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Mr. Spearing: My hon. Friend may wish to consider this point before he returns to the matter. In reply to the intervention that he courteously allowed me, the Secretary of State did not specify a possible route for subsidy or assistance to GPs, possibly associated with pharmaceutical services, as he will be able to direct if the Bill goes through, or with health stores or other equipment connected with the promotion of health. That remains, if not a huge loophole, at least a roadway--probably to the supermarket.
Mr. Smith: My hon. Friend is right to pinpoint that problem, to which I shall return in a moment. In the meantime, I shall concentrate on the points on which we agree.
We welcome the broad shape and thrust of the Bill. I think that all hon. Members strongly endorse the concept of a primary care-led NHS. It is correct to put the primary care team--doctors, nurses, health visitors, pharmacists and others who are closest to the patient--in the driving seat when making decisions about care and treatment. The Bill proposes a number of ways in which primary care can take a bolder or a better lead.
For example, the proposed new rules for appointing general practitioners to single-handed practices make absolute sense, and we shall support them. They are long overdue. There are many single-handed practices in inner-city areas, and at present the rules state that, if such a practice falls vacant, an applicant who is potentially sufficiently qualified must be appointed to the vacancy--even if he or she may not be the right person for the job. The Bill remedies that by ensuring that appointments to single-handed practice vacancies are appropriate and adequate.
The Bill's provision on the employment of salaried GPs is also welcome. Recruiting GPs is a serious problem--particularly in some urban areas--and this proposal for their salaried employment offers a partial solution. The Bill correctly envisages the employment of GPs by community health trusts. That is fine and we agree with it, as I have said before in the House, but it also envisages acute hospital trusts employing GPs.
Are the Government convinced that that is a sensible proposal? If a GP is employed by an acute hospital trust--particularly if it is the main local provider of surgery and secondary treatment for that GP's potential patients--one must ask: what price the purchaser-provider split? The Secretary of State knows that I do not particularly like the term "purchaser-provider"--I much prefer the "commissioner-provider" division. However, it is an important distinction, and, if a GP is employed by an acute hospital trust to which he sends some or all of his patients, that distinction vanishes.
Why have the Government ruled out the possibility of health authorities employing salaried GPs? I think that the danger of blurring the commissioner-provider distinction is far less in that instance than in the case of acute trusts employing GPs, yet the Government state clearly in the Bill that health authorities will not be entitled to employ salaried GPs. We shall certainly want to return to that matter if the Bill is sent to a Special Standing Committee. The Government must sort out their reasoning on that point.
The Bill's provision for pilot schemes to develop practice-based team care and to develop new models of providing NHS dentistry is very welcome. We particularly like the Government's new-found enthusiasm for pilot projects--it is a pity that they were not so enthusiastic six years ago when they put the internal market in place. At that time, the then Secretary of State--the present Chancellor of the Exchequer--said that he would not entertain the idea of pilot projects as it was simply a way of ensuring that nothing got off the ground. As a result, he implemented the big-bang approach, which led to the internal market and to many of the subsequent problems. It would have been far better if the Government had realised then that pilot schemes, pilot projects and phased introductions were a much more efficient way of examining changes in the health service than implementing the internal market.
I have several questions about pilot schemes. First, what consultation will take place? The Secretary of State pointed out correctly that clause 2(5) says that there will be consultation, but it does not specify who should be consulted. It does not state whether patients will be consulted at any stage in the process. We believe that they should be consulted, and the British Dental Association agrees with us. It has expressed concerns about the nature
and extent of consultation before a pilot scheme is established. We need much greater detail and clarification from the Government about that specific point.
Secondly, what provision will be made for nurse-led pilot schemes and schemes that are initiated not just by nurses but by others in the primary care sector? The Liberal Democrats' health spokesman, the hon. Member for Southwark and Bermondsey (Mr. Hughes), has also raised the issue. The Secretary of State has said that the Bill allows such pilot schemes to go ahead. However, that view is not shared universally outside the House, where there is serious concern about whether nurse-led pilots will be possible within the context of the Bill. We believe that that point should be clarified to ensure that such pilots can take place.
Mr. Gunnell:
Is it not correct that that provision--in the form of an amendment--was explicitly rejected by the Government in another place, on the quite arbitrary grounds that the Secretary of State would recognise nurses' rights?
Mr. Smith:
My hon. Friend is absolutely correct. The Opposition in another place tabled an amendment specifically to address that issue, and it was rejected. We shall try again if the Bill goes to Committee.
Thirdly, what independent evaluation mechanisms will be introduced for monitoring and assessing pilot schemes? Clause 5 says that the Secretary of State has the power to provide for evaluation. However, it is crucial that evaluation criteria are objective and not politically driven. It is no accident that a proper independent evaluation of what has happened with single-practice GP fundholding has not occurred at any stage in the past six years--despite the fact that it has been one of the major planks of the Government's reform of the health service in recent years. Perhaps the reason is that such evaluation must be objective and non-partisan. We shall press that issue in Committee to ensure that the Secretary of State has a duty to initiate independent and objective evaluation commensurate with his powers under the Bill.
On the subject of consultation, I want to ask the Secretary of State a specific question about the White Paper that led to the Bill. Before he issued it last autumn, at what stage did he discuss its contents with the Medical Practices Committee? The committee has a crucial role to play in ensuring proper accessibility to general practice around the country. The MPC must retain its crucial role, which will be even more crucial as the pilot schemes are established under the Bill. It would appear that, before the Government published their White Paper, they did not tell the MPC what was going to be in it. That strikes me as surprising, if not foolish.
I want to refer to two other matters that could have been dealt with in the Bill but were not. The first relates to the training of doctors, particularly the pre-registration house doctor year, part of which should be spent in general practice. The Medical Act 1983 prohibits general practice training in privately owned premises, whereas it can be provided in a health service-owned health centre. That is ridiculous. The General Medical Council has been raising this matter for 15 years. We should encourage students to learn about general practice, but the existing
law discourages them from doing so. Why will not the Government take the opportunity of this Bill to put that right? We will co-operate with them in Committee if they want to introduce proposals. I very much hope that this long-standing anomaly, which inhibits the proper training of doctors in general practice, can be and will be put right. We will do everything we can to assist that, if the Government agree.
Secondly, registration protection is required for the titles of "paramedic" and "ambulance". I was astonished to learn recently that anyone can put on a jacket with "paramedic" plastered across the back, can sit in his own private car with "ambulance" plastered along the side, can turn up at the scene of an accident and can offer assistance--sometimes perverse assistance--to the people involved.
Mr. Rhodri Morgan (Cardiff, West):
It is like the Secretary of State for Health speaking on Scottish devolution.
Mr. Smith:
As my hon. Friend pertinently observes, it is a little like the Secretary of State speaking on Scottish devolution.
The bogus paramedic may arrive at the scene of an accident in flying tartan colours. He may have no skill and no training, and what he is up to is not monitored. He may cause mayhem. Indeed, the more I think about it, the more apposite the analogy becomes. Surely, statutory protection of such titles as "paramedic" and "ambulance" is needed, and the Bill gives us an opportunity to put that right, too.
I must return to the issue of commercialisation. The Secretary of State said that the primary contract for the employer of a GP must be within the NHS family. So far, so good: we welcome the Government's U-turn. But the Bill continues to allow, and indeed could encourage, the development of an association, including a financial relationship, between a GP and a private commercial organisation.
At present, a GP can subcontract an element of the provision of services--for example, to a deputising service for out-of-hours work. That tends to be the exception rather than the rule, and such action is heavily circumscribed. The health authority must recognise the subcontracted service, must check its quality and must limit the amount of time that it can be used. From what the Secretary of State said today, it seems that he permits and encourages the development of far stronger associations with the private sector.
I am concerned that, even with the Secretary of State's promised amendment, the Bill provides no guarantees about the limits on such commercial involvement in the provision of GP services. We need to know what restrictions, if any, the Secretary of State will impose. This practice is, potentially, wide open to abuse. He may have stopped direct employment, but he is specifically allowing commercialisation by other means.
If, for example, a GP were to develop a link with Unichem--it would be associated with him and would offer complementary services--what guarantee is there that the confidentiality of patients would not be put at risk? What guarantee is there that patients would not be subjected to overwhelming commercial pressures to buy the products of companies involved in a financial
partnership? Will the Secretary of State reassure other GPs, who provide a high-quality service and have invested their lives and savings in their practices, that they will not be completely decimated by the activities of a commercial company that has teamed up with a neighbouring GP? Those important questions arise directly from the Secretary of State's comments this afternoon.
From the moment the White Paper was published, we said that the doctor-patient relationship was at risk from the original proposal in the Bill. It is less at risk now that the Secretary of State has climbed down on the issue of direct employment. But there remains the possibility of commercial involvement with GP services, and that also threatens to undermine the doctor-patient relationship. It is still at risk.
As Dr. Ian Bogle, the chair of the GP's committee of the British Medical Association, said recently:
"The GP must be free to be the advocate of the patient and to exercise independent clinical judgement. Commercial organisations inevitably have other priorities such as the needs of their shareholders and the requirement for profit. There is no room for a third party in the doctor's consulting room."
That statement expresses effectively and strongly the concern that we still have about the commercialisation of the doctor-patient relationship. That is why I shall urge my right hon. and hon. Friends to vote for our reasoned amendment.
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