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Lord Bruce of Donington: My Lords, I have just one question for the Minister. Will the account of the proceedings at ECOFIN that the Chancellor of the Exchequer gave in his Statement be supplemented by an official communique as to what happened and to which we can refer? On the basis of experience it is not always the case that the Commission, for example, and some member states, agree with the versions of various conferences that we for our part, in good faith, have laid before Parliament. What means have we of verifying that other member states will agree with our Chancellor of the Exchequer's version of what happened?

Lord Mackay of Ardbrecknish: My Lords, as my right honourable friend said in the Statement, he will, in

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the usual way, be making a Written Answer giving more of the detail of various other aspects discussed and agreed to at the Council. So far as concerns a communique at the end of the Council, these are more in the nature of working meetings. The communique on these matters will come at the end of the Dublin Summit at the end of next week.

National Health Service (Primary Care) Bill [H.L.]

5.18 p.m.

Debate on Second Reading resumed.

Lord Dean of Harptree: My Lords, now that we return to the Bill, I should like to begin by paying a tribute to the men and women who work in the NHS and our private health services. The critics of the service are rarely silent. We are always being told that the NHS is in crisis; that it is starved of resources; and that morale is at rock bottom. Of course there are problems. There are bound to be problems in a service which is nationwide and extensive. Of course there are bound to be pressures. They are inevitable with a service which is open-ended but where resources are finite.

If one looks at the sensitive figures which most concern patients, there is a good story to tell. The number of treatments is substantially up. The trend of the waiting lists, although they fluctuate, is firmly down, particularly for those waiting for a year or more. Medical techniques are advancing all the time. There are more staff to carry out treatments, and all that is made possible by the Government's commitment to provide more money in real terms for the service each year. The announcement by my right honourable friend the Chancellor of the Exchequer only the other day of a further £1.6 billion for the service next year is most welcome. At the helm of course, we have my noble friend the Minister and her colleagues in the Department of Health who provide such effective leadership to the service. We can be justly proud of our health services and their achievements. I am only sorry that we do not hear more about the success stories and the men and women who are responsible for them.

When I heard it announced in the gracious Speech that legislation will be introduced to improve and develop primary care services my first thought was, "Oh dear, not another reorganisation". But as I studied more fully what was intended it become clear that this was not another reorganisation. It is, in fact, legislation catching up with the tremendous developments that have taken place in primary care during recent years. The emphasis which appears in the White Paper is of more choice, more opportunity and more flexibility, as mentioned by my noble friend in her introduction.

The Bill follows logically from legislation on GP fundholding, which now covers half the population of the country. I am glad to see that it has the support of most organisations involved, including the British Medical Association and the Royal College of Nursing.

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They have some reservations and need clarification on certain points, but their support is clear. That is a good start for the Bill.

Primary care is, of course, the base of the pyramid. It may not be as dramatic as major operations, spare-part surgery and so forth, but care starts with the family doctor and the practice nurse and their team. I very much welcome the team-based approach in which all involved in primary care can work together for the good of the patients without barriers or demarcation lines. I am glad to see that the BMA has emphasised that very important point.

I also welcome the concept of pilot schemes under which different ideas can be carried out in different parts of the country. The noble Baroness, Lady Jay, had some reservations about the schemes and referred to flowers and weeds. My experience in my garden is that where there are flowers there will always be weeds, but it is the job of those concerned to ensure that the weeds are eradicated.

Concern has been expressed by the BMA that the Medical Practices Committee will find it difficult to ensure an equitable distribution of GPs throughout the country as it has no say in the pilot scheme. That point was mentioned by the noble Lord, Lord Walton, and it is important. I hope that my noble friend the Minister will be able to reassure the House in her reply. I also welcome the fact that participation in any of the schemes will be purely voluntary. No doctor or anyone else will be forced to try out new ways unless he or she wishes to do so.

I should be grateful if my noble friend the Minister would give clarification on three points. She mentioned the possibility of services in supermarkets. That is all to the good if it brings services closer to the patients. But there are obvious risks. We must be very careful to do nothing to weaken the doctor-patient relationship, which is of such great importance in our health services and gives great reassurance to patients.

I suggest that we must also ensure that doctors and others providing services outside their health centres retain full independence and clinical freedom and that they cannot be leant on by the owners of supermarkets. I believe that in the pilot schemes it will be necessary to avoid the duplication of services and equipment, which could be wasteful. Then there is a whole series of detailed points which will need careful consideration; for example, whether the practice notes are in the right place at the right time. I feel sure that my noble friend will be able to give reassurances on those issues.

The second point to which I wish to refer for clarification is the concept of practice-based contracts as distinct from contracts for individual GPs. I can quite understand that they could make it easier for other professionals, such as nurses, to be full members of the primary care team. I notice that both the BMA and the Royal College of Nursing mention those points. However, I hope that the concept of practice-based contracts will in no way undermine the position of GPs as independent contractors if they wish to remain in that position.

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Finally, for clarification I refer to nurses. I must admit to your Lordships that I have a soft spot for nurses. And before that remark is misinterpreted, I should explain that my mother did VAD nursing during the First World War, after which she went up to Bart's to complete her training. She finished as a theatre sister before leaving to marry my father. I notice that the Royal College of Nursing welcomes practice-based contracts which it believes will allow nurses to become full partners in the primary care teams. It suggests that a senior nurse can be taken into a partnership where nurses are employed in a practice. The noble Baroness, Lady Robson, mentioned that matter too. But the college also makes the point that as nurses become increasingly important in the primary care team there should be access for senior nurses to the National Health Service superannuation scheme. I hope that Her Majesty's Government will give sympathetic consideration to those points, particularly in view of the growing importance of nursing in the primary care team.

With those reservations, I warmly welcome the Bill and I hope that it will receive a speedy passage through Parliament.

5.27 p.m.

Lord Campbell of Croy: My Lords, I, too, thank my noble friend Lady Cumberlege for her very clear explanation of the proposals in the Bill. The principles appear to have been agreed by the medical profession, dentists and pharmacists. They are also supported generally by organisations representing the public and consumers. I believe that all of them have some issues to raise and no doubt they will arise at a later stage of the Bill's passage.

I welcome the Bill because it will introduce more flexibility. Schemes will be voluntary. The status quo will still be an option and, as I understand it, GPs and others can revert to the existing arrangements if they do not wish to continue with a scheme.

I have a few general comments to make. The first relates to pilot schemes. Their effectiveness can be judged by a form of evaluation, which seems to be implicit in the Bill. Clause 5 requires the three Secretaries of State for England, Scotland and Wales to conduct at least one review of every pilot scheme. That may be a check on how the scheme is proceeding. Will there be an evaluation of a scheme after it has been operating for a significant period? If so, how will judgments be made and against what criteria, or will they simply be carried out by comparing one pilot scheme with another? Will there be a time limit--for example, several years--in which an evaluation has to be carried out? I do not expect my noble friend to reply to all these questions this evening; indeed, there will be plenty of time for her to let us know the answers in due course.

I turn now to another matter. The Bill aims to introduce more flexibility into the arrangement for recruitment and employment of GPs. GP partners will have more say in selecting candidates to fill vacancies in their group practices. It seems that flexibility is also to be introduced in the appointments of GPs to

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single-handed practices, ensuring that a suitable person is appointed. I am very glad of that. I am also glad to note that the British Medical Association, the BMA, welcomes the Bill and the proposed changes.

There is one point to which I should like to draw attention and it is one which I believe the noble Baroness, Lady Jay, mentioned. The BMA is concerned that the Medical Practices Committee (the MPC--a statutory body responsible for the distribution of GPs throughout the country) will no longer cover GPs taking part in these pilot schemes. That may distort recruitment and replacement patterns and lead to a high proportion of doctors in some areas and low proportions in others. Is there any reason why the MPC should not still consider the whole country, including the proposed pilot schemes?

When I was a Member of another place, I was informed in the 1960s by the BMA that there was a higher proportion of doctors in relation to the population in my constituency in Northern Scotland, where my home is, than anywhere else in the country. I should add that that was before, not after, I was responsible as Secretary of State for the reorganisation of the NHS in Scotland by putting through Parliament the Scottish Bill in 1971, a year before my late colleague, Lord Joseph, presented the reorganisation Bill for England and Wales.

However, it was not as a Secretary of State responsible for health, but as a patient that I have had my main contacts and experience with the health services for well over 50 years. I hope that the House will bear with some personal particulars. I am by no means the only Member of your Lordships' House who has had such experiences. I was wounded when I was 23 and I emerged from St. Bartholomew's Hospital when I was 25. I still could not walk but I was successful in the Foreign Office exam and the subsequent medical examination. I guessed that I had passed the medical when the chairman of its small board said, as I was leaving, that as a diplomat, of course, I would not need to walk or stand. That may have been so then, but it was not so in later years. An embellishment has been added since that time--an uncharitable one--that the Foreign Office would have expected me to lie, if not stand or walk.

However, I should make it clear that in the subsequent four years I worked personally at times for the then Foreign Secretary, Mr. Ernest Bevin, and the Minister of State (later Secretary of State for Scotland) Mr. Hector McNeil, in London and at the United Nations in New York. I had the greatest respect for both as men of integrity. I was not asked to dissemble in any way during my period of service.

When vesting day for the NHS arrived in March 1948, I was working in the Foreign Office and having to go for treatment early every day to Westminster Hospital. Both in my medical contacts then and in Whitehall, I heard a view being expressed that the cost of the new NHS would in time decrease because the nation's health would be so improved. Well, of course, the opposite has happened. But those who were making that prediction were not taking into account the advances to be made in medical science, new operations,

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new treatments and drugs. In addition, people have been living for longer and needing medical services in their old age. It is worth recording from those days that, from the very start of the NHS in the late 1940s, contracts have been made by the NHS with private contractors--indeed, that happened from the very beginning--for supplying services in primary care. There is nothing new in that.

I have been an NHS patient since 1948, in hospital operations and outside treatment, including periods when I was a Cabinet Minister and, before that, a junior Minister. I happen to be of an age to have been a continuing long-term patient of the health service since its inception. That is why I speak from my personal experience.

During the whole time that I spent as a patient in St. Bartholomew's, which was evacuated in wartime from Smithfield to the Home Counties, I was warned that various troubles would arise in later life. However, if you have had a bullet through the middle--in the front and out of the back--that is not surprising; indeed, one is simply lucky to be alive.

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