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The Minister of State, Scottish Office (Lord Macdonald of Tradeston): I am grateful for the contribution by the noble Lord. He makes the case strongly that there are different circumstances in Scotland from the circumstances which existed in England. In England 50 per cent. of GPs were standard fundholders in April 1997, with a further 7 per cent. in community fundholding. Similarly, in Wales, 47 per cent. of GPs were standard fundholders, with a further 6 per cent. in community fundholding.
However, in Scotland, although about 50 per cent. of GP practices had joined fundholding by 1998, more than 30 per cent. were in the primary care purchasing scheme, the Scottish equivalent of community fundholding, but less than 20 per cent. as standard fundholders. In Scotland the new structures that we are building will be on the same principles as those in Wales and England. They will provide strong organisational support for the development of primary care and will involve local doctors and nurses in planning and influencing the high quality of services for patients.
Members may ask: why then the difference? The difference in the two models reflects the different starting points in Scotland compared with England and Wales, as well as the differences in culture and historic structure of the National Health Service. For example, purchasing of secondary services by GPs was much less widespread in Scotland, where the majority of GPs who had joined fundholding were community fundholders. There are also substantial parts of Scotland with rural and dispersed populations such as the Highlands and Orkney, the Shetlands and the Western Isles, where competition between providers was never really a reality. In Scotland we have a different situation and it deserves different treatment.
I turn to Amendment No. 186. We have made a clear commitment to end the internal market and replace it with modern arrangements founded on the principles of partnership and co-operation. Clause 36 abolishes the GP fundholding system which formed a major part of the old internal market. The regulations were laid on 17th February to bring the existing GP fundholding schemes in Scotland to an end on 31st March. A single remaining form of fundholding will operate from then until all fundholding is abolished, as we intend, through the provisions of this Bill. Clause 36 enables us to remove this remaining form of fundholding, which we intend to do as soon as practically possible. Fundholders recognise that it is now time to move on. We believed that it is important not only to signal the end of GP fundholding as swiftly as possible, but also to ensure that transitional arrangements are in place for as short a time as possible.
Lord Mackay of Drumadoon moved Amendment No. 187:
After Clause 36, insert the following new clause--
(" .--(1) Section 2 of the 1978 Act (health boards) is amended as follows.
(2) In subsection (3) after "order", in the first place it occurs, there is inserted "create an all Scotland Health Board or".").
The noble and learned Lord said: In the absence of my noble friend Lord Mackay of Ardbrecknish, in whose name the amendment stands, I rise to move it. In doing so, I preface my remarks with a view I know is shared by my noble friend; namely, to raise once again the general observation as to why a Bill containing the clauses to be found in Part II is being brought forward to this House on the very eve of devolution.
Having read the debate on Second Reading, I am well aware that the point was raised then by my noble friend, but I am not sure that the answer he received stands up. The answer was to the effect that the new primary care trusts will come into being on 1st April and need a full range of powers to do so. The legislation was necessary to bring that about. Whatever may come into being by 1st April 1999, one thing will certainly not; that is the Health Act 1999 based on the provisions which are to be found in the Bill currently before the Committee.
There is no possibility whatever that the Bill will have completed its parliamentary passage by that date. Therefore, the justification put forward on Second Reading, initially by the noble Lord, Lord Ewing of Kirkford, and subsequently adopted by the noble Baroness the Minister, does not hold water. If primary care trusts are to require some legal basis for their existence at 1st April 1999--and I do not dispute that that may prove to be necessary--they will not find it as at that date in the provisions of the Bill.
I have already referred to the fact that the Bill is brought forward on the eve of devolution coming into effect. As Members of the Committee will be aware, elections to the Scottish Parliament are due to take place on 6th May. All the parties have selected--in some cases, more accurately, appointed--those who are to stand as candidates at the election. Manifestos are being drafted; teams of election spokesmen are being appointed; and, I suspect, we are not far away from an embargo being placed on Scottish Office Ministers making any further official announcements or taking part in any further official visits in the immediate run-up to the election. Yet, here we are debating a Bill dealing with a major reorganisation of the National Health Service in Scotland. It is being considered initially by your Lordships' House and then in the fullness of time by another place.
From my reading of the Bill, the debate on Second Reading, the White Paper and surrounding documentation, I perceive nothing urgent in the subject matter of the clauses which requires the Bill to be enacted to include Part II. We will return to this matter, no doubt in somewhat greater detail, when the Committee comes to consider Amendments Nos. 219, 220 and 221.
The sharp political issue is that, if and when Part II becomes law, becomes part of an Act of Parliament, there may well be in position in Scotland a Scottish executive which is not composed entirely of members of the Scottish Parliament who are supporters of the present Government. It seems to me to be entirely wrong to place legislation on the statute book with no guarantee whatever that the people who will fall to bring it into effect and to implement it are full-blooded subscribers to the policy which lies behind the legislation.
There is also considerable force in the point made a few moments ago by my noble friend Lord Monro as to the lateness of the hour at which we are discussing this important issue. There is a certain irony in that one of the justifications for devolution, which I recognise has some force to it, is that it should do away with the need to discuss important legislation in the middle of the night. And yet here we are, on the very eve of devolution, doing that very thing and likely to be doing so, as I understand it, for not a little time yet.
Amendment No. 187 is a probing amendment which seeks to explore whether it is certain that there will always be a need to keep more than one health board in Scotland for individually defined geographical areas within Scotland.
In moving this amendment, I take the opportunity to renew the thanks of my noble friend Lord Monro to the Minister, the noble Lord, Lord Macdonald, for responding positively to the request made by my noble friend Lady Carnegy of Lour on Second Reading. She asked for a Keeling Schedule, which--possibly for understandable reasons--has not been made available. But the documentation which has been produced has certainly assisted in considering these amendments and in arguing them before the Committee.
As some Members of the Committee may be well aware, there is in fact in existence a statute law database but it is available only to parliamentary draftsmen and officials. Therefore, when one is in opposition, trying to scrutinise legislation, one is to some extent at a disadvantage. That disadvantage has been removed substantially by the extremely helpful co-operation which government Ministers have given in relation to the question that was raised.
It is clear from information made available to my noble friend Lord Mackay of Ardbrecknish that the Government propose to introduce two types of NHS trust in Scotland--the acute hospital trust and the primary care trust. It would be sensible to have a review of the boundaries and the number of health boards. One reason for the BMA putting forward this suggestion is to enable consideration to be given to the development of managed clinical networks, a concept which the Minister will be aware was discussed in a paper issued on 9th February of this year by the NHS Management Executive in Scotland.
As the Minister will know, managed clinical networks are defined as being linked groups of health professionals and organisations from primary, secondary and tertiary care working in a co-ordinated manner unconstrained by existing professional and health board
The amendment in the name of my noble friend Lord Mackay of Ardbrecknish seeks to amend the existing provisions of Section 2(3) of the 1978 Act to make it clear on the face of the statute that the figure could be reduced to a figure as low as one.
Some Members of the Committee may feel that that is a somewhat dramatic option to place in the hands currently of the Secretary of State but, come 1st July, it will be in the hands of the First Minister. Those Members of the Committee who were present on Second Reading or who have read the Hansard reports of the debate will be aware that the noble Lord, Lord Ewing of Kirkford, went one step further and argued very cogently at col. 148 for the abolition of all health boards from the scene. He justified his argument on a number of grounds, including a substantial saving in cost and also, by virtue of his experience as chairman of a health board, his view that strategic health planning, healthcare for the future, can be carried out over much wider areas than has hitherto been possible under the system of health boards.
Whether or not one agrees with the noble Lord, Lord Ewing, there is clearly a case to be made for the First Minister to be given power to restrict the number of health boards dramatically, possibly to one or possibly remove them altogether. This amendment will provide that the first option is clearly stated on the face of the statute. I beg to move.
1 a.m.
The Earl of Mar and Kellie: My noble friends are keen to move health into the care of local government. However, I look forward to hearing the Minister's explanation as to why we should not have one health board for Scotland, or indeed none at all, and instead have a situation where all the hospital trusts and primary care trusts report directly to the Scottish Minister for Health.
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