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Lord Walton of Detchant: At Second Reading I gave considerable support to the spirit underlying the Bill now being considered in Committee. However, I support in principle the spirit underlying Amendment No. 1. Having said that, perhaps I may make clear that I have long believed in the importance of a partnership between public and private medical care. I have certainly appreciated such developments in our hospitals. The efforts made 20 years ago by a former Labour Government to try to remove all private beds from our NHS hospitals did irreparable harm to the service and, at the same time, gave an enormous impetus to the development of private medical care outside NHS hospitals. Happily, many NHS hospitals now provide private medical care and derive a considerable income from doing so.
However, general practice is different. There is nothing to prevent a private company from employing salaried general practitioners who are offering private
primary care. That can surely not be an objection. But for many years it has been the case that private commercial companies have employed occupational health physicians. They are employees of the company. They are there in the interests of the company to examine and report on employees relating to their fitness to practice and also relating to issues that may arise in consequence of disorders or diseases resulting from their respective occupations. But if an occupational health physician detects evidence of an illness in someone whom the company has asked him or her to examine, then it is not up to that occupational health physician to prescribe or offer treatment. But, with the permission of the patient, that physician should report to the patient's general practitioner who would then offer treatment to that individual.The problem that I foresee if private commercial companies were able to employ general practitioners is that there would be a real or perceived conflict of interest between the commercial interests of the company on the one hand and the general practitioner services on the other. Many GPs have worked part-time as occupational health doctors, but in doing so they have separate contracts: one as an independent contractor with the NHS and the other on a sessional basis with the commercial company. The duties under those two contracts are totally separate and distinct. It is a possibility, as the noble Baroness, Lady Jay, said, that a doctor employed to give general medical services through a commercial company might feel under pressure to prescribe the products of that company and might not therefore be able to function properly and independently, as every general practitioner should, in the interests of his patient and in the interests of the community. For those reasons, I support the principle underlying this amendment.
Baroness Gardner of Parkes: I find the amendment rather complicated and I believe that a number of points have not been thought through. The amendment refers to "personal medical services". Does that mean medical services only or does it include dental services? If the term medical services includes dental services, perhaps I should point out that dental companies and companies that provide treatment already exist. British Petroleum employs a dentist within its building. He is paid by the company but operates on national health dental forms and claims fees from the National Health Service. I refer to British Petroleum because it was near my surgery. It took that course because it had many people--British citizens--coming in from different parts of the world who had to be seen rapidly and could not be sure of getting an appointment elsewhere. If that same firm wanted to have a general medical practitioner, would it be precluded from doing so under this amendment?
As a dentist I practised for years as one of the directors of a dental company. A number of dental companies are registered under the General Dental
Register. I do not know whether medical companies exist. I do not know whether dental companies are still registered, but they certainly are a fact of life.
Baroness Jay of Paddington: I agree with the noble Baroness. The question of the nature of the company is very difficult. That is why we used the terms in the amendment. They may not be precise but, as we know, if the principle of an amendment is accepted, the Government are always willing to help with that. Where a company pays dividends, that is different from a practice. We took the example of one in Dorset where a group of general practitioners working together form a company. However, they do not pay out dividends. That is the distinction which one can make in broad terms between the type of company we would wish to see excluded and a broad collection of professionals in practice, which I think is what the noble Baroness is speaking about.
Baroness Gardner of Parkes: I am interested in that comment. The General Dental Council had strict rules on what proportion of dentists had to be directors of the company. It was not an open matter and no new companies could be created. It was only companies created prior to 1957.
The noble Baroness referred to whether dividends are paid. Whether a number of practitioners working together share remuneration or whether payments are classified as dividends, are taxation matters. If tomorrow, or at some later stage, a new Chancellor said that it was more advantageous to be paid dividends than a salary, one would rapidly find practitioners wanting to pay themselves dividends. Therefore, I have doubts about that argument.
The noble Baroness, Lady Robson, was concerned about trusts employing people. At Second Reading I said that the trust of which I am chairman, which is a large teaching hospital, has general practitioners who come in on a salaried basis for so many sessions. They come into the accident and emergency department and are enormously valuable. So many patients, particularly in London, who should go to a general practitioner do not do so. They present themselves at the accident and emergency or casualty department. They take time and attention away from the proper treatment of emergencies. Therefore, I think it is important that we should be able to employ these people.
Baroness Robson of Kiddington: I am aware that hospitals do that. I was talking about health authorities setting up complete health service centres in some other part of the area in which they function.
Baroness Gardner of Parkes: When I was vice-chairman of the North-East Thames Regional Health Authority, there was such a scarcity of dentists in some parts of Essex that we had to consider setting up salaried practices there in health centres. All those situations exist. It is quite impossible to predict when and where these needs will arise.
Another point has been overlooked. A number of doctors, particularly younger doctors, quite like the idea of working as salaried practitioners. Many do not want the burden of practice management and would prefer to be salaried. Therefore, we want to leave open some flexibility for such a situation.
The noble Baroness, Lady Robson, referred to the trust between doctor and patient. Where that exists, it is marvellous. There could not be a better relationship. Sadly, however, although it works in the very best practices, it does not work everywhere. There would hardly be a practice in this country which did not have at least one disagreeable patient that it found difficult to get along with. Health authorities would say that they often have to allocate patients to doctors because no doctor wants to take the patients voluntarily. It is an idealistic and desirable thing for this trust to be continuing at the highest level; but, sadly, it is not always so.
I am opposed to any amendment which might limit possibilities for patients. We should be putting patients first. We tend--I say this as a dentist--to have a degree of self-interest as to what suits us as practitioners. That is not good enough. We have to put patients first. The walk-in private medical service at Victoria Station is a great success. The idea is such a success that centres will be set up elsewhere. It is clear that many patients would like to have that walk-in service. The system of a company setting up a practice would enable patients to have the right to walk in when they felt like it.
I would not want to insert anything into the Bill that would prevent that happening. We have to leave open our options--we are always hearing that expression in another context--because we do not know what good and innovative schemes will be brought forward. The amendment might well preclude schemes that would be of the greatest benefit to patients. I oppose the amendment.
Baroness Masham of Ilton: I wish to ask the Minister about the pilot schemes. Where will the patients' records be kept? If a practice sets up in a supermarket, will the records be kept in the supermarket? The noble Baroness, Lady Gardner, referred to the walk-in centre at Victoria Station, which I have heard is very popular. What happens there with the patients' records? Records take up quite a lot of space.
Baroness Gardner of Parkes: Perhaps I may reply to that point. I do not know what happens to the records at Victoria Station. I do know that we are now reaching the point where records can be available on line by computer much more readily. Therefore, they could be held at the original base and then be made available. However, we get into this tremendously complex situation regarding patient confidentiality. The patient would have to release the right for the records to be obtained from the original source, and you would have to be quite sure that when the original source received your request, it was satisfied that you were the legitimate person. I believe
that it might be a very complicated issue as regards patient confidentiality and computer records. But in technical terms it is possible to do that. The other aspect is that many people who use the service at Victoria Station just have an anxiety about something and want to see a doctor then and there at the moment of their choice.3.30 p.m.
Baroness Cumberlege: This amendment implies that GPs will find it hard to hold their own in the new system; that they will struggle to come up with proposals that will win approval as pilot schemes and that they need protecting. We strongly believe that none of those is the case. GPs have shown time and time again that they are innovative, imaginative and able to deliver better services to patients in new ways. GPs, dentists, NHS trusts and other frontline NHS staff are closest to patients and we look to them to bring forward proposals about how we can improve services for local people. That is why we have given GPs, dentists and NHS trusts, and only those groups, the automatic right for their proposals to be put forward to the Secretary of State for approval as pilot schemes. We are confident that they will seize the opportunity. We are sure that they do not need to fear competition, let alone be protected from it.
As well as being unnecessary, we believe that this amendment will be damaging to the NHS. The prime purpose of our proposals is to enable existing GP practices to do more and to do it better. But there may be circumstances, as my noble friend Lady Gardner said, where a salaried GP service would be the best option. We all know of the difficulties that arise in filling practice vacancies in some inner city areas. We are serious about tackling these difficulties and do not want to rule out any sensible opportunities, including a GP being employed by a commercial organisation. After all, what is piloting for if not to see if innovation works?
I should like to make this very clear: the Secretary of State will only countenance new arrangements if there are obvious gains attached to them. New services will be subject to NHS rules and standards. In particular, we will want to be absolutely sure that there is no potential for conflicts of interest before allowing any specific proposal to go ahead--a point made by the noble Lord, Lord Walton.
Talk of commercialisation in this context is a nonsense. GPs have always been in the private sector in that they are private contractors. Indeed, it might be practically impossible to differentiate between, say, a group of GPs and other healthcare workers who formed a limited company and a company already operating in the commercial sector with suitable experience of providing medical or dental services. To differentiate in this way would be unjust and unfair. Why rule out companies which pay dividends and not private companies? If private companies, why not partnerships? The point is that no one can draw firm lines between these bodies. What is important is that the services that they might offer should be NHS services for NHS patients to NHS standards.
The noble Baroness, Lady Jay, ignores the fact that schemes put forward by commercial organisations will have to be endorsed by health authorities and then approved by the Secretary of State. One of their concerns will be to ensure that pilot schemes meet local needs including, in particular, improving services in areas which are not currently well served. The example that I have already given is the inner cities. Our proposals open the way to greater equity and better access to NHS services for all.
Our commitment to NHS primary care is beyond doubt. We believe that this amendment will do nothing for primary care, nothing for professionals and nothing for patients. Therefore, I urge the Committee not to support it.
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