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

HL Deb 30 January 1997 vol 577 cc1252-81

3.39 p.m.

Baroness Cumberlege

My Lords, I beg to move that this Bill be now read a third time.

Moved, That the Bill be now read a third time.—( Baroness Cumberlege.)

Baroness Jay of Paddington

My Lords, before we move to the detailed consideration of the Bill, perhaps I may raise a general question which would be difficult to consider under the amendments put down in my name and in the names of other noble Lords. I do not wish to delay the House long and I have given the Minister notice that I would raise this general question at this point.

I raise it now, and not on the amendments concerned, because what needs to be said in moving the amendments, particularly the amendments in the first group to be considered by your Lordships, may change. I do so in a spirit of genuine inquiry because it is appropriate that we understand the context in which we are debating these important amendments as we do so.

Can the Minister tell us what has happened to a number of government amendments which were originally tabled for Report stage and are not now before the House even though the understanding of the House was that they would be brought back at Third Reading. Those amendments were either withdrawn before the Marshalled List was prepared or, in the case of a very important amendment—Amendment No. 18—withdrawn by the Minister at Report stage after debate with the commitment, given at col. 834 of the Official Report of 23rd January, to bring it back at Third Reading.

None of those amendments is on today's Marshalled List. I raise the matter because all of those government amendments referred to "companies" or "bodies corporate". As noble Lords who have been involved in previous proceedings on the Bill will understand, this is a crucial question because we are concerned that under the Bill there might be an involvement of private commercial companies—for example, the supermarket chain Asda or the pharmaceutical chain Unichem—and that they might become entitled to employ general practitioners.

I am grateful to the Minister for her letter dated 28th January which I received yesterday. It said that one of the amendments to which I refer needed further consideration by her and her department. However, I understand that there were meetings yesterday between the Secretary of State and representatives of the medical profession which may have changed the understandings on which we have all proceeded. Does the fact that the absence of these amendments, which the Government had, as we understood it, intended to put down, mean that they have changed their mind about the involvement of commercial companies in general practice? Can that option now be ruled out despite what the Minister said in Committee at col. 1403 of the Official Report on 17th December 1996 about not ruling it out; or do they simply intend to bring the amendments back in another place?

I raise this general question now because it could change the whole context of the consideration of the Bill at Third Reading and particularly the consideration of the very significant first group of amendments.

Baroness Cumberlege

My Lords, the noble Baroness is right. We are looking again at these provisions. In order to ensure that the clause is consistent, we have tabled two amendments to reverse the consequential changes to it which were agreed at Report stage and which were dependent on the withdrawn amendment. I intend to explain in a moment that we are holding further discussions with the medical profession on this and on other issues. We think it would be premature to reach a decision before we complete those discussions. I hope that this will satisfy the noble Baroness.

On Question, Bill read a third time.

Clause 2 [Proposals for pilot schemes]:

Baroness Jay of Paddington moved Amendment No. 1: Page 2, line 40, at end insert— ("( ) An authority may only act in accordance with subsection (2) upon the request of a qualified person.").

The noble Baroness said: My Lords, in moving this amendment I wish to speak also to Amendments Nos. 2 and 5. All three amendments stand in my name and the names of the noble Baroness, Lady Robson of Kiddington, and the noble Lord, Lord Walton of Detchant.

These three amendments address our central concern to which I referred in my general inquiry that the deregulation of primary care proposed by the Bill will lead to the commercialisation of general practitioner services. We debated these issues at Second Reading. At that stage the Government dismissed as chatter our fears that family doctors could be employed by supermarket chains. In Committee we produced amendments to prevent private dividend distributing companies from setting up services under the terms of the Bill. The Minister told your Lordships that local health authorities would operate a screening process which would only allow new primary care arrangements which were in the interests of their local populations. But she did not deny, as she had done earlier, that these new arrangements could be operated by supermarkets or, indeed, any other private company. Noble Lords will be aware that many such companies have already shown interest in the business opportunities that they could exploit by becoming involved in GP practices.

We did not return to this issue at Report stage because we understood—and the Minister confirmed earlier—that the Government were discussing these questions with the British Medical Association and other interested organisations. However, although these discussions continue—I believe there was an important meeting between the Secretary of State and the chairman of the British Medical Association only yesterday—nothing has emerged publicly to reassure us that the Bill will not lead to the privatisation of the family doctor service, a prospect which we deplore in principle. There is nothing in the Bill as it stands to prevent commercial organisations from employing GPs or indeed working in partnership with them or National Health Service trusts.

The three amendments before your Lordships today—Amendments Nos. 1, 2 and 5—seek to limit the possibility of private sector involvement to such an extent that it becomes commercially unattractive for profit-making companies. Amendment No. 1 restricts the scope of health authorities in assessing and putting forward to the Secretary of State proposals for pilot schemes for new services. If the amendment is agreed, only those who are "qualified persons" within the meaning of the Bill—that is, NHS trusts, GPs and dentists—will be entitled to be considered as suitable applicants. Health authorities which are approached by commercial companies will not be able to submit their proposals to the Secretary of State. We feel that this is an important additional safeguard which does not allow discretion to the health authorities to decide who should go forward.

Amendment No. 2 again restricts and limits the options of the Secretary of State to approve pilot schemes. The amendment proposes that majority control of any pilot must remain with GPs or suitably qualified nurses. The amendment also seeks to ensure that 75 per cent.—three quarters—of the net income must go to the qualified practitioners. This would make it very unlikely that a commercial company would judge a private practice organisation to be a worthwhile investment. At the same time it would leave open the possibility that the practice organisation could, for example, sub-contract commercially for some services such as out-of-hours deputising. I am sure your Lordships will know that that kind of arrangement already exists, particularly in large cities.

Amendment No. 5 to Clause 13 similarly seeks to limit those who can become health service bodies within the meaning of the Bill for the purposes of NHS contracts. It limits the health service bodies to qualified persons, thus again excluding commercial companies.

As I said earlier, the overall aim of the three amendments is to ensure that the family doctor remains an independent professional working within the National Health Service. Only if this system is maintained will patients have the confidence that they are getting the kind of objective advice and treatment on which trust in the NHS has been successfully built. A doctor who works for a commercial organisation is, as a human being, almost bound to be susceptible to the commercial pressures of a private company whose primary interest must be its bottom line profits rather than patient care.

Let me remind noble Lords—I tried to do this briefly in raising the general question before we reached the amendment—of what has happened since the Bill was introduced in your Lordships' House at the beginning of December. At first the Government denied completely that there was any intention of allowing commercial companies into GP services. The Minister said at Second Reading—at col. 592 of the Official Report of 4th December—that it was time to bring "speculation down to earth". By the Committee stage, and following the public announcements by companies like Asda, Unichem and Boots that they had what they saw as a legitimate interest in pursuing their own commercial concerns in this field if the Bill became law, the Minister said that she was surprised that anyone thought that NHS GPs would need protecting from competition. The noble Baroness admitted that there would be competition and that it might be from the private sector, but in her replies she relied on the resilience of GPs working on their own and the discretion of local health authorities to prevent the worst excesses. The noble Baroness also pointed out that, as our amendments sought to exclude dividend distributing companies, it might be difficult to draw the line between them and private practice partnerships.

I am sure that there can, and will be, similar objections to the details of the three amendments before your Lordships today. But the principle is clear: it is to prevent the commercialisation of general practice. It is a principle on which the British Medical Association is now conducting a campaign. It is seeking to mobilise the country's 36, 000 family doctors to lobby MPs if the Bill reaches another place. It has given a commitment to question candidates in the forthcoming parliamentary election about what their position will be on this matter. Of course, that cannot be a politically attractive prospect for a government in the few weeks before a general election bearing in mind that the prospect of getting the support of GPs has somewhat vanished since a poll yesterday showed that over 50 per cent. of doctors intend to vote Labour. However, if political reality has at last set in in the Department of Health, and the Secretary of State's meeting yesterday with Dr. Macara of the BMA has produced concrete concessions, I hope that the noble Baroness will make the position very clear and specific when she responds to these amendments. I beg to move.

Lord Campbell of Croy

My Lords, I, and I expect other noble Lords who have been taking part in the earlier stages of this Bill, received a letter from the BMA dated the 28th January which is only the day before yesterday. Therefore, we have received its views rather suddenly. I shall read out the particular part of the letter which I think is relevant. It hopes that it will be possible to alter any provision in the Bill which enables the Secretary of State to approve pilot schemes that are run for the benefit of commercial organisations rather than by NHS trusts or GPs". We also—I certainly did—received considerable briefing material from the BMA before Christmas, which some of us were able to use to make points, as I did on Second Reading and also in Committee. But at that time the British Medical Association was concentrating on other matters in the Bill. On the whole it gave the Bill its general support. The points that it raised were about the MPC and two or three other matters.

As the matter that it is now raising is very important, I was not surprised to hear my noble friend Lady Cumberlege, in her earlier statement, say that the Government were still in discussion with the BMA on these points with a view, if possible, to reaching agreement. The BMA may well have misunderstood what the Government are proposing. I was not in the least surprised to hear that discussions were taking place and I welcome the fact that they are.

There should be plenty of time during the Bill's passage in another place—because the Bill still has to go through the other House—for the results of those discussions to be carried into the Bill or considered in relation to the Bill as it stands. I point out to your Lordships that this recent demarche by the BMA has come at very short notice. I hope that the Government will be able to deal with it because it is important that the medical profession and the Government should, if possible, be in agreement on the interpretation of the Bill and its objects.

Baroness Robson of Kiddington

My Lords, we on these Benches very much support the amendment. I know the question was raised before that we do not know where the discussions between the Government and the BMA will lead. But it is important that we register our views as regards commercial companies taking part in the provision of health services in this country. It is desperately important that only people who are qualified persons in the NHS—that is to say, trusts, GPs and dentists—should have the right to provide the services.

As has been said, it is important because in any commercial organisation the freedom of the GP to advocate and exercise independent clinical judgment is bound to be impaired. He will have to look over his shoulder all the time to see whether what he is doing is in line with company policy. That does not give us a National Health Service which is the same for everyone. I sincerely hope that the Minister is able to reply to these questions. I do not look forward to sending the Bill to the other place without having this matter resolved. This House will have finished with the Bill when it goes from here. I should like to believe that we have completed the Bill before it goes to the other place.

Lord Walton of Detchant

My Lords, I, too, should like to support these amendments so ably proposed by the noble Baroness, Lady Jay, for a number of reasons. Perhaps I may say first that there is nothing whatever to prevent a commercial organisation—as indeed happens at present—proposing and in fact preparing to provide private medical services, as has already arisen in a number of railway stations and other areas in the country where there are private clinics to which an individual can, in an emergency or even at their own wish, go to seek medical advice. That is in the private sector. There is nothing to prevent that happening at all.

Equally, many commercial organisations have an occupational health service in which they employ doctors. In the great majority of instances, the purpose of those occupational health services is to enable the doctors so employed by a commercial organisation to consider the possibility that individuals working for those organisations may have developed work-related conditions which require the expertise of someone with a particular training in occupational health.

It is true that there are some organisations, such as universities, which employ doctors to provide a health service for their students and even for those, if they so wish, who are members of staff. But in such cases those doctors are independent contractors with the National Health Service, like general practitioners, with whom the individuals are registered.

I do not myself totally share the grave concerns expressed by officers of the British Medical Association that this Bill, if passed unamended, will lead to the creeping privatisation of the family doctor service. But I do have concerns about its provisions, unamended, which I believe it is right to share with your Lordships. The BMA supports the option of salaried service for GPs who wish to have such a service, recognising that there are many young doctors who might wish to work in the inner cities, which are very much in need of an improved family doctor service and where a salaried option may be of great advantage to them. The important factor there is that these individuals must, in our view, be employed by existing NHS organisations or by GPs themselves who should be the employing bodies.

The problem about the Bill, unamended, is that it could result in a third party entering into a contract or into a relationship between doctor and patient. There is no room for such a third party in the doctor's consulting room. As I said at Second Reading, my concern relates to a potential conflict of interest. Commercial organisations could seek to impose contracts with doctors which compromise the independence of GPs, perhaps requiring that treatment be carried out according to company protocols or that the doctors should prescribe particular drugs rather than being allowed to exercise their independent clinical judgment in the best interests of the patients.

I am concerned that the GP's role as the patient's advocate could be placed under pressure by commercial organisations seeking to cut costs and compromise on standards of care. Of course, doctors would be under a powerful professional obligation to resist such influences, but they could be placed in a difficult position of conflict with a commercial employer.

Is it evident to those concerned that all such commercial organisations (perhaps establishing the premises of a family doctor service within their own buildings) would be able to provide the very wide range of services which the existing family doctor services can provide for their patients such as out-of-hours calls, emergency care and the services of nurses and all other health professionals? It is possible that they could do so, but if a pharmaceutical company were the employing authority, is it not likely that the doctors might feel obliged, even if under no pressure, to prescribe the drugs that are the products of that particular company?

Those are some of my principal concerns. If it were possible that the commercial companies concerned would establish family doctor services under the NHS with salaried employees and in agreement with the local health authorities under an independent charitable trust funded by those companies, there would be no problem; or if those companies were prepared to establish a secondary not-for-profit company to provide such family doctor services, that is something which I would wholly commend. However, such companies would then ask what was in it for them. I suppose the answer is that the patients would be visiting the doctor's premises in such a setting and that the doctors would at least have the secondary ability to use the commercial premises and perhaps to purchase their products.

My concern is the potential conflict of interest between the employing company and the doctors. That is why, although not totally convinced of the strength of the case in every conceivable respect, I support the amendments which would have the effect of restricting those who can initiate pilot schemes for primary medical services to general practitioners and NHS trusts alone and prevent the Secretary of State from approving pilot schemes run for the benefit of commercial organisations. As things stand, under the amendments the commercial organisations would receive some benefit, but at least the employment of the doctors would not be a totally commercial proposition. That is why I support the view that NHS trusts or GPs should have the final say in the employment of such doctors under pilot schemes.

4 p.m.

Lord Dean of Harptree

My Lords, I was one of those who raised these points at earlier stages of the Bill. I was satisfied then with the clear assurances given by my noble friend the Minister. However, we now have the BMA's latest briefing in which it expresses concern about what it calls "commercial organisations" being involved in pilot schemes. As the noble Lord, Lord Walton, has just pointed out, the BMA fears that there could be a "conflict of interest" for doctors and other professionals. Clearly, that must be taken seriously. The professional integrity of doctors, nurses and others must be preserved. It is a vital ingredient in the doctor-patient relationship.

On the other hand, we have to bear in mind that flexibility is the essence of the Bill with a view to improving services for patients. Given that conditions vary greatly in different parts of the country, there has been a general welcome for that principle. As a consequence, it would be surprising if there were to be uniformity in the pilot schemes. Indeed, if uniformity in pilot schemes were to be the outcome, there is not much point in having the Bill at all.

The Bill contains at least five important safeguards which should help to reassure the BMA and others. First, it is clear that any pilot schemes must provide services on NHS terms. Secondly, those who work in pilot schemes must be "suitably qualified". Thirdly, the proposals for pilot schemes must be considered by the health authorities which will decide whether or not to submit those schemes to the Secretary of State. Fourthly, as I understand it, pilot schemes cannot go ahead unless the Secretary of State approves. In other words, the Secretary of State has the power of veto if he is not satisfied about the conditions or with the qualifications of those who are proposing to carry out the pilot schemes. Fifthly, the pilot schemes will be evaluated and can be stopped if considered to be unsatisfactory.

Those seem to me adequate safeguards. I hope very much that it will be possible in the negotiations which my noble friend and her colleagues are having with the BMA to reach an agreement which will preserve the integrity of doctors and others while allowing maximum flexibility in pilot schemes to improve services for patients.

Lord Rea

My Lords, I am not entirely convinced by the reassurances which the noble Lord, Lord Dean of Harptree, has given. He seems to have revealed a negative part of the Bill which gives a very great deal of responsibility to the Secretary of State over whether or not the schemes should continue. Of course, with the right Secretary of State, harm will be minimised, but on the face of the Bill the kind of developments that we have been considering can still go ahead. By their promotion of the idea of a primary healthcare-led National Health Service, the Government are showing how important they regard the part played by primary care in the NHS as a whole. For once, I agree with them. However, I must declare a bias as I have spent 35 years as a National Health Service GP.

Primary healthcare in the United Kingdom is improving, but it is still very far from perfect, particularly in the inner cities where, paradoxically, the need is much greater. I can see how pilot schemes might conceivably be helpful in terms of improving primary healthcare, particularly in deprived areas, but such schemes need to be part of the overall development of primary care which is occurring countrywide.

The amendments aim to keep pilot schemes in the hands of experienced NHS general practitioners working, I suggest, with nurses in almost every case. As my noble friend and the noble Lord, Lord Walton, said, the amendments would discourage those whose motivation in proposing pilot schemes is commercial gain. The amendments would strengthen rather than weaken the National Health Service whereas under the Bill as it now stands the weakening of the NHS is a possibility.

Like the noble Lord, Lord Walton, I am particularly concerned that pilot schemes might be financed by pharmaceutical firms which have very subtle ways of influencing how doctors prescribe. I can see many ways in which such firms might make life a lot nicer for doctors if they were to prescribe their products. I think that the House should support the amendments.

Lord Butterfield

My Lords, perhaps I may make just a few remarks which will raise wry smiles from my colleagues elsewhere. I regret one feature of this situation. We have heard a great deal about doctors and nurses and their views, but the question that we must now face is how we can do anything for those parts of our country which doctors and nurses have so far not come forward to serve. I am anxious that we do not forget the interests of the patients.

If we were to have proper monitoring and consultation with regard to the developments that are taking place, it might be possible to do something for the people in deprived areas. I do not want us automatically to close the door on efforts to bring better medical care into our deprived areas. It is most unlikely that very experienced people will move into these areas. They have not done so for 49 years, and I do not think that there is much chance that they will move now. Those who are likely to move are the younger men and women who want to make a contribution. I do not want to close the door to younger people who can come and practise general practice in deprived areas.

I hope that the noble Baroness, Lady Jay, will not be cross with me for taking the view that it would not be a bad idea to have some pilot schemes under which local medical committees had the possibility of giving guidance and advice to the health authority who would be passing up advice on whether it should be acted upon.

The noble Lord, Lord Rea, spoke about the possibility of a more wicked Secretary of State beginning to do awkward things if he viewed commercial enterprises in a better light than others. I concede that that is the one weakness in my argument. But can one ever legislate permanently for the future without the requirement for some kind of damper to be placed on things that are taken badly or used wrongly? I hope that my old friends will forgive me, but if there is a Division on this matter, I shall walk out with my new-found friends on this side of the House.

The Earl of Donoughmore

My Lords, I am a general practitioner and qualified doctor but have not practised for many years. I am horrified that anybody suggests that commercialism should enter into the relationship between a doctor and his patient. I do not believe that there can be any place for that in any circumstances. I am worried as to why the Government even contemplated allowing it. Perhaps the whole matter was a mistake and they let the wording creep in.

I am afraid that I was not present during previous debates in this House. I hope that noble Lords will excuse me if the reasons for the possibility of commercialism in these circumstances have already been explained. I cannot see any justification for a third person to be involved in the discussion between patient and doctor. Further, I cannot see any justification for running the risk of commercialism, whether it be profit or otherwise—I suppose that it will be mostly profit. From what I have heard said on both sides of the House, it appears that most noble Lords are of that view. I hope that my noble friend the Minister will accept the amendment.

4.15 p.m.

Baroness Cumberlege

My Lords, first I should like to reply to the points made by my noble friend. The purpose of these pilot schemes is to introduce a degree of flexibility. I reinforce the view put forward by my noble friends Lord Campbell of Croy and Lord Dean of Harptree that we need to work with the medical profession and all of the professions involved in primary care. During the course of this Bill we have been very careful to ensure that its provisions are based on discussions with the professions. We are at one with them, and indeed your Lordships, in our determination not only to take primary care forward but to ensure that nothing in this Bill undermines or reverses past achievements that have been made in the whole field of primary care. I assure the noble Baronesses, Lady Jay and Lady Robson, and the noble Lords, Lord Walton and Lord Rea, that we want to protect the key values of the NHS that we know are so prized by the people of this country—independent clinical judgment, equity of access and the right of every patient to choose his or her GP.

As the noble Lord, Lord Dean, has said, our initiative is directed primarily to those who already work in the NHS: GPs, NHS dentists and trusts. We expect the overwhelming majority of pilot proposals to come from them. I recognise the strength of feeling both in your Lordships' House and within the medical profession about the risk of commercialisation from any other proposals that may come forward. We have listened and taken note of these concerns. The Secretary of State has already given an assurance that any scheme will have to be in the interests of the NHS and its patients and based on NHS principles, and will have to continue to deliver NHS primary care. The Secretary of State and the Minister for Health have both discussed these points and the issue of commercialisation generally at length with representatives of the British Medical Association—most recently yesterday. They concluded that they had shared aims and objectives on the matter. We are now discussing with the profession the precise means of delivering our shared aims. I hope that your Lordships will find that reassuring.

I turn briefly to Amendment No. 2. This adds no effective safeguards that are not already provided for in the Bill. Clause 9 and the regulatory powers in Clause 19 state that doctors must have the requisite training and experience to perform personal medical services. This is exactly in line with the rules in the current system. When the Secretary of State takes decisions on pilot proposals, he will want to know who will hold contracts and who will deliver the service. If this is unclear or does not identify a suitably qualified doctor the proposal will fail. It is important that effective responsibility is supported by clear accountability. We have secured this in the Bill. Full responsibility for ensuring that the services specified are provided for patients rests with whoever holds the contract: GPs or perhaps trusts. Full responsibility for professional behaviour rests with the individual professional. There can be no "three-quarter" measures here, as set out in the amendment. All patients will retain the right to choose their GPs. We feel that this amendment could muddy this clarity. The proposal that such practitioners and nurses should remain beneficially entitled to at least three-quarters of the income would strike at the root of the idea, which has been generally welcomed, that we should provide added flexibility to enable NHS trusts to employ GPs as part of a pilot.

I turn to Amendment No. 5. Health service body status has always been intended for those with a substantial commitment to the NHS. To extend the concept to others would devalue it. Yet this amendment would prevent nurses or practice managers who are wholly committed to the NHS from jointly becoming health service bodies. They would not be able to share an NHS contract for services that they proposed to provide in partnership with GPs or dentists. It illustrates the difficulties that arise when trying to qualify the provision. But we are still looking at the right way of expressing Clause 13(1) of the Bill. In the meantime, I can confirm that the Secretary of State intends to exercise tight control over applications for health service body status.

In summary, these amendments do not take us forward. In the light of our amicable and positive discussions with the profession and the further work we are undertaking to deliver our shared aims and address concerns about commercialisation, I hope that your Lordships will reject these amendments.

Baroness Jay of Paddington

My Lords, I am grateful to the Minister for her reply, and to noble Lords who have taken part in this short debate. It is helpful to hear the views and concerns of so many distinguished members of the medical profession.

I refer first to the problem raised by the noble Lord, Lord Butterfield. I am not cross with him as he thought I might be; but, with respect, I suggest that he may have misunderstood both the nature of the Bill and the point that I seek to make in the amendments. We on these Benches have accepted and welcomed since Second Reading the fact that some liberalisation of primary care will enable doctors to be employed by NHS trusts and may provide young doctors with the opportunity to work in areas which they might not otherwise find attractive because they would not wish to be involved in private or independent practice in those areas. That is not the point. Our general concern about the principle is that although in particular circumstances it may be helpful for general practitioners to be employed by trusts—which the Bill refers to as "NHS bodies"—it is not acceptable that they should be employed by commercial organisations for the reasons so cogently made by noble Lords, in particular by the noble Lord, Lord Walton, who spoke about the inherent conflict of interest that this might introduce.

I am of course grateful to the Minister for describing the discussions that she and other Ministers are having with members of the BMA. I wonder whether I might ask her a direct question. She said that there had been general agreement with the BMA on shared aims. Does that mean that the Government now accept the position of the BMA which on 24th January said that the Bill, unamended, is the commercialisation of the family doctor service which will undoubtedly make privatisation of that service much easier. If that position is agreed between the Government and the BMA—if those shared aims include agreement about that—then there is no disagreement between us on these Benches and the Government.

My overall concern is that although the Minister's words were warm they were imprecise. We do not have a precise understanding of the nature of the general agreement with the BMA. My concern is that, if the amendment is put to your Lordships and is defeated, the Bill will pass from this House unamended and with only that general and imprecise form of words from the Minister to give an assurance that in another place, or in further discussions, our concerns will be met.

I am mindful of the points that the noble Lord, Lord Harris of Greenwich, made on Report. I am sorry that he is not in his place, and I hope that I shall not misquote him. He spoke about the timetable of the Bill and the fact that it would not reach another place on Second Reading until the second week of February. It would then take several weeks to be considered in Committee. Obviously, amendments to the Bill would not be able to be discussed until it reached Committee. My suspicion is that the Bill may just run out of steam, that it may not complete any serious discussion in another place before we run up against the barriers of a general election campaign.

In those circumstances it is important, and respectful to your Lordships, for the Minister to answer the question that I put to her—whether the general agreement which she expresses as having been reached with the BMA contains agreement that the Bill, unamended, would lead to the commercialisation of the family doctor service—before I decide whether to ask the opinion of the House. Perhaps the Minister would be kind enough to respond to that question.

Baroness Cumberlege

My Lords, it would be regrettable were the Bill to run out of steam, especially as its principles have the support of all three parties. I understand the concern expressed by the noble Baroness, Lady Jay. Her criticism that I have been imprecise is perhaps a worthy one. It is difficult, because we now have a general agreement with the BMA. I cannot be precise until those discussions have been carried further.

I am sure that within the next few weeks we shall see a degree of precision introduced. It will be a joint agreement, so that we can go forward together. At this moment I could not rule out amendments in another place, because it is obviously too early to say what those discussions will achieve. The principles have been established. We are at one with the BMA on our shared objectives. How we achieve them within the Bill will be difficult for us to determine until those discussions have reached a conclusion.

Baroness Jay of Paddington

My Lords, I am grateful to the Minister for that detailed reply. I am afraid that I feel that the principle of the Bill is still opaque. It is not respectful to your Lordships for the Bill to leave this House unamended and with that opaque nature of the central concerns that we and many noble Lords have about the undertakings which will be given on commercialisation. The Minister herself had to say that she was being imprecise. For those reasons, and because of the principle of the Bill which this central issue reflects, I must ask the opinion of the House.

4.24 p.m.

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

Their Lordships divided: Contents, 127; Not-Contents, 151.

Division No. 1
CONTENTS
Acton, L.	Hylton-Foster, B.
Addington, L.	Ilchester, E.
Allen of Abbeydale, L.	Irvine of Lairg, L.
Allenby of Megiddo, V.	Jay of Paddington, B.
Archer of Sandwell, L.	Jenkins of Putney, L.
Ashley of Stoke, L.	Judd, L.
Bamett, L.	Kennet, L.
Beaumont of Whitley, L.	Kilbracken, L.
Berkeley, L.	Kilmarnock, L.
Blackstone, B.	Kinloss, Ly.
Blease, L.	Lester of Herne Hill, L.
Borrie, L.	Lockwood, B.
Broadbridge, L.	Longford, E.
Bruce of Donington, L.	Lovell-Davis, L.
Callaghan of Cardiff, L.	Macaulay of Bragar, L.
Calverley, L.	McFarlane of Llandaff, B.
Carlisle, E.	McIntosh of Haringey, L.
Carmichael of Kelvingrove, L.	McNair, L.
Castle of Blackburn, B.	McNally, L.
Cledwyn of Penrhos, L.	Merlyn-Rees, L.
Clinton-Davis, L.	Meston, L.
Cocks of Hartcliffe, L.	Methuen. L.
Currie of Marylebone, L.	Mishcon, L.
David. B.	Molloy, L.
Dean of Beswick, L.	Monkswell, L.
Dean of Thornton-le-Fylde, B.	Morris of Castle Morris, L.
Desai, L.	Murray of Epping Forest, L.
Donaldson of Kingsbridge, L.	Nicol, B.
Donoughmore, E.	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.
Ezra, L.	Rea, L.
Falkender, B.	Richard. L.
Farrington of Ribbleton, B.	Rix, L.
Fitt, L.	Robson of Kiddington, B. [Teller.]
Gallacher, L.
Geraint, L.	Rochester, L.
Gladwin of Clee, L.	Rogers of Riverside, L.
Gould of Potternewton, B.	Russell, E.
Graham of Edmonton, L. [Teller.]	Sainsbury, L.
Grey, E.	Saltoun of Abernethy, Ly.
Hanworth, V.	Sefton of Garston, L.
Haskel, L.	Serota, B.
Hayman, B.	Sewel, L.
Henderson of Brompton, L.	Shannon, E.
Hilton of Eggardon, B.	Shepherd, L.
Hollick, L.	Simon, V.
Hollis of Heigham, B.	Smith of Gilmorehill, B.
Holme of Cheltenham, L.	Soulsby of Swaffham Prior, L.
Howell, L.	Stallard, L.
Hughes, L.	Stoddart of Swindon, L.

Strabolgi, L.	Walton of Detchant, L.
Symons of Vernham Dean, B.	Warnock, B.
Taverne, L.	Wedderburn of Charlton, L.
Taylor of Gryfe, L.	White, B.
Thomson of Monifieth, L.	Whitty, L.
Tope, L.	Wigoder, L.
Tordoff, L.	Williams of Elvel, L.
Turner of Camden, B.	Williams of Mostyn, L.
Varley, L.	Winchilsea and Nottingham, E
Wallace of Coslany, L.	Wise, L.

NOT-CONTENTS
Aberdare, L.	Gisborough, L.
Addison, V.	Goschen, V.
Ailesbury, M.	Granard, E.
AiLsa, M.	Gray, L.
Aldington, L.	Haig, E.
Alexander of Tunis, E.	Hailsham of Saint Marylebone, L
Ampthill, L.	Halsbury, E.
Anelay of St. Johns, B.	Harding of Petherton, L.
Annaly, L.	Harmsworth, L.
Astor of Hever, L.	Hayhoe, L.
Balfour, E.	Hertford, M.
Barber of Tewkesbury, L.	Holderness, L.
Belhaven and Stenton, L.	HolmPatrick, L.
Berners, B.	Home, E.
Birdwood, L.	Howe, E.
Blatch, B.	Inchcape, E.
Boardman, L.	Inglewood, L.
Bowness, L.	Jenkin of Roding, L.
Brabazon of Tara, L.	Kimball, L.
Brentford, V.	Kingsland, L.
Brigstocke, B.	Kinnoull, E.
Brougham and Vaux, L.	Knollys, V.
Buckinghamshire, E.	Lauderdale, E.
Burnham, L.	Lawson of Blaby, L.
Butterfield, L.	Lindsay, E.
Butterworth, L.	Liverpool, E.
Byford, B.	Long, V.
Cadman, L.	Lucas, L.
Caldecote, V.	Lucas of Chilworth, L.
Campbell of Alloway, L.	Luke, L.
Campbell of Croy, L.	Lyell, L.
Camock, L.	McColl of Dulwich, L.
Charteris of Amisfield, L.	McConnell, L.
Chesham, L. [Teller.]	Mackay of Clashfern, L. [Lord Chancellor.]
Clanwilliam, E.
Clark of Kempston, L.	Mackay of Drumadoon, L.
Cochrane of Cults, L.	Macleod of Borve, B.
Coleridge, L.	Marlesford, L.
Constantine of Stanmore, L.	Mersey, V.
Courtown, E.	Miller of Hendon, B.
Craig of Radley, L.	Milverton, L.
Cranbome, V. [Lord Privy Seal.]	Monk Bretton, L.
Cross, V.	Montgomery of Alamein, V.
Cullen of Ashbourne, L.	Mottistone, L.
Cumberlege, B.	Mountevans, L.
Davidson, V.	Moyne, L.
Dean of Harptree, L.	Munster, E.
Denbigh, E.	Mutton of Lindisfame, L.
Denton of Wakefield, B.	Noel-Buxton, L.
Derwent, L.	Northesk, E.
Dilhorne, V.	O'Cathain, B.
Dixon-Smith, L.	Orkney, E.
Downshire, M.	Orr-Ewing, L.
Dundee, E.	Oxfuird, V.
Elibank, L.	Palumbo, L.
Ellenborough, L.	Park of Monmouth, B.
Elles, B.	Pearson of Rannoch, L.
Elliott of Morpeth, L.	Pender, L.
Elton, L.	Pilkington of Oxenford, L.
Feldman, L.	Platt of Writtle, B.
Ferrers, E.	Pym, L.
Gainford, L.	Quinton, L.
Gardner of Parkes, B.	Rankeillour, L.

Rawlinson of Ewell, L.	Teviot, L.
Reay, L.	Teynham, L.
Rennell, L.	Thomas of Gwydir. L.
Renwick, L.	Trumpington, B.
Rotherwick, L.	Ullswater, V.
Seccombe, B.	Vinson, L.
Selborne, E.	Vivian, L.
Shaw of Northstead, L.	Waterford, M.
Skelmersdale, L.	Whitelaw, V.
Strathclyde, L. [Teller.]	Wilcox, B.
Swinfen, L.	Willoughby de Broke, L.
Taylor of Warwick, L.	Wynford, L.
Terrington, L.	Young, B.

Resolved in the negative, and amendment disagreed to accordingly.

4.34 p.m.

Clause 3 [Approval of pilot schemes]:

[Amendment No. 2 not moved.]

Clause 5 [Reviews of pilot schemes]:

Lord Walton of Detchant moved Amendment No. 3: Page 4, line 11, at end insert ("and (c) the appropriate local representative committee or local consultative committee, as the case may be.").

The noble Lord said: My Lords, the noble Lord, Lord Colwyn, has asked me to move the amendment in his place as he is exercising his professional skills elsewhere. If this had been a purely dental amendment I should not have felt able to move it. My friendly relationship with my dentist has always been based upon the old principle that in my life there is one greatest thrill; what the dentist does when he stops the buzz and puts away the drill.

The amendment relates to an issue of importance to both the medical and dental professions. In the amendment local representative committees embrace local medical committees, as referred to in the NHS Acts; local consultative committees, which are the Scottish equivalent; and committees of GPs, dentists, optometrists and pharmacists. That is why the amendment includes the word "appropriate".

At Second Reading on 17th December the Minister said that the Government, are committed to working with representatives of the professions at national level on matters such as detailed operational arrangements and general criteria for evaluation of schemes".

Locally, the Government will expect health authorities, GPs and dentists to work together on proposals. The Minister also said: Local representative committees have a role, particularly in considering the implications of the proposed pilot schemes on existing arrangements".—[Official Report, 17/12/96; col. 1426.]

She also referred to powers in the 1977 Act.

I have been advised that both the British Medical Association and the British Dental Association believe that the local medical committee and the local dental committee respectively have a unique overview of the provision of services in their locality such as workforce issues and the health needs of their local populations. They represent the voice of their local doctors and dentists as a whole, including those who may put forward proposals for pilot schemes.

The whole purpose of this simple amendment is that the necessity for the Government to consult with these local representative committees should be on the face of the Bill. I beg to move.

Lord Colwyn

My Lords, I apologise for arriving in the House just as the amendment was called. I took the precaution of ensuring that the noble Lord, Lord Walton, had a list of the points that I wished to make. I am sure that he made them perfectly adequately and I commend them to my noble friend the Minister.

Baroness Hayman

My Lords, I support the amendment, limited though it is. At other stages of the Bill we discussed our concerns about the need for wide consultation with members of the professions and the public both when the schemes are initially put forward and when the Secretary of State examines the results of pilot schemes. The amendment fulfils one area of those concerns in that it will ensure professional consultation at the stage when the Secretary of State is evaluating pilot schemes. We welcome that.

We are worried that the amendment does not deal with the wider issues of public consultation which were discussed and widely supported throughout the House. However, I am sure that my honourable friends in another place will return to that issue when debating the Bill. We support this limited amendment.

Baroness Cumberlege

My Lords, I hope that during the different stages of the Bill I have demonstrated that consultation will be a key feature of piloting. However, we are not indifferent to the strength of feeling expressed by many of your Lordships and in the light of this we will consider whether some of the undertakings we have given might be given greater force on the face of the Bill. We will, if appropriate, come back with amendments in another place. I hope that on that basis the noble Lord will not seek to press the amendment.

I should like to return briefly to a related matter—the amendments put forward by the noble Baroness, Lady Robson, in Committee and again at Report stage, about timescales for pilot schemes. We remain concerned that a minimum timespan of, say, 18 months could hold up evaluation and perhaps a wider application of straightforward schemes that quickly prove their worth. However, on further consideration we accept that three years is an appropriate maximum timespan for a pilot. For the vast majority of schemes, three years will be long enough to demonstrate whether they have met their objectives. If any need longer, it may well be appropriate to evaluate them so that interim lessons can be learned. I am grateful to the noble Baroness, Lady Robson, for putting forward that point and I confirm that we shall introduce an amendment in another place to insert a maximum time span of three years into the Bill.

Baroness Robson of Kiddington

My Lords, I am very grateful to the Minister for agreeing to the three years as a maximum length of time for the evaluation.

As I said when introducing the amendment, if the scheme goes on any longer, it becomes a permanent part of the National Health Service and is no longer a pilot scheme. I am deeply grateful for the concession that the Minister has made.

Lord Walton of Detchant

My Lords, with the assent of the noble Lord, Lord Colwyn, and in the light of the Minister's assurances, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Cumberlege moved Amendment No. 4: After Clause 11, insert the following new clause— RETURNING TO FUND-HOLDING STATUS (".—(1) Regulations must be made providing for a medical practitioner who—

1. (a) has provided or performed personal medical services under a pilot scheme, and
2. (b) in contemplation of doing so, gave up fund-holding status, to be allowed to return immediately to fund-holding status on satisfying the Secretary of State that, if he were granted that status, he would be able to fulfil the conditions for the time being in force for continuing to have it.

(2) For the purposes of this section "fund-holding status" has such meaning as may be prescribed.").

The noble Baroness said: My Lords, in moving this amendment, I should like to speak also to Amendments Nos. 9, 10, 15, 24, 25, 26, 37 and 41. The purpose of these amendments is to enhance choice and opportunity for GPs. Fundholding is at the cutting edge of primary care, leading the way to improved health care on a number of fronts. It will be no surprise if a number of fundholders want to take part in pilots. During the wide-ranging consultation that we carried out last year fundholders were instrumental in pressing for the flexibilities that the Bill provides. There is no doubt that fundholding continues to bring many benefits to patients; one only has to look at the effects that fundholders, who group together to form what are known as multifunds, have had in raising standards of care for patients in the inner city. In Newham this form of collaboration between fundholders, the Newham Multifund, has increased the influence of both doctors and patients and has raised the standards of primary care.

As your Lordships are aware, the principle of involvement by enthusiastic volunteers is central to the Bill. Piloting will be by volunteers and it follows that volunteers should be able to leave the pilot if they so wish. Amendments Nos. 4, 9 and 10 provide for those GP fundholders, who decide to enter into a PMS pilot, or later on into the permanent arrangements, to be able to return to the fundholding scheme. If they can fulfil the relevant conditions, they will be able to return without needing to apply in the same way as a new fundholder. Their previous experience of the scheme will carry with it the appropriate weight and it is right that they should be able to return to fundholding with immediate effect.

Amendments Nos. 15 and 24 make clear which health authority or board will be responsible where members of a fundholding practice also provide personal medical services. Because GPs who provide PMS will not be on the health authority or board's medical list, existing arrangements cannot simply be carried over into the new system. Amendments Nos. 15 and 24 provide that the relevant health authority or board will be the one in whose area most of the patients of the practice reside. I hope your Lordships will agree that that is a sensible and logical way forward.

Amendment No. 37 makes it clear that GPs who provide PMS, other than those who are employed, may apply for recognition as a fundholding practice.

Amendment No. 37 and the Scots equivalents, Amendments Nos. 25 and 26, make various further amendments to Sections 14 and 15 of the 1990 Act and Sections 87A and 87B of the 1978 Act concerning fundholding practices. Some of the amendments ensure that the fundholding provisions in the Act apply not just to doctors who have individual lists of patients but also to doctors who have one practice list. That will not undermine the personal relationship between a GP and his patients. That is clearly prized by both doctors and patients and the current right of a patient to choose his or her GP is restated in Clause 20. It merely recognises that, in the future, some patients may wish to choose to be a patient of a practice rather than an individual GP. I commend these amendments to the House.

On Question, amendment agreed to.

4.45 p.m.

Clause 13 [NHS contracts]:

[Amendment No. 5 not moved.]

Baroness Cumberlege moved Amendment No. 6: Page 7, leave out lines 16 to 19 and insert ("the applicant is").

The noble Baroness said: My Lords, I should like to move Amendment No. 6 and in speaking to this amendment, I should like to speak also to Amendments Nos. 7, 11, 12, 13, 14, 16, 34, 35, 36, 38, 39 and 40. These amendments all make minor, technical and consequential changes. They ensure that amendments to other Acts of Parliament extend to the same territories as those covered in the original Act, and also that the current range of rules and provisions that apply to family health services also apply to pilot schemes and permanent arrangements.

Amendments Nos. 6 and 7 reverse two changes to the provisions about applications for health service body status made on Report. Those changes were consequential on the amendment to Clause 13(1) which I withdrew on Report. We want to consider those provisions further and hold further discussions with the professions. In the meantime, we need to ensure that the whole clause is consistent and these amendments will achieve that.

Amendment No. 40 makes consequential changes to ensure that complaints to the health service commissioner against self-employed doctors and dentists who choose to work in the new system are treated in the same way as if they were working under existing arrangements.

Finally, Amendment No. 16 is a consequential amendment which simply ensures consistency of language between Sections 97 and 97A of the 1977 Act. These amendments tidy up and help to complete the Bill. I hope that your Lordships will support them.

On Question, amendment agreed to.

Baroness Cumberlege moved Amendment No. 7: Page 7, line 27, leave out subsection (6).

On Question, amendment agreed to.

Baroness Jay of Paddington moved Amendment No. 8: Before Clause 17, insert the following new clause— APPROVAL OF THK 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, the purpose of this amendment is to make one final attempt before the Bill leaves your Lordships' House to ensure that the Medical Practices Committee plays an appropriate role in any new arrangements for primary care which may develop if the Bill becomes law.

The House will remember that concerns about that issue were expressed on all sides during the Second Reading debate, in Committee and on Report last week. Until now, we have not pressed the amendment dealing with the Medical Practices Committee because at every stage we were assured by the Government that the Department of Health was in continuing discussion with the MPC.

We hoped that those discussions would be fruitful and that the Government would bring forward amendments to substantiate the MPC's position. I understand that the most recent meeting between the MPC and the department was on Tuesday of this week, but unfortunately that did not produce any positive outcome and as your Lordships will have observed, there are no government amendments to that effect on the Marshalled List today.

Therefore, we believe that it is very important to reintroduce Amendment No. 8 this afternoon. Perhaps I may briefly—and at the risk of wearying your Lordships who have heard the arguments before—remind the House that the MPC has the statutory responsibility for overall manpower distribution in general practice. The committee does that in the interests of trying to achieve equitable primary care services in the NHS, a goal which we on these Benches feel is an essential aim of the health service.

The MPC carries out that task through the negative power of refusing a GP the opportunity to practice in an area which, from its national perspective, is already adequately covered. On Report, the noble Baroness, Lady Miller, who replied to the amendment, was rather disparaging about the effectiveness and work of the committee. She said: 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".—[Official Report, 23/1/97; col. 839.]

But as the noble Lord, Lord Butterfield, pointed out in his contribution to that debate on Report, the MPC has been doing that work since the beginning of the NHS. The noble Lord, Lord Butterfield, said: It has done a wonderful job. We should try to retain its guidance to ensure we maintain a good distribution of general practitioners".—[Official Report, 23/1/97; col. 838.]

As I reported to the House last week, in the current issue of the Health Service Journal the chairman of the MPC points out that the percentage of patients in so-called "under-doctored areas" has gone down from 26 per cent. to 1 per cent. in the past 17 years. That is a very good record and shown by any international standards to be an extremely good performance.

Amendment No. 8 simply seeks to maintain and extend that good record to the new systems of personal medical services which will be created by the pilot schemes allowed under the Bill. Until this legislation proposed almost total deregulation of primary care, no government since 1948 had sought to undermine the strategic function of the MPC. Judging by their responses both in Committee and on Report, the Government seem to be content to pass all those decisions to local health authorities which really have no capacity for a national overview; in other words, the MPC is sidelined. We on these Benches see that as further evidence of the fragmentation of the NHS. We are convinced that the diminution of the MPC's role will produce greater inequities in services which we do not want to see as a result of the Bill. 1 beg to move.

Baroness Robson of Kiddington

My Lords, I support the amendment, as I have supported the proposal at earlier stages of the Bill. We have benefited enormously from the overview of the MPC over the distribution of GPs throughout the country. Without that we would have found it even more difficult to cover GP places in those parts of the country where it is difficult to find people willing to practise.

It has often been said that the MPC is bureaucratic. But if noble Lords look at the way it functions, I am sure that they will agree with me that it is not. The MPC currently grants applications from between 50 and 100 doctors a week to be included in the medical lists of health authorities. It does so at its weekly meeting, with a staff equivalent to two-and-a-half people who process the papers. If its functions were devolved to health authorities, each of the 105 health authorities in England and Wales would have to undertake such procedures, the object of which is to ensure that only properly qualified doctors practise where they have been given permission. Without doubt the MPC has given an invaluable service to the NHS. If it is to go on doing so, it must be involved in the personal medical services. Otherwise, the committee will not be able to do its job.

Baroness Miller of Hendon

My Lords, noble Lords will recall that this amendment was moved on Report. I informed the House then that officials planned to meet the chairman of the Medical Practices Committee and the chairman of the GMSC to discuss how an equitable distribution of GPs can be safeguarded in the light of the provisions in the Bill. I am pleased to say that we believe that good progress has been made.

Agreement has been reached that, subject to some "light touch" national safeguards, there should be greater scope for local people to decide on the distribution of doctors within an authority's area to enable service inequalities to be addressed by those who know best the needs and circumstances of patients and that we should issue further guidance shortly.

Agreement was also reached on the need for a robust national overview of the general practitioner workforce so that a fair distribution between health authorities can be achieved. The MPC has an important contribution to make to this as does the NHS Executive's national resource allocation group which has representatives from the professions and health authorities and input from the academic community. The group advises the Secretary of State on resource distribution to health authorities and has an expertise in assessing the need for different services in different areas. We shall be looking to both the group and the MPC to work together to formulate a national view of GP distribution which can be applied both to the existing arrangements and to the new ones provided for in the Bill.

We are now considering urgently the implications of this agreed approach. In considering both pilots and permanent schemes, health authorities will need to take proper account of local workforce plans and the national overview of the GP workforce in a way which will ensure coherence and consistency with the existing Part II arrangements and produce greater fairness. The Government will be considering amendments which they will need to bring forward in another place to help secure this in the Bill. In view of that response, I hope that the noble Baroness will not find it necessary to pursue her amendment today.

Baroness Jay of Paddington

My Lords, I am most grateful to the noble Baroness, Lady Miller, for that extremely encouraging reply. I am delighted to hear that agreement, in principle, has been reached with the MPC and that its important role is acknowledged by the department. That is something that I am sure the MPC will be very happy about; indeed, it is something that I do not believe we have heard before from the Government during deliberations on the Bill.

We welcome particularly the view expressed by the noble Baroness regarding the need to maintain the national overall perspective on the distribution of GPs, which we feel is of crucial importance if the liberalisation of primary care goes ahead as suggested by the Bill. I am also pleased to hear the Government make the commitment to introduce amendments to that effect to bring into practice such general agreement when the Bill reaches another place. On that basis, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 19 [Supplementary regulations]:

Baroness Cumberlege moved Amendments Nos. 9 and 10: Page 13, line 40, at end insert— ("( ) The regulations must include provision for a medical practitioner who—

1. (a) has provided or performed personal medical services in accordance with section 28C arrangements, and
2. (b) in contemplation of doing so, gave up fund-holding status, to be allowed to return immediately to fund-holding status on satisfying the Secretary of State that, if he were granted that status, he would be able to fulfil the conditions for the time being in force for continuing to have it.

For the purposes of this subsection "fund-holding status" has such meaning as may be prescribed."). Page 15, line 33, at end insert— ("( ) The regulations must include provision for a medical practitioner who—

1. (a) has provided or performed personal medical services in accordance with section 17C arrangements, and
2. (b) in contemplation of doing so, gave up fund-holding status, to be allowed to return immediately to fund-holding status on satisfying the Secretary of State that, if he were granted that status, he would be able to fulfil the conditions for the time being in force for continuing to have it.

For the purposes of this subsection "fund-holding status" has such meaning as may be prescribed.").

On Question, amendments agreed to.

Clause 36 [Short title, commencement and extent, etc.]:

Baroness Cumberlege moved Amendments Nos. 11 and 12: Page 33, line 36, leave out ("(7)") and insert ("(8)"). Page 34, line 4, leave out subsection (6) and insert— ("(6) Any amendment, repeal or revocation made by this Act has the same extent as the enactment or other instrument amended, repealed or revoked. (6A) Subject to subsection (6), only section 33 and this section (except subsections (5) and (7)) extend to Northern Ireland.").

On Question, amendments agreed to.

Schedule 2 [Amendments]:

Baroness Cumberlege moved Amendments Nos. 13 to 16: Page 37, line 18, at end insert— ("The Health Services and Public Health Act 1968 ( c. 46) —(1) Section 59 of the Health Services and Public Health Act 1968 is amended as follows. (2) In subsection (1), for "general medical services or general dental services" substitute "general medical services, personal medical services, general dental services or personal dental services". (3) After subsection (2) insert— (2A) In subsection (1), references to personal medical services and personal dental services are to be construed as references to services of those respective kinds under section 28C of the 1977 Act, section 17C of the 1978 Act or the corresponding provisions of the law in force in Northern Ireland or the Isle of Man."."). Page 37, line 18, at end insert— ("The Patents Act 1977 (c. 37) In section 56(4)(a) of the Patents Act 1977, for the words from "provision of to "Isle of Man" substitute "provision of—

1. (i) pharmaceutical services, general medical services or general dental services under Part II of the National Health Service Act 1977, Part II of the National Health Service (Scotland) Act 1978, or the corresponding provisions of the law in force in Northern Ireland or the Isle of Man, or
2. (ii) personal medical services or personal dental services provided in accordance with arrangements made under section 28C of the 1977 Act, section 17C of the 1978 Act, or the corresponding provisions of the law in force in Northern Ireland or the Isle of Man".").

Page 37, line 20, at end insert— ("—(1) Section 15 is amended as follows. (2) For subsection (1B) substitute— (1B) In relation to a Part II medical practitioner—

1. (a) whose name is included in the medical list of only one Health Authority, and
2. (b) who practises on his own or in partnership with others all of whom are Part II medical practitioners whose names are included only in that Authority's medical list,

any reference in this Act or the National Health Service and Community Care Act 1990 to the relevant Health Authority is to be construed as a reference to that Authority. (1BA) In relation to a medical practitioner who is not within subsection (1B), any reference in this Act or the National Health Service and Community Care Act 1990 to the relevant Health Authority is to be construed as a reference to the Authority in whose area most of the practice patients live. (3) After subsection (1C) insert— (1D) In this section— Part II medical practitioner" means a medical practitioner who provides general medical services under Part II and does not perform personal medical services under section 28C arrangements; and practice patient" means an individual who—

1. (a) is on the medical practitioner's list of patients; or
2. (b) in the case of a medical practitioner and one or more other medical practitioners who together have a single list of patients, is on that list.".").

Page 38, line 22, leave out from first ("subsection") to end and insert ("(1)(a), for "amounts allotted to them for that year under subsections (2) and (3)" substitute "amount allotted to them for that year under subsection (3)";").

The noble Baroness said: My Lords, with the leave of the House, I should like formally to move these amendments to which I have already spoken. 1 beg to move.

On Question, amendments agreed to.

Baroness Miller of Hendon moved Amendment No. 17: Page 38, line 37, leave out ("or purchase").

The noble Baroness said: My Lords, in moving the amendment I shall speak also to Amendments Nos. 18 to 23 and 27 to 33. These further amendments are designed to correct drafting points and also to refine the provisions relating to the sale of goodwill of medical practices. They are designed to meet our objective of prohibiting the sale of goodwill to those providing and delivering personal medical services in the same way as those providing general medical services. The amendments meet that objective with fairness for all concerned. I therefore urge your Lordships to support them. I beg to move.

On Question, amendment agreed to.

Baroness Cumberlege moved Amendments Nos. 18 to 23: Page 39, line 19, leave out ("general medical services or personal medical"). Page 39, line 20, at end insert ("(or as an employee of a person employing a practitioner who carries on a medical practice)"). Page 39, line 33, after ("practice") insert ("(or employing a practitioner who carries on a medical practice)"). Page 39, line 39, after ("practice") insert ("(or employing a practitioner who carries on a medical practice)"). Page 39, line 40, leave out ("subsequently"). Page 40, line 2, after ("of) insert ("section 54 and").

On Question, amendments agreed to.

5 p.m.

Baroness Cumberlege moved Amendments Nos. 24 to 41: Page 40, leave out line 21 and insert— ("—(1) Section 19 is amended as follows. (2) In subsection (2), omit paragraphs (b) and (c). (3) For subsection (8) substitute— (8) In relation to a Part II medical practitioner—

1. (a) whose name is included in the list of only one Health Board; and
2. (b) who practises on his own or in partnership with others all of whom are Part II medical practitioners whose names are included only in that Board's list, any reference in this Act to the relevant Health Board is to be construed as a reference to that Board.

(9) In relation to a medical practitioner who is not within subsection (8), any reference in this Act to the relevant Health Board is to be construed as a reference to the Board in whose area most of the practice patients live. (10) In this section— Part II medical practitioner" means a medical practitioner who provides general medical services under Part II and does not perform personal medical services under section 17C; and practice patient" means an individual who—

1. (a) is on the medical practitioner's list of patients; or
2. (b) in the case of a medical practitioner and one or more other medical practitioners who together have a single list of patients, is on that list.".").

Page 41, leave out lines 19 and 20 and insert— ("—(1) Section 87A is amended as follows. (2) In subsection (1), after "section 19", insert ", or (in the case of practitioners who are not employed by another person) personal medical services in accordance with section 17C arrangements, ". (3) In subsection (4), for paragraph (g) substitute— (g) the operation of this section in a case where one or more of the medical practitioners wishing to make an application under subsection (1) is also—

1. (i) on the medical list of a Health Authority established under section 8 of the National Health Service Act 1977; or
1276
2. (ii) providing personal medical services in accordance with arrangements made under section 28C of that Act;".").

Page 41, line 20, at end insert— (".—(1) Section 87B is amended as follows. (2) In subsection (3)(b), for "individuals on the lists of patients of any of the members of the practice" substitute "practice patients". (3) In subsection (5)(b)—

1. (a) after "general medical services" insert "or personal medical services provided in accordance with section 17C arrangements"; and
2. (b) for "individuals on the lists of patients of the members of the practice" substitute "practice patients".

(4) After subsection (6) insert— (7) In this section "practice patient" means an individual who—

1. (a) is on the medical practitioner's list of patients; or
2. (b) in the case of a medical practitioner and one or more other medical practitioners who together have a single list of patients, is on that list.".").

Page 41, line 33, leave out ("or purchase"). Page 42, line 15, leave out ("general medical services or personal medical"). Page 42, line 16, at end insert ("(or as an employee of a person employing a practitioner who carries on a medical practice)"). Page 42, line 29, after ("practice") insert ("(or employing a practitioner who carries on a medical practice)"). Page 42, line 35, after ("practice") insert ("(or employing a practitioner who carries on a medical practice)"). Page 42, line 36, leave out ("subsequently"). Page 42, line 48, after ("of) insert ("section 35 and"). Page 43, line 18, after ("of) insert (", or Schedule 1 to, "). Page 43, line 22, at end insert— ("The Copyright, Designs and Patents Act 1988 ( c. 48)

In section 240(4) of the Copyright, Designs and Patents Act 1988, for the words from "(a) pharmaceutical services" to the end of the subsection substitute— (a) pharmaceutical services, general medical services or general dental services under—

1. (i) Part II of the National Health Service Act 1977,
2. (ii) Part II of the National Health Service (Scotland) Act 1978, or
3. (iii) the corresponding provisions of the law in force in Northern Ireland; or

(b) personal medical services or personal dental services in accordance with arrangements made under—

1. (i) section 28C of the 1977 Act,
2. (ii) section 17C of the 1978 Act, or
3. (iii) the corresponding provisions of the law in force in Northern Ireland.".").

Page 43, line 24, at end insert— ("( ) In section 2(1)(a), for the words from "provision of general medical services" to "Act 1978" substitute "provision of—

1. (i) general medical services under Part II of the National Health Service Act 1977 or Part II of the National Health Service (Scotland) Act 1978; or
2. (ii) personal medical services in accordance with arrangements made under section 28C of the 1977 Act or section 17C of the 1978 Act".").

Page 43, leave out lines 32 to 34 and insert— ("—(1) The National Health Service and Community Care Act 1990 is amended as follows. (2) In section 14(1), after "principal Act" insert ", or (in the case of practitioners who are not employed by another person) personal medical services in accordance with arrangements made under section 28C of that Act, ". (3) For section 14(6)(g) substitute— "(g) the operation of this section in a case where one or more of the medical practitioners wishing to make an application under subsection (1) above is also—

1. (i) on the medical list of a Health Board; or
2. (ii) providing personal medical services in accordance with arrangements made under section 17C of the National Health Service (Scotland) Act 1978;".

(4) In section 15(4)(b), for "individuals on the list of patients of any of the members of the practice" substitute "practice patients". (5) In section 15(7)(b)—

1. (a) after "general medical services" insert "or personal medical services provided in accordance with arrangements made under section 28C of the principal Act";
2. (b) for "individuals on the lists of patients of the members of the practice" substitute "practice patients".

(6) In section 15, after subsection (9) insert— "(10) In this section "practice patient" means an individual who—

1. (a) is on the medical practitioner's list of patients; or
2. (b) in the case of a medical practitioner and one or more other medical practitioners who together have a single list of patients, is on that list." ").

Page 43, line 34, at end insert— ("The Access to Health Records Act 1990 (c. 23) —(1) The Access to Health Records Act 1990 is amended as follows. (2) In section 1(2), for paragraph (a) substitute— "(a) in the case of a record made by a general practitioner (other than an employed practitioner), or by a health professional employed by such a general practitioner—

1. (i) the general practitioner on whose list the patient is included (or, where the patient is included on the list of a medical practice consisting of two or more partners who are general practitioners, any such partner); or
2. (ii) where the patient is not on any such list, the Health Authority or Health Board by arrangement with whom a general practitioner last treated him;".

(3) In section 11, in the definition of "general practitioner", for the words from "providing" to "Act 1978" substitute "—

1. (a) providing general medical services in accordance with arrangements made under section 29 of the National Health Service Act 1977 or section 19 of the National Health Service (Scotland) Act 1978; or
2. (b) performing personal medical services in accordance with arrangements made under section 28C of the 1977 Act or section 17C of the 1978 Act".").

Page 43, line 34, at end insert— ("The Trade Union and Labour Relations( Consolidation) Act 1992 (c. 52) In section 279 of the Trade Union and Labour Relations (Consolidation) Act 1992—

1. (a) after "as a person" insert "performing personal medical services or personal dental services or";
2. (b) before "29" insert "28C,"; and
3. (c) before "19" insert "17C,".").

Page 43, line 34, at end insert— ("The Health Service Commissioners Act 1993 (c. 46) —(1) The Health Service Commissioners Act 1993 is amended as follows. (2) In section 2A(1), for the words from "if they are" to "Act 1977" substitute "if they are—

1. (a) individuals undertaking to provide in England general medical services or general dental services under Part II of the National Health Service Act 1977;
2. (b) persons (whether individuals or bodies) undertaking to provide in England general ophthalmic services or pharmaceutical services under Part II of that Act; or
3. (c) individuals performing in England personal medical services or personal dental services in accordance with arrangements made under section 28C of that Act (except as employees of, or otherwise on behalf of, a health service body or an independent provider)".

(3) In section 2A(2), for the words from "if they are" to "Act 1977" substitute "if they are—

1. (a) individuals undertaking to provide in Wales general medical services or general dental services under Part II of the National Health Service Act 1977;
2. (b) persons (whether individuals or bodies) undertaking to provide in Wales general ophthalmic services or pharmaceutical services under Part II of that Act; or
3. (c) individuals performing in Wales personal medical services or personal dental services in accordance with arrangements made under section 28C of that Act (except as employees of, or otherwise on behalf of, a health service body or an independent provider)".

(4) In section 2A(3), for the words from "if they are" to "Act 1977" substitute "if they are—

1. (a) individuals undertaking to provide in Scotland general medical services or general dental services under Part II of the National Health Service Act 1978;
2. (b) persons (whether individuals or bodies) undertaking to provide in Scotland general ophthalmic services or pharmaceutical services under Part II of that Act; or
3. (c) individuals performing in Scotland personal medical services or personal dental services in accordance with arrangements made under section 17C of that Act (except as employees of, or otherwise on behalf of, a health service body or an independent provider)".

(5) In section 3, after subsection (1) insert— "(1ZA) Any failure or maladministration mentioned in subsection (1) may arise from action of—

1. (a) the health service body,
2. (b) a person employed by that body,
3. (c) a person acting on behalf of that body, or
4. (d) a person to whom that body has delegated any functions.".").

Page 44, leave out lines 37 and 38.

The noble Baroness said: My Lords, I beg to move Amendments Nos. 24 to 41 en bloc.

On Question, amendments agreed to.

An amendment (privilege) made.

Baroness Cumberlege

My Lords, I beg to move that the Bill do now pass. In doing so I wish briefly to state that I think this is an important piece of legislation affecting a key part of our health service—primary care. Current arrangements have served us well for almost half a century. But it is clear that they lack flexibility to tackle some of the diverse health needs that arise in different areas.

The Bill aims to provide that flexibility. It seeks to do so in a way which maintains the principles of quality, fairness, accessibility, responsiveness and efficiency which are at the heart of primary care. It proposes a way forward, through piloting, which allows us to learn as we go.

I thank your Lordships for the attention given to the Bill. It has been good to see a consensus on the broad principles behind it—a consensus which also extends to the professions. We have had some lively and informative debates. The amendments moved by your Lordships have contributed greatly to that. I shall resist the temptation of mentioning noble Lords individually as I understand there is great pressure for further Business this evening. However, I am happy to have been able to give several undertakings on matters such as the relationship between patient and GP and consultation. I was especially pleased to accept earlier today the proposal of the noble Baroness, Lady Robson, on a maximum time-span for pilots.

It is with some regret that I was unable to agree with the noble Baroness, Lady McFarlane of Llandaff, on the role of nurses in the context of this Bill, but we are at one in both being vice-presidents of the RCN and in agreeing on the increasingly important role of that profession within the NHS and in primary care in particular.

The Bill does not impose a template for future services. Instead it frees health professionals to work with health authorities to develop local solutions to local needs. The UK primary healthcare system is the envy of the world and the Bill will allow it to develop its potential still further. I look forward to seeing its safe passage through another place and on to the statute book. I commend the Bill to the House.

Moved, That the Bill do now pass.—(Baroness Cumberlege.)

Baroness Jay of Paddington

My Lords, we have had some interesting and illuminating discussions on this innovative Bill. We on these Benches remain supportive—as we were at Second Reading—of the principle of making primary care organisation more liberal. We particularly welcome the idea that long-term changes will only be made once pilot schemes have been allowed to run their course and have been properly evaluated. However, we cannot forbear to remark, even at this late stage of the Bill, that this is certainly a change of direction for the present Government in making changes to the NHS.

As I said in earlier debates, this is essentially an enabling Bill and some of the changes in prospect we are sure will be useful. We particularly welcome the possibility that pilots may include the employment of GPs by hospital trusts in areas of deprivation where places have been difficult to fill under the long-standing arrangements of GP contracts. We are sorry—I gather from the Minister's remarks that perhaps she is sorry too—that the Government resisted amendments which sought to include nurses as lead players in the new role that they may have in new forms of general practice. We hope that this may still be considered.

We are also concerned that the Government resisted the amendments we proposed to broaden the consultation perspective on the Bill so that those outside the professions, as well as those inside them, could take a view on the future prospects for their local services. We were delighted to hear the Minister this afternoon accept the amendments which had earlier been proposed by the noble Baroness, Lady Robson, about the length of pilot schemes, which obviously had a great deal of force behind them. We are also grateful that the Government seem to be in positive negotiation with the Medical Practices Committee about the essential nature of an overall strategic approach to the manpower questions of general practice in the NHS as a whole.

We welcome, of course, positive liberalisation and experimentation, but our greatest concern is that it may become in practice a form of rather chaotic deregulation if commercial organisations are allowed to get a toehold in the general practice system. We tried again today to ensure that there are safeguards in this regard but once more our proposal was defeated. I hope that when the Bill reaches another place the general assurances about agreements that have been reached with the British Medical Association—the Minister spoke of them this afternoon—will be translated into specific amendments which protect general practice pilots from the kind of commercial influence which we still fear may occur.

I am grateful to the Minister and to the noble Baroness, Lady Miller, for their full and courteous replies to our amendments, even if they have not always been, in our view, totally helpful. I also thank the Minister for her detailed briefing on Government amendments which she gave us at the later stages of the Bill. I am particularly grateful to my noble friends Lady Hayman and Lord Rea whose long experience and understanding of the health service has meant that they have spoken with great authority on the amendments that they have proposed.

This is a short Bill but nevertheless an important one, as the Minister said. We have been helped by outside organisations who are concerned about the Bill. I particularly wish to mention the Royal College of Nursing, the Royal College of Midwives, the British Medical Association and the Medical Practices Committee whose concerns have been widely aired in your Lordships' House. We have also received useful advice from the Royal Pharmaceutical Society, local authority associations and the National Consumer Council, as well as the Consumers Association and the Association of Community Health Councils.

That long list of organisations which have aided our understanding of the Bill and which have raised questions on the Bill that we have subsequently asked gives a taste of the level of concern there is on these changes to primary care which the Bill proposes and promotes. We all wish the Bill well in another place. I suspect that there will be some vigorous attempts to amend it particularly in the areas that I have described which remain of concern to us. I look forward to those debates, and indeed to the acceptance of some other amendments by the Government.

Baroness Robson of Kiddington

My Lords, I wish to add a few words on the Bill. We believe that it opens up great opportunities to improve the primary care service within our communities but that process must be carefully controlled by set criteria so that the service does not end up being good in some parts of the country but not so good in others.

We are happy about the voluntary, non-enforcement aspect of the pilot schemes. Previously, the Government and the Department of Health have tended to lay down the rules from the centre. If that process is properly handled, it will grow of its own accord into something which will be of great value to the nation. I like some of the provisions in the Bill to which we have agreed, for example, that a general practitioner can now be employed on a salaried basis. That should be helpful to many practices.

The other provision we welcome with open arms is that health authorities are no longer forced to appoint, in single doctor practices, from among the three finalists in the competition. That was the previous procedure irrespective of whether or not anyone was any good. The new provision was overdue; now it is in the Bill. I am very grateful to the noble Baroness for agreeing to my suggestion that the pilot schemes should last for only three years.

As was evident today, we were worried about the problem of commercial contractors and the removal of overall control of manpower from the Medical Practices Committee. However, we received certain assurances from the Minister which we hope will be even more clearly defined when the Bill goes to another place.

My one regret is that we did not have written into the Bill provision on pension rights for nurses and staff working in the primary healthcare sector. I know that the Government gave an assurance in their White Paper, but I would love to have seen a reference on the face of the Bill. That aside, I join the noble Baroness, Lady Jay, in thanking Ministers, and all the various organisations which sent us so much advice. I wish the Bill great success in the other place.

Lord Colwyn

My Lords, in even fewer words than the noble Baroness, Lady Robson, used, I thank my noble friend for the splendid way in which she piloted this Bill about pilot schemes through the House. Often the Government do not consult dentists. Sometimes I am not sure that they even understand the difference between a general medical practitioner and a general dental practitioner. Dentistry is often forgotten in service planning and is added as an afterthought, far too late. I am delighted that in this Bill we see an assurance that dentistry will continue to play an important part in primary care. I hope that the attitude to my profession will remain the same. I welcome the Bill.

On Question, Bill passed, and sent to the Commons.