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Lord Graham of Edmonton: Yes.

Lord Campbell of Croy: I know that the noble Lord had a similar experience.

However, those people were right. Troubles have arisen ever since. In fact, GPs, mostly in Scotland, have had to cope, usually at short notice; but, in direct touch with St. Bartholomew's and with copies of my hospital notes. They have instilled the greatest confidence. The fact that the GPs and the BMA welcome the Bill reinforces my support for it.

5.36 p.m.

Baroness Eccles of Moulton: My Lords, I warmly welcome the proposals in this Bill and would like to thank my noble friend Lady Cumberlege for her very clear introduction. First, I should apologise to the House in that, I am sorry to say, I shall have to leave before the end of the debate. I am meant to be attending a workshop on how to manage change in the NHS.

The Bill allows the primary sector of the NHS to develop in innovative ways and with the emphasis on voluntary choice according to local need rather than by prescriptive means. It has become increasingly obvious that communities benefit most from a primary care service which is tailored to reflect their needs and that these needs can differ widely. The way in which primary services can be provided most effectively in a rural area, a small town, a seaside resort or a large and complex urban setting varies enormously.

Even in the part of London that I am concerned with--the boroughs of Ealing, Hammersmith and Fulham, and Hounslow--where you could expect a degree of uniformity of need, there is great diversity. Nearly 30 per cent. of our population belong to ethnic minorities. Also, some practices have a quarter of all patients over the age of 65, while in other practices they represent about 10 per cent. or under. Other factors

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which place additional and complex demands on the primary care services are a highly mobile population, many homeless people and a large number of refugees. Some practices provide a very high level of care tailored to meet the needs of AIDS and HIV positive patients.

A single national contract for all 30,000 GPs has been the longstanding link between the independent contractor and the health service, and this has provided the mechanisms by which the GP can be paid for services rendered to the individual patient, who, in turn, receives these services free at the time of use. However, the National Health Service has now reached a point of maturity and experience in its 50 years of history where it can respond more accurately and effectively, through locally agreed contracts, to both the needs of our diverse population across the country and also to the different aspirations of GPs.

It is worth spending a moment on how it is that we have arrived at a time when we can be considering the changes that this Bill proposes. It is not a bolt from the blue, in three respects. First, if we go back six years, the 1990 legislation, which arose out of two White Papers (Better Health and Working for Patients), introduced changes to the GP contract. Principally this was a departure from payment received based on items of service to capitation and target payments, and also indicative budgets for drugs were introduced at that stage. The other very important factor was the introduction of fundholding.

Secondly, a keystone of the current health service strategy is the primary care led NHS. As the purpose of this strategy is to ensure that services are organised around the needs of patients, it is important that GPs are placed in the best position to be co-ordinators of their care.

Thirdly, the Government have gone through an exhaustive process of repeated consultation, before publishing the White Paper. The Minister has already spoken of this. To recap briefly, the listening exercise was mounted in the early spring of this year. Views were sought from a cross-section of those both working in and receiving services from the NHS, including patient representative groups, and in areas where change would or could improve service. After that first stage the Government produced a document entitled Primary Care: the Future which sets out the results of this listening exercise.

This document was in its turn widely consulted upon. Both consultations were supported by road shows which made sure that very many GPs and others in the NHS contributed their ideas about how best to develop services to meet future needs. Finally, distilling the views and opinions gathered, the White Paper with which we are so familiar entitled Choice and Opportunity, was published.

In making provision for a wider variety of ways of organising primary care than the current law permits, this Bill not only makes it possible to adapt to diverse needs, but it also helps to meet the aspirations of GPs and other professionals working in primary care better than the limited range of options available at present.

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Young doctors, whether male or female, like so many other young people, have more varied career aspirations than used to be the case, and are often not wanting to make the traditional commitment involved in joining a partnership which, whether it is of GPs or any other professional group, is a considerable legal and financial as well as day-to-day working commitment. The Bill recognises this change in outlook of GPs, and other professionals working in primary care. As the noble Baroness, Lady Robson, has already said, it will make general practice a much more attractive career for the highly regarded young female GP, who simply may not want to combine both bringing up her children and the 24 hour commitment that the national contract requires.

Another fundamental change that has occurred in recent years is that the range of staff working in primary care has significantly widened. That fact has already been mentioned by previous speakers. Many practices now have attached to them a practice nurse, nurse practitioners, midwives, health visitors, district nurses, community psychiatric nurses, physiotherapists and social workers. That is not an exhaustive list. With this wide range of skills many practices can provide far more comprehensive care for a community than used to be the case. The option of practice-based contracts proposed in the Bill allows such multi-professional groups to be formally recognised as providing an extended range of services for the community.

Another important aspect of the Bill is the voluntary nature of the proposals. It does not demand changes in the way in which primary care is provided at the moment, and in that sense the Bill poses no threats. In many localities the present system works well and does not need to change. However, through the "try it and see" pilot schemes there is scope for innovation and experimenting with different combinations of service to reflect local needs. Appropriate new ways of working will emerge through the pilot schemes, which have already been much discussed. These pilots will be thoroughly evaluated before they can become permanent. Of course, the necessary mechanisms are being put in place to make sure that primary care is properly managed and delivered while these local variations are being developed.

There are exciting and challenging prospects before us. In a sense the primary sector is being given its head and is being asked to find solutions in a non-prescriptive environment. However, expectations are high amongst those who set the ground rules, those who provide the service, and not least those who receive it--the patients. This is an opportunity not to be missed.

5.45 p.m.

Lord Ewing of Kirkford: My Lords, the noble Baroness, Lady Eccles of Moulton, apologised for the fact that she could not be present for the closing speeches of the debate. The noble Baroness made it clear that she should be attending a workshop on managing change in the NHS.

In this country a whole industry has grown up around managing change in the NHS, such is the pace and the constant nature of change in the NHS. Here I declare

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my interest as chairman of Fife Healthcare NHS Trust. If I were to attend every seminar and workshop to which I am invited I should be lucky to spend one weekend at home and perhaps Christmas Day and New Year's Day, such is the constant change that is taking place in the NHS. I am not by nature a sceptic. I like to think of myself--generously, I suppose--as a forward looking person. However, I hope your Lordships will forgive me if I bring to this debate a healthy helping of scepticism.

However, I shall relieve your Lordships of any anxiety that I shall regale the House with my experience of the NHS because most of my wounds were self-inflicted and recounting them harms me more than those listening to me. But I was interested to hear the comments of the noble Lord, Lord Campbell of Croy, as I recall having served, in 1971 and 1972, on the committees to which he referred on the reform of the National Health Service in Scotland, which was undertaken a year before the NHS was reformed in England and Wales. Since that day I have never ceased to wonder and gaze in amazement at health Ministers--I include myself because I was formerly a Minister responsible for health in Scotland--who stand at a government Dispatch Box and present a proposal on change in the NHS and say with absolute and firm conviction, "This is the way ahead". I have experienced so many ways ahead that I am beginning to long for the road back.

The noble Lord, Lord Campbell of Croy, mentioned a 1971 reorganisation. It is worth recalling that until 1971 the health service in the United Kingdom was fragmented. The hospital service was managed separately from the general practitioner service. The preventive medicine sector was not managed by the health service at all but by the education authorities of local authorities which were responsible for the immunisation programme. The effect of the noble Lord's reform was to bring all three wings together and introduce an integrated health service. That was the way ahead. That reform lasted for nine years. That is not bad. It was pretty much a record.

Then in 1980 there was a further reform. A bit of fragmentation was reintroduced. There were stand alone district general hospitals designated as directly managed units and funded directly by the health boards that had been set up under the 1971 reform. Directly managed units became the way ahead. That reform lasted three or four years and then we had another reform. NHS trusts and the internal market were then introduced.

Today I was delighted to hear my honourable friend in another place announce that an incoming Labour government would abolish the internal market. NHS trusts and the purchaser/provider principle were established. A whole industry of negotiating contracts has developed. It has become so complex that to add further negotiation and further contract activity through the powers proposed in this Bill seems to me to be complicating an already complicated situation. The introduction of trusts and the purchaser/provider arrangement was "the way ahead". Then we come to this new, primary care led initiative. We have gone through

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fashions in the National Health Service. Every new fashion is to be the future upon which we build the NHS. The fashion now is primary care led initiatives.

There is a very strong movement among general practitioners in this country--I address this point particularly to the noble Lord, Lord Walton--which believes that health boards and health authorities should be abolished, and that all the funds should go to general practitioners. The feeling is that the whole system in this country should be primary care led. That is very much how the American system works. In my view it would be a very dangerous road to follow.

I have never been a supporter of GP fundholding. I see a great many dangers in it. We may talk about a two-tier health service. In GP fundholding there lies the distinct possibility that a two-tier health service will be created. I am not at all certain that that is not the purpose in any case. If a two-tier health service is created, in all honesty, and realistically, it is very easy to move the top tier of such a service into the private sector and leave the bottom tier with the NHS. As Nye Bevan would have said, there are familiar echoes from the past. There could be a return to former conditions, to when those who could not afford treatment simply had to make do with a much reduced level of care when they were ill.

I enter the debate on these proposals because Part II of the Bill amends the 1978 Act in Scotland and applies the Bill's provisions to the health service in Scotland. It proposes that pilot schemes should be established and then be assessed. My plea to the Minister is that the pilot schemes should be allowed to run, not just for a few months but for at least 18 months, so that they can be properly assessed; and that there should be no thought at all of trying to apply this principle to every area throughout the country--I refer to Scotland in particular. Of all four countries in the United Kingdom Scotland has the greatest number of large rural areas. This principle cannot be applied in the same way in those rural communities as it would be in the inner cities.

Members of this House talk of flexibility, as does the Minister. That is an under-statement. These measures will require great flexibility in different parts of Scotland, and indeed in the rest of the United Kingdom. In rural areas in Scotland we already have what are called dispensing practices: the general practitioner will diagnose the illness and prescribe the medicine, and will then dispense the medicine. That already happens in parts of Scotland. It is a very good model which could be applied elsewhere.

In all honesty, the whole question of salaried GPs attracts me. As chairman of a healthcare trust I have given it considerable thought. I would certainly not object to employing salaried GPs in my trust. I am not sure that the Government have thought the issue through properly in relation to their view of the health service. When in a few weeks' time my noble friend Lady Jay is a health Minister with responsibility for this matter, I believe that she will find the prospect of trusts employing salary earning GPs to be a very attractive proposition. I certainly do, but I am not sure that the Government have thought it through. I say this in

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relation to the general practitioner service and the resources that are made available for primary care led medicine.

The Government will need to be more forthcoming on a proposal that is not contained in the Bill but, if implemented, would be devastating in terms of funding for NHS trusts. I refer to the idea that is being widely canvassed that general practitioners should have the right to buy health centres. If it were implemented, the impact on National Health Service funding in Scotland would be devastating because of the way in which such properties are valued. They are not valued by the district valuer or by any professional valuer. In Wales they are valued by the Welsh Office; in England by the Department of Health; and in Scotland by the Scottish Office. However, when they come to be sold, it is done under the value given by the district valuer employed by the local authorities. In our experience the difference between the value placed on the property by the Scottish Office and that placed on it by the district valuer is very, very substantial indeed. There is an impact on funding because the loss has to be borne by the NHS trust which owns the property. Sums of many millions of pounds are involved. If the Government believe for a minute that a primary care led service can be run while at the same time the assets are sold off in this way--in the same way as council houses were sold, with massive discounts--I can tell the Minister that those two ideas will not work together.

Finally, much has been said about the voluntary approach outlined in the Bill. All my experience is that we soon move from a voluntary to a compulsory approach. Over the years I have seen aspects of policy introduced on a voluntary basis and then, because the policy was not being adopted by people in line with the wishes of the government of the day, we soon moved from the voluntary approach to compulsory imposition.

These changes badly need to be piloted and assessed over a very long period. Not only do they need to be assessed over a long period, but the results and outcome of that assessment need to be reported to both Houses of Parliament, and a meaningful debate needs to take place on the assessment.

I leave these thoughts with the Minister and with your Lordships. I hope that my remarks have sounded a few warning notes and made a few welcoming sounds, but, above all, sounded a number of notes of caution.

5.58 p.m.

Lord Colwyn: My Lords, before starting my remarks I must apologise to the House on two counts: first, for not following the argument of the noble Lord, Lord Ewing--I wish to say something constructive about the Bill--and, secondly, for the fact that I missed the opening speeches of my noble friend the Minister and the noble Baroness, Lady Jay. I declare an interest as a practising dental surgeon. That was the reason that I was late.

Whoever was responsible for fixing the order of speakers for this debate has lumped the two dentists together. I have not discussed the debate with my noble

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friend Lady Gardner. She has wide experience of dentistry and other aspects of the health industry and I am quite glad that I speak before she does.

The Bill proposes that the piloting of local commissioning of dental and medical services will start in April 1998--almost 50 years since the National Health Service was born. Since then, dentists have been working within the general dental services and have seen considerable improvements in the oral health of the nation. Quality dentistry has been brought to the whole population. The number of people with no natural teeth has fallen consistently and it is predicted that in just over 10 years' time, only 10 per cent. of adults in the UK will have no natural teeth. There have been considerable improvements in decay rates for patients of all ages, but especially for children over recent years. Much of this improvement is due to the hard work of dentists and to successive governments who have found the money necessary to pay for the service.

Noble Lords will have seen the recent publicity that in some parts of the country there is now a worrying trend towards an increase in tooth decay in children, except where water supplies have been fluoridated. Now is not the time to debate fluoridation, but it is interesting to note that, for example, five year-old children in non-fluoridated Bolton have around four times more tooth decay than five year-olds living in fluoridated south Birmingham.

There are still areas of poor oral health. A recent survey by the British Fluoridation Society--of which I am a vice-president--showed a high proportion of children in the north west of England with dental disease. That pattern is repeated in parts of Wales, Scotland and Northern Ireland. There are also places, especially in the south of England, where no dentist is available. To address those problems, the Bill proposes to introduce local commissioning of dental services to be known as personal dental services. They will run alongside existing dental services but will address specific problems where they exist.

The White Paper which preceded the Bill was called Choice and Opportunity. There will be a choice for dentists in whether they stay in the present system or move into a new way of working.

Sadly, many NHS dentists are having to leave the health service and, as a result, an increasing number of patients are unable to find an NHS dentist. I know that my noble friend will have figures which show that there is an increasing number of treatments provided within the NHS, but dentists and patients know that in reality there is a worsening problem of lack of access to NHS dental treatment affecting patients in affluent parts of the country as well as in poorer rural areas and inner cities. Seventy health authorities have applied for the Government's Access Fund which is only available in areas where there are serious problems. Twenty-two authorities have been successful and I am informed that this fund will be more substantial to cover more authorities next year. Perhaps my noble friend could confirm that when she replies to the debate.

Many of my dental colleagues have a strong commitment to the health service, but the fees which (not allowing for inflation) have only just returned to

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1991 levels are inadequate to meet practice expenses. In real terms they are too low. Other healthcare professionals are provided with premises, equipment and staff. Only NHS dentists have to provide those personally at their own expense and although provision is made for the expenses within the fee scale, the costs of premises, equipment and staff are now at 1996 levels, funded by fees which are still at a 1991 level. NHS dental practices must be provided with more resources if NHS patients are to be provided with up-to-date technology and materials.

However, the Bill will certainly provide opportunities for dentists to develop new services with their patients and, despite the resource allocation, I hope that the profession will see these changes as opportunities rather than threats.

The Bill marks the start of a new chapter in NHS dentistry. Noble Lords will be aware that the past five years have not been happy ones for my colleagues. Late in 1991, the Government realised that the budget for dentistry was running out of control and that there would be a considerable overspend for dental services. Through no fault of the profession who had been encouraged by the department to register as many patients as possible, it was decided in July 1992 to cut fees by 7 per cent. That caused considerable distress and started a dispute which was only ended this summer.

In April 1995, the Minister for Health sent an invitation to representatives of the General Dental Services Committee of the British Dental Association, which represents all high street dentists, to take part in talks with a view to introducing short-term reforms within the general dental services. The negotiations were difficult and protracted, but it is to the credit of both sides that they came to an agreement which was announced by the Minister on 12th June this year.

Those reforms should bring considerable improvements to the dental care of children. The dispute with the profession was formally called off and the overspend which occurred between 1991 and 1993 was written off by the Government. The end of the dispute saw a welcome new spirit of co-operation with the profession which has led to the publication of the Bill.

During the period of the dispute, both the Government and the profession entered into a large consultation exercise, starting with the fundamental review of dental remuneration by Sir Kenneth Bloomfield which was published in January 1993. Dentistry was investigated by the health Select Committee in another place which reported in June 1993 and finally the Government published the Green Paper in July 1994.

All those proposed a solution to the problems of dentistry based on the local purchaser/provider approach initiated in the National Health Service in the early 1990s. The proposed change was not universally popular with the profession, indeed only a third of local dental committees expressed an interest in taking part in pilot studies. Many misgivings were voiced both about the proposed pilot studies and the final shape of a new local system. I am glad to see that the profession's misgivings have been addressed in the Bill.

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What the consultation period showed was that the loss of morale in the profession was not just about money but a perceived lack of security and stability. During the consultation, many dentists proposed improvements to the services they could offer their patients and new ways of being paid for providing them. The Bill gives them the opportunity to develop these new services while retaining the choice to provide dentistry for their patients within the general dental services, as they have done successfully over the past 50 years.

In conclusion, I had intended to say something in support of community pharmacies and urge the Government to resist the proposed abolition of resale price maintenance on over-the-counter medicines but it has been well covered by the noble Baroness, Lady Robson, and must wait until a further stage of the Bill. I welcome the Bill and the opportunities it gives for improving services to patients and providing stability and security for the dental profession.

6.7 p.m.

Baroness Gardner of Parkes: My Lords, I, too, formally welcome the Bill. I find it interesting that it is supposedly full of new ideas, particularly the voluntary basis attached to them. I have received briefs and comments which I shall mention rather than reading them to your Lordships. They come from medical, dental, pharmaceutical, county council and consumer organisations. There is a wealth of advice and information in all of them, and I agree with some points but there are some with which I strongly disagree. I therefore thought that I would pick out relevant points.

All the comments emphasise the need for consultation. Like my noble friend Lord Colwyn, another dentist, I believe that the whole national health dental system went wrong on consultation. The supposed consultation did not really result in what the dentists wanted. At the time of the introduction of the present contract, which has proved such a disaster, 63 per cent. of dentists voted against it but the elected members of the General Dental Services Committee of the British Dental Association agreed with the Government who introduced it that it was desirable for dentists. Yet 63 per cent. of dentists voted strongly against it. It is not surprising that it proved to be unsuccessful.

The points made about people's problems in obtaining national health dental treatment are real. When I was on the regional health authority, we had to introduce a salaried service in certain parts of Essex where no national health treatment at all was available. Yet we had an obligation under the national health regulations to provide dental treatment.

When people consult, whether in dentistry or other spheres, it is important to ensure that the consultation produces answers from the people who should be consulted. In dentistry the General Dental Practitioners Association represents a great body of dentists whose views are never considered because the British Dental Association seems to be treated as the only body to be considered.

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As to the pilots of new ideas, I ask the Minister to clarify one point. The noble Lord, Lord Walton, referred to the possibility of doctors and dentists providing services together, but as I read the Bill it seemed that the first clause prohibited that. Clause 1(2) states:

    "A pilot scheme may not combine arrangements for the provision of personal medical services with arrangements for the provision of personal dental services".
I should like that point to be clarified because, like the noble Lord, Lord Walton, I believe it would be desirable to combine the services. I think the opposition to this goes back a very long way. When I started in practice, 35 or more years ago, I remember that you were not allowed, as a dentist, to have your surgery above or below a doctor. However, over the years that has been relaxed. Closer working between doctors and dentists would be very desirable.

Doctors in those days were pretty horrific. I remember phoning a local doctor to say that I had a patient in for an extraction who had a history of rheumatic fever and, of course, there was a great danger, in extracting a tooth, that this patient would develop a sub-acute bacterial endocarditis. Therefore, there should be penicillin cover for it. I was in the East End of London, and the doctor said, "Oh nonsense, nonsense. People in this area are tough and rheumatic fever is everywhere. Oh no, I would not consider that." I really was quite shocked. We ended up giving the penicillin to the patient ourselves because my Australian training was such that we would not have gone ahead without it.

Fortunately the standard of general practice--medical and dental--has improved over the years. We have heard many favourable references to the Medical Practices Committee but I think they should be looking into things more thoroughly than they do. I just offer this for consideration. There are many areas that are referred to as closed areas or intermediate areas and yet I keep meeting people who cannot get on to a doctor's list in these areas. In some of the smarter parts of London if you have a smart address they do not want you as a national health patient unless you can convince them that you are the housekeeper or the au pair. That is not good enough. There is also, I believe, a point at which it just pays a doctor to have a list of a certain size so that he has all the advantages without any of the unnecessary work. Certainly in dentistry I am told the same thing: there is rate support for your practice if you have a national health practice, so many practitioners just take enough patients to obtain rate support without making a proper and full input into the health service. These are abuses of the national health system which should not be continued.

In my day everyone was terrified of a salaried service for dentists but I think that times have changed and people are now willing to look at that. I am not at all in favour of the suggestion made by the Association of County Councils that they would like to run the health services. I would strongly oppose that because I believe that local authorities have more than enough to cope with. They have no understanding of the enormous task involved in taking on the running of the health service, which is a massive system. I would not like to see the day come when people have to choose between

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emptying the dustbins or providing better medical services. It is far better to have social services as they are now, run by the local authorities, and good consultation with those running the medical services, but I would certainly not support the view that has come from the county councils that there may be a role for them in running the health services. The primary care team is most important and the sole paymaster should be the National Health Service.

The pharmacists have put forward two points: the first relates to retail price maintenance, as mentioned by the noble Baroness, Lady Robson, and the second is their feeling that it is most surprising that the Bill allows everyone except the pharmacists and the opticians to produce and initiate a pilot scheme. They feel that this must be an oversight. They would like to be able to have this opportunity, particularly as the role of the community pharmacist has enlarged so greatly and pharmacists are often now the first stop for patients. They relieve the general practitioners of a great deal of work. They are often much more accessible at any hour of the day or night. Pharmacists suggest that perhaps pilot schemes might be considered under which they could visit people in their homes or could go to old people's homes to visit groups of people who might need medicines and to give advice. Again that might lift some burden from the doctors.

The position of general practitioners is already changing and there is an increasing collaboration between general practitioners and consultants. The noble Lord, Lord Ewing, mentioned that he would like to employ general practitioners. I would like to say, as Chairman of the Royal Free Trust, that we do that already. We have general practitioners who come to the accident and emergency department, on a salaried basis, a sessional basis. Of course this may be a central London problem because in central London so many people who should go to a general practitioner go instead to their local casualty or accident and emergency department. The doctors are invited in by the hospital to do work and fortunately many have taken this up. They take off some load by treating cases which are primary care cases but which have presented themselves at the hospital.

Then there is the other side where the consultant goes to the general practitioner's surgery. We have this in ENT, gynaecology and skin specialisms. This again is very beneficial because it is often much easier for the patient to be with the general practitioner than to have to go to the hospital.

A more recent development is tele-medicine, where the patient is with the doctor in his or her own surgery but has a consultation by modern technology through a screen. Digital imaging is so good. I saw this in Boston but it is in operation now in the UK.

In these ways, the traditional boundaries are gradually merging and being broken down. The days when a general practitioner had paper and a phone as his only tools have quite gone. We see more and more packages of care being formed around the individual. The aim is to have greater continuity of care and better care for the patient.

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I should like to comment briefly on some of the points that have been made. The noble Baroness, Lady Jay, spoke of fundholding and the fact that a statement had been made opposing fundholding. But I notice that the BMA, in their report, are very much in favour of fundholding. They say:

    "We are proud of the key role played by enthusiastic and committed individual GPs in driving the NHS forward through commissioning groups, fundholding and total purchasing, or in providing enhanced care through a wide variety of innovative schemes and the development of team work and appropriate skill-mix".
So the BMA is in favour of fundholding and I think that should be pointed out.

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