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Earl Howe: My Lords, the House will be grateful to the Minister for her explanation of these amendments. I have one brief question to ask on Amendment No. 37. In the amendment, under subsection (2) of new Clause 28A, I see that the determining authorities are defined. The Secretary of State is one of the determining authorities. Since health is a devolved matter, can we take it that the role of the Secretary of State will be assumed by the First Minister for Scotland, and that therefore we may, in due course, see different fees and allowances north of the Border from those that are in operation south of the Border?

The Earl of Mar and Kellie: My Lords, I wish to ask about Amendment No. 37. Looking at subsection (5) of new Section 28A and subsection (2) of new Section 28B, I see that the Bill seems to be introducing the idea of variable remuneration being permissible to enable services to be procured in difficult localities. Is that a new principle? If it is, is it intended to secure such services in, let us say, urban areas of deprivation, or is it aimed more at remote rural areas and the three island groups? Or is the intention to unleash a complete free-for-all in remuneration within the 15 health board areas, which, I confess, I do not see as being very helpful?

Baroness Carnegy of Lour: My Lords, my noble friend Lord Howe asked a question that is extremely important to people in Scotland. If "the Secretary of State" referred to in the Scottish amendment is the Secretary of State for Scotland, or a Minister of the Scottish Parliament--I imagine it means the latter--there is no reason at all why doctors and nurses, pharmacists, dentists and so on should not gradually receive salaries that diverge considerably from those south of the Border.

If the Minister will confirm that, it will help Members in another place when they come to study the Bill to know exactly what the implications are. Taking this legislation at Westminster will not enable the Scottish Parliament to examine this arrangement at all. It may or may not suit the Scottish Parliament.

Can the Minister confirm that the two amendments are virtually identical apart from the cross-references to the legislation that they amend? I cannot find any differences, but I may not have spotted them and it would be helpful to know.

Lord Clement-Jones: My Lords, I thank the noble Baroness for attempting to clarify what is obviously the Schleswig-Holstein question for the Department of Health. To mix metaphors further, I suspect that it is a kind of Bermuda triangle for politicians to get into in the first place. A number of issues arise from the clause. Perhaps the Minister will forgive me if I re-tread some of the ground that she covered in her introduction.

We assume that the department has now obtained independent legal advice and in a sense this provision cures the issues that it was designed to cure and we shall not be faced with a re-run of this matter at a future date

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in relation to another health Bill. Further to that, will the powers in the new clause be used only to allow PCTs to deal with the cash-limited payments made to GPs for their staff, premises and computers? Will the Minister give a reassurance that when a PCT takes over any of the powers of a health authority relating to the remuneration of GPs, the PCT will be under the same duty as a health authority is currently to abide by the rules in the Red Book? For example, when the Red Book requires a health authority to consult the LMC, will a PCT also be required to consult that body? Will the Minister give examples of how a PCT might use its powers as a determining authority. Subsection (5)(a) of new Section 43B states that:

    "Determinations may, in particular, provide that the whole or any part of the remuneration ... is payable only if the determining authority is satisfied as to certain conditions".
What will those conditions be? Will they be decided by the Secretary of State, or locally?

Finally, will the Minister give an assurance that PCTs will not be allowed to use their status as determining authorities to allow local variations from a national contract for GP remuneration?

Lord Colwyn: My Lords, this is a long new clause. I have seen it for the first time this afternoon. Will the Minister say when this amendment was published and whether she has had a chance to receive representations from the professional bodies referred to in new Section 43A. It is the first time that I have heard about it and I do not know, for instance, what the British Dental Association feels about it.

Baroness Hayman: Yes, my Lords, the amendment is complex. It is my understanding, which perhaps I may confirm at a later point to the noble Lord, that there have been discussions with the professional bodies on this area and that they understand the reason for bringing forward these amendments. It was very much an issue of the previous arrangements being on the basis of legislation built on legislation, on powers that have never formally been brought into force, and therefore not providing a secure legal framework. There was an anxiety not to put in place an additional layer of reliance on provisions that were not themselves fundamentally secure. Therefore the opportunity has been taken to tidy up the general basis for the determination of remuneration. I am clear that that will not come as a surprise to the professional bodies concerned.

On the issue of the Scottish provisions, I understand that the amendments for Scotland, England and Wales are fundamentally the same. I also understand that this will be a devolved matter and therefore it will be possible for different decisions to be taken north and south of the Border--although, to respond to the point made by the noble Earl, Lord Mar and Kellie, the provision is certainly not intended to allow for a free-for-all, but to allow local flexibility where it is required. That might be in a variety of different circumstances. Both the rural and the

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inner-city example could have relevance. The provision is based very much on flexibilities which are already in place and are used, rather than introducing a novel concept in this area.

On the specific questions raised by the noble Lord, Lord Clement-Jones, the purpose of the amendment so far as PCTs are concerned is to allow them to take on the function of determining cash-limited payments to GPs for those purposes. It also allows PCTs to set up and make payments in respect of general medical services local development schemes. That is a new flexibility that we have recently introduced to enable health authorities to establish what are in effect local incentive schemes to improve the standard and range of services provided within GMS.

The noble Lord asked for a reassurance about consultation. When the PCT takes on the function from the health authority of making cash-limited payments to GPs under the Red Book arrangements, it will also inherit any duty to abide by the Red Book which applies to the health authority. The point of delegating that function to PCTs is not to change Red Book arrangements but to give PCTS the ability to deploy resources into general medical services in support of those services.

The noble Lord asked for examples of how PCTs might use their powers as determining authorities. It would be broadly in one of two ways: first, to deploy resources into general practice under the existing national GP contract or Red Book arrangements to support the cost of employing practice staff or to support the cost of premises development or practice computers; or to set up with GMS local development schemes with the agreement of local GPs, in the same way as health authorities now can. This might involve, for example, funding of practices to provide chronic disease management programmes not covered by the Red Book or local incentives to improve coverage of immunisation programmes.

The noble Lord, Lord Clement-Jones asked about certain conditions which would have to be fulfilled if determinations were to take place. For payments made under the Red Book, the Secretary of State will, as now, continue to set down any conditions for those payments and will define, again as now, any discretion that health authorities and PCTs may exercise.

Health authorities and PCTs will have the same degree of discretion and duties under the Red Book. For GMS local development schemes which are outside the Red Book arrangements, the Secretary of State has set the parameters for the operations of those schemes in regulations. The regulations will apply to health authorities and PCTs. Within that framework, PCTs, like health authorities, will be able to determine the conditions that will apply to local development schemes. I am happy to give the assurance that the status of PCTs as determining authorities will not allow local variations from the national contract. PCTs will be required to comply with the national contract in the same way as health authorities.

I hope that I have covered the points that were raised in the debate. I shall write to noble Lords if I have missed any points.

On Question, amendment agreed to.

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4.30 p.m.

Clause 9 [Directions]:

Baroness Hayman moved Amendment No. 6:

Page 12, line 10, leave out ("16C") and insert ("16D").

The noble Baroness said: My Lords, in moving Amendment No. 6, I wish to speak also to Amendments Nos. 10, 11, 12, 63, 64, 72 to 74, 79, 82 to 85 and 91. Although it is a large group of amendments, I shall try to be brief. They bring forward provisions in relation to two issues which we discussed at Committee and Report stages: the "may or must" point, if I may characterise it as that, about publicising PCTs' audited accounts, annual reports and other documents; and a requirement on PCTs to secure appropriate professional advice.

On the first point, at Report stage I undertook to bring forward appropriate amendments on Third Reading that would have the effect of placing on PCTs an express duty to publicise the specified accounts and reports in accordance with requirements set out in regulations.

Amendments Nos. 63 and 64 meet that commitment. They require the Secretary of State to make provision in regulations requiring PCTs to publicise the relevant document. The regulations will set out what steps to publicise must be taken by the PCT. The Secretary of State, however, retains his discretion to determine in the regulations exactly what those steps should be. For example, the regulations may specify when the accounts and reports must be published and whether the list of documents that must be publicised should be extended to those other than accounts, annual reports and auditors' reports on matters of public interest. That arrangement will have the added benefit of retaining flexibility, to cater for future changes in circumstances.

On the second point, I said on Report that I intended to bring forward a government amendment so that PCTs, as well as health authorities, have a duty to make arrangements to secure appropriate professional advice. This is in response to a specific proposal during Committee from the noble Lord, Lord McColl, for which I am grateful. It also reflects a view which I think commands a good deal of support in the House--and which the Government certainly share--namely, that PCTs should secure sound professional advice from a wide range of groups in carrying out their functions.

There will, of course, need to be strong professional input into the way that PCTs are governed. But we also want PCTs to have arrangements for involving health professionals which extend beyond the "members" of the PCT. PCTs also need to engage with the broad mass of local GPs and community health service professionals, who are not PCT members. In developing local commissioning strategies and service agreements they need to involve, for example, acute sector clinicians, those engaged in NHS education research, Professions Allied to Medicine and the family health service professions. The importance of all those groups has cropped up at various points in our debates.

The amendment we have brought forward effectively mirrors the existing duty which Section 12 of the 1977 Act places on health authorities but also extends it to PCTs. When we looked at Section 12 we found that it referred

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specifically to some professions--namely, medical practitioners, nurses and midwives--but not to others. We think this distinction is unhelpful. It could be interpreted as implying that the contribution of other professions is somehow less important.

I turn to Professions Allied to Medicine, which I know has had particular concerns on this matter. A key point about our proposed provision is to ensure that groups like the PAMs are involved in shaping and delivering PCT plans. We want to remove the specific reference to doctors, nurses and midwives in the existing duty in order to reinforce the message that these are not the only groups that must be consulted. We are, in effect, putting PAMs on an equal footing with these groups in terms of PCTs' duty to secure professional advice. Perhaps I could also make clear that there must be flexibility in the precise balance of professional members at level 4 to reflect local circumstances, and in some cases it may be sensible and helpful to have PAMs on the PCT executive. I should add that PAMs could also of course be invited to take part in board discussions at level 3 on matters where they have a particularly important contribution to make.

To return to the amendment, we have opted for a duty to consult which is couched in a way which does not give special status to any professional group. But otherwise the new duty is essentially the same as that in Section 12 with the key difference that it applies to PCTs as well as health authorities. The amendment requires both these bodies to make arrangements to seek advice from healthcare professions in carrying out their functions. This is an important provision which further bolsters the role of professionals in PCTs.

The amendment inserts this new provision as Section 16C. Consequently the original Section 16C in Clause 9 has been re-numbered as Section 16D. The remaining amendments in this group are to reflect that re-numbering and to pick up on a number of references to the old Section 13 which is replaced by the new Section 16D. I beg to move.

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