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Baroness Robson of Kiddington: We on these Benches support this amendment. There is really nothing much to be said after that introduction by the noble Baroness, Lady Jay. However, we are concerned, as are most people, that although the idea of flexibility in the type of scheme that is introduced locally is appealing and basically good, the pilot schemes should be based on a national standard which everybody can understand and judge them against.

We suffer already, and have done for some time, from a lack of national standards of care over the whole of the National Health Service. In many parts of the country the standards vary enormously. We do not want the flexibility of the pilot schemes to add to that difference. We want them based on carefully considered national standards so that we are certain that they are an improvement on what is happening at the moment and

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that they will not endanger some of the undoubted benefits which we get from the present primary health care system.

Lord Winston: I should like to echo what my noble friend Baroness Jay said about the Government missing what is essentially a very important opportunity.

It must be recognised that general practice is among the most difficult of all medical specialties. That may seem a very odd thing to say, but this must be considered in the context of the general practitioner seeing a huge range of different medical problems and consequently having to spot among those medical problems the very occasional problem; for example, the one cancer of the colon that he might see once every three or four years in a typical general practice. He must be alert to such eventualities. That makes his responsibility a very grave one.

It seems to me that one of the key issues which has already been mentioned by the noble Baroness, Lady Robson, is the very great variability in the United Kingdom in the standards of general practice. Of course, most general practitioners in this country are excellent. They are among the best available anywhere in the world, but we do have a great variability of practice. Certainly many of us who work in the cities see that in the inner city areas general practice is often very poorly conducted. It troubles me that we might see a worsening of the position unless there is vigorous inspection of these pilot schemes. After all, this is not a new idea. It was this Government who instituted the notion of peer review, for example, of fertility units, which has been an important part of the inspectorate system, in order to make sure that adequate patient care and quality is maintained.

One of the aspects that concern me is that a general practitioner must ensure that he keeps a proper watching brief over a patient after referral to a hospital rather than simply losing that patient, that he maintains proper family care afterwards, and to ensure that he is actually referring the patient to the right place to get the best treatment. These are often omissions widely seen in general practice in this country. He must also make certain that there is adequate referral communication. I saw a patient only a week ago in my unit who had the most complex medical history with some five or six abdominal operations, and the referral letter simply said, "Please see and advise", with no recognition that the patient had this complex history which bore extreme elements to the nature of the referral.

Another issue is that when GPs decide to do investigations they do them adequately and at the right time. I have just seen a member of my family who, as it happened, turned up at my hospital, having been sent by a GP with the wrong forms, for a series of investigations. The investigations were not going to be done because they were on the wrong forms. However, those investigations were done over 10 days ago. As far as I know, the GP has never bothered to pick up the results, so he cannot act on them. It fortunately happens that that relative has a medical person in the family who can sort that out.

Finally, one of the issues that is troublesome is the variability in primary care medicine of how GPs pick up or attend post-graduate education. That is an area which

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could also be monitored in these schemes. It is important that the Government consider the implications of the amendment to see whether something could be done about that area.

Baroness Cumberlege: We are committed to introducing pilots only where there are demonstrable potential gains to be made in the quality of services delivered. As indicated in the document Primary Care: the Future and in the White Paper Primary Care: Delivering the Future, published today, we have identified the need to take action to bring up the standards of service in some areas to meet the overall high standard of primary care. The introduction of this Bill is one arm of our strategy to do this.

We are currently setting up arrangements to underpin our commitment to ensuring that pilots set up under this legislation deliver service improvements. We wish to discuss with the professions, with representatives of academic units and patients and with health authorities how standards might be identified in schemes for approval and subsequent evaluation of how successfully the aims and objectives of the pilots have been met. We do not underestimate the difficulties in doing this or the importance of getting it right. We will be establishing a representative group nationally to take this forward and have written out today on this matter to individuals. This will include discussion of what criteria should govern the approval of pilots.

We do not believe that in advance of that detailed work we can on the face of this legislation circumscribe the Secretary of State's decision-making powers in quite the way these amendments imply. We do not know to what extent the group will be able to come up with criteria which might be applied across the board in looking at prospective pilots. Pilots will inevitably vary considerably and it may be quite difficult to find criteria which are both generally applicable and sufficiently challenging to provide the assurances that both we and the noble Lords believe are needed. We have within the Bill in Clause 2 the powers for the Secretary of State to direct health authorities on what matters must be dealt with and what information included in preparing the proposals for any scheme.

We have within Clause 5 the powers for the Secretary of State to determine what procedures on any review should apply. It is within these powers that we intend to reflect the results of the representative national group's conclusions on both scheme specific and general criteria on the quality of services to be provided to patients. It could be positively harmful to prescribe a common procedure and criteria if this meant producing standards which met only the lowest common denominator and distracted attention from the vital quality and procedural issues specific to the pilot in question.

We would therefore ask the noble Baroness to withdraw Amendment No. 12 and not to move Amendment No. 23, as we think their intentions are better served by the provisions already within the Bill.

In looking at Amendment No. 18 we acknowledge the need to be open about pilots and the criteria on which reviews will be based, but I am not sure that this

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amendment is the best way to achieve this. Clause 4(4) is about providing useful information to local people about services being provided under schemes. What local people what to know is what services they can get where. Mixing up this information with details of what is being piloted and what the criteria for evaluation will be could cause confusion rather than be helpful.

I can assure the Committee that the criteria against which pilot schemes will be evaluated will be established prior to the scheme being implemented. In the main these are likely to be to what extent the pilot scheme has met the service objectives set out in the proposal. But there may be others. We certainly have no reason to keep the criteria secret. We want the evaluation to be open, thorough and credible.

Perhaps I may take up the points made by the noble Lord, Lord Winston, about inner city areas. We had a discussion about that earlier this afternoon. It is because we are so concerned about those areas that we have sought new ways of providing services. In the past we have been convinced that it is the rigidity of the NHS Acts that has prevented some imaginative proposals. If we do not improve primary care in those difficult and challenging areas, the Bill, if it becomes an Act, will have failed.

Training is an issue that has been taken up today in the White Paper. I hope that when the noble Lord has had a chance to see it he will come back to me if he feels that there are issues that need further exploration.

6.15 p.m.

Baroness Jay of Paddington: I am grateful to the Minister for that helpful and in some ways encouraging reply. Especially encouraging is the news she gave of the establishment of a national body to look at national criteria in relation to those pilots. We of course look forward to hearing a progress report on how that group develops. If it is possible, perhaps before the Bill leaves another place, for those criteria to be explained to Members of another place, I am sure that that will give us greater confidence about the exact terms by which the pilots will be judged. If that proposal is within the White Paper, I am afraid that I must plead, as did the noble Baroness, Lady Robson, earlier, that speed reading has not enabled me to find it.

I would say also--this is something which my noble friend Lord Rea mentioned in an earlier debate--that it seems a little unhelpful, to put it at its mildest, that the White Paper, which is relevant to the progress and understanding of the Bill, has been produced only today when we have reached Committee stage. If it had been published with the earlier White Paper, some of the things which we have said--the Minister has rightly responded by saying that some of the points have already been met--would not have been necessary, and we should not have wasted everyone's time in making them. However, that does not affect the status of this group of amendments, to which, as I said, there was an encouraging reply from the Minister. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 13 and 14 not moved.]

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