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Baroness Robson of Kiddington moved Amendment No. 7:

Page 2, line 46, at end insert ("and such matters shall include provision for the transfer of employment rights, including pension rights.").

The noble Baroness said: I am sure that everybody in this Chamber will agree with this amendment, including the noble Baroness the Minister, because it puts right an anomaly which has existed for some time; an anomaly whereby a nurse working in a general practice is not entitled to join the NHS superannuation scheme. Even though, over a number of years while working in the main part of the health service, she has contributed to

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the scheme she has to leave it. It is frozen and, if she wants to assure her pension at a later stage in her life, she has to start with a separate scheme.

That seems absolutely iniquitous, considering the fact that the general practitioners working in the service are entitled to be part of the NHS superannuation scheme. First of all, it is unfair that the nurses are discriminated against; but it might also militate against them wanting to join any of the new pilot schemes initiated by general practitioner services. It is important to treat all employees in the service in the same way.

If I had received somewhat earlier than about an hour before this debate started the new White Paper Primary Care: Delivering the Future, I should not have had to "speed read" in order to discover whether it said anything relevant to this amendment. On page 44, the Government admit that the situation was wrong and state:

    "The Government therefore intends to open the NHS Pension Scheme to staff employed by GPs. The new arrangements will take effect from September 1997".
The paper goes on to say:

    "The detail of how the Government intends to introduce these arrangements will be discussed with the profession's representatives".
That sounds very fine. It is in the White Paper. But I should still like this amendment to be on the face of the Bill to ensure that it is not forgotten over the coming months. If it is in the Bill, we should all feel satisfied that we were going to treat our nurses in exactly the same way that we treat the GPs in general practice.

In view of the statement in the White paper, I hope that the Minister will approve this amendment. I beg to move.

5.15 p.m.

Lord Rea: We very much endorse the views put forward by the noble Baroness, Lady Robson. It would seem as though the Government have conceded the principle embodied in the amendment. As the noble Baroness said, if the White Paper had come out at the same time as the White Paper which preceded the Bill, many things would have been clearer. But I agree with her that the amendment should still go into the Bill. After all, it is only a White Paper. The arrangements are to take effect from September 1997 and there may--there will certainly--be a change of government by then. It is very likely that the Government will be run by my noble friends on this side of the Chamber, although of course sitting on the other side of the Chamber. Would not the Government like to see their successors also bound to follow these excellent suggestions in the White Paper?

Baroness Gardner of Parkes: Without arguing the last point--I hope that we shall still be sitting here at that time--I should like to support the principle of the amendment. But I must query its wording. When I have on my other hat and sitting as a member of an industrial tribunal, I am very aware of continuing employment regulations or transfer of undertakings regulations. But

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from what the noble Baroness said, these people are not currently employees of the health service because they work for a general practitioner. If that is so, and they are not currently in the health service, the transfer of undertakings would not cover them. It would only cover people who are currently National Health Service employees. It may be that different wording is needed. I feel that one needs to create continuity of employment within the National Health Service or something of that kind.

I strongly approve of the noble Baroness's point about pensions. In the case of my husband and myself, we each paid 6 per cent. of our earnings into the National Health Service pension scheme. Yet if I die, he does not receive a penny from my pension; but if he dies, I get 50 per cent. from his. I understand that that anomaly has now been corrected. But I felt very bitter about the situation for a number of years. I believe that it is very important to ensure that pension rights are protected. But we might have to go into the legal technicalities of the employment situation and I am not sure that these words would do what the noble Baroness intends.

Baroness McFarlane of Llandaff: I too support the intention of the amendment put forward by the noble Baroness. In any other setting this kind of anomaly would lead to inflexibility and lack of mobility in the workforce. That is the very thing that we want to try to avoid in the National Health Service. I support the amendment.

Baroness Cumberlege: My noble friend Lady Gardner is right. Practice nurses have been employed directly by GPs in the past and therefore the Government felt it right that the employers should take on the responsibility of the pension scheme. But we have listened to nurses and recognise their concerns about this particular issue. So the Government are committed to widening the NHS pension scheme to practice nurses.

I think the Committee will agree that we need to discuss the matter with the profession's representatives. It would not be right just to go ahead without having discussed it with them. Therefore, we feel that it would be premature to put this amendment on the face of the Bill.

Baroness Robson of Kiddington: Of all the amendments that appear today on the Marshalled List, I felt that this was one to which the Government would agree. I can see the point in regard to nurses who are already outside the NHS scheme because they are working for a general practitioner; but I cannot understand why it is not possible to include this provision on the face of the Bill. I should very much like to see it included. I shall not press the matter today but will come back to it at a later stage. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 8 to 10 not moved.]

Clause 2 agreed to.

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Clause 3 [Approval of pilot schemes]:

Baroness Jay of Paddington moved Amendment No. 11:

Page 3, line 20, at end insert ("(if the pilot scheme is for personal medical services) ask the Medical Practices Committee for its assessment of the adequacy of medical services in the area likely to be affected by the proposed pilot scheme and its assessment of the likely effect of the pilot scheme on the adequacy of those services and, having taken into account those assessments, he shall").

The noble Baroness said: In moving Amendment No. 11, I shall speak also to Amendments Nos. 13, 14, 31, 54 and 62 and to Clauses 10, 11 and 12. I hope that that is in order. It may sound somewhat sweeping but, as we are in Committee and as the amendments and those short clauses are relevant to the status and position of the Medical Practices Committee--which all the other amendments address--I suggest that it may be appropriate to discuss them all together.

As the Committee will recall, when we spoke about this issue on Second Reading many Members on different sides of the Chamber raised concerns about the Medical Practices Committee and the position it would have under the new pilot schemes. The Minister, in reply, explained to us at that stage that she had already talked at length to members of the Medical Practices Committee and discussed its position in relation to the Bill or in relation to the pilots and further permanent schemes. At that stage she was not able to report any conclusion to the Chamber. However, she did say that she would be putting forward proposals in the light of those discussions. I hope that today the noble Baroness will be able to give us some report on the progress of those discussions and to say that these amendments as they stand will provide a stimulus to some of the solutions which we on this side of the Chamber and others who support the amendments feel may deal with the problem.

The purpose of the amendments is to ensure that the Medical Practices Committee continues to fulfil its statutory responsibility to ensure that as far as possible primary care services delivered by general practitioners are equitably distributed within a national framework. As I said, several noble Lords at Second Reading raised the concern that, by establishing the pilot schemes in the way that they are presently drafted in the Bill, that would mean that the Medical Practices Committee was effectively bypassed. There is anxiety in that committee that provisions in the Bill are designed to sideline it and make it irrelevant to the processes it justifiably and rightly feels are important.

I remind the Committee that at present the Medical Practices Committee, as a national body, has the duty which it has had since the NHS was instituted in 1948 to assess whether various areas are served by an adequate number of GPs; to exercise its discretionary power to refuse, where they are so served; and to ensure that as many areas as possible are so served. That is an essential function in the struggle to improve equity of access in the health service.

As I and other noble Lords who spoke at Second Reading described, there are large inequalities in the provision of services throughout the country. For example, it has been calculated that 700 doctors would

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have to move to the north from the south of England to provide a reasonably equitable distribution of general practitioners across the country. And, as I said in an earlier debate this afternoon on new Clause 1 and as my noble friend Lady Hayman emphasised in relation to the consultation process, we are fearful that some of the new proposals that could come forward under the pilot schemes, particularly those introducing commercial interests into primary care, may serve only to increase services for the better off and do nothing to improve overall equity, and indeed may work against it.

It is therefore extremely important that in a more deregulated system which this Bill opens up, the Medical Practices Committee should retain its power to act on a national overview of needs. Amendments Nos. 11 and 14 are specifically designed to ensure that that takes place. I prefer those two amendments to Amendment No. 13, which I feel is less stringent in its understanding and less precise in its demands on the regulations that the Medical Practices Committee should carry out.

The British Medical Association, as well as the Medical Practices Committee, is concerned that under the Bill as it stands there will be two different workforce planning systems--one where, through the Secretary of State, with prior agreement of health authorities and boards, decisions are made in relation to doctors entering pilot schemes and another where the Medical Practices Committee retains the remit for determining recruitment or replacement of GPs who are working under the present contract. Both the British Medical Association and the Medical Practices Committee feel that it is inappropriate, given the long experience of the Medical Practices Committee and its extremely extensive national database, that they should not be involved in assessing and agreeing to the involvement of GPs in the pilot that will take place under a rather different scheme.

The question also arises as to whether the way in which the approval of the pilots is obtained may adversely affect the ability of existing practices to recruit additional or replacement partners. That again relates to the matter of equity. It is suggested, for example, that if a local health authority agrees to pilots which are attractive to general practitioners, that may unfairly diminish the possibility of other GPs practising in that area gaining new partners or replacing old partners in a way which maintains the equity of the service.

The point overall is that there should not be two different systems for assessing and evaluating the way in which doctors are contracted and may be employed under the pilot schemes to provide services; that we have in existence the effective Medical Practices Committee which makes that provision possible within a national framework, and to make it more complicated by having a dual system may simply exacerbate inequities and do little to make it easier to establish a national picture of the way in which the workforce should be agreed.

There are also complications--referred to in the clauses we feel should not stand part of the Bill--in relation to why it is that the dual arrangements for

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contracting general practitioners and making them part of the pilots will have an inhibiting effect on the ways in which the general system is agreed. For example, under Clause 10, GPs entering into pilot arrangements are required to leave the medical list under Part II of the NHS Act. They would not be allowed to work under both parts of the Act or to hold lists of patients under both parts. If that was deleted it would mean there had to be special arrangements, as Clause 10 allows, for medical practitioners who provide medical services in pilot schemes to be separately looked at and assessed. They could stay on the medical list. They would be part of the original system and would not be required to resign.

Clause 11 is another area where the same problem arises in relation to treating general practitioners within a pilot scheme in a different way from the system nationally understood and already working which is arranged through the Medical Practices Committee. For example, if Amendment No. 31 is accepted, a doctor who was included in the medical list under Clause 17 (if that were amended) would be included on the local list by the Medical Practices Committee. If the pilot scheme failed, the doctor would still be on the list and would not need to be given preferential treatment to return to the list.

In other words--I know this sounds extremely complicated--the basic point is to maintain one unified system for dealing with all general practice and for allowing all general practitioners to be assessed under an effective and well managed national scheme which takes into account both local and national needs and is able under the scheme which has been working since 1948 to make assessments on the basis of long experience and with an invaluable database. Indeed, if Clause 12 was deleted, the difference between "personal medical services" and "general medical services" would be effectively eliminated by bringing all the personal medical services into the control exercised by the Medical Practices Committee (that would be under Amendment No. 31) and this clause would also not be necessary.

This is an extremely complicated area and there may well be different points to which the Minister will want to reply when she responds to this group of amendments. However, the basic point is that in the Medical Practices Committee there is a well organised and long established national body which has a statutory responsibility. It is unclear from the discussion we had at Second Reading why its remit should not be extended to cover pilot schemes. It seems important that the MPC should be included. If it is not to be included--if it is to be excluded--that should be made more specific.

At Second Reading the Minister said that she and other colleagues were engaged in discussions with the Medical Practices Committee. Noble Lords will recall that in many debates in your Lordships' House we have spoken of the need to maintain a national framework for the National Health Service. We have also expressed fears from these Benches about recent fragmentation. In her reply to the Second Reading debate when speaking about the Medical Practices Committee the Minister was

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specific. At col. 649 of the Official Report of 3rd December 1996 she said that she wished to ensure that a coherent local and national approach was applied to new proposals. I hope she will accept that these are in a sense probing amendments, because we want to establish the role of the Medical Practices Committee will have in future, but we are trying to seek to ensure a continuing role for the MPC and we are seeking to ensure that the aspiration which the Minister expressed at Second Reading for a coherent local and national approach becomes a reality. I beg to move.

5.30 p.m.

Lord Alderdice: In supporting Amendment No. 11, I should like also to refer to Amendment No. 13, which stands in my name, Amendment No. 31 and the proposition that Clauses 10, 11 and 12 be excluded from the Bill. The concern that I represent on behalf of my colleagues on these Benches is not merely about the continued existence and satisfactory functioning of the Medical Practices Committee, now almost at its 50th anniversary, but a much more fundamental one about whether a health service continues to be a truly national health service.

We strongly welcome the notion that local sensitivity and local creativity might be expressed in the development of pilot schemes in order that new ideas come forward which might be properly evaluated and then taken up by practices in other parts of the country. That is exactly what one would want to see in best practice. However, if things work out as described by the Minister and there is, in her words earlier today, "a rapid expansion of schemes", it is much more likely that, rather than a number of well constructed pilot schemes being embarked upon, reviewed, adopted widely and continuing to develop and to benefit a national health service, we shall see a rapid expansion of very different pilot schemes throughout the country which will lead to a fragmentation of service. Unless there are bodies which will properly monitor what is going on we shall undoubtedly see our health service no longer national but even more different and less coherent than is the case at present.

In supporting these amendments we express our serious concern that if the excellent idea of pilot schemes is not properly monitored, it could be the beginning of an even further fragmentation of the National Health Service, which is one of the most prized commodities and institutions of our country.

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