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Baroness Jay of Paddington: My Lords, I wonder whether the Minister can help us with some explanation of the terminology in Amendment No. 18 with regard to the phrase "or body corporate" which refers to the type of body which could become a health service body for the purposes of application for a pilot scheme.
Your Lordships will remember that in Committee we raised concerns which were expressed in an amendment that we attempted to make to Clause 1
dealing with the fact that we were unhappy with the idea that organisations which distributed dividends--that is, were within the common sense meaning of the words "body corporate"--should be excluded from the possibility of being pilot proposers.This is something which is giving rise to concern within the British Medical Association, which has now formally expressed its opposition to corporate bodies, in the general meaning of the word, becoming involved in pilot schemes. I believe that on a first reading Amendment No. 18 suggests that the Government are giving formal credibility to that understanding. Perhaps the Minister will explain whether that suspicion is correct or whether in the context of Amendment No. 18 "body corporate" has a meaning other than that which it might generally and colloquially seem to mean.
Baroness Cumberlege: My Lords, as I understand it, there has been some discussion with the General Medical Services Committee about that. I thought that it was satisfied with the interpretation that we have put on the word "corporate". Perhaps before Third Reading it may be helpful if I write to the noble Baroness giving her further details about that.
Baroness Jay of Paddington: My Lords, before Third Reading, perhaps the noble Baroness will also have another conversation with representatives of the BMA and the GMSC, because my conversation with the leader of that group of the BMA this morning suggested that it is still unhappy with that wording.
Baroness Cumberlege: My Lords, I shall certainly undertake to do that.
Lord Rea: My Lords, in giving examples of what could constitute a health service body and in illustrating how Amendment No. 18 would work, if I heard the noble Baroness aright, she mentioned doctors who are already providing general medical service and dentists already providing general dental services in the same way as we hoped would be put into the Bill in my Amendment No. 7.
However, reading the new words, it seems to me that quite a wide variety of people could qualify to become health service bodies. Again, my anxiety level is raised a little by that. The Minister reassured me in replying to Amendment No. 7. Perhaps she will say whether my anxiety is justified in this case.
Baroness Cumberlege: My Lords, I am well aware that your Lordships are unhappy about Amendment No. 18 and, with the agreement of the House, I shall withdraw it and bring it back on Third Reading. However, I do wish to move the other amendments in the group.
Amendment, by leave, withdrawn.
Baroness Cumberlege moved Amendments Nos. 20 to 26:
On Question, amendments agreed to.
Baroness Miller of Hendon moved Amendment No. 27:
Page 6, line 44, leave out ("the applicant is") and insert ("--
(a) in the case of an application under subsection (1), the applicant is, and
(b) in the case of an application under subsection (1A), the applicants together are,").
Page 7, line 4, leave out from ("to") to end of line 8 and insert ("such a health service body ("a pilot scheme health service body"), acting as acquire, as if the functions referred to in subsection (1) of those sections were the provision of piloted services.").
Page 7, line 8, at end insert--
("( ) Except in such circumstances as may be prescribed, a pilot scheme health service body resulting from an application under subsection (1A) is to be treated, at any time, as consisting of those with whom, at that time, the authority have arrangements under the scheme.").
Page 7, line 9, leave out subsection (6) and insert--
("( ) A direction as to payment made under section 4(7) of the Act of 1990 or section 17A(8) of the 1978 Act against, or in favour of, a pilot scheme health service body is enforceable--
(a) in England and Wales, in a county court (if the court so orders) as if it were a judgment or order of that court; and
(b) in Scotland, by the sheriff as if it were a judgment or order of the sheriff and whether or not the sheriff could himself have made such a judgment or order.").
Page 7, line 14, leave out subsection (7).
Page 7, line 20, leave out ("person who is a health service body by virtue of this section") and insert ("pilot scheme health service body").
Page 7, line 25, leave out ("those who are health service bodies by virtue of this section") and insert ("pilot scheme health service bodies").
After Clause 13, insert the following new clause--
(".--(1) Regulations may confer such powers or impose such duties on the Board, in relation to pilot schemes under which personal dental services are provided, as may be prescribed.
(2) The regulations may, in particular, make any of the following kinds of provision.
(3) They may authorise or require the Board--
(a) to perform on behalf of an authority functions of a prescribed description (including functions relating to remuneration) which have been delegated to the Board by the authority in accordance with a power conferred by the regulations;
(b) to conduct or commission surveys or other research;
(c) to carry on such other activities as may be prescribed.
(4) They may provide that functions conferred by the regulations are only to be exercised by the Board in accordance with directions of the Secretary of State.
(5) They may enable the Board to direct a dental practitioner to submit to the Board, in relation to treatment or a description of treatment that he has carried out or contemplates carrying out, such information (including estimates, radiographs, models and other items) as may be prescribed.
(6) In this section "the Board" means--
(a) in relation to England and Wales, the Dental Practice Board; and
(b) in relation to Scotland, the Scottish Dental Practice Board.").
The noble Baroness said: My Lords, in moving the above amendment I shall speak also to Amendments Nos. 33, 35, 40 and 42. The amendments in this group give the Secretary of State powers to make regulations to give the Dental Practice Board functions in relation to personal dental services. In practice, this will enable the Secretary of State to extend the role of the DPB so that it can provide a range of support services in respect of dental services provided under pilot and permanent schemes in a similar way to those it currently provides for the general dental service. That will ensure that the skills and experience of the DPB can be used to best effect in the new system.
Among other things, it will allow the extensive experience of the DPB in operating dental payment systems to be applied to the personal dental services. It will also enable us to make use of the DPB's expertise in monitoring treatment provided under the new system and carrying out quality checks through the Dental Reference Service. The aim of these amendments is to provide for cost-effective and high quality support for the new arrangements in dentistry. I very much hope that noble Lords will support them. I beg to move.
On Question, amendment agreed to.
Baroness Jay of Paddington moved Amendment No. 28:
Before Clause 17, insert the following new clause--
(". All agreements made under this Act for the provision of personal medical services shall be submitted by the Health Authority concerned to the Medical Practices Committee, and shall be subject to the approval of the Committee, as if they were applications to provide general medical services under sections 29 and 30 of the 1977 Act.").
The noble Baroness said: My Lords, while moving the above amendment I shall speak also to Amendment No. 49. The two amendments are intended to ensure that the important role of the Medical Practices Committee, which, as your Lordships know, now provides a strategic approach to the organisation of primary care, is maintained. We on these Benches feel that this is in the interest of equity in the NHS, about which we are very keenly concerned. I introduced a series of amendments to that effect in Committee. In response the Minister said:
Perhaps I may briefly reiterate the points that I made in Committee about the necessity of involving the MPC in the pilot schemes proposed by the Bill. I would remind the House that the MPC has the duty (which it has had since the NHS was established in 1948) to assess whether a health authority area is served by an adequate number of general practitioners. It does this by the "negative" power of refusing a GP the opportunity to practice in an area which in its very authoritative view is already adequately covered.
I know that there has been some recent discussion about whether the MPC is adequately fulfilling that task. As noble Lords on these Benches will know and as I mentioned in my introductory remarks, we are concerned about overall equity within the NHS at present. But I am convinced that the MPC is working appropriately to try to ensure a proper distribution of general practitioners across the country. Mary Leigh, the chairman of the MPC, said in a letter to the Health Service Journal which is published today:
If the MPC is excluded from playing a role in assessing and authorising pilot schemes under the legislation as it now stands, it seems to me that that improvement will almost certainly be reversed. Your Lordships discussed earlier today and in Committee the fears that we on these Benches, and, indeed, the professional bodies led by the BMA, have about the rather unrestrained influence of commercial organisations if the Bill becomes law unamended.
It seems to me that removing the powers of the MPC in approving pilot schemes lends additional credence to those fears. It seems more and more clear that commercial companies will seek to operate primary care pilots. Indeed, your Lordships might have seen recent reports that the PPP (the well-known private insurance firm) has mentioned in public print its intention to become involved. It says that its pilots,
It is also clear, as I said in Committee when speaking to another amendment, that these commercial companies are almost bound to want to work in prosperous areas where they will make a profit. Otherwise, why would they want to do it? If there is no manpower distribution screening on an objective basis as the MPC carries out at present, there is every possibility that there will be a cluster of privately organised primary care services in the better parts of town at the expense of improved services in the more deprived communities.
In response to our amendments on the subject in Committee, the Government said that they felt that they could rely on the health authorities to sift and screen applications which were inappropriate before they went to the Secretary of Sate. But I believe that it is obvious that health authorities must only have the perspective of their own areas to consider as a primary concern and that they do not have the national, overall picture in mind when they make references upward to the Secretary of State. They also do not have the experience for scrutiny of general practitioners and the recommendations to practice which 50 years of the MPC has afforded.
The MPC continues to feel very strongly that its concerns are not being listened to by the Department of Health; that its overall role is essential; and that it cannot be excluded without serious damage to the distribution of general practitioners. The MPC has certainly convinced me of the importance of its role. I hope that the Government will reconsider and at least enter into proper dialogue with the MPC about an appropriate focus that it can have if the Bill goes into statute. I beg to move.
"The Government are committed to fairness in the distribution of services".
but went on to say:
"It would be wrong and potentially damaging to sensible development to pre-empt these discussions"--
that is to say, discussions with the Medical Practices Committee--
"in the way the amendments seek to do".--[Official Report, 17/12/96; col. 1435.]
I am reintroducing these amendments because I understand in conversations with the chairman of the MPC, the most recent of which took place this morning, that at present it sees no movement in the Government's position about its concerns. The MPC still feels that it is being rather politely sidelined as the Bill proceeds.
"When the current criteria [for establishing the right number of GPs across the country] were introduced in May 1981, there were 400 under-doctored areas out of 1,500 in England and Wales. At 1 January 1997 there were only 15 such areas. The percentage of patients in under-doctored areas, in terms of average list size, has gone down from about 26 per cent. to 1 per cent. in 17 years"--
a record which I believe speaks for itself.
"would be modelled on South Africa's 'medi-clinics' where private hospitals offer on-site primary care, including investigative facilities".
If primary care of that kind falls without the remit of the MPC as it exists at present, it seems to me that those commercial interests will become prominent and that all of our fears about the influence that that may have will come to fruition.
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