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Lord Clement-Jones moved Amendment No. 6:

Page 2, line 27, at end insert--
("( ) Appropriate arrangements shall be made with a view to securing that a Primary Care Trust's functions are exercised with due regard to the principle that there should be equality of opportunity for all people."").

The noble Lord said: My Lords, to some degree this is a re-run of the amendments that we discussed in Committee on the addition to the duties of primary care trusts of the duty of equality of opportunity. Amendments Nos. 9 and 31 are grouped with this amendment. In Committee, the Minister indicated that she would consider the best way in which to take forward the points raised about adding to the existing duties of primary care trusts the duty to observe equality of opportunity and--I believe that her reply on this was rather more equivocal--adding to the duties of the commission for health improvement in a similar fashion.

We have not changed the amendment raised in Committee for PCTs. It states in broad terms the principle that there shall be equality of opportunity for all people. However, the amendment as regards the commission for health improvement has been made more specific in response to some of the criticisms that Members of the Committee made when that was discussed. It is an important area and it is important for primary care trusts. It would be easy to say that we need a general statement about the duties of the NHS which covered all bodies in the NHS, and we could spend a lot of time devising appropriate forms of language.

However, it is particularly important that that should cover primary care trusts, for a variety of reasons. I recognise that recently the Government launched their own initiative, with a circular to managers across the National Health Service, to take tough action to tackle racism; for instance, by April 2000 every NHS employer

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will need to be in a position to tackle racial harassment wherever committed by staff or by patients and progress will be measured and targets for reducing incidents will be set.

However, the issues of management in primary care trusts will be more difficult. Structures in primary care are much more devolved than they are in secondary care. The historical independent contractual status of GPs has led to a more fragmented and, at times, resistant approach to mainstream equality initiatives coming from the Department of Health and the NHS Executive.

Many primary care providers are covered by the small partnership exemption in the Race Relations Act. In other primary care professions there has been evidence that ethnic minority professionals are more likely to suffer obstacles to career progress, such as disproportionate appearances at disciplinary hearings. A further reason is that the Health Education Authority's health and lifestyle study in 1994 showed that some ethnic minority groups use GP services more than the majority of the population. That also shows that people from ethnic minorities wait significantly longer in surgery to see a doctor. Among south Asians in particular there is a tendency to register with a GP of south Asian origin.

The proposed policy for dispersal of asylum seekers will have enormous implications for primary care across the country. There are bound to be misunderstandings about entitlement to healthcare and lack of access to interpreters or specialist help for trauma resulting from their experience prior to coming to the UK. There are a number of other reasons that I could go into.

On the commission for health improvement, we had less of a debate on that subject in Committee, but the commission for health improvement must see as part of its remit the function of ensuring that equality standards are met for all ethnic groups, whether those are specified in national service agreements or the NHS Charter--no doubt that is to be revised--or local standards. Such a principle should be a founding principle and should be enshrined in law. It is a new public body and it must be in a strong position to guard against institutional racism, as defined in the Macpherson inquiry report.

I draw your Lordships' attention to two thoughtful and well considered editorials in the Lancet and the British Medical Journal in the past week. Both make the point that action by the NHS is very much needed. I quote from the BMJ:

    "The NHS needs to go further. We need to take a needs led, evidence based approach to understand the reasons for disparities. We need actively to assess services using a centralised body as this would afford economies of scale and proper levels of expertise and independence"·
I suggest to your Lordships that CHIMP is the very body that would fulfil that role. I beg to move.

Lord Astor of Hever: My Lords, I rise to support Amendment No. 6. As the noble Lord, Lord Clement-Jones, said, this is an important area. There is concern that older people and those from ethnic minorities are discriminated against in the NHS. Older people often experience difficulties in primary care provision and are more likely to be dropped off GPs'

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lists than younger people. There are even reported examples of GP surgeries that refuse to deal with patients over the age of 65.

In addition, the incidence of illness is patterned by ethnic difference; for example, people of Pakistani and Bangladeshi backgrounds have 50 per cent. greater rates of heart disease than white people. Historically, many primary care practitioners were exempt from the Race Relations Act, so primary care has not been subject to the same drive for equality as the rest of the NHS. Healthcare policy must ensure equality of access to primary care trusts. I strongly urge the Government to accept the amendment.

4.30 p.m.

Lord Skelmersdale: My Lords, of this group, I find Amendment No. 31 by far the most attractive and the most sensible. In Committee, the Minister made it clear (at col. 1294 of the Official Report) that she would like to consider the points that were made then. She went on to say that not only would she consider those points but that she would like to look at the best way to tackle the matters put forward and whether they could be accommodated in terms of amendments to the Bill. I therefore looked at the Marshalled List with interest today and at the government amendments on Friday but found absolutely nothing to give me any hope in that regard. I am sure that the noble Lord, Lord Clement-Jones, and my noble friend Lord Astor did exactly the same. I hope that the Minister has some good news for us today in anticipation of Third Reading.

Baroness Masham of Ilton: My Lords, may I ask the noble Lord, Lord Clement-Jones, whether this amendment would end prescribing by postcode? Also, disabled people could have difficulties getting on GPs' lists.

Earl Howe: My Lords, my noble friend Lord Astor has already covered one essential aspect of this and I shall not repeat what he said so eloquently. However, a further point needs making. It relates to the Government's entirely laudable ambition to see a levelling up of patient care not a levelling down. I am afraid that we are seeing just the opposite around the country. Practice-based budgets are being absorbed into unified budgets. In the process, services are being run down. There are numerous examples currently being reported in the medical press and they all relate to mainstream services, not to services at the fringe. I am prepared to accept the Government's assurances that they do not want to see such services disappear as a result of their reforms, but the question has to be asked: what are they going to do to stop it happening?

The other big concern relates to the burden of pay settlements. There are already reports in the medical press that the only way in which some health authorities will be able to fund their pay bill in its entirety will be to make cuts in the GP prescribing bill. The estimated cost of the inflation-plus element of the pay bill could be as much as £1 million for each health authority--and there are 100 such authorities. That is an enormous amount of money to find. It would be totally

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unacceptable for it to come out of the prescribing budget. The question I need to ask the Minister is this: can she give an assurance that no treatment currently available to patients under the fundholding system will cease to be available under the system of primary care groups and primary care trusts?

Baroness Carnegy of Lour: My Lords, I should like to reiterate the question asked by my noble friend Lord Skelmersdale: does the Minister have it in mind to do anything in the Bill in this respect, because it is most important, and in Committee she said that she had it in mind to put some such provision into the Bill?

While I am on my feet, when the noble Lord, Lord Clement-Jones, replies to the amendment, perhaps he could comment on this. In Committee I suggested that,

    "equality of opportunity for all people",
was a somewhat fatuous and meaningless phrase. I am sorry that the noble Lord did not take my stricture into account. I still think that such a phrase would be an extremely unhappy insertion into the Bill. We all know what "equality of opportunity" means. It is defined in law and is well understood. Saying that we can have,

    "equality of opportunity for all people",
sounds like something that only the good Lord could say and I do not believe that he would believe it.

Baroness Hayman: My Lords, in Committee we had some thoughtful and serious debates about equal opportunities in relation to primary care trusts and the commission for health improvement. Some of those arguments have been rehearsed today. I hope that it was clear from my comments in Committee that the Government seek to address this issue in a range of policies.

Perhaps I may advise the noble Baroness, Lady Masham, that there are a range of ways in which we are trying to tackle the problem of postcode prescribing--not only through this legislation but also with regard to the national service frameworks, the work of the national institute for clinical excellence and through the institution of clinical governance, by which people will have to justify--if I may put it in that way--any deviation from the kitemark standards that are available. I have never pretended that that is an easy task--not least because we do not want a service that is totally centrally controlled and we have to have a proper level of local decision-making about local priorities. We need to get that balance right.

Perhaps I may return to the issue of equal opportunities. A central part of the Government's agenda is to achieve fairer access to services, to reduce health inequalities and to promote equal opportunities for all those who work in the NHS as well as for those who use it. The noble Lord, Lord Skelmersdale, said that the Government have put nothing on the Marshalled List in this regard. That is absolutely correct. It is simply because in Committee I agreed to consider a large number of points across a wide range of subjects and this is one of the areas on which we have not yet

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managed to reach a conclusion about the best way forward in legislation. Indeed, the noble Baroness, Lady Carnegy, drew attention to the drafting.

This is an extremely important area, but it is also quite complex in terms of legislation. It is important that we consider the issues carefully. I quite understand why the noble Lord, Lord Clement-Jones, has focused on primary care and on the commission for health improvement--not least because they are the issues with which we are dealing in this Bill, but also because they are very important areas that we must tackle in terms of equal opportunities. I do not for a minute challenge that point. However, it is important that we come back with appropriate solutions for the NHS as a whole, not simply for primary care trusts and the commission.

I should like to reassure the House that we are considering the points raised in Committee. We shall also look at the additional points that have been raised today. I am certain that we shall return to these matters during the passage of the Bill. However, I am not at a stage to go further than that now and I ask the House for a little more leeway on the subject.

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