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Baroness Hayman: I am grateful to the Minister for giving way. She has spoken of midwives being lead professionals in some areas and of nurses being equal partners in others. In that case, why are proposals that are put forward by nurses, midwives or other professionals dealt with not through the system that applies to doctors and dentists where there is an automatic referral to the Secretary of State but through what was described earlier as a sifting system reserved for the Asdas, the supermarkets and commercial organisations? Surely, that is not sending the right message regarding the esteem and value which we are placing on those professionals.

Baroness Cumberlege: The difference is that the majority of health visitors, district nurses and midwives are already employed by NHS trusts, whereas doctors and dentists are private contractors who choose to have a contract with the health service for part of their activities. Certainly that is the case for dentists and that covers the vast majority of GPs' activities. That is the difference.

The noble Baroness, Lady Jay, asked whether a group of GPs who are not in partnership will be able to put forward a proposal. Yes, they will. There is no reason why individual GPs not in a formal partnership should not be able to put forward a proposal.

The noble Baroness, Lady Robson, cited a scheme where mental health services could be improved and the majority of the work would be done by community psychiatric nurses. That is a scheme which I am sure the health authority would wish to consider and there would be no objection to that being put forward to the Secretary of State if it was felt that that would improve services locally. The same applies to the point made by the noble Lord, Lord Walton, in relation to health visitors working with the homeless. I believe that in every scheme that I have seen, the health visitor was employed by the trust and of course, the trust would have a fast track, as it were, to the Secretary of State.

Therefore, we feel that these amendments are unnecessary. We believe that the Bill meets the aspirations which are being sought, and we hope that the noble Baroness will not seek to press the amendment.

Baroness Masham of Ilton: Before the Minister sits down, perhaps I may ask her (or perhaps I should ask the noble Baroness, Lady McFarlane) what would happen about insurance if midwives and nurses were taking full responsibility for patients? Is it not the case that insurance costs for doctors have gone sky high? Would nurses and midwives be able to afford that? I just ask that as a question.

Baroness McFarlane of Llandaff: I feel tremendously encouraged by the support that I have received from all sides of the Committee. It is

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encouraging to have the tributes to the professions other than medicine and dentistry which we are thinking about here.

To turn to the independent practice of nurses and midwives to which the noble Baroness, Lady Masham, referred, nurses, midwives and health visitors are practitioners in their own right and they are insured for their full professional indemnity through various agencies, although they hold joint liability as an individual, with the trusts employing them and with the medical staff who may be involved in a case. Therefore, nurses, midwives and health visitors have professional liability for their actions.

I have tried to follow the Minister's arguments in the case. I have difficulty in understanding her inability to accept the amendments and to allow access by nurses, midwives and health visitors in particular, and some other professions, to this right to submit pilot schemes in their own right. Nevertheless, I wish to consider very carefully what the Minister said on this occasion, and I should like an opportunity to study the White Paper that has been published today and perhaps return to this matter on another occasion. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Rea moved Amendment No. 3:

Page 1, line 15, leave out subsection (2).

The noble Lord said: This amendment would remove subsection (2) of Clause 1. It would remove the words:

    "A pilot scheme may not combine arrangements for the provision of personal medical services with arrangements for the provision of personal dental services".
When the Minister replies to the amendment, she will probably tell me that there are good technical reasons why medical and dental services cannot both be included in a single pilot scheme. If so, I hope that she will spell those out for our benefit.

I have personal experience of working in a health centre which housed both medical and dental practitioners providing National Health Service general medical services and general dental services. That was very much appreciated by the patients of the health centre, the GPs and the dentists. It was a convenient and professionally fruitful arrangement. Several times a week there would be cross-referrals between the dentists and the doctors. As the noble Lord, Lord Walton, will know only too well as a neurologist (although I am sorry that he is not in his seat) a headache can sometimes be due to dental pain. Dentists often found that it was useful to ask GPs about the health or allergic status of particular patients which concerned them. As the records were on the premises, it made it easy to obtain that information.

Sadly, that arrangement terminated because the dental practice felt that the health authority was overcharging it for the premises, quite apart from the fact that it did not feel that the NHS was paying dentists enough for their services either.

If a scheme were to be proposed which provided needed dental and medical services in, for example, a deprived area, would two separate but perhaps

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co-operating pilot schemes have to be put forward simultaneously--one for dentists and one for doctors? That seems rather cumbersome.

This is a probing amendment to find out what this prohibition on merging the two services in one scheme is all about. I beg to move.

4.30 p.m.

Baroness Cumberlege: We support wholeheartedly the objective behind this amendment--that of encouraging better integration of services provided by different professions. This has been one of our aims in primary care for some time and we have made good progress. Primary health care teams are stronger than ever and there is co-operation between GPs and dentists in some of the total purchasing pilot schemes.

The provision in the Bill, which the amendment seeks to remove, will not hinder further progress. On the contrary, the provision in the Bill helps to provide a framework of rules within which innovation and integration can flourish and without which we might in future face unnecessary complications. The provision rules out the option of a single scheme--and a single contract--covering both personal medical and dental services. General practice and dentistry are very distinct services, as I am sure the noble Lord will agree, with very different financial and practical arrangements. The Bill maintains this distinction and avoids the complexities that could arise if the services were covered by the same contract.

The provision serves a useful purpose, but it will certainly not prevent co-operation between doctors and dentists in a range of different ways. Indeed, we will encourage such developments which in some locations, though probably not generally, will be the best way to provide both services. Co-operation may involve the sharing of premises or planning services together. It may well involve examining local health needs together and co-operating over the preparation of pilot proposals which tackle these. The main constraint is that the contracts which emerge from successful proposals will be separate. I hope that I have made the reasons clear as to why we would not want to pursue this line. I hope that the noble Lord, in his probing amendment, has received a sufficient reply.

Baroness Gardner of Parkes: I am quite baffled by my noble friend's explanation. I do not understand the clause. I sat here quietly to listen to the explanation in the hope that it might make it clear to me. Unfortunately, it has not; indeed, I am still quite confused. There was a time--I mentioned this on Second Reading--when doctors and dentists were not allowed to practise in the same building, but that went a long time ago.

I can understand that the provision for payment, and so on, might be different and that, for example, one might be on a different contract from the other. However, the wording in the Bill seems to me to be most specific. Subsection (2) says:

    "A pilot scheme may not combine arrangements for the provision of personal medical services with arrangements for the provision of personal dental services".

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That appears to be very limiting, and unnecessarily so. I do not understand the reason for having that provision in the Bill. If it were to be removed from the legislation, surely there would at least be the option to consider whether in a given area it was suitable. However, when such a provision is in the Bill it specifically precludes any such consideration. That seems to me to be contrary to the purposes of the Bill as a whole; namely, to bring forward innovatory ideas.

Lord Rea: I agree with the noble Baroness. The Minister's explanation did not satisfy me; in fact, it increased my bewilderment rather than decreasing it. Surely it is less complicated to have the two types of practitioner working in a pilot scheme, and, although they are paid from different sources, to make the arrangements within that scheme, than it is to have two entirely separate pilot schemes. I am still at a loss to know why the provision is in the Bill. I wonder whether the Minister will agree to think about it before the next stage. If she will agree to do so, I shall not press the amendment.

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