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5.13 pm

Mr. Nick Harvey (North Devon): The Bill gives effect to many provisions in the NHS plan, which was published in July last year. We welcomed the plan because it made a valuable contribution to the renaissance of the NHS, and we appreciated the investment that the Government pledged. However, we had reservations about specific aspects of it. Similarly, although we welcome some of the Bill's provisions, we have reservations.

At the outset, however, let me restate for the record the Liberal Democrats' absolute commitment to the founding principles of the NHS. We believe that it should be comprehensive, free at the point of delivery and paid for by general taxation. We do not think that it should be supported by induced contributions from people who have to pay for themselves, either directly or through insurance contributions.

We have significant reservations about three aspects of the Bill. First, it provides for free nursing care, but does not take up the royal commission's recommendation for free personal care. Secondly, although we welcome the fact that it creates care trusts that bring together social care and primary and community health care, we have some misgivings about how that will be achieved. Thirdly, we are concerned about the abolition of the community health councils--and, more specifically, about the manner in which their functions will be distributed.

However, we agree with many of the provisions in the Bill and believe that they will make a valuable contribution to the continuing progress and development of the NHS. We welcome the commitment to ensuring that more funding gets through. I disagree with the comments of the hon. Member for Woodspring (Dr. Fox) about the so-called traffic light system--one of the mechanisms by which additional funds are provided. The Government's approach does not seem entirely unreasonable, although I have some reservations about specific aspects. Their proposal is far more sensible than any equivalent idea that has been considered in the past.

Rewarding areas that have done especially well with extra funds will increase existing inequalities. Conversely, rewarding areas that have done badly gives an incentive

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for everybody to try to achieve a red light. As I understand it, the strength of the proposed system is that the funds will go through come what may, but more strings will be attached to what must be done with them in "red light" areas.

My specific misgiving is that the Government seem to want to predetermine the proportion of trusts, primary trusts and authorities that fall into each category. That approach does not seem ideal. Surely it would be better to work on the basis of merit. The obvious ideal is that everybody should have green light status, so I am not sure that preconceived notions about the proportion for each status will create the incentives that we seek. Nevertheless, the idea is worth working on.

The Liberal Democrats also welcome the provisions for greater use of nationally agreed terms and conditions for NHS staff. One of the especially adverse aspects of the internal market was local trusts' arrangement of their own contracts. I hope that the Bill will ensure the rolling back and ending of those arrangements. I make a particular plea for practice nurses, who are not--in a manner of speaking--currently part of the NHS. but are employed directly by general practitioners. It would be useful if they, too, could be incorporated into a national framework.

We welcome the opportunity that the Bill provides for modernising GP contracts, on which I agreed with the general tone of the hon. Member for Woodspring. I hope that compulsion will not be necessary, but an overhaul is undoubtedly needed. I hope that the Bill provides a framework for ensuring that that happens in a constructive way.

The Opposition's reasoned amendment refers to the new powers of the Secretary of State to intervene. I confess that I was mildly astonished to discover that he did not already have such powers. If he does not, and is to be given new powers to make interventions from the centre, they must be exercised with great care. I hope that the trigger point for the powers will be the discovery, through one of the various checks introduced by the Bill, that a hospital, trust or primary trust has been failing and requires such intervention. I am slightly worried that the Secretary of State seems able to make such interventions almost on a whim. Perhaps that matter can be probed in further detail later during the Bill's passage.

As for health service resources in areas with too few GPs, I understand that the Medical Practices Committee may be seen to have had its day, but I thought that the Secretary of State was rather too harsh about it. Although it has not by any means delivered a perfectly even distribution throughout the country, I am sure that things are a great deal better than they would have been without it. If the new arrangements are to be based on a market in which health authorities bid in accordance with the resources available to them, there is a serious risk of mayhem. I hope that we will hear about the mechanisms for performing the functions now exercised by the Medical Practices Committee. We welcome the extensions of prescribing rights, and pharmaceutical pilots. The requirement for GPs to declare gifts, on a similar basis to that which applies to other doctors, is right even if it will discomfit some pharmaceutical companies.

As the Bill progresses, we shall need to define in rather more detail proposals for scrutiny and assessment of doctors. We have welcomed much of what the Government

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have done to date to address the issue of patient safety, especially in the wake of the tragic circumstances surrounding the Shipman case. In addition to further modernisation of the General Medical Council and the creation of the Commission for Health Improvement, the Government have proposed the creation of the National Clinical Assessment Authority. The Bill proposes that the role, authority and responsibility of health authorities should be extended, particularly with regard to the list system. Clearly, interaction between the various bodies will be crucial if they are not to duplicate each other's work--and, which is perhaps more important, if practitioners are not to fall between the remits of those bodies. We shall certainly want to probe the matter further as the Bill progresses.

The hon. Member for Wakefield (Mr. Hinchliffe) spoke persuasively and convincingly about personal care. The Bill leaves many unanswered questions, and many opportunities have been lost to improve welfare and rights, particularly those of older, disabled and mentally infirm people. Above all, it means that hundreds of thousands of older people will have to pay for the essential help that they need in their daily lives to dress, take meals and bathe.

The Government's proposals to distinguish personal and nursing care are likely to be almost impossible to administer in practice. No one chooses to leave home, abandon independent living and seek long-term care in a residential setting. That choice is imposed on people by necessity, and it is unfair and iniquitous for the state to penalise people for it.

Mr. Dawson: I follow the hon. Gentleman's remarks, but I am slightly disturbed about where they seem to be leading. Is he seriously saying that entering residential care cannot be a positive choice for an older person?

Mr. Harvey: Of course it can, but it should--and, I hope, usually would--be the last choice. There should be a commitment to fulfil the adage of Florence Nightingale, who said originally that everybody's hospital should be their home. I would have thought that there is a commitment across the political spectrum to provide help in a person's home where at all possible.

That was why I was mystified by the Secretary of State's saying that our policy of implementing in full the recommendations of the royal commission somehow ran contrary to, and was in conflict with, the Government's proposals to expand intermediate care. I remind the House that the royal commission recommended that all personal care should be provided free, whether in a domiciliary context or a residential home. I would have thought that provision of both services was essential, and that the overriding objective in all cases should be to preserve independent living.

The hon. Member for Wakefield has already alluded to some of the anomalies that will arise. He rightly pointed out some of the difficulties that will occur in practice. It seems impossible that we will reach a definition of nursing care when we are told by the Secretary of State that neither he nor the Minister of State, the hon. Member for Barrow and Furness (Mr. Hutton), will hand one down, but that it will be determined by nurses on the ground. That will be impossible to administer. There does not seem to have been any rational debate about what

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constitutes nursing care. I am also very sceptical that such care will be provided within the Government's estimate of £420 million over three years. That seems most improbable; I think that the bottom-line cost of providing free nursing care will be considerably more than that.

Dr. Brand: Is there not a risk that nurses will have a closed budget for this service, and will be asked to become gatekeepers and rationers of services?

Mr. Harvey: I am sure that that will happen, and we will have the same spectre as we have now, but on a wider scale. Social services directors warn us that as the financial year goes on and budgets get thinner, their funds run out and it is not possible to give the care that should be given. That leads to a fairly crude system of rationing. That is why the measure will prove difficult in practice.

The proposal leaves some aspects of health care to be paid for, when in other settings it is free.

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