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Baroness Jay of Paddington: Would the noble Baroness allow me to intervene? I do think that there is a slight confusion in the terminology. There is a difference, is there not, between the individual fundholder and the groups which the noble Baroness has rightly referred to: commissioning groups, total purchasing groups in which GPs work together as consortia rather than as individuals who may purchase services on behalf of their patients which are to the detriment of other patients. If commissioning groups work on behalf of all the patients in a locality then that is certainly to be welcomed.
Baroness Gardner of Parkes: My Lords, I thank the noble Baroness for that but I think the difference is a very fine line. If you are a single practitioner, practising on your own, the only way you could be vying with other people is by joining a consortium. If you are a large group practice, there are enough of you there to form your own group fundholding nucleus and you do not need to be part of a consortium. People have taken this phrase "consortium" simply as a politically acceptable term to cover what everyone else calls GP fundholding. In my view, GP fundholding means that the GP controls the budget and controls where the money is spent for patient care. In that sense I completely support it. I would like to see much greater control over treatment and cost of treatment exercised by the general practitioners as opposed to any other way. The personal doctor and the health team know the needs of the patient better than anyone else. I believe that if, instead of adopting the attitude that we are against GP fundholding, we had universal GP fundholding, we should not have a problem at all.
I have spoken about dentistry and finding a dentist, which again were points raised by the noble Baroness. The noble Baroness, Lady Robson, spoke about the Medical Practices Committee, which I have mentioned also. The noble Lord, Lord Dean, spoke of nurses. I should like to pay tribute to the nursing profession. They are the backbone of the health service and have done marvellous work. But, in raising the profile of nurses, as we have done through Project 2000--I am all for raising their academic status and their personal status--I am concerned that we may now have such a high entry qualification that many people who might wish to be nurses feel that they cannot enter the profession. In these days of Calman, when there are new methods for training medical consultants, junior doctors
I should like to comment on one or two of the points which came to me in the briefs. The Royal College of General Practitioners made some interesting points. It said that it considered it very important that people who were going to set up pilot schemes should be actively working in general practice as part of a primary health care team. It thought that it was very important that there should be an input from active general practitioners. It is indeed important. We do not want people who have retired and think that they might dabble in some new idea or people who are not currently in touch with treating patients. That feature is desirable.
It is also important that we should have the medical workforce properly distributed. Everyone is concerned about areas which are unattractive. Years ago in certain parts of Wales one could have nothing done in dentistry except an extraction. The dentist ran a Rolls Royce on the fact that everyone came to him just to have a tooth out. No one ever received any more treatment than that. He was the only dentist in the area. People had to pay for whatever treatment they had and he did very well out of it but nobody received any comprehensive dental health treatment.
I believe that we could use the carrot and stick and produce some form of incentive. Over the years incentives have been used to encourage people to practise in less attractive or less profitable areas. There should be some equivalent of the higher pay for antisocial hours or antisocial work that we see in other professions. Something of that type would help ensure that people practised in areas which may at the moment look less attractive to them.
I have covered most of the points that I wish to make, with the exception of a mention of the Consumers' Association, on which I shall pass just the briefest comment. As I gave way to the noble Baroness, Lady Jay, perhaps I may speak for just one more second. The Consumers' Association report makes the point about access that people should be able to have their choice of GP or dentist and the doctor/dentist should be able to have his choice of patient. However, it is sometimes very difficult to reconcile those two choices. The consumer interest, which is very real and concerns us all, is sometimes misguided. Trying to force a doctor or dentist to accept a patient is no way to build up a good and close patient-doctor/dentist relationship. There has to be voluntary acceptance on both sides that they are suited to one another and the practice must be the one
Baroness McFarlane of Llandaff: My Lords, I add my voice to those who welcomed the Bill. It reflects very ably the White Paper, Choice and Opportunity, and the aspiration in that paper to make arrangements for the delivery of primary care services more flexible, so that they are better attuned to local needs and circumstances.
The Second Reading of this Bill provides us with an opportunity to restate what may appear to be two very self-evident truths. One is that primary health care services are the foundation of our healthcare system, a foundation on which all the superstructure is built. The noble Lord, Lord Dean, referred to primary care services as the base of a pyramid.
Episodes of acute illness and the need for acute care services may be very dramatic but relatively infrequent episodes in the normal healthcare trajectory of an individual. They call for expert services. But the day to day healthcare of the nation over a much broader spectrum of provision belongs to primary care. I believe that we cannot stress too much the need for health promotion, preventive services, treatment of early deviations from normal health and long-term care. Those form the bedrock of our health services.
It follows that the roles of nurses, midwives and health visitors are of absolutely paramount importance in achieving the objectives of the health service. I welcome the tribute from the Minister, the noble Baroness, Lady Cumberlege, in her introductory remarks, to the importance of nursing services. The White Paper itself pays tribute to them. It says:
So I welcome the practice-based contracts which will allow nurses to become full partners in the primary healthcare team. It would be useful to have some clarification of how that might be worked out. I had not perhaps imagined it as had the noble Baroness, Lady Robson; namely, that a nurse might take the place of a practitioner in the team. Rather I thought that as a partner, she would offer services in line with her training and qualifications and as a full member of the team. But I welcome that opportunity.
Very briefly I shall deal with some of nurses' concerns about the Bill. Some of them relate to employment conditions. The more flexible employment opportunities would allow general practitioners to employ community nurses other than practice nurses--for example, health visitors. But in that event, issues of professional supervision and accountability need to be addressed. It is there that I believe that a senior nurse in partnership would commend itself as a solution. In terms of employment rights, the noble Baroness, Lady Robson, mentioned pension rights and having access to
I welcome the pilot schemes and their evaluation. That seems to be a new trend in our way forward in the health service. But as we test those schemes, nurses will want to know what their employment rights will be if a pilot scheme fails. General practitioners and general dental practitioners are identified as qualified people to propose a pilot scheme. No mention is made of a nurse being able to propose such a scheme and it would be useful to have clarification on that point. Neither is there any indication that a nurse could apply to be a health service body, and that is another point on which nurses seek clarification.
The noble Baroness, Lady Robson, as always, spoke feelingly of the interests of nurses and raised the question of a need for the extension of prescribing rights. As we enter these experimental schemes it would be useful to know the extent to which any consideration has been given to the need to extend the prescribing rights of nurses.
Those are just some of the issues about which nurses have concern. I confess that I am watching the clock anxiously. I may be running out of the time I need to catch the last train to Manchester. I hope to stay until the end of the debate but, if I cannot, I ask the House to accept my apologies.
We are able to choose our doctor. Thankfully, most of us for practically all our lives only need treatment from the GP. The surgery is usually comparatively close to our home, so the more that can be achieved by local treatment the better. That can be of particular importance to those patients who are old and frail, to those unable to drive and to those whose condition is made worse by travel. We all know how a visit to a consultant can be a lengthy and tiring exercise.
So, under this Government, a primary care led NHS has moved from aspiration towards reality. Primary care professionals include GPs, dentists, community pharmacists, practice nurses and community nurses. Those professionals work in the community and are thus closest to patients and often know them well. That makes them best placed to meet patients' needs in the local setting.
This Bill will take forward primary care in the NHS. It follows extensive consultation within the NHS and enjoys the full support of the British Medical Association. As Dr. Sandy Macara, Chairman of the BMA, said on the "Today" programme on BBC Radio 4 on 15th October last:
A report on GP fundholding by the independent Audit Commission earlier this year concluded that all fundholders have secured some benefits for their patients and some have secured spectacular benefits. Fundholding allows GPs to be innovative in the way they plan services, allowing them, for example, to hold outreach clinics by consultants in their surgeries or, as has happened in various places, keeping or re-opening cottage hospitals. Since the scheme began in April 1991, it has been broadened by the Government. Community fundholding allows those GPs who wish to, to opt to buy a more limited range of services for their patients. Total purchasing allows those GPs who wish to, to purchase all services for their patients. A primary care led service is not about developing primary care to the detriment of other parts of the NHS; it is about improving the whole service in a way which reflects the needs of patients.
In October 1995 my right honourable friend Gerald Malone, Minister of State for Health, began an extensive series of consultative meetings across the country listening to primary care professionals. The purpose of those meetings was to identify obstacles to the further development of primary care and to agree a shared agenda for overcoming them. The result was the publication of Primary Care: The Future in June of this year. It summarised the results of Mr. Malone's meetings and set out an agenda for the way forward. A further round of consultations followed which culminated in the publication of the White Paper, Choice and Opportunity, which explained the Government's proposals.
The main aim of the general practice aspects of the legislation is to enable new approaches to contracting for general practice to be developed locally, piloted and then evaluated. That is intended to encourage local people to put forward proposals on different contractual arrangements which could better suit their circumstances and the needs of the service in their locality. Seizing the new opportunities presented by this legislation will be entirely voluntary--yes, "voluntary".
I was interested to hear what the noble Baroness, Lady Jay, said in relation to commissioning. It seemed as though we were talking about more regulation and making sure that groups of practices got together and became commissions. But some doctors do not wish to become fundholders; my doctor is not a fundholder. The Government are keen to create choice and opportunity for health professionals, which are lacking in the socialist approach. Labour appears to want to take away that opportunity by ruling out the popular option of fundholding.
Additionally, there will be no disadvantages for GPs who remain in the current contractual arrangements. Legislation should enable local flexibility but also ensure that there are adequate safeguards for both patients and professionals. Patients will retain their right to be registered and to choose their GP.
The proposed legislative changes will allow health authorities more flexibility when contracting for community pharmacy services. It will also abolish the anomaly which prevents community pharmacists from providing some services to patients across a health authority's borders. Patients will still have the right to take NHS prescriptions to the community pharmacy of their choice.
The Opposition suggested that the changes the Bill will herald could lead to commercialisation of NHS general practice. That is wholly wrong. Since 1948 general practitioners have been private contractors providing NHS services, and NHS pharmacy, for example, is already provided within commercial premises such as Boots. The fact that it is provided within Boots does not change the fact that it is still an NHS pharmacy.
The Bill is not about supermarkets--or any other commercial concern--providing private general practice; it is about making the provision of NHS general practice more flexible. It will remain free at the point of use and available on the basis of medical need, not the ability to pay. The Bill is not about changing the nature of general practice in the NHS. It is about helping GPs to remove the obstacles they have encountered in providing better services for their patients.
With structural change now behind us, the Bill demonstrates how the Government are working with NHS professionals to produce a positive agenda of service improvement that we all wish to see go from strength to strength. I support this Bill wholeheartedly and look forward to it being on the statute book.
Lord Harmsworth: My Lords, may I briefly welcome this Bill. It seems to me to do two things which are eminently worth while and which follow a strong trend in healthcare legislation, certainly in the past six years and earlier still so far as general governmental approach to administrative handling is concerned.
The first principle, which I thoroughly commend and which is anyway now a necessity, is the enabling of total flexibility in the ways in which professionals in primary care can organise themselves. The second principle is that decision-making continues to be devolved to the people at the sharp end: those who know exactly what their local community requires and are best able to supply it. I have always considered the NHS to be almost over-endowed with talent. The move away from central control is to be welcomed. Giving groups of primary care professionals the chance to crack their own problems for themselves is to be welcomed even more.
Baroness Anelay of St. Johns: My Lords, like so many other speakers this evening, I welcome the Bill because I believe that it gives health professionals the opportunity to increase still further the range of primary healthcare services so that they match even more closely the needs of the people who live in the area they serve.
As the National Health Service has developed and managed change, it has had to respond to the advances in medical science and to the increased expectations of the public about the extent and quality of the service which they should receive. Throughout that period of change my focus of concern has always been to examine whether those patients who are particularly vulnerable have the quality of their care at the very least maintained during the period of change, and then improved as a consequence of any changes which become part of normal practice.
If I have to describe the kind of patients I mean, I would say that I am thinking of those who do not or cannot choose to seek healthcare outside the National Health Service and those who find it difficult to negotiate the highways and byways of medical bureaucracy. It may be that they are too ill to be able to make judgments about the care which they should seek or about the care offered them; or perhaps they simply lack either the information or the ability to be effective advocates on their own behalf. With the greatest respect to those noble Lords who are medical practitioners, my experience of working with the citizens advice bureaux and as a past member of my local community health council means that I am not always convinced that the medical profession is the patient's best advocate.
When I combine all these factors together I think in particular of those who are elderly and frail. Community care policies have made it possible for them to live in the familiar and reassuring surroundings of their own homes rather than entering a residential care home or nursing home until it is absolutely necessary. For them, the GP is almost always their first recourse when seeking medical care, and of course community care policies mean that they will now have recourse to the GP rather than the health services within residential care. So it is even more important than ever to them that the GP services are centres of excellence. I therefore concentrate my remarks today upon the services offered by GPs.
When changes to primary healthcare provision were proposed my litmus test was, "Will they be of benefit to the elderly frail and, above all, how will they be protected during the period of change?" Any change, however beneficial it is intended to be, can seem threatening and can undermine one's confidence. It is vital that the elderly frail remain confident in the services provided by their general practitioner service. So does this Bill pass my litmus test? Yes, I believe that it does, and for several reasons. First, it underlines the Government's commitment to NHS care free at the point of use. Secondly, I welcome Clause 19, which re-states the patient's right to be registered with a GP and their right to choose their GP, whether or not that doctor is taking part in a pilot scheme. Where patients cannot be registered with a doctor of their first choice, the Bill maintains their right to be allocated to a practice.
Clause 19 also includes a provision for the Secretary of State to give directions imposing a limit on the number of patients to be accepted by a medical practitioner who provides personal medical services in accordance with Section 28C arrangements. I note what my noble friend Lady Gardner of Parkes said about the practice of some doctors maintaining a limited list for their own advantage. However, I think that it is also important to have this regulation so that we can be sure that GPs do not extend their patient lists beyond their capacity to serve them properly.
It is important that patients who are in practices which take part in pilot schemes can have confidence in the quality of their treatment. This Bill meets that point because Clause 4(1) provides that when the Secretary of State has approved a pilot scheme it must be implemented in the format that has been approved. GPs cannot alter it thereafter just to suit themselves. In addition, Clause 6 includes provisions to enable the Secretary of State to vary or terminate pilot schemes if they prove to be unsatisfactory.
Much mention has been made already this evening about the value of evaluating pilot schemes. Clause 5 promises that pilot schemes will have evaluation. I shall be interested to hear from my noble friend the Minister what methods will be used to judge the schemes and whether and how the views of patients will be sought. The Bill also provides reassurance about the quality of work to be carried out by those within the range of services provided in the pilot schemes. Clause 21 enables regulations to be made covering the liabilities and obligations of Part II general medical practitioners who either deputise for medical practitioners working under Part I of the 1977 Act or engage medical practitioners working under Part I of the Act to deputise for them. Clause 9 specifies that medical practitioners who provide medical services under a pilot scheme must be suitably qualified within the terms of Section 31(2) and Section 32 of the 1977 Act.
All patients will benefit from the development of a primary care service within the National Health Service, which embraces non-medical professionals, including nurses, therapists and managers. The advantages to patients will be that the staff will be more motivated and their skills further developed. There is also another consequence which sounds mundane but which is
Lord Rea: My Lords, it is good to hear from the noble Baroness, Lady Anelay, the first time for me. She obviously knows what she is talking about and I am sure that she will definitely be contributing to debates on health in future to the benefit of all of us. I must apologise for my voice, which has practically gone. I hope that it will just about last out for the next 10 minutes. It has been a very interesting debate. Almost all the points that I was going to make have been made by other speakers, but I shall just cover some of them and re-emphasise those which I believe to be the most important.
Any Bill which sets out to improve the effectiveness of primary healthcare should be welcomed. On these Benches we support moves in that direction. But as my noble friend Lady Jay and many others have pointed out, there are concerns about this Bill from a number of different directions. The noble Baroness, Lady Cumberlege, and her right honourable friend the Minister have tried to allay those concerns, but they persist. In summary, those concerns have the common theme that the proposed changes may undermine or damage the very features of British primary healthcare which makes it such a valuable and internationally admired institution. I refer to its improving coverage of the whole population. It is not perfect, as the noble Baroness, Lady Gardner of Parkes, and others have pointed out, but it is moving in the right direction.
There is also the right of patients to register with the doctor of their choice who will provide continuing care. The noble Baroness has reassured us about that a number of times, but we are still concerned about it. I refer also to the system of lifelong medical records which follow patients to all parts of the country wherever they move. As has been mentioned by a number of speakers, there is also the helpful gatekeeper role in which the hospital services are truly secondary care services with 90 per cent. of illness episodes dealt with in primary healthcare.
Of course, everything in the garden is not as rosy as these principles might suggest. There is obviously need for continuous improvement, both to improve patient care and to maintain--and this is very important--morale and recruitment to the service. Some doctors do not provide care of the standard required--the noble Baroness, Lady Anelay, pointed that out--despite the very great improvement which the noble Lord, Lord Walton, mentioned, as a result of vocational training over the past 25 years. Many practices still do not have the additional staff or premises to allow the comprehensive team approach of the best practices.
While on that point, I would like to voice a worry of the Royal College of Nursing. Why is the Bill about primary care and not about primary healthcare? The noble Baroness knows that good primary healthcare provides an ideal opportunity for preventive medicine and health promotion, and internationally in the World Health Organisation frontline care is known as primary healthcare. I believe that the title of the Bill should reflect the wide scope that primary healthcare involves.
While on the subject of nurses, I believe that the Bill does not fully emphasise the central role that nurses will play in future, and which they are increasingly playing in primary healthcare. They should be able to be partners--that is fine. This Bill enables that to be done. But why cannot they initiate pilot schemes themselves or form themselves into what are called National Health Service bodies? At the moment nurses tend to be bodies to be kicked about in the National Health Service, particularly when it comes to nationally agreed norms of pay.
The concerns about the Bill that have been brought to my attention, which have been mentioned by many other speakers, include first, and perhaps most important, the role of the Medical Practices Committee. I quote from its statement:
In her reply can the noble Baroness address these important points. Amendments, which could give the MPC a more central part in decisions about pilot schemes, may well be proposed at later stages of the Bill.
Another important concern is that of resources. The sum of £6 million has been promised for the pilot schemes although I am not quite sure exactly from which section of the health service that money is to come. There is also the question of costs of continuing to operate the successful pilot schemes. Part II of the 1977 Act covers hospital and community services and Part I the primary care services--or have I got it the wrong way round? My understanding is that money to
As other speakers have pointed out, and as the noble Baroness well knows, hospital budgets are extremely tight. That was pointed out particularly by my noble friend and the noble Lord, Lord Walton. In many cases those budgets are overspent. Can the Minister give us some information about how the successful schemes are to be paid for and out of what part of the National Health Service budget?
Another point was mentioned by the noble Lord, Lord Campbell of Croy, and many other speakers: who will design and carry out the evaluation of pilot projects? For that to be properly done academic departments of health service research need to be involved at a very early stage. I believe that the thinking out of the scheme in the early stages was mentioned in particular by the noble Lord, Lord Campbell of Croy. I suggest that there needs to be an independent, well-qualified body to review all the proposals before they start. I hope that the Minister will be able to give us some information. Perhaps she will agree that such a body should be set up in order to advise Ministers.
The aims of each scheme need to be carefully stated so that their success or otherwise in improving care or professional morale can be properly measured. One of the criteria for acceptance of a pilot project should be that the services in that area are inadequate in some way at present. Such a scheme must augment, not detract from, the existing primary healthcare services in needy areas.
Other concerns have been mentioned. I refer to the need to include local authorities in the planning of pilot schemes. To answer the noble Baroness, Lady Gardner of Parkes, I do not think that local authorities have suggested taking over the running of parts of the National Health Service. That has certainly not been stated in any document that I have received. However, they do suggest that their departments of social services, housing, education and environmental services may all have important parts to play in the schemes that are to be evaluated. I hope that the schemes to augment the roles of pharmacists and optometrists and which seek to attract dentists to what perhaps I might call "under-dentisted" areas will be deemed possible. They would be very welcome from our point of view.
To take up the point raised by the Royal College of General Practitioners, I hope that at every stage the changes resulting from the Bill will build on what has been suggested by the experts--the doctors, nurses and dentists who are now working in primary healthcare and who know what the problems are. The White Paper states that consultations were held with a wide group of professionals concerned with primary healthcare. If that is the case, it is surprising that almost all of the relevant professions have serious reservations about the Bill. Under this Government, "consultation" tends to mean that plans are waved in front of people, but that those plans go ahead regardless of the suggestions made by those who have been "consulted".
However, I agree that the Government have grasped one important point--the need to try out and to evaluate new schemes. We should be truly grateful for that, providing that the evaluations are carried out properly.
We can regard this House and the other place as a form of hatchery; the Bills that pass through being the eggs. Government Bills going through your Lordships' House can be thought of as a variety of different kinds of egg, ranging from good eggs, which are the necessary Bills which please most people, to rotten eggs, which are usually based on ideology and are to the detriment of many people. Your Lordships know that I am going to say that this Bill is a curate's egg--good in parts. Roget's Thesaurus provides an alternative meaning for the phrase "a curate's egg"--"room for improvement". In Committee, we shall try to bring about the improvements that are necessary.
As the noble Baroness, Lady Robson, said, this Bill will not come into force until after the election. I suggest that in the hands of a government run from this side of the House comprehensive primary healthcare will be safe and that this Bill, suitably amended of course, will be of use. In the unlikely event of the present Government being returned to office, we still have some serious doubts about the effects of the Bill.
Baroness Cumberlege: My Lords, we have had a lively and informative debate. That bears witness to the importance which your Lordships attach to the future development of primary healthcare. It was encouraging to see a degree of consensus in your Lordships' House over the broad direction in which we should move.
The noble Baroness, Lady Jay of Paddington, said that she accepted the overall aims of the Bill and welcomed the principles underlying it. I was sad, however, to learn today that the Labour Party has stabbed primary healthcare in the back since it has stated its wish to end the individual practice of fundholding which has brought so many improvements not only to patients and to primary care but to the whole of the NHS, as it ties together primary healthcare and hospital services. This morning the Labour Party disenfranchised over 50 per cent. of GPs from holding budgets. According to the Labour Party, they are not fit to be trusted. The noble Baroness talked of low morale--a view with which I disagree. But nothing will lower morale more than disqualifying all those who have put so much time and effort into fundholding from holding budgets for their own practice population. The Labour Party seeks to take away their control, to ignore their judgment and to pressgang them into area committees. I say to fundholding GPs, "I warn you: New Labour, new danger".
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