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Baroness Jay of Paddington: My Lords, I am afraid that I must intervene. I know that my honourable friend Mr. Smith spoke only this morning about our plans, and given the time that she had to spend preparing for this debate, I quite understand that it has not been possible for the Minister to read precisely what he said. However, there is certainly no question of fundholders--people who are now joining together to
commission the new work that is being carried out by individuals--not being able to hold budgets. They will have financial responsibility, as collective bodies, for the collective interests of their patients. We on this side of the House feel that it is in the best interests of the health service--and in accordance with its best principles--for there to be collective responsibility for collective health rather than the individual queue-jumping, which is what individual fundholding has resulted in.
Baroness Cumberlege: My Lords, I am grateful to the noble Baroness, but perhaps she can enlighten me further by saying whether the Labour Party is giving a guarantee that individual fundholders will be able to continue having responsibility for the budgets that they hold for their practice population?
Baroness Jay of Paddington: My Lords, I am not sure that the House is particularly anxious for us to debate this matter in such detail. However, it is certainly the case that this morning my honourable friend referred to the possibility, in certain circumstances, of individual practices continuing to hold their own funds. He made very clear--we certainly support this--that the development of individual fundholding will not be encouraged. I suppose that I should say that it will be "frozen" after a Labour victory at the general election. I repeat that we believe that collective fundholding and the collective use of money under GP commissioning arrangements are more advantageous and more equitable for the population at large.
Baroness Cumberlege: My Lords, I do not find that at all reassuring because it means that in the future GP fundholders will not be able to have the responsibility that they currently have for holding funds for their particular practice. Whether they like it or not, they will have to work with other GPs and form committees to decide how to purchase services. One thing that comes through strongly in discussions on GP fundholding is that GPs are individuals. They run their own businesses and are successful in doing so. They have been innovative beyond all measure. They have done things of which we would never have dreamt and, because they are in control, they have been able to introduce services like physiotherapy and more complementary therapies. They now provide all sorts of different services. It is a tragedy that that development will not be allowed to continue if a Labour Government come to power.
Baroness Jay of Paddington: My Lords, I hesitate to intervene again, but I must answer the Minister's point, although it was an inappropriate one to raise when replying to such a debate. However, as the noble Baroness insists on developing these points, I shall respond. The fact of the matter is that, as the Audit Commission demonstrated, some GP fundholders have made innovations in their practices. They have often been those individual GP fundholders who have had advantages of locale, who have had specific government grants and who are working in areas where there is access to good DGH provision. We all know that. However, that system has also increased the inequities
in the provision of care in the health service. We on this side regard the attempt to iron out inequities as more important than giving advantage to individuals.
Baroness Cumberlege: My Lords, the Audit Commission said that to some extent all GP fundholders had improved their services. Even if it is only to some extent, the Labour Party's policy launched today will ensure that those further improvements do not take place.
Referring to the question of equity, the first essential issue is whether there is equity of funding for the patients of fundholders and non-fundholders. As the noble Baroness is aware, the setting of budgets is not an exact science. However, the Government's guidance is clear: health authorities must seek equity of funding for all patients in their areas. From an equitable base fundholders may use their budgets differently, but they will reflect the different needs of their practice population, different priorities and management of funds throughout the year and service innovations which lead the way and so often spread to patients in other practices. My noble friend Lady Seccombe is right to say that a primary care led NHS brings decisions closer to patients. Fundholders have brought many benefits undreamt of when the schemes were introduced.
The noble Baroness, Lady Jay, also raised the prospect of the Bill opening the door to privatisation of primary care. This is primarily a measure to enable those who already provide NHS services--GPs, general dental practitioners and NHS trusts--to develop provision in new ways. We are confident that they will seize the opportunity. The Bill gives them a guarantee that their proposals will be forwarded to the Secretary of State. My noble friend Lord Dean is right to stress that in any new schemes the doctor-patient relationship is of prime importance. For that reason we are safeguarding the current registration system that sets the whole tone and nature of primary care in this country.
The noble Baroness, Lady Robson, asked about regulation by affirmative resolution. I understand her concerns. However, the Delegated Powers and Deregulation Select Committee of your Lordships' House has considered the Bill in detail and does not want to alter it. The proposals are on all fours with all the primary healthcare legislation passed since 1946.
My noble friend Lord Dean referred to the welcome given to this measure by the RCN. The noble Baroness, Lady Robson, asked whether new partnerships formed with a nurse if a GP retired would affect the patients' registration system. That issue was also raised by the noble Baroness, Lady McFarlane. If a patient is not on the list of a specific GP but is on the practice list there will be no change. A patient may always choose to be on an individual GP's list, in which case he or she can choose on which alternative GP's list to appear. The nurse may not have a separate list of patients but may undertake a wider range of work for patients within the practice.
The noble Baronesses, Lady Robson and Lady McFarlane, asked about nurse prescribing. There can be no one more convinced, no one more determined, no
one who has worked longer and harder to make nurse prescribing a reality. For 10 years I have fought this cause. Progress has been slow. Initially, I believed that it would be accomplished in two years but I was naive. I was told that it did not require legislation, but it did. I was told that it would be easy to negotiate, but it was not. I was told that money would not be a problem, but money has been a problem. I was told that training would be minimal, but training has been problematical. I am pleased to inform your Lordships that I believe that most of the obstacles have been overcome. An announcement will be made shortly by my right honourable friend the Secretary of State.The noble Baroness, Lady Robson, was concerned about the closure of pharmacies due to the possible abolition of resale price maintenance. I believe that my noble friend Lady Gardner also touched on that issue. There is an essential small pharmacy scheme under which financial support is provided to small pharmacies which are more than 1 kilometre from the next nearest pharmacy. That model can be developed further if it proves necessary. As far as resale price maintenance is concerned, that is a matter for the Department of Trade and Industry. I understand that RPM on medicines is with the Restrictive Practices Court, and therefore I do not want to go into that issue at the moment.
The noble Lord, Lord Walton, was right to chart the beginnings and progress of primary care. From his personal experience he left us in no doubt that primary care had never been stronger, training never more thorough and primary healthcare teams never more real. I am grateful to my noble friend Lord Dean of Harptree for highlighting the successes. I believe that it is right to remind ourselves that, compared with the rest of the world, we receive an outstanding service at relatively little cost to the nation through the present system of funding of the National Health Service. But we recognise the pressures to which my noble friend Lord Campbell of Croy so eloquently referred. Clearly, he has knowledge of this matter through personal experience (which I wish had not been necessary). We fund it very generously. We have the guarantee of my right honourable friend the Prime Minister that so long as the Conservative Party is in power there will be more money year on year for the National Health Service. The United Kingdom spends £4.8 million every hour on the National Health Service. Next year we plan to invest a further £100 million in primary care.
The noble Lord, Lord Rea, and other noble Lords referred to resources. The £6 million is for the pilot schemes. Clearly, that will not cover the cost of setting up the schemes on the ground. The whole of the £100 million is available for primary care and clearly some for the pilot schemes. The noble Lord, Lord Walton, asked whether a partnership of GPs and nurses would be accepted as health service bodies under the proposals. The Bill will allow nurses to put forward proposals in partnership with GPs. One of the key aims is to encourage greater integration of the work of different healthcare professions. To allow new forms of partnership in pilot schemes will help to achieve this.
The noble Lord also addressed the issue of the shortage of doctors. It is true that the number of trainees has declined, but the number of GPs has increased. Eighty per cent. of vacancies are filled in a matter of months. On average, every vacancy attracts nine applicants to the post. Those who make appointments of general practitioners assure us that they do not have to compromise on quality.
The noble Baronesses, Lady Jay and Lady Robson, and the noble Lord, Lord Walton, dealt with evaluation. My noble friend Lord Campbell asked some probing questions in that regard. Perhaps I may seek to reassure my noble friend Lord Harmsworth, who I understand is sceptical about pilot schemes. The Bill requires that each pilot scheme should be reviewed and that such reviews take place before the pilots are spread more widely. The precise approach to evaluation has not yet been set out. We wish to discuss with the professions, health authorities, representatives of academic units and patients the best way to evaluate schemes. We will be establishing a representative group nationally to take this forward and to consider the application process for pilots and the criteria that govern their approval. I am sure that one of the issues that that group will wish to consider is the question of consultation, which was referred to you by my noble friend Lady Anelay. We have demonstrated our commitment to evaluation by ensuring that the requirement is on the face of the Bill. As yet, we have not set a period of time, but obviously it must be long enough to test the new arrangements properly.
A number of your Lordships referred to the Medical Practices Committee. The Government strongly endorse the principle of equity in medical services both in health authorities and nationally. We want to make further progress. I have talked at length to Mary Leigh, Chairman of the MPC, as have my honourable friend the Minister of Health and my right honourable friend the Secretary of State. We have discussed the MPC's role in relation to pilots and the more permanent arrangements which may follow pilots if they are successful. This issue is being discussed also with Dr. Bogle, Chairman of the BMA's General Medical Services Committee. Shortly, we will put forward proposals in the light of those discussions to take the issue forward and ensure that a coherent local and national approach is applied to both pilots and the existing arrangements. We want to continue to work with both parties.
My noble friend Lord Dean raised the question of GPs' responsibility for patient and practice records in a practice-based contract. I can assure him that GPs will continue to be responsible for the patients they treat. That is only to be expected given their status as professionals. That will be the case whether they are part of a team which has a practice-based contract or operate single handedly. Perhaps I may make it clear that under the new arrangements patients who want to be on a specified GP's list will be able to be.
My noble friend Lady Eccles of Moulton is right to point out that change in the 21st century is inevitable. As a health authority chairman, she knows well the benefits that recent changes have brought. The noble
Lord, Lord Ewing, advocated change for industry and commerce but perhaps not quite so much change for the NHS, as he outlined all the reorganisations that have taken place since 1948. I should like to suggest to him that it is because the NHS has accepted change that it has survived to the 21st century. I look forward to the day when he will take me on one side and tell me exactly what is Labour Party health policy, because he said that the Labour Party has today announced its intention to abolish the internal market, but I understood that it was to keep trusts and the purchaser/provider split. No doubt we shall hear more in Committee.The noble Lord was worried that voluntary schemes would become mandatory, but he will know as a member of a trust that trust status is always a voluntary initiative. He may be slightly disappointed that all units have chosen to become trusts and that through a voluntary approach we have now changed the whole system. GP fundholding--another voluntary scheme--has resulted in England, as my noble friend said, with 50 per cent. of GPs choosing fundholding. That is an honourable record in ensuring that voluntary schemes are treated as voluntary schemes. The noble Lord has no reason to question us on that.
I shall not disappoint my noble friend Lord Colwyn, who suggested that I might put forward some figures. This September there were 19,147 NHS dentists in Great Britain--an increase of 2,403 over 10 years and an all-time peak. The number of adult courses of treatment has also increased by 18 per cent. over 10 years, from 24.2 million in 1985 to 28.6 million in 1995. But I would agree with him and my noble friend Lady Gardner of Parkes that the national picture may mask buoyant services in some localities and an inadequacy of availability of NHS services in other areas. Patients have always had to travel to get to the dentist. We must ensure that they do not have to travel excessive distances.
We are taking action to tackle local problem areas. We encourage health authorities to make use of the community dental service to provide primary care services, and on 12th June we announced a package of reforms which we believe will do much to promote an atmosphere of stability and security for the dental profession.
One of the measures was an access fund to help finance local schemes to improve access to NHS dentistry. My noble friend Lord Colwyn is right that there are 22 grants to help authorities with innovative schemes. We have been encouraged by the range of schemes put forward by health authorities, and we shall want to evaluate them carefully before deciding whether and in what form to extend the scheme. Dentists' fees are set annually, as my noble friend realises, by the Doctors and Dentists Review Body, so as time is getting on I do not wish to get into the whole issue of expenses.
My noble friend Lady Gardner of Parkes asked about pharmacists initiating schemes. The Government are already funding a number of pilot schemes in pharmacy, and the Bill will enable health authorities to enter into NHS contracts to purchase those services. They will be informed by the existing pilots.
The noble Lord, Lord Rea, asked about prevention. I agree with him that primary care is an effective and important tool in preventing disease, but he will know of our Health of the Nation strategy which is all-embracing and described by the WHO as a model for other countries to follow. The noble Lord also mentioned medical records. I can reassure him that the existing arrangements will continue under the pilot schemes.
The drive to innovate has always been the hallmark of good health professionals and our consultation with a broad range of people over the past year revealed a genuine enthusiasm for innovation. Primary care has been an area in which an already successful service has not rested on its laurels. We have only to witness the integration of teams involving doctors, nurses, therapists and others. We have seen the creation of primary healthcare teams. We have seen them strengthened. We have seen the success of fundholding. We have seen community pharmacists strengthen their role through the New Horizon: Pharmacy in the New Age--a document that shows all their determination to use their experience and skills within the profession. Dentistry has made huge strides, and our oral health has never been better.
We have made an encouraging start. We are building on the consensus which emerged from the primary care listing exercise. The main representative bodies have given a positive response to the White Paper, Choice and Opportunity, which sets out our proposals.
It has been an interesting debate. I am sure that there will be an even more robust debate when we come to Committee stage. At this point I should like to thank noble Lords for all the contributions that they have made and to ask them to give the Bill a Second Reading.
On Question, Bill read a second time, and committed to a Committee of the Whole House.
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