Denham, L.	Milverton, L.
Denton of Wakefield, B.	Montgomery of Alamein, V.
Dixon-Smith, L.	Mottistone, L.
Downshire, M.	Mountevans, L.
Dundee, E.	Mowbray and Stourton, L.
Eccles, V.	Munster, E
Elibank,L.	Murton of Lindisfarne, L.
Ellenborough, L.	Newall, L.
Elles, B.	Norfolk, D.
Elliott of Morpeth, L.	Northesk, E.
Erne, E.	O'Cathain, B.
Ferrers, E.	Oxfuird, V.
Flather, B.	Palumbo, L.
Fraser of Carmyllie, L.	Park of Monmouth, B.
Gainford, L.	Pearson of Rannoch, L.
Goschen, V.	Pender, L.
Hacking, L.	Pilkington of Oxenford, L.
Hailsham of Saint Marylebone, L.	Platt of Writtle, B.
	Plummer of St Marylebone, L.
Harding of Petherton, L.	Quinton, L.
Harmsworth, L.	Rankeillour, L.
Hayhoe, L.	Reay, L.
Hemphill, L.	Renton, L.
Henley, L.	Holderness, L.
HolmPatrick, L.	Richardson, L.
Romney, E.	Rotherwick, L.
Hooper, B.	Saatchi, L.
Howe, E.	St. Davids, V.
Inglewood, L.	Saint Levan, L.
Jenkin of Roding, L.	Seccombe, B.
Johnston of Rockport, L.	Shaw of Northstead, L.
Kimball,L.	Skelmersdale, L.
King of Wartnaby, L.	Strange, B.
Knollys, V.	Strathclyde, L. [Teller.]
Lauderdale, E.	Strathcona and Mount Royal, L.
Lindsay, E.	Sudeley, L.
Long, V.	Swansea, L.
Lucas, L.	Swinfen, L.
Lucas of Chilworth, L.	Terrington, L.
Lyell, L.	Teviot, L.
McColl of Dulwich, L.	Thomas of Gwydir, L.
McConnell, L.	Vivian, L.
Mckay of Ardbrecknish, L.	Wilcox,B.
Mackay of Clashfem, L. [Lord Chancellor.]	Wise, L.
	Young, B.

Resolved in the negative, and amendment disagreed to accordingly.

4.10 p.m.

Lord Rea moved Amendment No. 2: Page 1, line 15, leave out subsection (2).

The noble Lord said: My Lords, this amendment is the same as Amendment No. 3, which I moved at Committee stage. Before I explain what the amendment entails, I should like just to quote the last part of the noble Baroness's reply at Committee stage. She said: 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".—[Official Report, 17/12/96; col. 1419.]

The Government have not tabled an amendment embodying those further thoughts and I had no alternative but to move the amendment again. It removes from the Bill 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".

I said at Committee stage how I personally had benefited from working in a health centre where both dental practitioners and general medical practitioners working for the National Health Service collaborated very beneficially for both the professions and the patients concerned. It seemed to me strange that the two helping, clinical professions could not put forward a scheme together. But the noble Baroness said: General practice and dentistry are very distinct services … 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".—[col. 1418.]

To that I replied a little later that although they would be paid from different sources, it would surely be easier to make the arrangements within a pilot scheme than to have two entirely separate pilot schemes. The noble Baroness, Lady Gardner of Parkes, expressed the same opinion as myself. That is why the Minister said that she would go away and think about the matter.

I gather that the British Medical Association is slightly more in agreement with the Minister than I am and sees the complexities that she mentioned as very important. Personally, I do not see the matter that way. But I should be grateful if she could say what deliberations she has had between Committee stage and now. I beg to move.

Baroness Cumberlege

My Lords, as the noble Lord said, we discussed this matter at some length at Committee stage. I should like to reassure noble Lords that I support wholeheartedly the objective behind this amendment, that of encouraging better integration of services provided by the different professions. After all, that has been one of our aims in primary care for some time. It remains a priority.

I undertook to consider further the need for Clause 1(2) and to advise your Lordships at Report stage of the outcome. I have done so. But I remain convinced that the provision in the Bill which this amendment seeks to remove will not hinder further progress towards co-operation between the medical and dental professions. There will be nothing to stop doctors and dentists examining local health needs together and co-operating over the preparation of pilot proposals, perhaps sometimes involving joint premises, which was one of the examples given by the noble Lord at Committee stage. Those proposals would then go forward together but be presented as separate schemes.

The Bill certainly will not stand in their way. It simply requires separate contracts for what are already two distinct services with very different financial and practical arrangements. They will need separate consideration locally and probably different evaluation. It will help to ensure that funding for dentistry is spent on dentistry. Failing to maintain the distinction between the two services could produce confusion for little gain.

I know that the provision as currently drafted in the Bill has the full support of the General Dental Services Committee. I hope that your Lordships, having heard my explanation and reassurances, will not seek to press the amendment.

Lord Rea

My Lords, I understand the position of the noble Baroness a little better, though I still do not understand why that provision has to be on the face of the Bill. It seems to me that in drawing up pilot schemes, that would automatically have been sorted out. But it is an academic point. So long as the noble Baroness can assure me that there will be schemes in which the two professions can collaborate, I see no point in pressing the amendment further. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

4.15 p.m.

[Amendment No. 3 not moved.]

Clause 2 [Proposals for pilot schemes]:

Baroness Jay of Paddington moved Amendment No. 4: Page 2, line 37, after ("scheme") insert— ("(aa) satisfy themselves that there is no diminution in the quality or range of services provided in an area which is covered by the pilot scheme.").

The noble Baroness said

My Lords, my name is to the other amendments in this group. Perhaps I may speak to those and the noble Baroness, Lady McFarlane of Llandaff, may wish to follow me. I should certainly like to move Amendments Nos. 9 and 13 which are in this group and to which my name is attached.

The purpose of all the amendments is to deal with the need to ensure that the quality of service is maintained in pilot schemes. That is the particular requirement of Amendment No. 4 in the name of the noble Baroness, Lady McFarlane. Amendments Nos. 9 and 13, standing in my name, are proposals for pilot schemes and subsequently for judging whether those pilot schemes should become part of the permanent local services.

We raised those issues at Committee stage because we feel it is very important that consistent standards and services so far as possible should be offered by all primary care providers, whatever part of the country they are in or on whatever basis that provision is made, however widely the notion of the pilot experimental scheme is drawn. The House will be familiar with the great concern on these Benches that in the past few years what we describe as a fragmented health service is producing a system in what you get depends on where you live and not necessarily on what you need. We fear that the defects of the system may be exacerbated by the deregulation proposed in the Bill without a statutory requirement to establish national criteria for standards.

Therefore, the amendments propose that requirement to adhere to national standards of care and service which would be established by a nationally representative body. That would also avoid the suspicion that local health authorities might promote local schemes on the basis simply of cost and that cost saving might become the determining criterion for successful applications in hard-pressed health authorities. We have used the expression "a nationally representative body" because at Committee stage the Minister and I agreed that it was extremely difficult to establish what one might colloquially call "gold standards" within primary care, or indeed any other part of healthcare for that matter. We also agreed that, particularly within the context of the development of evidence-based practice in the NHS, it was very important to strive to achieve it.

I was encouraged that at Committee stage the Minister said that the Department of Health was establishing "a nationally representative group"—the expression used in these two amendments—to take this matter forward and to discuss criteria governing the approval of pilot schemes. She developed those points in Committee (Hansard, col. 1445).

The noble Baroness also said that the criteria would be established and published before pilots were considered and indeed, of course, the proposals for long-term service change which might arise from those pilots. That is also welcome.

Amendments Nos. 9 and 13 simply seek to give force to those understandings which the Minister expressed at an earlier stage by establishing on the face of the Bill that the national representative group which she said was being established would have statutory authority to set criteria on which the Secretary of State will make decisions about the value of pilot schemes to the communities they are intended to serve. I beg to move.

Baroness Cumberlege

My Lords, as the noble Baroness said, these amendments focus on the quality and standards in the pilot schemes. We share those objectives. We believe firmly that we will secure them through the Bill as it stands and through our approach to implementation.

Amendments Nos. 9 and 13 concern the setting up of statutory groups of interested parties to advise on quality and standards and on criteria for evaluation. We are already doing that. As the noble Baroness said, two such groups have already been set up—one for medical services and one for dentistry—with representatives from the professions, patients and other interested parties. They are to help identify the standards and criteria that should apply before pilots are approved and to advise on a framework for evaluation. The first meetings will be held next week. We see those groups as playing an important role but do not see the need to enshrine them in legislation.

I hope that the noble Baroness, Lady Jay, will agree that, while we share her concerns, we have largely met them. We regard an open, consultative approach as the best and probably only way for our initiative to get off the ground and flourish. We see the groups as playing a leading role but do not see the need to enshrine them in legislation.

Since piloted schemes will vary enormously, it is important that the overall standards and values are clearly set out and that individual schemes have clearly defined aims and objectives against which health authorities and others can judge whether they have achieved their initial aims. We will consult widely before the areas to be covered by the Secretary of State's directions to health authorities are drawn up. The kind of issues we will expect authorities to cover and on which we will seek views at the drafting stage will include the intended benefits to patients, how pilot proposals fit in with other local NHS services and ensuring that they are not detrimental to the wider NHS, and how any potential conflicts of interest will be satisfactorily resolved before the pilot scheme begins.

I hope that I have shown that we are committed to a broad national framework of standards and values within which pilots will operate and be evaluated. I hope that I have demonstrated also how serious we are about seeking the advice and views of those with an interest. I trust that the noble Baroness will agree that that meets many of the worries expressed in her amendment and that she will not therefore seek to pursue it.

The approach I outlined also satisfies the aims of Amendment No. 4. I made clear that we do not underestimate the importance of raising the standards and quality of services. It will be one of the key agenda items for our national representative groups. Our initiative is unequivocally about achieving improvements in services. I hope your Lordships will accept my assurances that any pilot proposal that does not set out how it will improve services will not be allowed to proceed and that your Lordships will not press the amendments.

Baroness Masham of Ilton

My Lords, perhaps I can raise one matter before the noble Baroness sits down. As we do not know what the pilots are to be, is it not better to have the standards emphasised? I support the amendment.

Baroness Cumberlege

My Lords, the noble Baroness, Lady Masham, is right in that we do not know the details of the pilots. But we are trying to achieve criteria which we believe are better drawn up with the professions and with lay representatives. That is what the groups will do. We will therefore have a broad framework against which we can test the pilot schemes. In view of what goes on elsewhere in the NHS and the fact that there are many other such groups whose role is not enshrined in legislation, it would be extraordinary, in regard to these small pilot schemes, to put these two groups on the face of the Bill. We work with many other important consultative bodies whose existence does not have to be enshrined in legislation.

Baroness Jay of Paddington

My Lords, I am grateful for that reply and pleased to hear that the national consultative groups have been convened and are meeting. We look forward to the outcome of some of those meetings, hopefully before the Bill leaves another place if not your Lordships' House.

I remain concerned in relation to the concept of good will in establishing the national criteria if they are solely dependent on those bodies which are convened by the National Health Service on this kind of voluntary basis. Many times over the past few years we have expressed anxiety about establishing national criteria and national standards for services, whether in regard to discharge procedures from hospitals or the interface between the NHS and social services. We have often been told that the good will and assurances of the Department of Health are all that we need to rely on. Sometimes we have been very disappointed by the outcomes.

Perhaps I may remind your Lordships of the debate we had recently in your Lordships' House at Question Time regarding the provision of single sex-wards. In that instance we were told that the Government had good aspirations and intentions; that instructions were being given to local health authorities to act in accordance with the Patient's Charter. Yet, as we also heard in your Lordships' House at Question Time, Ministers themselves are disappointed with the outcome of that voluntary attempt to achieve standards which they sought for the National Health Service.

It is important, therefore, when we embark on a widespread piloting scheme which will change the nature of primary care in this country if it succeeds in the way the Government suggest they want it to succeed, according to the White Papers that came with the legislation, that we are given firm guarantees of what the standards may be and a statutory means of carrying them out. Of course, we respect the good intentions of the Minister when she gives them, but this afternoon we had a vivid example of how good intentions, even at ministerial level, may not result in good practice. In those circumstances, I must seek the opinion of the House on Amendments Nos. 9 and 13. First, I beg leave to withdraw Amendment No. 4.

Amendment, by leave, withdrawn.

Baroness Robson of Kiddington moved Amendment No. 5: Page 2, line 46, at end insert— ("The matters mentioned in this subsection shall include provision for the transfer of employment rights, including pension rights.").

The noble Baroness said: My Lords, the House will remember that during Committee stage on 17th December I moved a similar amendment to Amendment No. 5. It coincided with the day on which the Government's White Paper, Primary Care: Delivering the Future, was published. I had but an hour to scan through it on that day but was tremendously cheered when I read that the Government intended to alter the arrangements for nurses to enable them to have the same employment and pension rights if they were working in the community.

The reply that I received from the noble Baroness, the Minister, on that occasion was that it was necessary to discuss the matter with the profession's representatives; that it would be wrong to include the amendment on the face of the Bill without first having those discussions. Has the Minister now been able to discuss this proposition with the professions?

The General Medical Services Committee of the BMA supports the amendment, as does the Royal College of Nursing. They are concerned with one specific problem. They feel that it is necessary to put the amendment on the face of the Bill in order to recognise the developing role of practice nurses in the NHS. However, the amendment is not primarily concerned with practice nurses and further clarification may be necessary. It should include all staff working with GPs or with GP practices.

It concerns me that the Government's current intention is that GPs will become employing authorities under the NHS pension scheme regulations and that they will be able to choose whether they wish their practice staff to become members of the scheme. It seems to me wrong to allow general practitioners to choose whether or not nurses receive pension rights, and it goes against the spirit of the White Paper Primary Care: Delivering the Future. It could create new anomalies when we have just begun to remove one of the anomalies relating to nurses. I wonder whether the Minister can assure me that the discussions she has had with the profession have convinced her that we can now put this amendment on the face of the Bill.

4.30 p.m.

Lord Rea

My Lords, I strongly support the amendment. I remind the noble Baroness that by the time the Bill gets on to the statute book there may well have been a change of government. If this Government are anxious, as they state in the rather grandiosely entitled White Paper, Primary Care: Delivering the Future, that these rights should be granted, then, if they really mean that, these provisions should certainly be in the Bill and not simply in a White Paper for the guidance of the next government.

Baroness Cumberlege

My Lords, I am grateful to the noble Baroness, Lady Robson of Kiddington, for bringing forward the amendment. It would only secure NHS pensions, of course, for those staff who already had them and who transferred their employment in the course of a pilot. But the Government in fact have gone much further. As the noble Baroness said, the White Paper, Delivering the Future, announced that the NHS pension scheme would be open to GP practice staff from 1st September 1997. We are now putting words into action. GPs will become employing authorities for the purpose of the NHS pension scheme regulations, and they will be able to choose whether they wish their practice staff to become members of the scheme. We aim to complete discussions of the details of the new arrangements by the end of February. Providing access to the scheme through this Bill we believe would serve no purpose. The changes are already in train and there is no question of our going back on them. Therefore, I hope that the noble Baroness will not press the amendment. We feel that it is unnecessary.

Baroness Robson of Kiddington

My Lords, I am no more happy with that reply than I was with the one at Committee stage. I believe it is quite wrong that it should be in the hands of the GP. It should be as of right for the people who are working in the health service that they are able to make use of the NHS pensions right. It is incomprehensible that it should be governed, perhaps, by a general practitioner who may have a different view.

However, I am heartened by the fact that the commitment exists in the White Paper and I trust that the Government will fulfil the promises they have made. I agree with the noble Lord, Lord Rea, that it is a shame that we do not put it on the face of the Bill so that we can make certain that whoever forms the government, even a Liberal Democrat government, would have to comply with it. For those reasons at this stage of the Bill I cannot press the amendment. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Hayman moved Amendment No. 6: Page 3, line 3, leave out from ("enactment)") to end of line 5 and insert— ("(a) consult and take account of the views of representatives of all relevant professions and of patient and consumer organisations (including community health councils) and of relevant local authorities which appear to them to be affected by the pilot scheme; and (b) comply with any directions given to them by the Secretary of State about the extent and manner of such consultation.").

The noble Baroness said: My Lords, this amendment and Amendment No. 29 with which it is grouped return to the issue of consultation which we debated in Committee over a number of amendments, some of them quite complicated. We come down to these two amendments on two straightforward issues. One is consultation when pilot schemes are being proposed by health authorities; the other concerns the obligations which Amendment No. 29 would put on the Secretary of State to take into account public and professional views before making permanent arrangements after pilot schemes have been implemented.

When we debated these issues at an earlier stage there was general support for the fact that pilot schemes, personal schemes and permanent schemes that were innovative would be more successful if they were understood by, and welcomed by, those who would use them and those whose professional life would be affected by them. Indeed, the Minister said at col. 1424 of the Official Report of 17th December 1996 that she welcomed the objective behind the amendments.

What we seek in the amendments is to will the means as well as the ends of ensuring wide consultation on these issues. Amendment No. 6 puts a responsibility on health authorities to consult and take into account the views of representatives of relevant professions, of patients and of consumer organisations, and of relevant local authorities. That is a very important provision. Unless we provide proper collaboration between local authority services, primarily, but not exclusively, social services and health services, then patients and clients of local authorities will be the people who suffer. It is only sensible and prudent that those local authorities who may well be affected by pilot schemes should be consulted.

The objection raised to the amendments was not an objection in principle; the principle of consultation was accepted. The objection was that we were being over-prescriptive by putting on the face of the Bill the professional and other organisations, the public bodies and the representatives we thought should be part of the consultation process. I do not demur from the original judgment that it is sensible to write those provisions into the Bill. The point made in our earlier debates was that in the vast majority of cases these were exactly the people whom prudent health authorities would, as a matter of course, consult.

I do not believe that the amendments we propose today are in any way over-prescriptive. They would allow good practice to take place. But they would also ensure that good practice takes place. These points were made by my noble friend Lady Jay earlier. The amendments would ensure that nationally we set some standards and some benchmarks for exactly what good practice would be. I believe that the Bill is under-prescriptive, not over-prescriptive, on the issue of consultation and that it is only prudent that all the people whose support is necessary for the schemes to flourish—all of us wish them to succeed—should be consulted and listened to in order to ensure success. The Royal College of Nursing, the representatives of doctors, dentists and pharmacists, the Community Health Council, the local authority associations and the consumer organisations have all expressed the view that they would feel more secure with the consultation written on to the face of the Bill. I do not see that the Government or health authorities have anything to lose in that process. I beg to move.

Baroness Masham of Ilton

My Lords, I support the amendment very much indeed. It is a national health service. It is a service for the people and therefore they should have as much say in it as anyone else. I hope that the Minister will accept the amendments. They will not cost anything. So why not accept them?

Baroness Cumberlege

My Lords, perhaps I may take up the point just made by the noble Baroness, Lady Masham. Even consultation costs time and energy, and, sometimes, money.

As the noble Baroness, Lady Hayman, said, we discussed this subject at length in Committee. The Government acknowledged then, as we do now, that changes in primary care matter deeply to local communities. We agree wholeheartedly that local people and others with an interest should be well informed and, where appropriate, consulted on changes. Consultation in the NHS is standard practice and there is no reason why, in considering pilot schemes, health authorities and boards will not continue with this well established approach. But we are also backing custom with statutory safeguards to ensure that patients have a voice.

The Bill gives the Secretary of State new powers to make directions setting out who is to be consulted. I can assure the House that he is committed to exercising these powers. Before he does so, he will take into account the advice of the professions, health service managers and others already involved with us in preparing for the implementation of the Bill. When he considers pilot proposals, the Secretary of State will be looking for clear evidence that consultation has been genuine and comprehensive.

We do not believe that the amendment would lead to more or better consultation. Instead, it would give us an inflexible set of rules which could be less than adequate for very major pilot proposals but excessive in the case of very minor ones. Rigid rules often produce a mechanistic exercise. None of us wants that, but we believe that it is what the amendment would create.

I hope I have shown that the arrangements are in place to ensure genuine consultation and that we have a strong and genuine commitment to it. I hope therefore that the House will not support the amendment.

Amendment No. 29 was also discussed in Committee. I wish to re-emphasise the safeguards surrounding the introduction of permanent arrangements which are already included in the legislation. First, the Bill requires the Secretary of State, in permitting permanent arrangements, to have regard to the reviews of pilot schemes which have been conducted and to be satisfied that such a step is in the interests of the health service. That is a clear defence against any attempt to introduce permanent arrangements where there is inadequate evidence that they will work. It could, if necessary, be tested in the courts.

Secondly, permanent schemes can only be set up once the Secretary of State has set out the rules under which they will operate in regulations under Clause 18 of the Bill. It is accepted practice to consult on draft regulations and I can confirm that the Secretary of State is committed to doing so in this case. Such consultation will not be mere form.

Finally, once regulations permit health authorities to set up permanent arrangements, the Secretary of State will also continue to have powers to require health authorities to undertake appropriate consultation on proposals.

I have tried very hard to demonstrate how the principle of consultation is inherent in the way we wish to proceed. The amendments would not add anything to the safeguards already in the Bill and the commitments I have given. I therefore hope that the noble Baroness will not pursue them.

Baroness Hayman

My Lords, I am grateful to the noble Baroness for what she said. I would not in any way question her personal commitment in these areas—nor that of the Secretary of State—and the assurances she has given us. However, there is an issue of principle here. I do not believe that the amendments are either inflexible or over-rigid. They put the balance of power and responsibility on the face of the Bill rather than let it lie with the Secretary of State.

Over the past years one of the main problems with which the NHS has had to tussle has been the lack of public confidence in decision-making processes. There is a great deal of trust to rebuild in those areas as we change and develop the service for the future. A small measure towards rebuilding that public confidence would be to ensure that on the face of the Bill we set out the areas and the people with whom we believe consultation should take place. In view of that, I should like to test the opinion of the House.

4.45 p.m.

On Question, Whether the said amendment (No. 6) shall be agreed to?

Their Lordships divided: Contents, 83; Not-Contents, 128.

Division No. 2
CONTENTS
Acton, L.	Lockwood, B.
Archer of Sandwell, L.	Longford, E.
Ashley of Stoke, L.	McFarlane of Llandaff, B.
Beaumont of Whitley, L.	McIntosh of Haringey, L.
Berkeley, L.	McNair, L.
Borrie, L.	McNally, L.
Broadbridge, L.	Masham of Ilton, B.
Bruce of Donington, L.	Mason of Barnsley, L
Calverley, L.	Merlyn-Rees, L.
Chapple, L.	Monkswell, L.
Clancarty, E.	Morris of Castle Morris, L. [Teller]
Cledwyn of Penrhos, L.
Clinton-Davis, L.	Murray of Epping Forest, L.
Cocks of Hartcliffe, L.	Nicol, B.
Darcy (de Knayth), B.	Ogmore, L.
David, B.	Palmer, L.
Donoughue, L.	Paul,L.
Dormand of Easington, L.	Peston, L.
Dubs, L.	Plant of Highfield, L.
Eatwell, L.	Prys-Davies, L.
Exmouth, V.	Ramsay of Cartvale, B.
Falkland, V.	Rea, L.
Gallacher, L.	Richard, L.
Geraint, L.	Robson of Kiddington, B.
Gould of Potternewton, B.	Rodgers of Quarry Bank, L.
Graham of Edmonton, L. [Teller]	Russell, E.
Grenfell,L.	Sainsbury, L.
Grey, E.	Serota,B.
Halsbury, E.	Stoddart of Swindon L.
Hanwotth, V.	Strabolgi, L.
Harris of Greenwich, L.	Symons of Vernham Dean, B.
Haskel, L.	Tenby, V.
Hayman, B.	Thurlow, L.
Hilton of Eggardon, B.	Tordoff, L.
Hughes, L.	Turner of Camden, B.
Hylton-Foster, B.	Wallace of Coslany, L.
Jay of Paddington, B.	Walton of Detchant, L.
Jeger, B.	White, B.
Jenkins of Hillhead, L.	Williams of Crosby, B.
Jenkins of Putney, L.	Williams of Elvel,L.
Judd, L.	Williams of Mostyn, L.
Lester of Herne Hill, L.	Winston, L.

NOT-CONTENTS
Aberdare, L.	Byford, B.
Addison, V.	Cadman, L.
Ailsa, M.	Campbell of Alloway, L.
Alexander of Tunis, E.	Campbell of Croy,L.
Allenby of Megiddo,V.	Carnegy of Lour, B.
Anelay of St. Johns, B.	Carnock, L.
Ashbourne, L.	Chesham, L. [Teller]
Astor of Hever, L.	Clark of Kempston, L.
Balfour, E.	Coleridge, L.
Barber of Tewkesbury, L.	Courtown, E.
Belhaven and Stenton, L.	Craigavon, V.
Beloff, L.	Cranborne, V. [Lord Privy Seed.]
Bethell, L.	Cumberlege, B.
Birdwood, L.	Davidson, V.
Blake, L.	Dean of Harptree, L.
Bowness, L.	Denbigh, E.
Brabazon of Tara, L.	Denham, L.
Brookes, L.	Demon of Wakefield, B.
Butterfield, L.	Dixon-Smith, L.

Downshire, M.	Merrivale, L.
Eccles of Moulton, B.	Miller of Hendon,B.
Eden of Winton, L.	Milverton, L.
Elibank, L.	Monteagle of Brandon, L.
Ellenborough, L.	Mottistone, L.
Elles, B.	Mountevans, L.
Elliott of Morpeth, L.	Mowbray and Stourton, L.
Elton, L.	Munster, E.
Erne, E.	Murton of Lindisfarne, L.
Flather, B.	Norfolk, D.
Fraser of Carmyllie, L.	Northesk, E.
Goschen, V.	O'Cathain, B.
Greenway, L.	Oxfuird, V.
Hailsham of Saint Maiylebone, L.	Park of Monmouth, B.
Harding of Petherton, L.	Pender, L.
Harmsworth, L.	Pike, B.
Harris of Peckham, L.	Pilkington of Oxenford, L.
Hayhoe, L.	Platt of Writtle,B.
Hemphill, L.	Plummer of St Marylebone, L.
Henley, L.	Quinton, L.
Holderness, L.	Rankeillour, L.
	Reay, L.
HolmPatrick, L.	Renton, L.
Howe, E.	Renwick, L.
Inglewood, L.	Romney, E.
Jenkin of Roding, L.	Rotherwick, L.
Johnston of Rockport, L.	St. Davids, V.
King of Wartnaby, L.	Saint Levan, L.
Knollys, V.	Seccombe, B.
Lauderdale, E.	Selsdon, L
Leigh, L.	Shaw of Northstead, L.
Lindsay, E.	Skelmersdale, L.
Liverpool, E.	Strange, B.
Long,V.	Strathcarron, L.
Lucas, L.	Strathclyde, L. [Teller.]
Lucas of Chilworth, L.	Sudeley, L.
Lyell, L.	Swansea, L.
McColl of Dulwich, L.	Swinfen, L.
McConnell, L.	Taylor of Warwick, L.
Mackay of Ardbrecknish, L	Terrington, L.
Mackay of Clashfem, L. [Lord Chancellor]	Teviot, L.
	Thomas of Gwydir, L.
Mackay of Drumadoon, L.	Trumpington, B.
Macleod of Borve, B.	Vivian, L.
Marlesford, L.	Wise, L.
Massereene and Ferrard, V.	Young, B.

Resolved in the negative, and amendment disagreed to accordingly.

4.54 p.m.

Lord Rea moved Amendment No. 7: Page 3, line 15, after ("lists)") insert ("and who is actively working in general practice as part of a primary health care team").

The noble Lord said: My Lords, this amendment seeks to ensure that pilot schemes involve general practitioners who are in active general practice. We believe that the Bill should clarify that only general practitioners currently on medical lists and who are active in the National Health Service should be involved in pilot schemes. The concern of the Royal College of General Practitioners, and of many others, is that doctors who are eligible to work in general practice, but who are not currently involved actively in it, may become involved in pilot schemes; for example, in a trust, or even a private company setting up some kind of pilot scheme which will deliver only parts of the full range of primary care. As the Bill stands, it seems that pilot schemes could be set up without reference to general practitioners. We are concerned that the present system, which is the envy of other countries, should be helped to work better by these schemes and not be fragmented by them.

One of the key roles of general practitioners is to be the advocate of patients and their interests. It is particularly important to ensure that patients have appropriate, necessary and timely access to secondary care services. As an independent contractor within the NHS, a GP has a unique role through the referral system in obtaining access to secondary care for patients. We believe that that may be undermined by general practitioners who may be recruited from outside the present system. They may be salaried and they may have a conflict of interest between the commercial interests of their employers who are setting up the pilot scheme and those of their patients.

These are the anxieties that I have and which have been expressed to me by other general practitioners. I shall be very grateful if the noble Baroness can either accept this amendment or give me some reassurance that the Government will follow at least the principles which it implies. I shall be very interested to hear her reply. Perhaps it will not be necessary to press this amendment if she can give us something to go on. I beg to move.

Baroness Cumberlege

My Lords, I shall do my best to reassure the noble Lord. This amendment aims to reinforce the emphasis on a team-based approach in primary care. That is an objective that the Government very strongly share. The White Paper Delivering the Future puts forward specific proposals to this end. We shall expect proposals for pilot schemes to reflect that approach. But putting conditions on GPs who have an automatic right to have their pilot proposals put forward will not necessarily help. On the contrary, it might even hamper desirable proposals from those who wish to use piloting to develop more collaborative ways of working, perhaps through a practice-based contract.

We would also see difficulties emerging over how, actively working in general practice as part of a primary health care team", would be defined in practice. It would be unhelpful if a relatively simple application process were made more complex and subject to argument simply over status.

We believe that the principle of encouraging team-based family health care service teams is better served through the assessment of the quality and suitability of proposals in the approval process. I hope that that gives the noble Lord enough to go on, as he put it, and that he will not press this amendment.

Lord Rea

My Lords, I thank the noble Baroness for those words, which we shall read in detail. She certainly reassures me that it is her intention at least that these pilot schemes will improve primary care in this country. I am sure that she means what she says. But we have to look at what the Bill will allow. After we have scrutinised her words and had another look at the Bill, I give notice that we may yet return to this matter at Third Reading. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 8 not moved.]

Clause 3 [Approval of pilot schemes]:

Baroness Jay of Paddington moved Amendment No. 9: 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 will satisfy standards and criteria for the quality of services provided to patients determined by a national representative group established by the Secretary of State for this purpose.").

The noble Baroness said: My Lords, I spoke to this amendment with Amendment No. 4. I beg to move.

4.58 p.m.

On Question, Whether the said amendment (No. 9) shall be agreed to?

Their Lordships divided: Contents, 74; Not-Contents, 122.

Division No. 3
CONTENTS
Acton, L.	Lester of Herne Hill, L
Addington, L.	Lockwood, B.
Archer of Sandwell, L.	Longford, E.
Ashley of Stoke, L.	McFarlane of Llandaff, B.
Berkeley, L.	McIntosh of Haringey, L.
Borne, L.	McNair, L.
Broadbridge, L.	McNally, L.
Bruce of Donington, L	Masham of Ilton, B.
Calverley, L.	Mason of Barnsley, L.
Chapple, L.	Merlyn-Rees, L.
Clancarty, E.	Morris of Castle Morris, L. [Teller.]
Cledwyn of Penrhos, L.
Clinton-Davis, L.	Murray of Epping Forest, L.
Cocks of Hartcliffe, L.	Nicol, B.
Darcy (de Knayth), B.	Ogmore, L.
David, B.	Paul, L.
Donoughue, L.	Peston, L.
Dormand of Easington, L.	Plant of Highfield, L.
Dubs, L.	Prys-Davies, L.
	Ramsay of Cartvale, B.
Eatwell, L.	Rea, L.
Gallacher, L.	Richard, L.
Geraint, L.	Robson of Kiddington, B.
Gould of Potternewton, B.	Rodgers of Quarry Bank, L.
Graham of Edmonton, L.	Serota, B.
Grenfell, L.	Stoddart of Swindon, L.
Grey, E.	Strabolgi, L.
Hanworth, V.	Symons of Vernham Dean, B.
Harris of Greenwich, L.	Thurlow, L.
Haskel, L. [Teller.]	Tordoff, L.
Hayman, B.	Turner of Camden, B.
Hilton of Eggardon, B.	Wallace of Coslany, L.
Hughes, L.	White, B.
Jay of Paddington, B.	Whitty, L.
Jeger, B.	Williams of Crosby, B.
Jenkins of Hillhead, L.	Williams of Elvel, L.
Jenkins of Putney, L.	Williams of Mostyn, L.
Judd, L.	Winston, L.

NOT-CONTENTS
Aberdare, L.	Barber of Tewkesbury, L.
Addison, V.	Beloff, L.
Ailsa, M.	Bethell, L.
Alexander of Tunis, E.	Blake, L.
Anelay of St.Johns, B.	Blaker, L.
Astor of Hever, L.	Blatch, B.
Balfour, E.	Bowness, L.

Brabazon of Tara, L.	Mackay of Drumadoon, L.
Brookes, L.	Macleod of Borve,B.
Butterfield, L.	Marlesford, L.
Byford, B.	Massereene and Ferrard, V.
Cadman, L.	Merrivale, L.
Campbell of Alloway, L.	Mersey, V.
Campbell of Croy, L.	Miller of Hendon, B.
Carnegy of Lour, B.	Milverton, L.
Chesham, L. [Teller.]	Monteagle of Brandon, L.
Dark of Kempston, L.	Mottistone, L.
Coleridge, L.	Mountevans, L.
Courtown, E.	Mowbray and Stourton, L.
Craigavon, V.	Munster, E.
Cranborne, V. [Lord Privy Seal.]	Murton of Lindisfarne, L.
Cumberlege, B.	Nelson, E.
Dean of Harptree, L.	Norfolk, D.
Denbigh, E.	Northesk, E.
Denham, L.	O'Cathain, B.
Demon of Wakefield,B.	Orr-Ewing, L.
Dixon-Smith, L.	Oxfuird, V.
Downshire, M.	Park of Monmouth, B.
Eccles of Moulton,B.	Pender, L.
Eden of Winton, L.	Pike, B.
Elibank, L.	Pilkington of Oxenford, L.
Elles, B.	Platt of Writtle,B.
Elliott of Morpeth, L.	Plummer of St. Marylebone, L.
Elton, L.	Quinton, L.
Flather, B.	Rankeillour, L.
Fraser of Carmyllie, L.	Reay, L.
Goschen, V.	Renton, L.
Hacking, L.	Renwick, L.
Hailsham of Saint Marylebone, L.	Romney, E.
	Rotherwick, L.
Harding of Petherton, L.	St. Davids, V.
Harmsworth, L.	Saint Levan, L.
Hayhoe, L.	Seccombe, B.
Hemphill, L.	Selsdon, L.
Henley, L.	Shaw of Northstead, L.
Holdemess, L.	Skelmersdale, L.
HolmPatrick, L.	Strange, B.
Howe, E.	Strathcarron, L.
Inglewood, L.	Strathclyde, L. [Teller.]
Jenkin of Roding, L.	Strathcona and Mount Royal, L
King of Wartnaby, L.	Sudeley, L.
Lauderdale, E.	Swansea, L.
Lindsay, E.	Swinfen, L.
Liverpool, E.	Taylor of Warwick, L.
Long,V.	Tebbit,L.
Lucas, L.	Terrington, L.
Lucas of Chilworth, L.	Teviot, L.
Lyell, L.	Thomas of Gwydir, L.
McColl of Dulwich,L.	Trumpington, B.
Mackay of Ardbrecknish, L.	Vivian, L.
Mackay of Clashfern, L. [Lord Chancellor.]	Wise, L.
	Young, B.

Resolved in the negative, and amendment disagreed to accordingly.

5.7 p.m.

Baroness Cumberlege moved Amendment No. 10: Page 3, line 26, leave out ("participants") and insert ("any participant other than the authority").

The noble Baroness said: My Lords, in moving Amendment No. 10, I should like to speak also to Amendments Nos. 11, 23, 30, 32, 36, 39, 43, 45, 46, 65, 67, 76 and 78 to 84. These amendments tidy up the drafting of the Bill and aid interpretation by clarifying some of the provisions. Examples include Amendments Nos. 10, 11, 30 and 36 which ensure that, while providers of services such as GPs and dentists will be able to withdraw from taking part in the schemes if they wish to, the health authorities taking part will not. That will protect the provider by ensuring that health authorities will not by themselves be able to decide to terminate a scheme.

Amendment No. 65 provides that where references are made in any legislation to Section 28C or Section 17C arrangements, that should be read as referring to both pilot and permanent schemes. That means that the clauses in the Bill such as those securing the right of patients to choose their doctor and dentist, and the consequential amendments to other legislation contained in Schedule 2, apply to all PMS and PDS schemes. In addition, we shall need to bring forward a number of consequential amendments at Third Reading to ensure that various relevant Acts of Parliament apply to the new system, as they do to the existing one.

We worked hard to table as many government amendments as possible at the end of last week and at the beginning of this week to give noble Lords the maximum time to consider them. We accept, however, that your Lordships may not have had adequate time to consider some of the amendments that were tabled later. We have therefore withdrawn many of those amendments and propose to return to the matters that they cover at Third Reading. Those matters are fundholding, principally providing a return ticket to those fundholders involved in the new arrangements, ensuring that NHS trusts can play their full role in the new arrangements, making a number of minor and consequential changes to the provisions in connection with the sale of medical practices, and making further minor or consequential amendments, including changes to other legislation. I hope that your Lordships will be content to consider those matters at Third Reading. The amendments in this group are technical but important and I commend them to the House. I beg to move.

Baroness Jay of Paddington

My Lords, we are grateful to the Minister for the length and breadth of her reply, she having listed a number of amendments proposed in this group. We are also grateful for her consideration of whether amendments have been tabled rather late in the day for appropriate consideration at this stage of the proceedings. I hope that it is agreeable to the House—as the Minister has proposed it, I am sure that it will be—to consider at Third Reading some matters which must necessarily, although not in accordance with the previous proceedings of the House as I understand them, raise issues that have not been considered before. But because there has been an understanding about the progress of business today, we on these Benches are happy to accept it.

I should like to raise one issue relating to Amendment No. 65 that has been drawn to my attention. It deals with cross-border pilots. Queries have been raised, particularly by the professional bodies concerned with the organisation of general practice, about who in a cross-border pilot will be the primary authority. For example, which Secretary of State will approve an application? Which health authority or Scottish board will process it? There are also questions about dispensing where the systems in Scotland and England are different. Further, the complaints system which we discussed in connection with another piece of legislation in a previous debate in your Lordships' House is different north and south of the Border. Where in the geographical sense there are cross-border pilots that may be in the interests of the local population, questions may arise as to who is the authority with primary responsibility and whose legislation in some technical but important areas—for example, dispensing and complaints systems—will prevail: how will it be worked out between the two different systems should any conflict arise?

Baroness Cumberlege

My Lords, I imagine that for cross-border schemes the same principles will apply to pilots as to current services that are provided by GPs through general medical services. I do not have detailed information with me. I shall be happy to write to the noble Baroness about these matters, in particular the point about dispensing.

Lord Rea

My Lords, Amendments Nos. 45 and 46 change the word "provide" to "perform". That is exactly the opposite of what I proposed in amendments at Committee stage. I suggested that "performing" was not appropriate and "providing" was better. Far from taking my advice, the noble Baroness has gone one better and found two more "provides" and turned providing doctors into performing doctors. I understand that for technical reasons "perform" is the proper word. Although it sounds rather silly, at least the Bill is now consistent.

Baroness Cumberlege

My Lords, I am grateful to the noble Lord. We have tried to ensure that providers are the bodies that hold the contract and performers are the people who supply the service. We are grateful to the noble Lord for bringing this matter to our attention. I am sure that in turn he is grateful that we have listened to his comments and tried to incorporate them wherever possible.

On Question, amendment agreed to.

5.15 p.m.

Baroness Cumberlege moved Amendment No. 11: Page 3, line 27, leave out ("they wish") and insert ("he wishes").

On Question, amendment agreed to.

Clause 5 [Reviews of pilot schemes]:

Baroness Robson of Kiddington moved Amendment No. 12: Page 4, line 3, at end insert ("not less than 18 months and not more than three years after the date on which the pilot scheme comes into operation").

The noble Baroness said: My Lords, I rise to move an amendment that I also moved at Committee stage. It provides that the review process should be at least 18 months and not more than three years from the start of a pilot scheme. At Committee stage the noble Baroness replied that it was likely that the vast majority of pilot schemes would be evaluated within the timescales specified in this amendment but that there might be exceptional cases where they would be inappropriate. She quoted one possibility: as one learnt from experience one should not have to go through the full panoply of a thorough evaluation with every single scheme if it followed the model of one that had already been successful. A pilot scheme that has been successful sets a precedent. I do not believe it is necessary to have the same evaluation as with a brand new scheme. That is only common sense. It does not prevent the majority of new schemes requiring 18 months in order to be thoroughly evaluated.

One further problem is that the Secretary of State may feel that some schemes should go on for longer than three years. But I believe that a three-year period provides adequate time for a scheme to be reviewed and for lessons to be learned. If it goes on for more than three years, the danger is that it will become almost an accepted part of the NHS and it cannot any longer be called a pilot scheme. To set a timescale for pilot schemes to be reviewed under NHS primary healthcare should allow greater emphasis on the speedy evaluation of schemes and the rapid dissemination of the results so that patients may quickly benefit from new and innovative practice. One cannot possibly call something that has gone on for five or six years a pilot scheme. It should be perfectly possible to reach a conclusion on whether a scheme has possibilities within a period of three years. I sincerely hope that the Minister will change her mind as to this amendment. I beg to move.

Lord Rea

My Lords, we on these Benches very much support the amendment. As I said at Committee stage, the imposition of time limits on pilot schemes acts as a stimulus and helps to concentrate the minds of those who carry out the evaluation. It means that they must think about it from the very start. They know when it is to finish and when they must have their report ready. This is a useful additional instruction to insert into the Bill.

Lord Harmsworth

My Lords, does the noble Baroness, Lady Robson, acknowledge that when a large number of pilot schemes are up and running, quite a few may fall into the same pattern and each may be able to learn from the other? If that is so, it may be possible to reach a decision before the 18 months are up. I am more attracted to her view that they should not last for longer than three years, but surely a shorter period than 18 months should remain an option.

Baroness Robson of Kiddington

My Lords, I said that where a pilot scheme followed the pattern of one that had already been approved, the evaluation period should be reduced or done away with.

Baroness Cumberlege

My Lords, as the noble Baroness has said, this matter was discussed in Committee. Your Lordships are aware that we are committed to an open and thorough process of evaluation. We do not want to evaluate schemes before they are established; nor do we want to run them as pilots for longer than is necessary in order to demonstrate their worth. It is difficult to decide the right timescales for pilot schemes. We do not yet know what those schemes will be. Although it is difficult to make a judgment, I suspect that for the majority of schemes the timescales proposed by the noble Baroness will be about right. However, we believe that there are dangers in setting them in stone.

For example, we should not rule out the possibility that there will be schemes which are only subtly different from current arrangements or draw on ways of working which are already well established in other areas of the health service. As my noble friend Lord Harmsworth said, such arrangements may not require 18 months before they are ready to be evaluated. As the noble Baroness said, it would be most unfortunate if the service benefits that they offer could not be made more widely available more quickly because of the rigid rules on timing as set out in the Bill.

I hope that I have reassured the noble Baroness and the noble Lord that we have every intention of ensuring that pilots run for an appropriate time before being evaluated. However, we believe that timescales in primary legislation would be counterproductive and I hope that the noble Baroness will not pursue the amendment.

Baroness Robson of Kiddington

My Lords, I take on board some of the arguments about the period of 18 months in cases where there is little difference. However, I believe that a minimum time should be set. I am most upset that the Minister will not accept three years as the right timescale for evaluating schemes. I am deeply concerned that if there is no set time period many schemes will run for years and will become an accepted part of the NHS without having been properly evaluated.

I shall not press the amendment at this stage, but I shall consider coming back on Third Reading about the three-year period—

Baroness Cumberlege

My Lords, with the leave of the House, perhaps I may answer that point because I understand what the noble Baroness is saying about schemes which run on after three years. We do not know the details of schemes and we suspect that as they are running some will change and some will evolve. Therefore, it will be difficult to say exactly whether the evolving scheme is the same as the initial pilot scheme. To set a timescale will be difficult, but I understand what the noble Baroness said and will certainly think about it further.

Baroness Robson of Kiddington

My Lords, as regards an evolving scheme, that can be subject to three years, but there is no reason why another 18 months cannot be added for further evaluation of a scheme that has been slightly changed. However, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 13 not moved.]

Baroness Hayman moved Amendment No. 14: After Clause 6, insert the following new clause— ANNUAL REPORT (". The Secretary of State shall report annually to Parliament with a general survey of developments during the preceding twelve months on the pilot schemes, including references to—

1. (a) decisions for approval taken under section 3;
2. (b) the findings of reviews of pilot schemes carried out under section 5; and
3. (c) decisions taken to terminate pilot schemes under section 6.").

The noble Baroness said: My Lords, the amendment returns to an issue which we discussed in Committee regarding an annual report to Parliament on pilot schemes. I hope that I have taken on board some of the criticisms which were made of the amendment tabled in Committee and that this is a better version. I say that optimistically because I fully admit that its wording is plagiarised. The noble Earl, Lord Ferrers, brought forward a similar amendment to the Gas Bill in response to similar arguments from my noble friend Lord Peston about the interests of Parliament and the public in having an annual report and overview of developments under these provisions.

The provisions, if successful, will allow a range of interesting and innovative experiments in primary care. There will be lessons to be learnt from those which are successful and those which are not and are withdrawn or which the Secretary of State does not wish to continue. It is important for confidence building that there is an annual report to Parliament and a report giving an overview that is available to the public.

It was suggested that the report which was delineated in the previous amendment would be in the nature of an encyclopaedia—perhaps in these technological days I should say a whole CD-Rom. This report is a more overarching overview of developments. It will be less onerous on the Secretary of State but it will perform the functions which the National Consumer Council and the Consumer Association are keen to see in spreading public and parliamentary information about developments under what will be the National Health Service (Primary Care) Act. I beg to move.

Baroness Cumberlege

My Lords, we discussed accountability to Parliament at the Committee stage. I appreciate that there is much interest in this Bill and that noble Lords will wish to keep in touch with the progress of our initiative. However, I believe that a system of annual reports to Parliament would be out of proportion to other scrutiny arrangements. It would be inappropriate and probably unjustified.

The NHS is constantly undergoing service developments in a range of fields. Some are of significant national importance, others of local interest. Piloting will be similar, with some pilots involving major changes in the way primary care is provided, others less so. Yet, in no other area of NHS development are annual reports to Parliament required. I suggest that it would be anomalous to single out this initiative.

We have no intention of shying away from giving information about the pilot schemes. We are committed to an open, consultative approach. But there are better, existing ways of ensuring that appropriate information is made available to Parliament.

The information the amendment calls for may well in future be called for by a Select Committee. It can certainly also be called for—in a variety of ways and to varying degrees of detail—in Parliamentary Questions which can target the point specifically of interest. The initiative is also likely to feature in health debates in your Lordships' House and another place. Surely, these established mechanisms are the right way for such information to be put before the House, rather than through an annual report whose format may not satisfy particular needs anyway.

Although we agree with the noble Baroness in the philosophy she is portraying, we believe that it is not practical in these circumstances.

Baroness Hayman

My Lords, I am grateful to the Minister for her comments. Perhaps her argument can be interpreted as being that Parliament should have several annual reports on several issues connected with the NHS and not that it should have none.

Developments such as primary care are key areas. The Director General of Ofgas can report on the development of competition policy in gas annually to Parliament; I am not sure that this is a less important area. However, we must consider what has been said and perhaps return to it at a later stage. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 11 [Preferential treatment on transferring to medical lists]:

Baroness Cumberlege moved Amendment No. 15: Page 5, line 34, leave out from first ("the") to ("must") in line 35 and insert ("Secretary of State approves a pilot scheme, he").

The noble Baroness said: My Lords, in moving Amendment No. 15 I shall speak to Amendments Nos. 16, 17, 31, 34, 38, 41 and 71. I set out the provisions of Clause 11 on the last occasion that this Bill was before the House. These amendments are improvements which will allow the arrangements for preferential return to apply more widely, underlining the voluntary nature to the arrangements.

Clause 11(1), as set out, requires the Secretary of State to determine, before a pilot scheme is implemented, whether a GP who participates in a pilot will be given preferential treatment on applying to transfer to the medical list. Amendment No. 15 will require the Secretary of State to decide whether a particular GP has a preferential right of transfer to the medical list before he approves the pilot scheme, rather than before the pilot scheme is implemented, which might be any time from approval to when the scheme "goes live". This amendment will strengthen Clause 11 by making sure that before a pilot begins to be implemented, the GPs taking part know whether they have been given a preferential right of transfer.

Amendment No. 16 will require the Secretary of State to make a determination in relation to GPs after the scheme has been approved. This means that where a GP joins a pilot scheme once it is up and running he may also be eligible for a preferential right of transfer back to a medical list. Thus, when one partner retires and a new one takes his place and takes on the commitments that go with partnership, he will know what his position will be should the pilot arrangements end. The provision will also allow changes of status to be taken into account in the Secretary of State's determination; for example, when a salaried GP already in the practice, previously refused a right of transfer, takes over the responsibilities of an outgoing partner.

Amendment No. 17 also makes clear that once the Secretary of State has reached a decision on these matter, he must make it known to the health authority and the GP concerned.

The amendments to Clause 18 refine and clarify the detail as to how the broad regulatory powers within the clause may be carried forward in regulations. They also make more explicit the fact that medical practitioners who perform personal medical services in permanent arrangements should not also provide general medical services except in laid down circumstances—exactly as is the case for pilot schemes.

Finally, Amendment No. 71 is about the NHS Tribunal's power to direct (if it thinks fit) not only that the GP's name be not included in any medical list in England and Wales kept under the 1977 Act, but also that it be not included in any list in Scotland kept under the 1978 Act. I commend these amendments to the House. I beg to move.

On Question, amendment agreed to.

5.30 p.m.

Baroness Cumberlege moved Amendments Nos. 16 and 17: Page 5, line 38, at end insert— ("(1A) Before a pilot scheme is varied so as to permit a new medical practitioner to perform personal medical services under the scheme, the Secretary of State must make a determination under this section in relation to the new practitioner. (1B) The Secretary of State may at any time make a determination under this section varying a determination about a medical practitioner if he is asked to do so by the practitioner concerned."). Page 6, line 1, at end insert— ("(3A) The Secretary of State must notify the authority and the medical practitioner or practitioners concerned in writing of any determination made by him under this section.").

On Question, amendments agreed to.

Clause 13 [NHS contracts]:

The Deputy Speaker (The Viscount of Oxfuird)

My Lords, I must advise your Lordships that if this amendment is agreed to, I cannot call Amendment No. 19 due to pre-emption.

Baroness Cumberlege moved Amendment No. 18: Page 6, line 32, leave out subsection (1) and insert— ("(1) In the case of a pilot scheme entered into, or to be entered into, by an authority with a single individual or body corporate, that individual or body may make an application under this section to become a health service body. (1A) In the case of any other pilot scheme, all of those entering into, or proposing to enter into, arrangements with the authority to provide personal medical services or personal dental services under the scheme may together make an application under this section to become a single health service body.").

The noble Baroness said: My Lords, I beg to move Amendment No. 18. In doing so I shall speak to Amendments Nos. 20 21, 22, 24, 25 and 26 also. These amendments deal with outstanding points concerning the way in which NHS contracts will work in piloted arrangements. Their aim is to ensure that the benefits of NHS contracts—simplicity and dispute-resolution by the Secretary of State—can play a full part in the new arrangements.

Our original thinking had been that the provisions in the National Health Service and Community Care Act 1990 which allowed pre-contractual arbitration by the Secretary of State before an NHS contract is drawn up might not always be applicable in the context of the Bill. We therefore reserved the regulatory power to exclude these provisions in prescribed circumstances. Following discussion with representatives of the General Medical Services Committee, we are persuaded that it will provide an important element of reassurance for health service bodies in pilot schemes to be able to seek the Secretary of State's arbitration if difficulties arise over a proposed contract. We believe that such arbitration will arise only exceptionally. But we agree that it should be available, and Amendment No. 24 puts that beyond doubt.

These amendments also clarify who may make an application to become a health service body. Individual GPs or GDPs can already do so under the Bill as it stands. These amendments also make it clearer that applications can be made by various groupings—for example, partnerships of GPs—and ensure that such groupings can comprise a single health service body and share the same NHS contract. They also provide for partnerships to retain their health service body status when individual partners change; for example, on retirement. The provision fits in well with the flexibility in the provision of services which the Bill aims to permit. It will give appropriate groupings of providers access to the full benefits of health service body status. I commend them to the House.

Baroness Jay of Paddington

My Lords, I wonder whether the Minister can help us with some explanation of the terminology in Amendment No. 18 with regard to the phrase "or body corporate" which refers to the type of body which could become a health service body for the purposes of application for a pilot scheme.

Your Lordships will remember that in Committee we raised concerns which were expressed in an amendment that we attempted to make to Clause 1 dealing with the fact that we were unhappy with the idea that organisations which distributed dividends—that is, were within the common sense meaning of the words "body corporate"—should be excluded from the possibility of being pilot proposers.

This is something which is giving rise to concern within the British Medical Association, which has now formally expressed its opposition to corporate bodies, in the general meaning of the word, becoming involved in pilot schemes. I believe that on a first reading Amendment No. 18 suggests that the Government are giving formal credibility to that understanding. Perhaps the Minister will explain whether that suspicion is correct or whether in the context of Amendment No. 18 "body corporate" has a meaning other than that which it might generally and colloquially seem to mean.

Baroness Cumberlege

My Lords, as I understand it, there has been some discussion with the General Medical Services Committee about that. I thought that it was satisfied with the interpretation that we have put on the word "corporate". Perhaps before Third Reading it may be helpful if I write to the noble Baroness giving her further details about that.

Baroness Jay of Paddington

My Lords, before Third Reading, perhaps the noble Baroness will also have another conversation with representatives of the BMA and the GMSC, because my conversation with the leader of that group of the BMA this morning suggested that it is still unhappy with that wording.

Baroness Cumberlege

My Lords, I shall certainly undertake to do that.

Lord Rea

My Lords, in giving examples of what could constitute a health service body and in illustrating how Amendment No. 18 would work, if I heard the noble Baroness aright, she mentioned doctors who are already providing general medical service and dentists already providing general dental services in the same way as we hoped would be put into the Bill in my Amendment No. 7.

However, reading the new words, it seems to me that quite a wide variety of people could qualify to become health service bodies. Again, my anxiety level is raised a little by that. The Minister reassured me in replying to Amendment No. 7. Perhaps she will say whether my anxiety is justified in this case.

Baroness Cumberlege

My Lords, I am well aware that your Lordships are unhappy about Amendment No. 18 and, with the agreement of the House, I shall withdraw it and bring it back on Third Reading. However, I do wish to move the other amendments in the group.

Amendment, by leave, withdrawn.

[Amendment No. 19 not moved.]

Baroness Cumberlege moved Amendments Nos. 20 to 26: Page 6, line 44, leave out ("the applicant is") and insert ("—

1. (a) in the case of an application under subsection (1), the applicant is, and
2. (b) in the case of an application under subsection (1A), the applicants together are," ).

Page 7, line 4, leave out from ("to") to end of line 8 and insert ("such a health service body ("a pilot scheme health service body"), acting as acquire, as if the functions referred to in subsection (1) of those sections were the provision of piloted services."). Page 7, line 8, at end insert— ("() Except in such circumstances as may be prescribed, a pilot scheme health service body resulting from an application under subsection (1A) is to be treated, at any time, as consisting of those with whom, at that time, the authority have arrangements under the scheme."). Page 7, line 9, leave out subsection (6) and insert— ("() A direction as to payment made under section 4(7) of the Act of 1990 or section 17A(8) of the 1978 Act against, or in favour of, a pilot scheme health service body is enforceable—

1. (a) in England and Wales, in a county court (if the court so orders) as if it were a judgment or order of that court; and
2. (b) in Scotland, by the sheriff as if it were a judgment or order of the sheriff and whether or not the sheriff could himself have made such a judgment or order.").

Page 7, line 14, leave out subsection (7). Page 7, line 20, leave out ("person who is a health service body by virtue of this section") and insert ("pilot scheme health service body"). Page 7, line 25, leave out ("those who are health service bodies by virtue of this section") and insert ("pilot scheme health service bodies").

On Question, amendments agreed to.

Baroness Miller of Hendon moved Amendment No. 27: After Clause 13, insert the following new clause— THE DENTAL PRACTICE BOARDS (".—(1) Regulations may confer such powers or impose such duties on the Board, in relation to pilot schemes under which personal dental services are provided, as may be prescribed. (2) The regulations may, in particular, make any of the following kinds of provision. (3) They may authorise or require the Board—

1. (a) to perform on behalf of an authority functions of a prescribed description (including functions relating to remuneration) which have been delegated to the Board by the authority in accordance with a power conferred by the regulations;
2. (b) to conduct or commission surveys or other research;
3. (c) to carry on such other activities as may be prescribed.

(4) They may provide that functions conferred by the regulations are only to be exercised by the Board in accordance with directions of the Secretary of State. (5) They may enable the Board to direct a dental practitioner to submit to the Board, in relation to treatment or a description of treatment that he has carried out or contemplates carrying out, such information (including estimates, radiographs, models and other items) as may be prescribed. (6) In this section "the Board" means—

1. (a) in relation to England and Wales, the Dental Practice Board; and
2. (b) in relation to Scotland, the Scottish Dental Practice Board.").

The noble Baroness said: My Lords, in moving the above amendment I shall speak also to Amendments Nos. 33, 35, 40 and 42. The amendments in this group give the Secretary of State powers to make regulations to give the Dental Practice Board functions in relation to personal dental services. In practice, this will enable the Secretary of State to extend the role of the DPB so that it can provide a range of support services in respect of dental services provided under pilot and permanent schemes in a similar way to those it currently provides for the general dental service. That will ensure that the skills and experience of the DPB can be used to best effect in the new system.

Among other things, it will allow the extensive experience of the DPB in operating dental payment systems to be applied to the personal dental services. It will also enable us to make use of the DPB's expertise in monitoring treatment provided under the new system and carrying out quality checks through the Dental Reference Service. The aim of these amendments is to provide for cost-effective and high quality support for the new arrangements in dentistry. I very much hope that noble Lords will support them. I beg to move.

On Question, amendment agreed to.

Baroness Jay of Paddington moved Amendment No. 28: Before Clause 17, insert the following new clause— APPROVAL OF THE MEDICAL PRACTICES COMMITTEE ("All agreements made under this Act for the provision of personal medical services shall be submitted by the Health Authority concerned to the Medical Practices Committee, and shall be subject to the approval of the Committee, as if they were applications to provide general medical services under sections 29 and 30 of the 1977 Act").

The noble Baroness said: My Lords, while moving the above amendment I shall speak also to Amendment No. 49. The two amendments are intended to ensure that the important role of the Medical Practices Committee, which, as your Lordships know, now provides a strategic approach to the organisation of primary care, is maintained. We on these Benches feel that this is in the interest of equity in the NHS, about which we are very keenly concerned. I introduced a series of amendments to that effect in Committee. In response the Minister said: The Government are committed to fairness in the distribution of services".

but went on to say: It would be wrong and potentially damaging to sensible development to pre-empt these discussions"—

that is to say, discussions with the Medical Practices Committee— in the way the amendments seek to do".—[Official Report, 17/12/96; col. 1435.]

I am reintroducing these amendments because I understand in conversations with the chairman of the MPC, the most recent of which took place this morning, that at present it sees no movement in the Government's position about its concerns. The MPC still feels that it is being rather politely sidelined as the Bill proceeds.

Perhaps I may briefly reiterate the points that I made in Committee about the necessity of involving the MPC in the pilot schemes proposed by the Bill. I would remind the House that the MPC has the duty (which it has had since the NHS was established in 1948) to assess whether a health authority area is served by an adequate number of general practitioners. It does this by the "negative" power of refusing a GP the opportunity to practice in an area which in its very authoritative view is already adequately covered.

I know that there has been some recent discussion about whether the MPC is adequately fulfilling that task. As noble Lords on these Benches will know and as I mentioned in my introductory remarks, we are concerned about overall equity within the NHS at present. But I am convinced that the MPC is working appropriately to try to ensure a proper distribution of general practitioners across the country. Mary Leigh, the chairman of the MPC, said in a letter to the Health Service Journal which is published today: When the current criteria [for establishing the right number of GPs across the country] were introduced in May 1981, there were 400 under-doctored areas out of 1,500 in England and Wales. At 1 January 1997 there were only 15 such areas. The percentage of patients in under-doctored areas, in terms of average list size, has gone down from about 26 per cent. to 1 per cent. in 17 years"—

a record which I believe speaks for itself.

If the MPC is excluded from playing a role in assessing and authorising pilot schemes under the legislation as it now stands, it seems to me that that improvement will almost certainly be reversed. Your Lordships discussed earlier today and in Committee the fears that we on these Benches, and, indeed, the professional bodies led by the BMA, have about the rather unrestrained influence of commercial organisations if the Bill becomes law unamended.

It seems to me that removing the powers of the MPC in approving pilot schemes lends additional credence to those fears. It seems more and more clear that commercial companies will seek to operate primary care pilots. Indeed, your Lordships might have seen recent reports that the PPP (the well-known private insurance firm) has mentioned in public print its intention to become involved. It says that its pilots, would be modelled on South Africa's 'medi-clinics' where private hospitals offer on-site primary care, including investigative facilities".

If primary care of that kind falls without the remit of the MPC as it exists at present, it seems to me that those commercial interests will become prominent and that all of our fears about the influence that that may have will come to fruition.

It is also clear, as I said in Committee when speaking to another amendment, that these commercial companies are almost bound to want to work in prosperous areas where they will make a profit. Otherwise, why would they want to do it? If there is no manpower distribution screening on an objective basis as the MPC carries out at present, there is every possibility that there will be a cluster of privately organised primary care services in the better parts of town at the expense of improved services in the more deprived communities.

In response to our amendments on the subject in Committee, the Government said that they felt that they could rely on the health authorities to sift and screen applications which were inappropriate before they went to the Secretary of Sate. But I believe that it is obvious that health authorities must only have the perspective of their own areas to consider as a primary concern and that they do not have the national, overall picture in mind when they make references upward to the Secretary of State. They also do not have the experience for scrutiny of general practitioners and the recommendations to practice which 50 years of the MPC has afforded.

The MPC continues to feel very strongly that its concerns are not being listened to by the Department of Health; that its overall role is essential; and that it cannot be excluded without serious damage to the distribution of general practitioners. The MPC has certainly convinced me of the importance of its role. I hope that the Government will reconsider and at least enter into proper dialogue with the MPC about an appropriate focus that it can have if the Bill goes into statute. I beg to move.

Lord Butterfield

My Lords, perhaps I may make a few remarks in support of the noble Baroness, Lady Jay, and her well argued case that the MPC should not, so to speak, be swept aside in all the present developments. I hope that the Minister will excuse me standing up for the MPC, but it has been among my "arbiting" arbiters since the NHS began. All of us who had young colleagues who went into general practice have been most impressed by the work that the MPC has performed over the years.

I know that the MPC tends to be thought of as a rather small, and, therefore, uninfluential organisation. It has a budget of about £400,000 plus a year, but, after all, it covers over 104 areas and maintains careful watch over the proper distribution of general practices in those areas. In my view, it is not a very expensive operation to make sure that someone is keeping a careful eye on the distribution of general practitioners in our country. Professor Jarman at St. Mary's thinks highly of the performance of the Medical Practices Committee over the years. We should look at it as the defender of an even distribution of practitioners. I refer to compensation, where necessary, for practices in areas where the local population is deprived, or where people cannot speak English and may need to be provided with a general practitioner who can speak their language.

We should compare the wonderful distribution of practitioners under the NHS with the sad distribution, for example, in the United States of America, where perhaps 35 to 37 million people have not been properly provided for. As I say, I hope this committee will not, so to speak, be swept aside. It has done a wonderful job. We should try to retain its guidance to ensure we maintain a good distribution of general practitioners. I support the amendment of the noble Baroness, Lady Jay.

Lord Harris of Greenwich

My Lords, I wish to comment on wider issues as well as on the amendment. The noble Baroness, Lady Cumberlege, always tries to be of help to the House, but I think it right to make one or two observations on this and other amendments. We are now coming to the last few weeks of this Parliament. There is no prospect whatever of this Bill going through the House of Commons unless it is agreed. We are talking about a dissolution possibly at the end of March and the early part of April when we shall reach the statutory end of this Parliament. I do not want to waste time discussing what the result of the general election will be, but the reality is that in this period, when an announcement is made, a large number of Bills will die almost immediately. Unless this Bill is agreed in the House of Commons, it will almost certainly die. The department has to recognise the reality of that situation. I hope that when we discuss this Bill this week and next week the Government will recognise that unless they go to some trouble to try to meet the anxieties expressed by the Opposition, the prospects of its ever reaching the statute book in this Parliament are negligible.

Baroness Miller of Hendon

My Lords, before I discuss the amendments that the noble Baroness, Lady Jay, has just dealt with, I should say to the noble Lord, Lord Harris, that my understanding is—I think it is the understanding of noble Lords in this House who have been through the Second Reading and the Committee stages of the Bill—that amendments have been tabled by noble Lords who have sought in some way to improve the Bill. I think that has the general acceptance of everyone. Therefore it is not necessary to go into further detail as regards the noble Lord's comments. He has his opinion but we do not agree with it.

Amendment No. 28 seeks to ensure that any agreements for personal medical services are submitted to the Medical Practices Committee for approval before such arrangements are put in place. As the noble Baroness, Lady Jay, said, the Medical Practices Committee is concerned with the distribution of general medical practitioners throughout England and Wales. Pilots, and any permanent arrangements likely to flow from them, will not necessarily have medical manpower implications. Rather, they are concerned with providing services in different and innovative ways to meet the health needs of the local population. In many cases pilots will have no impact on the number and distribution of medical practitioners in the area. Where they do so, the Medical Practices Committee will be informed to ensure that, in carrying out its function in relation to general medical services, full account can be taken of the numbers of all medical practitioners delivering services within that area. In considering the contractual arrangements to be entered into for the provision of personal medical services, health authorities are best placed to judge local service needs. We find it difficult to see how the Medical Practices Committee—a small committee of some nine people in central London—could effectively second guess judgments taken locally by health authorities about such service issues and effectively have the power of veto over such decisions. Nevertheless, we understand the concerns which the Medical Practices Committee and the profession—and the noble Baroness, Lady Jay, and my noble friend Lord Butterfield—have expressed over the implications of pilots and any future arrangements for the even distribution of doctors. We continue to discuss this matter with the profession. I know your Lordships will be pleased to know that the chairman of the Medical Practices Committee and our officials will be taking these discussions forward at a meeting arranged for 28th January. The noble Baroness, Lady Jay, was hopeful that that would happen. We shall continue to take a close interest and will let noble Lords know the outcome and the decisions we have made at Third Reading of the Bill.

Our aim in this Bill is to streamline the general practitioner appointment process. Amendment No. 49 put forward by the noble Baroness, Lady Jay, instead re-introduces bureaucracy but adds no substance to the clause. We intend that in all cases the Medical Practices Committee will decide whether or not a vacancy exists, but once that decision is made either the health authority or partners within a practice should select a candidate. As now, the health authority will check the qualifications of that candidate. This is all that is necessary and further involvement of the Medical Practices Committee would add nothing but delay to the process. I therefore hope the noble Baroness will not feel it necessary to proceed with these amendments.

Baroness Jay of Paddington

My Lords, I am grateful to the noble Baroness for her reply. I am also grateful for the interventions of the noble Lords, Lord Butterfield and Lord Harris of Greenwich. I have some sympathy with the remarks of the noble Lord, Lord Harris of Greenwich. I have felt at certain stages of this Bill, particularly as regards the provisions relating to pilot schemes, which may, if the legislation is completed, come into force in April 1998, that we are dealing in the realms of what I have now come to call "virtual" legislation. I also understand that the timetable of the Bill is such that it will not reach Second Reading in another place until the second week in February. Given the length of our deliberations and the number of government amendments that have been tabled at this late stage, I suspect it will be several weeks in Committee in another place. Therefore I reiterate my view that this is "virtual" legislation.

However, let us proceed on the basis that we are speaking in the realms of reality. I found the point that the noble Baroness made that local needs were more readily met by local health authorities difficult to understand. I, of course, appreciate that that view may be most easily judged on the local patch, as it were, but the whole point of the Medical Practices Committee is that it takes a wider and broader overview of needs and the manpower situation in general practice. If the Government feel, as the noble Baroness suggested, that some eight people (as she described in a slightly pejorative way) sitting in London are inadequate to take an overview, I am surprised the Government have not introduced earlier legislation to abolish that organisation, rather than simply ignoring it in relation to the new development in primary care which we are debating today.

As regards her response to Amendment No. 49, we have had our usual discussion, which I believe my noble friend Lady Hayman has already dealt with this afternoon, about whether we are speaking of bureaucracy or, as we would describe it, of safeguards. Once again, we fall heavily into the school of those who felt that safeguards were what we were seeking to achieve. To dress it up in some pejorative way as bureaucracy does not take us much further. I was, of course, pleased to hear the noble Baroness say that the department will meet the Medical Practices Committee again next week. I hope that that will result in the Government laying amendments after that meeting. However, I understand the meeting will take place on Tuesday and therefore we may once again be faced with rather late government amendments. However, if government amendments were to be laid, that would be acceptable. If there are no government amendments, I shall return to this subject at Third Reading. But, at the moment, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 17 [Provision of personal medical or dental services]:

[Amendment No. 29 not moved.]

6 p.m.

Clause 18 [Supplementary regulations]:

Baroness Cumberlege moved Amendment No. 30: Page 11, line 41, after ("participants") insert ("other than Health Authorities").

The noble Baroness said: My Lords, I have already spoken to the amendment. I beg to move.

On Question, amendment agreed to.

Baroness Cumberlege moved Amendments Nos. 31 to 36: Page 12, line 12, at end insert— ("(ee) prevent (except in such circumstances and to such extent as may be prescribed) a medical practitioner who performs personal medical services in accordance with section 28C arrangements from providing general medical services;"). Page 12. line 21, leave out from ("for") to end of line 26 and insert ("directions, as to payments, made under section 4(7) of the Act of 1990 (as it has effect as a result of regulations made by virtue of paragraph (g)) to be enforceable in a county court (if the court so orders) as if they were judgments or orders of that court;"). Page 12, line 26, at end insert— ("(hh) confer powers or impose duties on the Dental Practice Board in relation to agreements made by virtue of section 28C(1) under which personal dental services are provided;"). Page 12, line 34, at end insert— ("() Regulations made by virtue of subsection (3)(f) may, in particular, include provision—

1. (a) requiring (except in prescribed circumstances) Health Authorities to remove from their medical lists persons who are performing personal medical services in accordance with section 28C arrangements;
2. (b) conferring a right to transfer to a medical list on persons who have ceased to perform such services;
3. (c) that any provision in relation to medical lists made by or under any enactment is not to apply;
4. (d) as to conditions to be attached to entries in medical lists;
842
5. (e) conferring powers of disqualification on the Tribunal constituted under section 46.").

Page 12, line 34, at end insert— ("() The power to make provision under this section of the kind mentioned in subsection (3)(hh) includes power—

1. (a) to authorise or require the Dental Practice Board to perform on behalf of a Health Authority functions of a prescribed description (including functions relating to remuneration) which have been delegated to the Board by the Health Authority in accordance with a power conferred by the regulations;
2. (b) to provide that functions conferred by the regulations are only to be exercised by the Board in accordance with directions of the Secretary of State;
3. (c) to require information for the purpose of performing any functions conferred or imposed on the Board under this section.").

Page 12, line 43, after ("participants") insert ("other than Health Boards").

The noble Baroness said: My Lords, I have already spoken to the amendments. I beg to move.

On Question, amendments agreed to.

Baroness Hayman moved Amendment No. 37: Page 12, line 49, at end insert— (c) include the provision of a complaints system for patients which is equivalent to that required of general medical and general dental practitioners").

The noble Baroness said: My Lords, the amendment provides for the complaints system available for patients receiving personal medical services or personal dental services under pilot schemes or schemes made permanent under the provisions of the Bill.

The arrangements for complaints are not clear on the face of the Bill. The lines of accountability for doctors, dentists, nurses or others providing services under this legislation are in some doubt. At present there are clear lines of complaint and procedures for complaint either against individual general practitioners, general dental practitioners or health service trusts. It is not certain whether the bodies providing personal medical services or personal dental services under pilot schemes under the legislation would be subject to exactly the same procedures.

The purpose of the amendment is to make clear that patients who receive services under these schemes should have access to complaints procedures that are at least equivalent to those available to patients under conventional schemes.

The amendment is straightforward. The Minister may be able to reassure us that those processes are already in place. However, a simple reading of the Bill does not give that reassurance. The Consumers' Association and the National Consumer Council are most anxious that it should be made explicit that people should not be disadvantaged by being patients of doctors or dentists under these schemes.

The noble Baroness, Lady Miller, was right to say that we have attempted to improve this Bill as it proceeds through the House; it is generally welcomed. However, there is a major issue of contention as regards private companies providing those medical services. We shall return to that issue next week in this House. If it is not resolved happily here, it will undoubtedly be dealt with at length and with passion by my honourable and right honourable friends in another place. The passage in another place may not be straightforward given the circumstances that exist. Were personal medical services to be provided by commercial organisations, patients would wish to know whether they should refer complaints to a National Health Service system of procedure or whether they should go to the same person to whom they complained that their chicken was past its sell-by date. It is important to reassure patients that the standard and quality of the complaints procedure available at present will be available under the scheme.

Having had some experience of dealing with complaints, I do not put forward this argument because I wish to encourage a confrontational attitude between patients and providers, but from the knowledge—I know that it is shared by the Minister—that if one deals properly, sensitively and speedily with complaints one avoids litigation and expense for the National Health Service and distress for patients and complainants. It is an important issue. I look forward to hearing from the Minister. I beg to move.

Baroness Masham of Ilton

My Lords, in recent years there have been many changes in the various complaints procedures. Therefore I agree that one needs great clarification.

Baroness Cumberlege

My Lords, we agree with the noble Baroness that when a patient wishes to complain the procedures must be broadly the same regardless of whether the patient has been treated by, say, a general practitioner working in a pilot scheme or a GP working within the existing system. Patients should feel that they are fully part of the NHS regardless of whether they are treated under the existing or new arrangements.

We intend that the Secretary of State will require standard NHS complaints procedures to be part of the terms of the contracts drawn up between health authorities and boards and providers of services. That way each provider of service, be it general practitioner, general dental practitioner, NHS trust or other body, will have explicitly signed up to the standard complaints arrangements. There may be minor modifications, taking account of the circumstances of each pilot, but overall the arrangements will be on all fours with those which apply now to the family health services and trusts.

Existing NHS complaints procedures do not appear in primary legislation, and nor do we feel that they should do so for pilot arrangements. We are convinced that individual contracts are the appropriate place for stipulating complaints arrangements. We will build on the framework set out by the Bill in discussion with our national consultative groups and, where appropriate, set out more detail in secondary legislation. I hope that I have been able to reassure both noble Baronesses and that the amendment will not need to be pursued.

Baroness Hayman

My Lords, I am grateful to the noble Baroness. Her response appears to cover many of our concerns. I wish to study what she said in detail. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Cumberlege moved Amendments Nos. 38 to 43: Page 13, line 13, at end insert— ("(ee) prevent (except in such circumstances and to such extent as may be prescribed) a medical practitioner who performs personal medical services in accordance with section 17C arrangements from providing general medical services;"). Page 13, line 21, leave out from ("for") to end of line 25 and insert ("directions, as to payments, made under section 17A(8) (as it has effect as a result of regulations made by virtue of paragraph (g)) to be enforceable by the sheriff as if they were judgments or orders of the sheriff and whether or not the sheriff could himself have made such judgments or orders;"). Page 13, line 25, at end insert— ("(hh) confer powers or impose duties on the Dental Practice Board in relation to agreements made by virtue of section 17C(1) under which personal dental services are provided;"). Page 13, line 33, at end insert— ("() Regulations made by virtue of subsection (3)(f) may, in particular, include provision—

1. (a) requiring (except in prescribed circumstances) Health Boards to remove from their medical lists persons who are performing personal medical services in accordance with section 17C arrangements;
2. (b) conferring a right to transfer to a medical list on persons who have ceased to perform such services;
3. (c) that any provision in relation to medical lists made by or under any enactment is not to apply;
4. (d) as to conditions to be attached to entries in medical lists;
5. (e) conferring powers of disqualification on the Tribunal constituted under section 29.").

Page 13, line 33, at end insert— ("() The power to make provision under this section of the kind mentioned in subsection (3)(hh) includes power—

1. (a) to authorise or require the Dental Practice Board to perform on behalf of a Health Board functions of a prescribed description (including functions relating to remuneration) which have been delegated to the Dental Practice Board by the Health Board in accordance with a power conferred by the regulations;
2. (b) to provide that functions conferred by the regulations are only to be exercised by the Dental Practice Board in accordance with directions of the Secretary of State;
3. (c) to require information for the purpose of performing any functions conferred or imposed on the Dental Practice Board under this section.").

Page 13, line 34, leave out first ("section") and insert ("Act").

The noble Baroness said: My Lords, I have already spoken to these amendments. I beg to move.

On Question, amendments agreed to.

Clause 19 [Right to choose medical practitioner]:

Baroness Jay of Paddington moved Amendment No. 44: Page 13, line 39, leave out ("choose") and insert ("be registered with").

The noble Baroness said: My Lords, the purpose of the amendment is similar to that moved by my noble friend Lady Hayman regarding complaints. It reflects our concerns about whether the right to choose a general practitioner is the same within the meaning of this legislation as the right to be registered with the general practitioner.

Two aspects need to be more specific on the face of the Bill than at present. The first is the patient's right to know, for example, the type of general practice with which he or she is registered. Secondly, will the GP practising under Part I pilot arrangements have a personal list, or will there be a practice list? There are obvious reasons why it is important for patients to know what type of contractual arrangement the GP has. For example, it would affect the hours of availability. A salaried GP might have an agreement under his pilot scheme to work for certain hours. That would be of obvious relevance to a patient who was concerned to make contact with him or her. It affects the nature of the services offered. After all, a GP may also be an independent contractor or employed by a trust.

Originally we and the professional bodies who look after these issues on behalf of the medical profession had understood that patients would continue to register in a pilot scheme with an individual general practitioner regardless of the type of contractual arrangement which was being undertaken by him in that pilot scheme. We understand from the Minister that there would be practice lists. We need to clarify the implications of a practice list before we move to another stage of the Bill.

The questions that arise come under various headings. For the purposes of this debate I merely list them in this order. Is, for example, the right of a patient to choose a GP the same as the right to be registered with an individual GP; or is it a right to be registered with a practice and to choose a GP in that practice without registering with that GP? If it is with a practice, what happens to patients if the GP in a Part I pilot, or indeed a permanent arrangement that may come out of a pilot, wishes to leave the partnership and return to Part II arrangements in the same area? Earlier government amendments were designed to facilitate that on behalf of the general practitioner. But will there be equal safeguards to allow the patient the right to choose whether to remain with the Part I practice in the pilot scheme or to move with his or her original GP who may be leaving the partnership?

When general practitioners in Part IT arrangements move to Part I, do they have a right to continue to have their own practice list, or will there be a mechanism that will require a practice to register the GPs? I refer to the expression used by the Minister, "a practice list". Is that what "a practice list" will mean? What then happens if general practitioners want to return to being Part II doctors? Do they automatically take their lists back with them?

Those are all significant questions. Earlier we examined government amendments designed to facilitate the rights of GPs to move in and out of pilot schemes. It is extremely important that we have equal clarity in respect of the rights of patients.

There are all kinds of practical arguments and questions. For example, if practice lists are to be created, who would be responsible for patient cover out of surgery hours; and how would patients be made aware of those arrangements? Additional questions were raised in another context by my noble friend Lady Hayman about the responsibility for complaints. In a practice list, who will take the ultimate responsibility for any complaint that is made, however it is administered? These are very important issues on which we need to have clarity. This amendment seeks to put them on the face of the Bill unless the Minister can help us by providing that clarity in her explanation of what lies behind the Government's intentions. I beg to move.

Baroness Cumberlege

My Lords, the problem is principally one of language. I believe our intentions are absolutely at one. We believe that the direct relationship between a doctor and a patient on his list is one of the cornerstones of general practice. We certainly do not seek to change that in any way in the Bill.

Clause 19 secures a patient's right to choose a GP and extends the effects of the existing law to cover personal medical services. We believe that the present wording of the clause in the Bill is the best way to confirm a patient's right, subject to GP consent and any limitation on list size, to that personal relationship.

I shall try to answer some of the questions put by the noble Baroness. I believe she asked: is the right of a patient to choose a GP the same as the right to be registered with an individual GP, or is it a right to be registered with a practice and to choose a GP in that practice without registering with that GP? The patient will continue to have the right to choose to be on an individual GP's list and be registered with that GP, subject to the existing provisions about GP consent and list size. The practice could also choose to run a practice list system. The patient may also choose not be registered with an individual GP but with the practice as a whole. It would therefore be possible to have each doctor in a practice with an individual list of patients and a separate list of patients shared between the practice as a whole depending on the choices that patients made.

The noble Baroness also asked what happens if a practice list is in operation and a partner chooses to move out of the practice. What happens then to the patients—do they stay with the practice or do they move with the GP? Where that is a difficulty, a practice may operate a practice list system. When one or more of the partners decides to leave, both the patients on any individual list of the leaving doctors and those on the practice list have to be notified of the change. They will then have the opportunity to decide either to go with the leaving doctor or stay with the practice.

The noble Baroness asked a whole range of other questions. I am very happy to answer them now; however, I am aware that time is going on and there is other business. Especially in the light of the views expressed by the noble Lord, Lord Harris, I am extremely anxious to be conciliatory. Perhaps the noble Lord was not in the Chamber when I withdrew one of the government amendments in just the spirit that he indicated. In addition, I succeeded in speaking with the noble Baroness, Lady Robson, last night, when I gave her an explanation of some of the amendments that we were putting forward, as I did with the noble Baroness, Lady Jay.

Lord Harris of Greenwich

My Lords, I was indeed here when the noble Baroness withdrew that amendment and rejoiced at the time that she had done so. I very much hope that, so far as the remaining stages of the Bill are concerned, the Government will adopt the same position. Without being, as she terms it, conciliatory, the prospect of this legislation getting on to the statute book in this Parliament would be seriously jeopardised.

6.15 p.m.

Baroness Jay of Paddington

My Lords, I am grateful to the Minister for her reply. As she says, this may be a question of language. However, it is obviously not as clear as many people, including professional organisations, are concerned to have it.

I take the Minister's point about not replying in detail to the questions I raised. However, they were put to me by those with a professional concern about this matter, both from the point of view of the patient and that of the profession. This may be another amendment which it would be sensible for her to discuss further with the department and perhaps even with the British Medical Association, as she intends to do with Amendment No. 18, simply in order not to prolong discussion this evening but to be sure that those understandings about language, if it is simply a question of language, are appreciated and agreed upon by all sides.

Baroness Cumberlege

My Lords, I would be very happy to do that.

Baroness Jay of Paddington

My Lords, I thank the Minister and beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Cumberlege moved Amendments Nos. 45 and 46: Page 14, line 13, leave out ("provides") and insert ("performs"). Page 14, line 45, leave out ("provides") and insert ("performs").

The noble Baroness said: My Lords, I have already spoken to Amendments Nos. 45 and 46. I beg to move.

On Question, amendments agreed to.

Lord Walton of Detchant moved Amendment No. 47: Before Clause 27, insert the following new clause— GENERAL MEDICAL SERVICES: ADDITIONAL PROVISION BY MEDICAL PRACTITIONERS ("In the 1977 Act, at the end of section 29(2) insert— (h) for the circumstances in which a medical practitioner who is not suitably experienced within the meaning of section 31 or who does not have an acquired right prescribed or otherwise provided for by regulations may provide general medical services.".").

The noble Lord said: My Lords, in speaking to this amendment I must express the hope that my voice will last out. I suspect that I may shortly be seeking primary care. The objective of the amendment is perfectly straightforward, but the practical implications are a little more complex. The 1977 Act to which the amendment refers is the one that required a statutory period of vocational training for all individuals wishing to enter general practice before they could become principals in general practice in the National Health Service.

The amendment would permit the Secretary of State to introduce regulations enabling doctors from outside the European Economic Area—that is not just the European Union, but also doctors from Iceland, Norway and Liechtenstein—who are fully qualified in their own countries, to be involved in international exchanges, visiting the UK for short periods to leam from the experiences of working in general practice and possibly contributing to the education of UK undergraduates.

Many doctors from across the world have come to this country; some junior, seeking postgraduate training and experience, but some of them senior—professors and distinguished consultants—spending periods of sabbatical leave learning about medical practice in the United Kingdom and becoming involved in teaching the programmes. Since vocational training was introduced here in 1977 the quality of general practice and the nature of that training have become greatly admired overseas, not least in the United States, which is far behind us in the development of training programmes in primary care.

The General Medical Services Committee has been talking to the Department of Health on this topic. Many of us had thought that the department would be anxious to resolve the issue to enable doctors from overseas to obtain experience in general practice in this country. We believe that this amendment will provide a useful opportunity to give the Secretary of State power to introduce regulations to facilitate international exchange.

The purpose is that doctors from outside the EEA could be issued with time-limited certificates to enable them to work as supervised deputies in a named practice, assisting with the provision of general medical services. Overseas doctors, including professors of primary care and long-established general practitioners from other countries, should be able to visit the UK for that purpose.

Educational visits to general practices in the UK by GPs from abroad had proved of value but ceased in January 1995 following the implementation of Title IV of EC Directive 93/16, which facilitates the free movement of doctors and the mutual recognition of their diplomas, certificates and other evidence of formal qualification. Each member state is now required to institute vocational training in general medical practice. I look back to the years I spent on the Advisory Committee on Medical Training in Europe in the late 1970s and early 1980s, when it took a great deal of time and effort to persuade the other countries in the European Community, as it then was, that such a period of training was needed.

The Joint Committee on Postgraduate Training for General Practice in this country does not issue UK certificates to non-EEA doctors unless the individual concerned has completed a period of training in the UK, but my understanding is that that provision applies to individuals who might wish to become principals in general practice. I am subject to correction by the Minister but I do not believe that that should, or indeed could, preclude the issue of time-limited certificates to doctors from overseas wishing to work in a supervised capacity in a named practice.

One hopes that the passage of this amendment will enable regulations to be introduced requiring that a visiting doctor would work under the supervision of a principal on a medical list who had been approved as a supervisor; secondly, that the GP supervising the visitor would be responsible for any breach of terms of service occasioned by the visiting doctor; and, thirdly, that a time-limited visiting certificate could be issued which would not carry with it any right to make application for inclusion on a health authority's medical list and which would require that the doctor could only practice in a named practice or practices. My understanding is that recent draft proposals relating to immigration and employment would allow such doctors to be attached to practices in the UK.

I believe that the problems of registration with the General Medical Council could be overcome. After all, for many years temporary full registration has been offered to visiting professors coming to this country from abroad. There was even a situation some years ago when Japanese doctors coming to look after Japanese nationals working in the UK were allowed to have temporary full registration to enable them to work in that capacity.

The amendment covers only England and Wales. If, as I hope, it is acceptable to the Government, a similar amendment would be necessary to amend the 1978 National Health Service (Scotland) Act. I beg to move.

Baroness Jay of Paddington

My Lords, I rise briefly to support the noble Lord, Lord Walton of Detchant, on this amendment. The case has been eloquently made by him. It is clearly to everybody's benefit that these doctors from overseas should play a temporary role and have their education enhanced by visiting this country.

Sometimes we on these Benches are accused of undermining the NHS by the concerns which we express about it; let me say that I believe it would be of enormous benefit to any overseas doctor trying to establish or conduct a proper primary care service in his or her own country to observe how well it is done here.

Baroness Cumberlege

My Lords, we agree with both the noble Lord, Lord Walton, and the noble Baroness, Lady Jay, that international exchanges of the nature described by the noble Lord are of enormous value. Indeed the Joint Committee for Postgraduate Training in General Practice already has the power to issue certificates allowing overseas doctors to enter general practice in this country as a principal, but only where it considers their experience to be equivalent to that required of domestic GPs.

We do not believe that it would be in the interests of patients to allow exchange doctors entry on the strength of a lesser requirement. That would undermine the single standard of entry to UK and EC general practice necessary to maintain the quality of service to patients. Permanent supervision of the doctors concerned could not be guaranteed, with the result that patients could find themselves being treated by a GP whose qualifications did not meet the required standards.

I can assure the noble Lord that we have put forward to the professions proposals which would enable exchanges to take place within existing primary legislation and which would not fall foul of the principle I have just set out. With that reassurance, I hope that the noble Lord will not press his amendment.

Lord Walton of Detchant

My Lords, I thank the Minister for that reply. I would only say that there have been occasions in the past when the Joint Committee for Postgraduate Training in General Practice has refused to offer certificates of equivalence or appropriate certificates to doctors of great distinction with extensive experience of general practice overseas solely on the grounds that those individuals have no experience of working in this country within the National Health Service. If the Minister can give me the assurance that discussions with that body and the profession have overcome that difficulty and that it will be possible for such doctors to come here on exchanges and work in general practice, providing the concerns that their experience and qualifications are of an appropriate standard are satisfied, I believe that that should be sufficient reassurance and I will beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 27 [Medical lists and vacancies: England and Wales.]:

Baroness Miller of Hendon moved Amendment No. 48: Page 23, line 21, after ("relates") insert ("(whether wholly or in part)").

The noble Baroness said: My Lords, I beg to move Amendment No. 48 and with it I should like to speak to Amendments Nos. 50, 52, 53, 54, 55, 56, 57, 58, 59, 70, 72, 77 and 88. This group of amendments is concerned with some matters of detail relating to our proposals on GP appointments contained in Clauses 27 and 28. Amendment No. 50 will enable a health authority to make a reference to the Medical Practices Committee concerning a possible future practice vacancy, where, for example, it is known that a general practitioner is to retire at some future date. At the moment references can only be made where a vacancy actually exists. This will aid an authority's forward planning. Amendments Nos. 52 and 53 deal with technical matters concerning cross-border vacancies between England and Scotland, and Amendment No. 54 makes it clear that a reference to a health board in this Bill has the same meaning as in the National Health Service (Scotland) Act 1978. Amendment No. 70 ensures that medical practitioners with preferential rights to return to an authority's medical list can do so in relation to a vacancy which covers only part of that authority's area. Amendments Nos. 72 and 77 are drafting amendments.

I commend these amendments to the House. I beg to move.

On Question, amendment agreed to. [Amendment No. 49 not moved.]

Baroness Cumberlege moved Amendment No. 50: Page 24, line 4, after ("is") insert (", or will be,").

The noble Baroness said: My Lords, I have already spoken to this amendment. I beg to move.

On Question, amendment agreed to.

6.30 p.m.

Baroness Jay of Paddington moved Amendment No. 51: Page 24, line 23, leave out from beginning to ("or") in line 24.

The noble Baroness said: My Lords, this amendment deals with another concern about the independence of the Medical Practices Committee. Its purpose is to delete the increased power which the Secretary of State seems to be giving to himself to vary or revoke decisions which at the moment are made within the law by the Medical Practices Committee. As we discussed on earlier amendments, we understand that the Government will meet next week with the Medical Practices Committee on this and other concerns.

With that in mind, given the reply that I expect to hear from the noble Baroness—I hope this will be the subject of those discussions—at this point I would simply like to register our concern on this additional matter about the Medical Practices Committee, to which we may have to return at Third Reading. I beg to move.

Baroness Miller of Hendon

My Lords, Amendment No. 51 is concerned with the appeals process as it relates to the filling of vacancies. We find it rather baffling. Our intention in Clause 27(3)(b) is to provide a regulatory power for decisions taken by health authorities on filling vacancies to be reconsidered by the Secretary of State through an agreed appeals process. The amendment as tabled removes this power and effectively would mean that there would be no right of appeal to the Secretary of State over non-selection by a health authority to a medical practitioner vacancy. We do not think that would be a very fair way to proceed. I therefore hope that the noble Baroness will withdraw her amendment.

Baroness Jay of Paddington

My Lords, I shall certainly withdraw the amendment this afternoon, on the understanding that I had when I moved it. This subject obviously lacks some clarity—certainly, views have been given to me expressing concern about the nature of the wording of this particular part of the Bill and its effect on the independence of the Medical Practices Committee. As I said in moving the amendment, I trust that it will be subject to the discussions which we understand will take place next Tuesday. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Cumberlege moved Amendments Nos. 52 to 54: Page 24, line 25, leave out from ("vacancies") to end of line 26 and insert ("relating to the area of one Health Authority which also relate to the area of another Health Authority or a Health Board,"). Page 24, line 28, at end insert— ("(3A) Regulations which make provision about vacancies which relate partly to the area of a Health Board may, in particular, provide that section 29A(2)(b) is to have effect in prescribed circumstances as if the reference to regulations under this section were a reference to regulations under section 19B of the National Health Service (Scotland) Act 1978."). Page 24, line 37, at end insert— (""Health Board" has the same meaning as in the National Health Service (Scotland) Act 1978;").

The noble Baroness said: My Lords, I have already spoken to these amendments. I beg to move them en bloc.

On Question, amendments agreed to.

Clause 28 [Medical lists and vacancies: Scotland]:

Baroness Cumberlege moved Amendments Nos. 55 to 59: Page 25, line 16, after ("relates") insert ("whether wholly or in part)"). Page 25, line 46, after ("is") insert (", or will be,"). Page 26, line 20, leave out from ("vacancies") to end of line 21 and insert ("relating to the area of one Health Board which also relate to the area of another Health Board or a Health Authority,"). Page 26, line 23, at end insert— ("(3A) Regulations which make provision about vacancies which relate partly to the area of a Health Authority may, in particular, provide that section 19A(2)(b) is to have effect in prescribed circumstances as if the reference to regulations under this section were a reference to regulations under section 29B of the National Health Service Act 1977."). Page 26, line 32, at end insert— (""Health Authority" has the same meaning as in the National Health Service Act 1977;").

The noble Baroness said: My Lords, I have already spoken to these amendments. I beg to move them en bloc.

On Question, amendments agreed to. Clause 29 [Sale of medical practices]:

Baroness Miller of Hendon moved Amendment No. 60: Page 27, line 11, at beginning insert ("provided or").

The noble Baroness said: My Lords, in moving this amendment I shall speak also to Amendments Nos. 61, 62, 63 and 89. Since the inception of the National Health Service it has been unlawful to sell the goodwill of a medical practice. The Bill extends the prohibition to all those involved in providing and delivering personal medical services. Our aim is simply to ensure that the extension of the prohibition is done in a fair and even-handed way.

Amendments Nos. 60, 61, 62, 63 and 89 that we placed before the House are minor and consequential and are intended to ensure that our aim to extend the goodwill prohibition fairly to those who provide and deliver personal medical services is fully met. I very much hope that your Lordships will support the amendments. I beg to move.

Baroness Jay of Paddington

My Lords, two of the amendments are in my name. They relate to a question which the noble Baroness has not addressed; namely, the difference in this legislation between the sale of goodwill, to which we understand the provisions are addressed, and the previous legislation in which the words "partial goodwill" were also used. There is some concern that in a sense this may disguise an area about partial sale of assets within a general practice or within any kind of practice set up under the pilot schemes. The words "any part of goodwill" as opposed to "goodwill" in general, would make it more comfortable for those who are concerned about the implications of removing that provision. Perhaps the Minister can help me with that point.

Baroness Miller of Hendon

My Lords, I do not think the amendment will have the intention that the noble Baroness supposed. But we shall take it back and look at it with our officials.

On Question, amendment agreed to.

Baroness Cumberlege moved Amendment No. 61: Page 27, line 23, leave out from ("Authority") to end of line 25 and insert ("by arrangement with whom a person has at any time—

1. (a) provided general medical services, or
2. (b) provided or performed personal medical services in accordance with section 28C arrangements, means the area, district or locality of that Council, Committee or Authority (at that time).").

On Question, amendment agreed to.

Baroness Cumberlege moved Amendment No. 62: Page 27, line 36, at beginning insert ("provided or").

On Question, amendment agreed to.

Baroness Cumberlege moved Amendment No. 63: Page 28, line 2, leave out from ("Board") to end of line 3 and insert ("by arrangement with whom a person has at any time—

1. (a) provided general medical services, or
2. (b) provided or performed personal medical services in accordance with section 17C arrangements, means the area of that Council or Board (at that time).").

On Question, amendment agreed to.

Baroness Cumberlege moved Amendment No. 64: After Clause 30, insert the following new clause— EXPENDITURE OF HEALTH BOARDS (".—(1) In section 85 of the 1978 Act (expenses of certain bodies), after subsection (1) insert— (1AA) Notwithstanding subsection (2), the amount allotted by the Secretary of State to a Health Board under subsection (1) shall include provision for expenditure of that Board which is attributable to—

1. (a) remuneration which is paid to persons providing additional pharmaceutical services (in accordance with directions under section 27A), in respect of such of those services as are designated; or
2. (b) remuneration which is—

1. (i) paid to persons providing general medical services under Part II;
2. (ii) determined by the Health Board concerned; and
3. (iii) of a designated description.

(1AB) In subsection (1AA), "designated" means designated in writing by the Secretary of State for the purposes of that subsection and in relation to the allotment in question.". (2) In subsection (2) at the beginning insert "Subject to subsection (1AA),".").

The noble Baroness said: My Lords, this new clause permits health boards to make payments from cash limited funds to GPs with whom they agree to develop specific areas of general medical services locally and to persons who undertake to provide certain additional pharmaceutical services. The clause is the Scottish equivalent of the English provisions contained in Clause 30(3A)(c) and (d) of the Bill. I commend it to the House. I beg to move.

On Question, amendment agreed to.

Clause 33 [Interpretation]:

Baroness Cumberlege moved Amendment No. 65: Page 29, line 40, leave out subsections (3) to (6) and insert— ("(3) Except in sections 28C and 28D of the 1977 Act and sections 17C and 17D of the 1978 Act—

1. (a) references in any enactment (or in any instrument made under any enactment) to arrangements made under section 28C of the 1977 Act or section 17C of the 1978 Act are to be read, except where the context otherwise requires, as including references to pilot schemes; and
2. (b) references in any enactment (or in any instrument made under any enactment) to services under section 28C of the 1977 Act or section 17C of the 1978 Act, or to services provided in accordance with arrangements made under either of those sections, are to be read, except where the context otherwise requires, as including references to piloted services.").

The noble Baroness said: My Lords, I have already spoken to this amendment with Amendment No. 10. I beg to move.

On Question, amendment agreed to.

Clause 34 [Short title, commencement and extent, etc.]:

Lord Rea moved Amendment No. 66: Page 30, line 11, after ("Primary") insert ("Health").

The noble Lord said: My Lords, the purpose of the amendment is to introduce the word "Health" into the Short Title of the Bill between the words "Primary" and "Care", so that it becomes the National Health Service (Primary Health Care) Act.

The reason is twofold. First and most important is to emphasise that primary care is a highly appropriate place to offer preventive as well as curative health services. For many years preventive services have been provided by the best primary healthcare teams. They include, for example, ante-natal and post-natal care, immunisation and child health surveillance. More recently, health promotion and preventive care, including screening, have been made available to a wide section of the population through the best primary healthcare teams, aiming to reduce the incidence and severity of many serious disabling conditions, such as asthma, raised blood pressure and obesity, among physical conditions, as well as counselling and care for patients with drug, alcohol and some mental health problems. Including the word "Health" in the Title of the Bill will remind those who are approving pilot schemes of the wider role of primary healthcare.

In the second place, "primary health care"—often now shortened to the initials PHC—is the term by which it is known internationally, especially by the World Health Organization. It is accepted as the description for the wide range in care that is appropriate in frontline community settings. It was the term used at the pioneering international conference in 1978 at Alma-Ata, which gave such a worldwide boost to primary health care as a concept. I do not suggest that "Primary Health Care" should be substituted throughout the Bill but that we should have it in the Title to show the type of activity we hope will be covered by the many schemes the Bill will allow. I beg to move.

Baroness Cumberlege

My Lords, the objective behind the amendment is one that we can subscribe to wholeheartedly. Indeed, the recognition that healthcare provision needs the team effort of a range of health and social care professionals has been an important theme in recent years. In the family health services, the idea that everything centres around the general practitioner in his surgery has increasingly given way to a team approach.

We want the new arrangements that the Bill will allow to continue and build on that approach. One significant development is that contracts for personal medical services will not have to be held exclusively by GPs; partnerships made up of, say, nurses, GPs and perhaps other professionals will be able to put forward proposals to provide services. We will also want to continue to encourage an approach to service provision which takes proper account of social factors. The White Paper, Delivering the Future, published on 17th December explicitly encourages that.

The fact that the Short Title of the Bill refers to primary care and not primary health care will not affect that in the least. The Short Title is primarily an indexing tool. It will helpfully identify the services that the Bill deals with as those which people can access directly rather than via a referral. The Short Title will in no way restrict the way such services can develop in future. I hope that the noble Lord will therefore not press the amendment.

Lord Rea

My Lords, naturally I shall not press the amendment, particularly at this stage. However, I am a little disappointed that my advocacy has not had the desired effect. The amendment may well crop up again—not at Third Reading in this House but perhaps in another place. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Cumberlege moved Amendment No. 67: Page 30, line 26, at end insert— ("() Orders under subsections (3) and (7) must be made by statutory instrument.").

On Question, amendment agreed to.

Baroness Cumberlege moved Amendment No. 68: Page 30, line 27, at beginning insert ("Part I of).

The noble Baroness said: My Lords, in moving Amendment No. 68 I shall speak also to Amendments Nos. 69, 85 and 90. The amendments in this group make minor technical changes to clarify ambiguities, tidy up the drafting and remove obsolete provisions in NHS legislation in preparation for a consolidation Bill. These will ensure that the statute book is easier to follow and remove the need to repeat inaccuracies in the consolidation. I beg to move.

On Question, amendment agreed to.

Baroness Cumberlege moved Amendment No. 69: Page 30, line 27, at end insert— ("() Part II of Schedule 2 makes amendments to facilitate, or which are otherwise desirable in connection with, the consolidation of certain enactments relating to the health service.").

On Question, amendment agreed to.

Schedule 1 [Preferential Treatment on Transferring to Medical Lists]:

Baroness Cumberlege moved Amendments Nos. 70 and 71: Page 31, line 19, after ("relates") insert ("(whether wholly or in part)"). Page 32, line 12, at end insert ("(whether kept under the 1977 Act or the 1978 Act)").

The noble Baroness said: My Lords, with the leave of the House I shall move Amendments Nos. 70 and 71 en bloc. I have spoken to these amendments already. I beg to move.

On Question, amendments agreed to.

Schedule 2 [Minor and Consequential Amendments]:

Baroness Cumberlege moved Amendment No. 72: Page 33, line 30, leave out ("as to whether there is a vacancy").

On Question, amendment agreed to.

[Amendments Nos. 73 to 75 not moved.]

Baroness Cumberlege moved Amendments Nos. 76 to 85: Page 36, line 11, at end insert— (" In Schedule 12, in paragraph 1 (1)(b), after "drug or medicine" insert "(otherwise than in accordance with section 28C arrangements)"."). Page 36, line 25, leave out ("as to whether there is a vacancy"). Page 36, line 37, at end insert— ("In section 28(2)(b), after "that" insert "(i)", and after "arrangements" insert ", and (ii) all additional pharmaceutical services provided in accordance with a direction under section 27 A,"."). Page 37, line 13, leave out from ("body"") to end of line 14 and insert ("means a person or body within the meaning of section 17A(2);";"). Page 37, line 18, leave out ("means arrangements made under section 17C"") and insert ("has the same meaning as in section 17D(4)""). Page 39, line 5, at end insert— ("In Schedule 11, in paragraph 1 (1)(b), after "drug or medicine" insert "(otherwise than in accordance with section 17C arrangements)"."). Page 39, leave out lines 14 to 16 and insert ("or (iii)"). Page 39, line 20, leave out from first ("section") to ("at") in line 21 and insert ("17,"). Page 39, line 24, at end insert ("or section 27A of the National Health Service (Scotland) Act 1978""). Page 39, line 28, at end insert— ("PART II PRE-CONSOLIDATION AMENDMENTS

The National Health Service Act 1966 (c. 8) 34.—(1) Section 10 of the National Health Service Act 1966 is amended as follows. (2) In subsection (1), omit "Part II of the National Health Service Act 1977 or" and "section 56 of the said Act of 1977 or". (3) In subsection (2), omit "the Minister or, as the case may be,". (4) Omit subsection (3).

The National Health Service Act 1977 (c. 49) 35. The 1977 Act is amended in accordance with paragraphs 36 to 43. 36.—(1) Section 29 is amended as follows. (2) In subsection (1), after "regulations" insert "which shall be made for the purpose". (3) In subsection (2)(a), for "of lists" substitute "by each Health Authority of a list" and after "services" insert "for persons in the Health Authority's area". (4) Subsection (4) continues to have effect as originally enacted. 37. In section 35(1), after "regulations" insert "which shall be made for the purpose". 38. In section 36(1)(a), for "of lists" substitute "by each Health Authority of a list" and after "services" insert "for persons in the Health Authority's area". 39. In section 38(1), after "with regulations" insert "which shall be made for the purpose". 40. In section 39(a), for "of lists of medical practitioners, and ophthalmic opticians, respectively," substitute "by each Health Authority of a list of medical practitioners and a list of ophthalmic opticians" and after "services" insert "for persons in the Health Authority's area". 41. In section 41, after "with regulations" insert "which shall be made for the purpose". 42. Omit section 43A(3). 43. Omit paragraph 37 of Schedule 15.

Transitional provisions for amendments to 1977 Act 44.—(1) This paragraph applies where an amendment made by this Part of this Schedule to section 29(1), 35(1), 38(1) or 41 of the 1977 Act imposes a duty on the Secretary of State to make regulations for certain purposes. (2) If immediately before the amendment comes into force— (a) regulations made for the same purposes are in force under the provision concerned or a related provision; and (b) the regulations would have wholly, or to any extent, discharged the duty if it had been operative when they were made, the regulations shall be deemed to discharge that duty, wholly or (as the case may be) to that extent. (3) Nothing in this Part of this Schedule shall affect the validity of the regulations mentioned in sub-paragraph (2). The National Health Service and Community Care Act 1990 (c.19) 45. In section 14(6)(g), for "health board" substitute "Health Board". The Health and Medicines Act 1988 (c. 49) 46. In section 17(1) of the Health and Medicines Act 1988, for "36, 39 or 42" substitute "35, 36, 38, 39, 41 or 42". The Health Service Commissioners Act 1993 (c. 46) 47. In section 6(5) of the Health Service Commissioners Act 1993 for "36,39 or 42" substitute "35, 36,38, 39,41 or 42".").

The noble Baroness said: My Lords, with the leave of the House I shall move Amendments Nos. 76 to 85 en bloc. I have already spoken to these amendments. I beg to move.

On Question, amendments agreed to.

Schedule 3 [Repeals and Revocations]:

[Amendments Nos. 86 and 87 not moved.]

Baroness Cumberlege moved Amendments Nos. 88 to 90: Page 40, line 38, column 3, leave out (", (3), (4), (6) and (7)") and insert ("to (8)"). Page 40, line 41, column 3, leave out from ("1") to end of line 43 and insert ("paragraphs 19,22(a) and (c) to (g) and 36"). Page 40, line 43, at end insert— ("PART II PRE-CONSOLIDATION REPEALS

Chapter	Short title	Extent of repeal
1966 c. 8.	The National Health Service Act 1966.	In section 10, in subsection (1) the words "Part II of the National Health Service Act 1977 or" and "section 56 of the said Act of 1977 or", in subsection (2) the words "the Minister or, as the case may be," and subsection (3).
1977 c. 49.	The National Health Service Act 1977.	Section 43A(3). In Schedule 15, paragraph 37.")

The noble Baroness said: My Lords, with the leave of the House I shall move Amendments Nos. 88 to 90 en bloc. I have already spoken to these amendments. I beg to move.

On Question, amendments agreed to.