Mr. Denham: I shall address those points hopefully in order.
I have already dealt with the way in which Government thinking has moved on since the debates in July 1999. As far as I can recall, the assurances given on how the 1999 legislation would operate were correct at the time and remain correct in respect of the legislation. We now propose further changes to the legal framework, which I explained this morning.
Some feel that in politics the worst thing that Ministers can do is to change their thinking on an issue. Such people attach the highest premium to sticking to a position. However, I believe that if a Minister gains a new insight or a new understanding of where problems may lie, it is perfectly proper for him to bring it to bear on future policy. That is what we doing now.
I am not sure whether it is appropriate to go into detail during a clause stand part debate on how the new procedures will operate, especially as we shall be discussing that in relation to other clauses. I have signed the declaration that, in my judgment, the measures in the Bill are compatible with human rights requirements. Although, under our proposals, the ability to suspend or disqualify will pass to the health authority, it will not have escaped the notice of the hon. Member for Runnymede and Weybridge (Mr. Hammond) that we are reconstituting the Family Health Services Appeal Authority so that it is no longer a body of the Secretary of State; otherwise, it would not have had the independence necessary to meet the requirements of the Human Rights Act 1998.
I believe that we are taking the necessary measures to ensure the proper procedures. For instance, we shall be discussing in later clauses whether suspension would affect the human rights of practitioners, and I am sure that we shall consider maintenance of income in such circumstances. We have studied what is necessary to make the Bill compatible with human rights legislation.
Mr. Hammond: I accept what the Minister says, which is why the final court of appeal will be quasi-judicial. I want to focus on what might be called the court of first instance. Will the health authority's informal role, which the Minister outlined during our debates on the 1999 Act, be clearly and distinctly separate from its formal role in disqualifying practitioners? Will a formal hearing procedure have to take place, and will that be quasi-judicialwill a burden of proof be required at that stage, or will the whole process be informal until the point when an appeal is lodged to the FHSAA?
Mr. Denham: The hon. Gentleman will be aware that future clauses provide for the ability to make regulations on how the health authority should conduct that process. For example, the Bill makes it clear that we shall set out the criteria that health authorities must take into account when considering whether to suspend or disqualify a practitioner. That implies that a process has to be followed, and that the health authority would have to demonstrate that it had done so in order to comply with the legislation. The process will include written notification and the opportunity for a hearing. There will not be a slide from general performance management into taking practitioners off the list; there will always be a point at which the practitioner will know that the process is taking place. It is worth re-emphasising that the provision is part of a wider picture and that it should give health authorities better informal powers.
A few weeks ago, we announced the formation of the National Clinical Assessment Authority, a body to which health authorities could informally refer GPs if they had doubts about their performance or assessment. Since July 1999, we have moved to strengthen the early intervention powers available to health authorities if they were concerned about doctors' practices.
The hon. Gentleman asked other specific questions. The Bill does not abolish the NHS tribunal for Scotland; the NHS tribunal will continue to operate there. It is a matter for the Scottish Parliament. We shall be discussing later the arrangements between England, Wales and Scotland, to ensure that practitioners who are not on the list in one country are not on the list in the others.
I hope that I have answered all the points raised by the hon. Member for Runnymede and Weybridge, if only briefly.
Question put and agreed to.
Clause 19 ordered to stand part of the Bill.
Payments relating to past performance
Mr. Hammond: I beg to move amendment No. 178, in page 14, line 6, leave out from `shall' to end of line 7 and add:
(4) The remuneration to be paid under the arrangements mentioned in subsection (1) above to a practitioner who provides general medical services shall, at least in part be dependent upon the quality and outcome of the services provided and shall not ordinarily consist wholly or mainly of a fixed salary.'.
The clause is four lines long instead of one, so it lent itself to amendment. It is designed to repeal the requirement that general medical services remuneration should not consist wholly or mainly of a fixed salary paid to the practitioner.
When the 1977 Act was written, or when this provision was inserted, the assumption was that the basis of such remuneration would be capitationthat practitioners would be paid a sum per person on their list. The Government's policy is clearly to move away from capitation payments, and broadly speaking we would support that policy. It can provide a perverse incentive to practitioners to get the largest list they possibly can in order to maximise remuneration. A high number of patients on a practitioner's list does not necessarily correlate with a high quality of care provided by that practitioner. There might be prima facie reasons for assuming that the larger the practitioner's list, the lower the quality of the care that he is able to provide.
We understand the Government's desire to allow practitioners to be remunerated by reference to quality and outcomes, rather than simply by reference to the number of patients on their list. However, the clause is not necessary to achieve that objective. I refer the Committee to the explanatory notes, which state:
Clause 20 ends the requirement under 29(4) of the 1977 Act that the majority of remuneration of GPs should have reference to the number of patients the GP has undertaken to provide services under General Medical Services.
That is not what section 29(4) of the 1977 Act states. This is not the first time that I have found the explanatory notes to be misleading, so that a member of the Committee who does not have time to read the base legislation may be misled.
Section 29(4) of the 1977 Act states:
The remuneration...shall not...consist wholly or mainly of a fixed salary
that does not relate to capitation. It does not state that the remuneration cannot be calculated with reference to some other criteria such as quality or outcomes. The notes are misleading, and might lead somebody to believe that clause 20 was required in order to allow the Government to introduce remuneration based wholly or mainly on quality of outcomes into the GMS contract. That is not the case. It is already possible to introduce remuneration based on such criteria.
The amendment specifically includes a reference to quality and outcomes. It requires consideration to be given to those factors as a basis of remuneration. To allow remuneration to be based either wholly on capitation, or wholly on a fixed salary, would be a step backwards. Everything that the Government have said suggests that they want to move away from capitation-based payments to ensure that quality of patient experience and outcomes are the principle criteria in determining the remuneration of a practitioner. Clause 20 would allow practitioners to be paid a fixed salary. It removes from the 1977 Act the prohibition on fixed salaries without reference to capitation, which is neither positive nor helpful and flies in the face of the Government's stated objectives.
I am unsure what is in the Government's mind. Members of the Committee will be familiar with the distinction between personal medical services and general medical services. Under personal medical services, practitioners are paid a salary, while under general medical services, they are remunerated in a variety of ways, though with capitation as a significant element of the package.
During the debates on the Health Act 1999, which introduced personal medical services, the Minister assured the Committee that personal medical services would co-exist alongside general medical services. They would not replace them and there would be no pressure to move from GMS to PMS. Despite the assurances, some GPs areor will beunder pressure to move from GMS to PMS, particularly single-handed practitioners, and that flies in the face of the assurances given in 1999.
The clauseand its ramificationssuggests that the Government, in addition to a full-frontal assault on GMSto persuade, entice and cajole practitioners into PMSare working a flanking movement. They are undermining the principals of GMS by giving themselves the power to make a fixed salary the basis of a GMS service contract, which would give it most if not all the characteristics of a PMS contract. Perhaps the Minister can explain what the distinction between GMS and PMS will be? Perhaps he will give an assurance that, even if the clause is passed without the benefit of the amendment, there will still be a distinctive GMS system.
If the Government have a benign reason, such as the one that they gave in ``The NHS Plan'' and other documents, for wanting to re-negotiate the GMS to make it more quality sensitive, they will have no difficulty accepting the amendment. The Minister should either accept the amendment or admit that the Government have a plan to out-flank GMS with a fixed salary system that will make it almost indistinguishable from PMS.