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Mr. Milburn: If the hon. Gentleman wants to be a member of the Committee and wants to go into those issues in detail, he will have an opportunity to do so--there is an offer he cannot refuse. The Bill says that to practise in any health authority, a locum has to be on the list of one health authority. I hope that that will get the balance right in ensuring that we provide proper safeguards for patients but do not over-bureaucratise the system, and that my remarks offer him the reassurance that he wants.

Dr. Howard Stoate (Dartford): I am grateful to my right hon. Friend for giving way. [Interruption.] There is a doctors' lobby going on, I am afraid, and the doctor will see the Secretary of State now.

My right hon. Friend rightly says that certain parts of the country have to rely too heavily on locum doctors. Will he clarify the point about the Medical Practices Committee, which is able to oversee the number of GPs across the country to ensure equitable access to services for patients? If that committee is abolished as the Bill proposes, how will he ensure that there remains a good spread of GPs and that that spread will be overseen centrally to ensure that pockets of real shortage do not exist next door to pockets of relative plenty?

Mr. Milburn: My hon. Friend speaks as more than a locum GP--he is an expert GP on those issues. On the question of the Medical Practices Committee, the Bill proposes to establish yet another quango and devolve that down to the local health services. The Medical Practices Committee is supposed to ensure an even distribution of GPs between areas, but the truth is that it has failed to do its job properly. Hon. Members have only to look to Barnsley, Sunderland and some inner-city areas to realise that those places are not over doctored, but under doctored. It is entirely right and proper that the people who should take decisions about whether they need to recruit more GPs should be those responsible for overseeing the provision of local health services, rather than some national committee that has simply failed to do the job.

I offer my hon. Friend this reassurance: the Department of Health and the NHS executive must and will ensure that there is oversight to get the incentives in the right place, particularly through the new personal medical services contracts. That will ensure that we recruit family doctors to the areas where they are needed most.

Mr. David Chaytor (Bury, North): Will the new powers for health authorities include one to monitor in detail the performance of individual doctors? I speak as one of the few Members--perhaps the only one--whose

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family was registered at one of the group practices where Dr. Shipman formerly worked, so I have a close interest in the matter. It is surprising that I am here, in view of the circumstances. At a very early stage in the Shipman case, there was well-documented local evidence of malpractice, which was not picked up and not formally fed into the system. Will the health authorities' new powers change that?

Mr. Milburn: I think that they will do so. As my hon. Friend knows, there is a raft of measures to strengthen the safeguards that he seeks. Some of those measures are contained in the Bill and require new legislative powers, although others can be introduced under existing powers.

The most important of the measures that we are taking, apart from the establishment of the Commission for Health Improvement and the new National Clinical Assessment Authority, is the introduction of a requirement for all doctors, whether family or hospital doctors, to undergo annual appraisal. Many people would expect similar arrangements to exist in other industries and other parts of the public sector. Although such measures can be controversial, the provision enjoys a great deal of support not only among patients and patients' organisations, but in the medical profession. There is now a recognition that things cannot continue as they have done.

We must be careful with the assumption that there is a raft of doctors who go around killing their patients, as that is not the case. We must be clear about Harold Shipman and his crime. He was a cold, calculating and evil killer who manipulated the system and abused trust in the most callous way imaginable. The Bill deals with poor performance and with spotting problems early on. That is what we must deal with.

I remind my hon. Friend the Member for Bury, North (Mr. Chaytor) of what happens every time the cases in question arise. There is a recurring pattern. Everybody knows that there is a problem, except, of course, the patients themselves. It is gossiped about by managers and clinicians in the local health service, but nobody does a damn thing about it. That is what we must change. Such change is difficult, controversial and will not always enjoy support, but I say to my hon. Friend that it is the right thing to do. Things must change and move on. In my three and a half years in the Department of Health, I have found that a big sea change has also occurred in the medical profession, which now recognises that these matters must be hammered out jointly between it, the Government and patients' organisations. That process is in the interests of the profession and of patients, and the Bill is a big step forward in that respect.

The Bill contains other measures that will improve services for patients. Not least among them is the formation of local care trusts. The Bill gives local health and social services the power to form new care trusts, bringing their services together under one organisation to provide more seamless care for patients. In the overwhelming majority of cases, care trusts will be formed as a result of agreed local decisions between health and social services. In the rare case in which either service is failing patients, however, the Bill provides powers to compulsorily form a care trust.

As hon. Members from all parties know, the truth is that local services, which often serve markedly similar populations, have different levels of performance. Some

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are good, a few are bad and all could be better. That lottery in care is not good enough. It was made worse by the fragmentation associated with the internal market, but no one should believe that a return to old-style, centralised command and control can deliver for the NHS in the 21st century. The NHS is too large and too complex an organisation to be micro-managed from Whitehall. What is needed instead is a combination of clear national standards so that patients know that they can expect a quality service, regardless of where they live. Local responsibility should determine how best to meet those standards.

Rev. Martin Smyth (Belfast, South): I appreciate the Secretary of State's remarks, but does he accept that there is some concern about the division that may still remain between health care and social care, and about the definition of nursing care? Will guidance be provided to ensure that the trust will pay for health care? I should also like to check another point now, to avoid intervening later. I take it that clause 60, which deals with prescribing rights, brings Northern Ireland into line with the rest of the United Kingdom, especially in respect of nurse prescribing.

Mr. Milburn: Yes, it does, and I hope that that is welcome. The provision will extend the right to prescribe to nurses and other health professionals such as pharmacists. That will make for better and faster services for patients and will reduce pressure on the family doctor service.

The hon. Gentleman's first point concerned health care, social care and funding. I shall deal in a moment with the royal commission's recommendations and with the part of the Bill in question. When we have hammered out agreement on the definition of free nursing care, we will expect that, if the go ahead is given to free nursing care for the individual patient, it will be funded by the local health service.

What is needed today in the NHS is a combination of clear national standards with responsibility for local delivery. For exceptional circumstances, where services persistently fail, the Bill proposes new powers to replace failing management teams and to bring in new leadership. The more that standards rise and modernisation takes hold, the more that devolution can take place. The concept of earned autonomy, which was outlined in the NHS plan, has gained widespread support within the NHS. The Bill seeks to enshrine it through a new performance fund, which will rise to £500 million a year. The best performers will be free to spend those extra resources without strings attached; others will have to earn the right to that flexibility.

The views of patients will, for the first time in the NHS, help to determine the cash that local services receive. That seems to me to be right. The relationship between the patient and the service must fundamentally change. For too long, patients have been too much talked at and not enough listened to. When they have had an immediate problem with a service, they have not always been able to have it addressed quickly. The complaints system is discredited; few rights of redress have been available. The patient's voice does not sufficiently influence the provision of services. Local communities and local

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democracy are poorly represented in NHS decision- making structures. The culture is more of the last century than of this century: that must now be reformed.

Giving patients new powers is one of the keys to unlocking patient-centred services. The Bill will strengthen the way in which we involve patients in the NHS. It will give patients more say than ever over how their health service works for them--but that, too, requires fundamental reform.

I know that there are concerns in the House about some of the proposals, most notably about the abolition of community health councils. We listened very carefully to the arguments that were put to us and took action when drafting the Bill to respond, most notably by strengthening still further the independence of the new structures that we propose.

The first major change to make local health services more accountable to the local communities that they serve involves giving new powers of scrutiny over the local NHS to those elected by the local community--to the local council. On democratic grounds, I believe that that is right. Health authorities will have a duty to consult local authorities on proposed major changes to service development. Scrutiny committees in the local authority--formed on an all-party basis--will be able to refer contested proposals to the new independent national reconfiguration panel if they think that the plans are not in the interests of local people.

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