Health and Social Care Bill

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Mr. Hammond: In principle, we do not have any problems with the Government amendments. We accept that there is a need to ensure that locum GPs and non-principal GPs are properly covered by all the rules and regulations and are subject to the same kind of scrutiny as principal GPs. When I read the clause, I suspected that the phrase

    persons approved by the Health Authority for the purpose of assisting in the provision of general medical services

might have a precise, technical meaning. However, that meaning is not explicit in the Bill. The lady who makes the tea for the nurse who assists the doctor who delivers the general medical services could be regarded as

    assisting in the provision of general medical services.

Can the Minister tell me where to find definition of who is and who is not a person

    assisting in the provision of general medical services

given that cursory glance through the amended 1977 Act has not furnished me with that information? For the moment, I will take it that, as stated, it is clear that the measure applies only to doctors and not to any other employee or any other person who assists in the provision of general medical services.

The hon. Member for Isle of Wight and my hon. Friend the Member for New Forest, West (Mr. Swayne) both mentioned nurse-led practices, but the issue extends further than that. More and more of the services that comprise GMS and are provided to patients in the general practitioner's surgery are and will continue to be provided by nurses or persons other than qualified medical practitioners. The Government are encouraging that trend and I expect them to continue to do so, because it makes sensible use of scarce manpower, but it raises the question of why nurses are not to be regulated in a way similar to that in which GPs are to be regulated.

There is no doubt that in some places nurses provide services that in other places are provided by employee or principal doctors. Some patients will be treated in a given way by a person who has to be on a list, and others going into a similar surgery in another place will be treated in the same way but by a nurse, who does not have to be on any list. The Minister may be unable to deal with that problem immediately, but he will probably agree that, as the barriers between what medical practitioners and other practitioners do are broken down, there will be a need to do so.

Dr. Brand: Returning to an earlier discussion, the hon. Gentleman's point illustrates that, under PMS, the employer must be held accountable. Under GMS, a practice nurse would be accountable for her actions to whoever has the contract—the partner responsible. However, in the circumstances described by the hon. Gentleman, would be no accountability to the practitioners listed under the clause. In fact, there would be no accountability at all.

Mr. Hammond: I think that I understand the hon. Gentleman's point. A bizarre situation could arise. Take two people who are, in effect, doing the same job in different practices. One of them is an employee GP in a practice that does not have a large nursing input; the other is a nurse in a forward-looking practice in which nurses perform many of the roles that traditionally have been performed by doctors. The former would have to apply to be put on an approved list by the health authority before he was allowed to do the job, despite having medical qualifications. The latter, despite not having medical qualifications, would not be required to seek any approval to be subject to the procedure for possibly having to provide certificates under the Police Act 1997. The distinction does not seem logical, and it certainly does not seem logical that the medically qualified person has to jump over the hurdles while the non-medically qualified person does not. I hope that the Minister will ponder on that apparent inconsistency and comment on it.

I also want to test the Minister on short-term locum roles. If a person is on a principal list somewhere and performs a short-term role as a locum elsewhere, will he be required to register again on the supplementary list, or will his inclusion on the principal list be sufficient to give him cover? I am simply trying to think of situations in which the proposals might become cumbersome and unnecessarily bureaucratic. If I have understood the clause correctly, its provisions allow someone, once he has registered with any health authority, to practise as a locum or a person assisting in provision of services in any other health authority area, albeit not across the border between England and Wales. Is there any logical reason for creating that Berlin wall, in the phrase of the former Secretary of State, the right hon. Member for Holborn and St. Pancras (Mr. Dobson)?

Mr. Swayne: Offa's dyke.

Mr. Hammond: That does not quite have the ring of the Berlin wall; I have never heard of anyone tearing down Offa's dyke in recent years. I shall not speculate on that but merely ask the Minister why there is no ability to transfer across the border. I hope that there is a practical reason, and that it is not owing to some post-devolution political correctness.

The Government amendments are so extensive that, inevitably, one refers to the clause as a whole when speaking to them. I would like to be sure that we are not sanctioning a development that could be used to undermine further the independent contractor status of GMS providers by, for example, requiring their adherence to certain terms and conditions of service. I would like the Minister to assure us that the provisions are designed solely to ensure that people providing assistance are appropriately qualified and are not dodgy characters. I would also like an assurance that the regulations will not create conditionality about being on the supplementary list that will mean greater involvement of the health authority in contractual relationships between the principal and the employee.

There is a clear need for such provisions, but a light touch is required to provide a clear set of regulations that do not leave too much room for local discretion and that apply clear criteria across the country. I have to believe that that is the Minister's intention, given that the Bill will allow people registered in the list in one place to practise in another. I look forward to hearing his remarks.

Mr. Denham: The hon. Gentleman raised some interesting questions, which were essentially about whether, as roles develop in primary care, there should be equivalent lists for nurses. It is important to recognise that, at the current point in the evolution of the NHS, individual roles are changing. Nurses are now carrying out procedures, taking responsibility for various treatments and giving advice in surgeries that would previously have been done by GPs. However, formal responsibility for patients and for their care in GMS still rests with the GP. Analogous situations exist in pharmacy. It is professional responsibility that is important, along with the contractual relationship that exists under GMS to provide those services.

Normal professional regulations are still in place in respect of practice nurses, and although it is legally possible for a patient to be on a GP's list, it is not legally possible to be a nurse's patient, even though it may be the nurse who gives the treatment. That is how the law is structured. It was an interesting speculation, but we are dealing with the responsibilities of practitioners towards their patients. A slightly different situation pertains in PMS, but a nurse-led practice has a different form of accountability because of the PMS contract between the employer or contract holder and the health authority.

Mr. Hammond: The Minister sayd that the difference between doctors and nurses is that contractual responsibility under GMS lies with the doctor. Surely the contractual responsibility lies with the principal practitioner and the employee practitioner is in the same contractual relationship to GMS as the nurse employed by the practice—or even the therapist employed by the practice, as many now do.

Mr. Denham: It is true that the principal who holds the list is responsible for the patients. It should be recognised that the locum doctor who steps in for a fortnight while the principal is on holiday is being asked to fulfil the principal's role in a way that the practice nurse is not; that is how the work is normally delegated. There is great concern about the weakness of the checks on locum doctors that I have not heard expressed about the role of practice nurses. We are trying to deal with a genuine problem. One of the advantages of having a list of locums is that it does not take from principal GPs the responsibility to assure themselves of the suitability of a locum, but provides a framework within which the appraisal of locums can take place.

Dr. Brand: I should be grateful if the Minister could solve a conundrum. If someone who wants to work as a locum for a PMS project have to be on a list, or does an individual contractual arrangement have to be entered into every time someone wants to work for a PMS set up?

Mr. Denham: Those who want to work as a locum will be required to appear on either a PMS list or a supplementary list. Under the Bill's provisions, it will not be possible for anyone to provide NHS services unless they are on the appropriate list. That brings me to the point raised by the hon. Member for Runnymede and Weybridge about principals on the medical list seeking to act as locums. The Bill provides that a principal on the medical list would be able to act as a locum in another health authority.

Dr. Brand: I should like to return to the PMS question, about which I am still unclear. I presume that, in a nurse-led PMS contract, the doctor employed by a nurse would have to be accountable by being on a list, but that the nurse employed by a practice nurse would not. There is no accountability between the practice nurse and practice doctor, so the practice doctor cannot have any responsibility for the actions of the practice nurse under the PMS scheme. Does that not leave the practice doctor vulnerable and the practice nurse controlled only through her employer?

4.30 pm

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