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Baroness Jay of Paddington: I am grateful to the Minister for her detailed response to this series of amendments and the Question whether the clauses under discussion should stand part of the Bill. I am tempted to follow the response of my noble friend Lady Hayman to the earlier debate on Amendment No. 5 and the related group of amendments. This afternoon there have been a number of double arguments that attempt to make the same point. For example, in this debate each time we try to put in place a safeguard to protect standards, or in this case to protect the way in which general practice is developed in different parts of the country, we are told that it is needless bureaucracy. However, we are always assured that detailed planning will be carried out and enormously elaborate systems put in place before any pilot scheme is agreed, let alone determined to be a permanent change of service.

The more one discusses the Bill, the more it appears that what we are considering are good intentions rather than safeguards or exact provisions on the face of the Bill. In response to this group of amendments the noble Baroness referred to the Government's commitment to equity as being a basic plank of the Bill, but when in this and in an earlier debate on another group of amendments we have tried to ensure that equity is explicitly required on the face of the Bill, that is denied. In her response to this series of amendments the noble Baroness speaks of the central role of health authorities and their ability to assess local needs in a much more significant way than the Medical Practices Committee, which would look at the matter on the basis of only GP services. We are led to suppose that GPs are not

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absolutely central and that a wider provision of services is looked for under the Bill. That was exactly our understanding. We understood that the idea behind the Bill was to improve and increase the flexibility of local services. However, earlier this afternoon when the noble Baroness, Lady McFarlane, sought to introduce an amendment to enable other professionals to become the lead proposers of alternative arrangements under pilot schemes, it was rejected by the Government.

As we progress further with the Bill, it is difficult to understand precisely who are the principal instigators of the new schemes, who is to have the controlling influence in ensuring that they provide equity, together with the other principles that we are told are essential to the changes, and who is to assess the overall standards and framework within which we have always believed that the National Health Service operates.

The noble Baroness in her reply also said that she and her honourable and right honourable friends in another place, the Minister for Health and the Secretary of State, continued to discuss with the Medical Practices Committee the contribution that it could make under the new pilot schemes. However, if I were a member of the MPC, on the basis of the remarks of the Minister I would be extremely pessimistic.

The British Medical Association is also in tune with the Medical Practices Committee in agreeing that there should be a means of looking at the overall doctor workforce, whether or not they are regarded as central to the new pilot schemes. I agree with that. I believe that in the interests of equity--which the Minister emphasises is the primary aim of the Bill--there must be an organisation to do precisely that. I also agree with the noble Lord, Lord Alderdice--I am sorry that he feels that I have not emphasised it sufficiently--that the main principle behind all of these amendments is to try to avoid further fragmentation of the National Health Service. All of us are concerned about that. Within the Medical Practices Committee there is a national body that has some remit to try to prevent that fragmentation. However, from what the Minister has said--she has left the door slightly open--the Government do not see the role and overall perspective of the workforce as being particularly important in the development of the new pilot schemes. As we have feared, this is all about deregulation rather than the equitable organisation of services.

I am disappointed by the Minister's reply, but at this stage I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

6 p.m.

Baroness Jay of Paddington moved Amendment No. 12:

Page 3, line 24, at end insert--
("( ) The Secretary of State may not approve proposals for a pilot scheme unless he is satisfied that the scheme meets nationally agreed criteria for the quality of services provided to patients.").

The noble Baroness said: I beg to move Amendment No. 12 and speak also to Amendments Nos. 18, 22 and 23. All four amendments are designed to ensure that the

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pilot schemes for new primary care are not simply approved and evaluated on the basis of a described local need or comparative cost but will also meet nationally agreed criteria to ensure that the care that is offered is of the highest national standard of practice. To an extent, this is a continuation of the debate on the previous group of amendments. It is an attempt to prevent the fragmentation and disorganisation of services simply in the interests of diversity.

If this amendment is accepted we hope that agreed criteria are published before the machinery of establishing the pilots gets under way. On these Benches we accept that the increased flexibility in local practice arrangements may well extend the types of primary care services to be offered, something which we have already discussed this afternoon. For example, we discussed under earlier amendments that we welcomed the possibility that nurses and others would have a wider responsibility in health care promotion. Indeed, if the amendments of the noble Baroness, Lady McFarlane, had been accepted we would have liked to see them as lead partners in pilot schemes, but we are also concerned to ensure that increased diversity does not lead to reduced overall quality.

At Second Reading the Minister emphasised the need for quality controls in these pilots--also mentioned in the White Paper Choice and Opportunity, which spoke of promoting consistently high quality across the country. In introducing the Bill at Second Reading the Minister said, at col. 591 of the Official Report that local flexibility should be balanced by national safeguards for patients and practitioners. However, she did seem to see this more in terms of the professional relationship between individuals and their general practitioners rather than protecting or, even more importantly, promoting the quality of services to be offered under the new schemes.

I realise that the question of evaluating and standardising quality in medical care is extremely complex and very delicate. Doctors rightly resist what they now call recipe book clinical practice. However, one of the positive changes in the health service in the recent past has been the overall professional acceptance that evidence-based practice, peer group review and the general bench-marking techniques widely used in business and industry can play a role in health care. My noble friend Baroness Hayman has already referred to the scepticism which has grown up in some places within the health service about the fact that they are constantly asked to deliver evidence-based care without any reference to evidence-based policy. That lack of evidence-based policy has been very apparent in the fact that the Government have so far resisted developing what I suppose one might call NHS gold standards for the quality of service.

It is true that today we have the almost unenforceable aspirations of the Patients Charter, but there also seems to be very little official enthusiasm for producing and agreeing national workable criteria for assessing high quality care; criteria which presumably should be based (at least in the first instance) on comparative research and measuring outcomes. This Bill is a golden opportunity to initiate such research and agree such a

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system. Basically our concern, which has been expressed in several of the groups of amendments, is that unless the pilot schemes are developed and evaluated within a national framework of standards then more may simply mean worse. Clearly evaluation of these schemes, once they have been established, is absolutely crucial and we would hope to see that done on the same kind of previously published criteria as those which are agreed for setting up the pilots in the first place.

At the Second Reading debate the Minister said that the evaluation process would be determined following discussions with professions, health authorities, academic units and patients. However, it seemed to leave a great deal open in terms of the different types of review processes which might be applied to different schemes and it seems to us important that those proposing pilot schemes should know that there are at least some nationally agreed criteria which will be involved in determining the review process. Such criteria could again be very similar to those which were agreed on a national basis for setting up a pilot in the first place. They might, indeed, include all of the things about quality of outcome as well as responsiveness to local needs, which would be strengthened if the amendments which my noble friend Baroness Hayman introduced about local consultation had been agreed as well as, of course, cost effectiveness.

When the noble Baroness introduced the Bill at Second Reading she gave assurances about maintaining standards, as did the White Paper which preceded the Bill. We are back to this question of goodwill and assumptions about people's intentions which I referred to when I was summing up on the previous group of amendments. Assurances have been given but the Bill as it stands really gives no indication as to how maintaining standards will be achieved. The purpose of Amendment No. 12, and the others in this group, is to enable a national system of criteria to be developed against which pilots can be established and tested in terms of the broad overall quality of services to patients. I beg to move.

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