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Baroness Gardner of Parkes: I thank the Minister for her reply and the other participants for their exchange of views. I note that the noble Lord, Lord Rea, referred to the main professionals. I did not like the word "main". It seems to confirm exactly what I said: that those three groups were more important than anyone else in the health service.

Lord Rea: Perhaps the noble Baroness did not hear me. I qualified that remark by saying "the most numerous".

Baroness Gardner of Parkes: I did not understand the noble Lord to say that. I note that the Minister said that. I had intended to ask the noble Lord whether he referred to numbers when he used the word "main". His intervention cheers me greatly. The important point is—

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it is the point that I seek to make in proposing the amendment—that all health professionals are equally important in the overall pattern of team care for patients.

The Minister stated that consultation must involve the whole range of professionals. She referred to about 20 groups. That statement in Hansard will give considerable reassurance to people who have been worried that they are being overlooked or, as the noble Lord, Lord Carter, said, put into the second team.

I shall read what has been said, as I am sure will others. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Dean of Thornton-le-Fylde moved Amendment No. 14:

Page 5, line 18, at end insert ("and registered Health Visitors").

The noble Baroness said: The amendment adds health visitors to Schedule 1(3) (a). However, I certainly take to heart the points made by the noble Baroness, Lady Gardner of Parkes. Clearly a whole range of professionals is absolutely crucial in delivering health services to patients. Patients, of course, must be the first criterion that we address when dealing with the Bill and its effects.

We assessed that Amendment No. 13 probably would not be agreed and decided to leave Amendment No. 14 on the Marshalled List. The logic underlying the amendment derives from the 1979 Act which specifies nurses, midwives and health visitors. We believe that the provision adds to the Bill.

Health visitors play a crucial role in the delivery of healthcare. They visit families in their homes—something that many nurses and doctors do not have the opportunity or the need to do on a regular basis. They play a key role, too, in child protection matters. It is not as though the patient comes to them in the health environment. Health visitors go into the home and see the family and children. They see the family in the round, whether it is a single parent or two-parent family. They see the circumstances in which the family live and the way in which that affects the family's health matters.

The provision is particularly important as health visitors increasingly play a bigger role because of the drawdown in social service support in the community. It is equally important, as much health care is now being delivered in the home; and quite rightly so. More health care takes place outside the hospital, which is right and good for the community and the family. Since that is the case, I hope that the Minister will be able to accept the amendment. I do not venture to suggest that she does not recognise the valued service that health visitors give and their crucial role within the community. I therefore hope that the amendment finds favour and is accepted. I beg to move.

Baroness Cumberlege: I am grateful to the noble Baroness for giving me this opportunity to emphasise the importance of the role of health visitors and the part they will play in the new health authorities. She is right in supposing that I have long been an admirer of that section of the nursing profession. I have a little

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understanding of the difficult work they undertake and the impact they can have in strengthening parents' confidence and abilities in bringing up their families.

Let me make it clear that the new duty in the Bill requiring health authorities to secure professional advice certainly includes health visitors. There should be no doubt about this. Health authorities will be under a statutory obligation to involve health visitors in their work where their special skills and experience are relevant.

Health visitors are, of course, registered nurses who have gone on to take an additional specialist qualification. They are therefore already within the provision. The definition "registered nurse" also covers many other specially qualified nurses such as district nurses, mental health nurses and so on. I know, though, that health visitors have a particularly distinct professional role.

The draft guidelines on professional involvement, on which the Government have just finished consulting, reflect that. The guidelines highlight the vital role of health visitors in child protection, mentioned by the noble Baroness. Of course, they have a much broader contribution to make in health needs assessment, prevention of illness and health promotion because of their close involvement with families and children and the local communities in which they live. My department's good practice document, Targeting Practice, provides many examples of the contribution that health visitors make to The Health of the Nation targets.

I hope that the Committee will accept that the amendment is not required and that health visitors will be firmly involved in the new health authorities. I hope that the noble Baroness will see fit to withdraw it.

Baroness Dean of Thornton-le-Fylde: I thank the Minister for that reply, particularly the reference to the guidelines on which consultation has just concluded. That is helpful, but it does not answer the point about having "health visitors" on the face of the Bill as a requirement. However, I take encouragement from what the Minister said. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Rea moved Amendment No. 15:

Page 6, line 45, at end insert:
(" "(1A) The Secretary of State shall give directions with respect to the exercise of the responsibilities exercised prior to the passing of the Health Authorities Act 1995 by Regional Health Authorities in respect of—
(a) the holding of contracts of registrars and senior registrars, and
(b) the organisation and rotation of medical staff placements,
so as to require that those responsibilities should continue to be exercised on a regional basis." ").

The noble Lord said: In moving the amendment, I wish to thank the officials in the Box for supplying me with a draft of the memorandum on options for the future management of postgraduate medical education

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which is to be placed in the Library tomorrow. I shall refer later to the document which I have had only a brief chance to read.

The amendment seeks to retain the current arrangement whereby the contracts of junior doctors above senior house officer level are held on a regional basis. There are several reasons for wanting to retain the arrangement. Registrars and senior registrars are in training to become consultants. They have special requirements as part of that training. The requirements are facilities for consultants to give them tutorials and time for study. The junior doctors should be regarded as a national and not a local resource since from their ranks will come the next generation of specialists. They often need to move during training rotation from one hospital or community trust to another to obtain the relevant experience—sometimes crossing borders of health authorities.

At present junior doctors are employed on national terms and conditions of service so as to maintain high standards throughout the National Health Service. Devolution of their contracts to trusts would, we feel, jeopardise these arrangements. These training posts need to be overseen by someone independent of the trust for which they are working at a particular time to ensure, for example, as I mentioned earlier, that time is set aside during the course of a week in which consultants can teach juniors. If it is left entirely to the trust, pressure of work might well seem to be a higher priority. This amendment would ensure that these important concerns are addressed.

I turn briefly, after a very cursory reading, to the new memorandum. I have to say that I find it quite confusing. Instead of coming down firmly for one solution, it offers several choices. I feel almost certainly that the authors of this memorandum were fully aware that the issues were contentious. It seems to be another example of making up legislation as you are going along. There are options in the memorandum which it seems will be given out for consultation.

Employment contracts for junior doctors—which is the topic of the amendment—could, according to the memorandum, be organised in three different ways. I refer to the document itself:

    "all contracts to be held by the Trust responsible for the hospital in which the doctor is working ... contracts to be held by a nominated 'lead Trust' for the training programme in that specialty, with junior doctors working on secondment for the other Trusts participating in the rotation",


    "all contracts held by a single 'lead Trust' for the region, either the Trust with the most training posts overall ... or a 'neutral" Trust'"—

whatever that is.

    "Again junior doctors would be seconded to the other Trusts providing training on a rotational basis".

A fourth alternative is also offered; namely,

    "the possibility of the contracts being held by a purchasing health authority".

I do not honestly feel that any of those options answers the problems that I outlined would occur if the current satisfactory arrangements are interfered with. The document turns down altogether the option of a contract being held by the health commissioning

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(purchasing) authority; and it does not mention at all, so far as I have read, the possibility of the contract being held by either the postgraduate dean or the regional health commissioner.

While, of course, we have to study this document with greater care, it does not offer an answer which would allow me to withdraw this amendment. It is quite important that the principles enunciated in the amendment should be adhered to. I beg to move.

9.30 p.m.

Baroness Cumberlege: I appreciate that the noble Lord, Lord Rea, has not really had time to read this document. But if he had just read the next sentence he would have noted that,

    "The NHS Executive's preferred option is for all contracts of NHS employees",

and so on. But I am sure that we shall return to the subject on Thursday when we discuss the other amendments.

Perhaps I may put this matter into some context. There are two distinct issues in relation to the contracts of registrars and senior registrars—whose contracts are currently held by regional health authorities. First, employment contracts need to be held elsewhere when RHAs go. Secondly, the continuity and quality of training programmes need to be properly protected under any new arrangements. It is our intention that the training programmes of registrars and senior registrars, and in the future those doctors in the proposed new unified training grade, will be managed at regional level by the postgraduate medical deans.

We are currently discussing the detail with the deans but we envisage the negotiation by the deans with NHS trusts of educational contracts. The doctors themselves might also be party to those contracts. Such contracts would ensure that the quality and continuity of training is protected while also recognising trusts' responsibilities for the effective delivery of services to patients.

It will not be necessary for the doctors' employment contracts also to be held at regional level to safeguard the doctors' training interests. It would not be right for them to be held by the regional offices as part of the Civil Service.

As we made clear in the report published in the summer, Managing the new NHS, our preferred option is for contracts to go to trusts. That is consistent with the treatment of other medical staff, with the principle that personnel issues are generally best managed at local employer level and with trust freedoms to determine the quantity and type of resources that they employ.

The Government have tabled amendments which we shall debate at a later stage in Committee. When we come to debate those amendments, I shall be able to explain more fully the safeguards that we propose to enable contracts to be held by trusts.

We are committed to high quality medical education and training, which underpins our objective of providing high quality healthcare to patients. The interests of the profession, universities and postgraduate deans will be taken fully into account in developing the detailed

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framework for medical education and training. We shall ensure that the staff concerned are treated fairly and that continuity and quality of training is maintained. Therefore I sincerely hope that the noble Lord will withdraw his amendment.

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