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The Deputy Chairman of Committees: In calling Amendment No. 161, I point out to the Committee that if it is agreed to I cannot call Amendment No. 162.

Earl Howe moved Amendment No. 161:

The noble Earl said: The amendment is grouped with Amendment No. 162. The amendments are necessary to ensure that the general medical services payment system appropriately rewards quality and service outcomes. Clause 24 ends the requirement that the majority of a GP's remuneration should be linked to the number of patients on his list. At present there is a provision that ordinarily GPs will be paid for the number of patients on their list. The clause removes that provision and changes the criteria on which they are paid to the quality and outcome of the services that they provide.

It may be of help to the Committee to know that the British Medical Association's General Practitioners Committee supports the move away from the majority of GP remuneration being capitation based. That move weakens the dependency on list size. The emphasis of the amendment is on GPs being paid for their work rather than being paid a fixed monthly salary. Clearly, their workload varies with the number of patients on their list. It is appropriate that the

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amount that doctors are paid should continue to reflect their workload as well as the quality of the services that they deliver. I beg to move.

Lord Hunt of Kings Heath: I understand and sympathise with the thrust of the noble Earl's comments. The Committee will know from my remarks during earlier Committee days that we are working with the profession and its representatives to produce a revised national GP contract. We want to reflect the emphasis on quality and improved outcomes, which form a key feature of the locally agreed personal medical services contracts. Our aim is to secure greater convergence between the two contractual frameworks, which will build on the best of both approaches.

There is the prospect of significant progress on the way in which GPs work for the NHS. Initial discussions have begun with the BMA to scope the work. Those discussions have been constructive and there has been an encouraging start in addressing a major challenge for both parties.

Clause 24 contributes modestly to that task by removing an unnecessary statutory impediment to progress. That makes me reluctant to accept the amendments, which would impose constraints, specifically by providing that the remuneration of GMS GPs should be linked to quality and outcomes of service and should not consist wholly or mainly of a fixed salary. While that is in line with the aim in the NHS Plan to link GPs' remuneration more closely to improved quality and outcomes--I very much agree with the noble Earl on that--my worry is that using legislation would create a constraint that might be unhelpful in discussions and negotiations. We want to work with GPs and their representatives to revise the national contract. That is the best approach.

Amendment No. 161 would also require that if a fixed salary was paid, it should be referenced to the number of patients. Amendment No. 162 would ordinarily prevent wholly or mainly fixed salary payments. It is true that no GPs in the GMS are on a fixed salary and we have no plans to introduce such a category, but we do not want to rule out that possibility for all time. We are concerned about the constraints that the amendment would put in place.

I hope that the noble Earl recognises that we strongly agree with the thrust of what he said.

Earl Howe: I entirely accept the Minister's point. The BMA's attitude to the general direction in which the Government are moving is based on the belief that it is helpful to make GPs' contracts more dependent on quality by making it easier to reduce list size. That is also fairer to GPs who necessarily have a low list size, such as those in rural areas. The Minister has given a useful answer and I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 162 not moved.]

Clause 24 agreed to.

Clauses 25 and 26 agreed to.

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Clause 27 [Medical, dental, ophthalmic and pharmaceutical etc. lists]:

Earl Howe moved Amendment No. 163:

    Page 24, line 5, at end insert--

"(2BC) Regulations made by virtue of subsection (2BA) shall not have effect unless the Secretary of State has consulted any person appearing to him appropriate to consult as representing the profession subject to the regulation.""

The noble Earl said: In moving the amendment, I shall speak also to Amendment No. 164. The amendments were suggested to me by the Royal Pharmaceutical Society. As the Committee will know, among the many responsibilities of the RPS is the maintenance of the register of pharmaceutical chemists for Great Britain. I understand that the society supports the intention of the proposals in the Bill to enhance scrutiny of the profession.

I understand from my discussions with the society that it is concerned to ensure that any lists established by health authorities are transparent and practical. It is therefore of critical importance that criteria, particularly for exclusion from such lists, should be developed in partnership with the relevant professional regulatory body or bodies.

I have been in touch recently with the RPS. It was surprised to hear that, according to health Minister Mr Denham, the list of criteria to be considered before determining unsuitability--and therefore exclusion from a list--may include such matters as the impact on the National Health Service of a practitioner's action. That sounds somewhat open-ended and unclear. That leads me to ask whether the clause sufficiently differentiates between practitioners who operate single-handed and those who practise through companies. I am sure that the Government have every intention of consulting all the professional bodies concerned, but the amendment would make such consultation obligatory. Such a safeguard seems entirely appropriate and I would be a little disappointed if the Government were inclined to resist the suggestion.

I further understand that the society is concerned that the criteria, which will be listed in the statutory instrument, may not be exhaustive, again, as the Minister, Mr Denham, said, in order to allow health authorities to apply other criteria that are relevant to each case.

By allowing local discretion, which may have some arguments in its favour, the very real possibility will arise that local variations in eligibility criteria for practitioner lists will develop; for example, a pharmacist could be eligible for employment in one health authority but not in another. I wonder whether the Government want such a situation to develop, not least because it militates against the development of clear and consistent national standards. My amendment to Clause 28 would prevent such variability, and I should be interested to hear what the Minister has to say about it.

Perhaps I may add a quick comment on the Government's statement made in Committee in another place that there will be an independent appeal

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process. I believe that that is absolutely essential. However, I believe that it will also be important to ensure that any such appeal system is consistent with the existing professional regulatory framework. I hope that the Minister will be able to reassure me that that is so. I beg to move.

Lord Hunt of Kings Heath: I certainly take the point that consultation with the appropriate groups would normally be expected to take place. I can assure the noble Earl that we shall consult as necessary. I do not believe that it is necessary to set that out on the face of the Bill, but I can assure him that, so far as concerns the Department of Health, consultation is the name of the game. With regard to many of the matters that we are discussing in the Bill, it is essential to implement ownership among all the people involved.

I also understand the point that the noble Earl raises in relation to variability between different health authorities. I understand why his amendment requires that the imposition of conditions by health authorities--for example, when conditionally including a practitioner in a list--must be carried out with a view to preventing local variability in criteria for inclusion in the list.

I want to make it clear that it is the responsibility of health authorities to make decisions conditionally to include a practitioner in a list. It is absolutely right that that responsibility is placed at health authority level. I can assure the noble Earl that the department will issue guidance to all health authorities in order to facilitate consistency in their decision-making. Again, I very much accept that point. The FHS Appeals Authority will also have a role in ensuring consistency of decisions between health authorities.

As with all the issues that we have discussed so far, clearly a tension exists between the aims of devolving responsibility and ensuring consistency. Both are important. Sometimes the noble Earl, Lord Howe, wishes us to decentralise; perhaps more than occasionally he wishes us to centralise. A problem arises when we become over-centralist and over-prescriptive. I hope that the Committee will consider that we probably have the balance right in relation to this matter, particularly in view of the safeguard that we shall give guidance to health authorities and in view of the fact that the FHSAA, through its judgments over the months and years, will itself clearly ensure consistency.

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