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Baroness Eccles of Moulton: In considering the proposals put forward with regard to the Medical Practices Committee it is important that we accept the current situation in terms of equity of service across the country. The noble Baroness, Lady Jay, said that a certain number of GPs will have to move from the south to the north in order to achieve that. The Medical Practices Committee has only the power of veto and therefore it seems difficult to accept that pilot schemes going forward under the form of approvals we have already discussed will necessarily exacerbate the inequities. Unless it is given a try it will be difficult to know whether this is the right was forward.

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Another point is worth making. It has been said that the Medical Practices Committee is the repository of a great deal of knowledge about GPs' qualifications and their records of service. It is not the only repository of that information. The committees that sit to appoint GPs also have that information. I should have thought that GPs themselves, when applying for a new practice or for a first practice, would be well able to supply that information.

I do not think it will be at all helpful to the success of the pilot schemes if they are not established in the most unfettered way possible.

Baroness Cumberlege: The Government are committed to fairness in the distribution of services. That was a fundamental principle underpinning Primary Care: the Future and restated in the White Paper Choice and Opportunity. It is because we want to ensure equity that we presented the Bill.

The existing mechanisms have worked well in many places in the past but not everywhere. We need to be extremely careful about imposing constraints on decisions concerning pilots. The Government believe that pilot schemes should improve fairness both within health authority areas and between health authorities. That will be a key consideration when pilots are considered and before approval is given. We wish to have full discussions with the profession and others before determining how this can best be achieved. We have already started these discussions with the chairman of the Medical Practices Committee and my right honourable friend the Secretary of State, Stephen Dorrell, has written to the General Medical Services Committee. It would be wrong and potentially damaging to sensible development to pre-empt these discussions in the way the amendments seek to do.

Perhaps I may now deal with each specific amendment. Amendment No. 11 would require the Secretary of State to involve the Medical Practices Committee in the decision to approve a pilot. In particular it would place a requirement on the Secretary of State to obtain an assessment from the Medical Practices Committee about the adequacy of medical services in the area likely to be affected by the scheme and the likely effects of the pilot scheme on the adequacy of those services. Assessments would have to be taken into account in reaching a decision.

The amendment refers to medical services and not to adequacy of general medical practitioners. An important distinction needs to be made here. The distribution of general medical practitioners, by using negative direction, is quite a different role from that of assessing the health needs of populations and planning service provision to meet them. The former is about the input of a specific resource, albeit a crucial one, while the latter goes much wider, involving other considerations, including the part other professions have to play in the provision of family doctor services.

Health authorities have to assess the health needs of their populations and to judge the nature and extent of services required across primary and secondary care. They must make judgments about the balance between

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primary and secondary care and the priority to be afforded to particular services to best suit the needs of patients. They must also make judgments about the inputs into services--human and financial--balanced against outcomes. It is for this reason that health authorities will produce workforce plans for general medical services which are consulted on locally.

Plans will take account of all professional groups--medical practitioners, nurses, professions supplementary to medicine and administrative and clerical staff. These plans will be consequential upon careful planning of services to meet needs and will inform decisions about recruitment, education, training and development of the workforce. It is crucial to success that health authorities' plans for services and consequential workforce plans form a single point of reference to inform other decisions. That is what we intend to achieve.

Decisions by the Medical Practices Committee and decisions by the Secretary of State on pilots must be fully informed by these plans. This amendment would mean that the Medical Practices Committee not only second-guessed health authorities' decisions about the health needs of its population and the services required, but also the Secretary of State in the process of approving pilots. It would result in needless bureaucracy and take decisions about services further away from the patient.

As I have tried to make clear, I do understand the concerns which have been expressed about pilots leading to an inequitable distribution of services. I too would be concerned. But this will not be the case. Areas of high need will be targeted where perhaps the more traditional ways of providing general medical services has not delivered the quality or range of services required.

Pilots will cover a diverse range of services provided through a variety of professions. While for the most part they will be led by a family doctor, the emphasis will be on team working with other professionals--nurses, physiotherapists and others. The aim is to provide an environment which encourages innovation and flexibility.

In general medical services, resources have tended to follow general practitioners who themselves are not distributed entirely equitably in relation to population. The distribution of GPs per head of population varies across the country. Some health authorities have average patient list sizes which are 50 per cent. higher than in others. In some parts of the country expenditure is almost two-thirds higher than elsewhere. Recently published papers and articles have pointed to similar inequities. While it is probable that this may be overstating the case, because we need to develop better measures of need for general medical services, we do accept that there is an underlying problem.

It is not surprising that such inequities have occurred. As the noble Lord, Lord Walton, said in the Second Reading debate, the Medical Practices Committee has had considerable experience in ensuring an even distribution of general medical practitioners. But this is based on the distribution of GP principals through negative direction. In other words, while they can only

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prevent a doctor practising in over-doctored areas they cannot stimulate a doctor to work in an area. The provision of services in areas which are less desirable are best achieved if health authorities, GPs and other service providers are together able to explore ways in which services might be provided. Pilot schemes will provide new opportunities for such development.

The noble Lord, Lord Walton, also said that the Medical Practices Committee is the only body which has a detailed overview of the national GP manpower situation at any one time. But this understates the position. National manpower planning is a key task of the Department of Health. It is an essential component of financial planning and distribution of resources and providing the trained workforce for the future. Information is collected from health authorities at regular intervals to feed into this work, which is highly detailed and requires particular skills and abilities. This is a proper role for the department, which will continue to be taken forward. It is for this reason we have asked health authorities to undertake workforce planning for general medical services so that local needs and difficulties can be better understood and fed into the national picture.

This is not the role of the Medical Practices Committee nor would it be appropriate that it should be. The committee comprises of nine people, working part-time, dealing with applications from doctors to join medical lists. I am not questioning their expertise in this area; but it is wrong to believe that their role goes wider or indeed that it would be appropriate for it to be so widened. I repeat, we shall be discussing with the Medical Practices Committee ways in which its knowledge and expertise might usefully feed into the work on national workforce planning in collaboration with the profession and others who have an interest in this area.

As I said, we are committed to achieving equity and this is fundamental to our aims. We have already taken forward work within the department which has looked at the distribution of resources for general medical services. We need to develop this work further, in particular how to measure need and discuss with those who have an interest.

Amendment No. 13 is intended to complement the earlier amendment giving an inappropriate role, we believe, to the Medical Practices Committee. The amendment would mean that the Secretary of State may not approve proposals for a pilot scheme for personal medical services unless he is satisfied that the proposals have proper regard to the needs of other areas and the assessments made by the Medical Practices Committee. Thus, the Medical Practices Committee would be required to make an assessment of the impact of any pilot schemes for personal medical services on areas other than those in which the pilot is intending to operate.

As I hope I have already made clear, it is health authorities who must judge the health needs of their populations and determine how services should be provided to best meet those needs. Pilot schemes will be reflected in any plans, as will the more traditional

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ways of providing family doctor services. I expect health authorities to consult locally with LMCs and other interested groups about their plans for general medical services and the effect of any pilots on those services. Similarly, health authorities will be expected to consult the Medical Practices Committee about their plans for general medical services so that a coherent view can be formed over the number of general medical practitioners required to deliver services. These discussions will include any plans for pilots to enable the Medical Practices Committee to take these into account when carrying out its statutory role in relation to general medical services. It is totally inappropriate for the Secretary of State to have to seek any reassurances from the MPC about pilots.

Amendment No. 14 also seeks to ensure that, in approving pilot schemes, the Secretary of State has to have paid due regard to an assessment made by the MPC about the need for those services. In making such an assessment, the MPC would assess whether or not there is already adequate provision of general medical services in the area likely to be affected by the pilot scheme compared with the needs of other areas. That assessment would then have largely to determine whether or not the Secretary of State approved the scheme.

As with earlier amendments, this places a responsibility on the MPC well beyond its current statutory duty and provides for it to second-guess health authorities in their strategic, financial and human resource planning role. Perhaps even more importantly, it would fetter the discretion of the Secretary of State. In accepting such amendments he would no longer be responding to the clear messages received from the profession, public and health service managers through our listening exercise that the biggest need which currently exists is for primary care services to be provided in flexible ways to meet the needs of patients and the professionals working within those services. Instead we would be tying ourselves into a bureaucratic process, which would confound robust and clear decision-making processes and confuse lines of accountability and responsibility. Therefore, we do not support this amendment.

Amendment No. 31 is connected to earlier amendments which attempted to provide a role for the MPC in agreeing pilot schemes for personal medical services. This amendment is intended to provide a process whereby any permanent schemes which followed from successful pilots were considered by the MPC.

However, the amendment is defective. Decisions currently made by the MPC are concerned with the distribution of doctors providing general medical services and only that.

That is carried out by a process of negative direction whereby the committee does not admit a doctor to a health authority's list if the area is over-doctored.

The second part of this amendment confuses two quite different processes, which are in place for two different types of service provision: the process of admission to a list by the MPC so that a doctor can

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provide general medical services in a particular area, and decisions made by health authorities to provide personal medical services which do not involve admitting a doctor to a list. We cannot therefore agree to such an amendment.

Amendments Nos. 54 and 62 deal with our revised appointment procedures for doctors providing general medical services. These new procedures are required to remove anomalies and provide a sound basis for GP appointments. In particular, it is intended to reduce bureaucracy. These amendments would leave in place Section 30 of the Act, which requires the names of all doctors wishing to provide general medical services to be submitted to the Medical Practices Committee for approval and inclusion in the health authority's list. The section would remain alongside the clause we have drafted as a replacement. This confuses the roles and responsibilities of the MPC and those of health authorities. I am sure that that cannot have been the intention. I hope that these amendments will not be pursued by the Committee.

I should like to address the Question that Clause 10 stand part. This clause will ensure that medical practitioners who provide care for their patients under pilot schemes may not also provide services under the national arrangements. This should bring clarity to the arrangements under which services are provided for patients. It is important that GPs and health authorities are clear as to whether the services provided by a particular GP are provided under one arrangement or the other. To allow a mix and match arrangement, with a patient receiving some treatment under one system and other treatment under the other, could lead to confusion.

However, the clause provides for regulations to allow exceptions to this rule. There may be circumstances where such exceptions are sensible and necessary. For example, it may be necessary to allow GPs who provide a specialist obstetric service to the patients of other GPs to provide such a service to patients of medical practitioners working in pilot schemes. It is hoped that your Lordships will agree that Clause 10 should stand part of the Bill.

Clause 11 underpins the voluntary approach to pilot arrangements by ensuring that GPs can be given the right to transfer to the medical list and to the existing national arrangements if and when they leave pilot schemes. When a doctor sets himself up in general practice he is setting himself up in business and he takes the commitments that go with that. Whether he is a single-handed GP or a partner in a practice, he will have premises that need to be paid for, staff to pay and overheads to bear. GPs who work in pilot schemes will need the security of knowing that they can, if they want, transfer from pilots to the national arrangements with ease. It is particularly important that they should not have to go through the whole application procedure as if they were not yet practising GPs, especially since in most cases they are likely to bring lists of patients with them.

The clause provides that before a health authority or board makes a pilot scheme the Secretary of State will publish criteria dealing with such transfer arrangements.

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He will decide whether a particular GP should be given preferential treatment if, once he has ceased to provide services under a pilot scheme, he makes an application to a health authority or board asking for his name to be included in the health authority's or board's medical list. Naturally the GP would need to meet the eligibility criteria in force for the time being, for example those on age. The Government believe that this is a central plank of the Bill, and we ask the Committee to support the clause.

Clause 12 is important in safeguarding the quality of the services that patients receive when they are treated by a deputising GP. It will enable regulations to be made which will set out clearly the liabilities and obligations of GPs working in the existing system in circumstances where doctors working in a pilot either act as deputies for them or else use them as deputies. The situations that arise under the current arrangements are provided for by regulations made under the 1977 Act. Until now there has been only one arrangement around which to regulate. Under the pilots doctors will work under contracts that will differ from place to place and from circumstance to circumstance. Their arrangements will vary from the national terms of service. However, it is important that arrangements regarding liabilities and obligations are consistent and fair. This is the aim of these provisions. This clause will provide for a seamless primary care medical service where deputising services are used. I invite your Lordships to agree that Clause 12 should stand part of the Bill.


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