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Baroness Jay of Paddington: I am very grateful to the Minister for that reply. I am disappointed by her response, particularly as regards the amendment on the election of a chairman of a health authority and her response to the amendment as regards the independent advisory body. For the reasons which I believe I gave in my earlier intervention and those which were expressed by the noble Baroness, Lady Robson, I find the arguments which the Minister advanced for not having a chairman elected for a local health authority to be not very convincing.

I can only repeat what I said when I intervened earlier; that if all members of a health authority are regarded as being of equal responsibility by the Secretary of State, I am sure that the members of the health authority themselves will be perfectly able to distinguish between their relative skills. If the chairman of a health authority is clearly inappropriate to the tasks,

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surely that can be left to the good judgment of the authority. There does not need to be somebody hand-picked from above by the Secretary of State.

On the question of independent bodies to advise on appointments, I understand what the Minister said about the size of Scotland and the relative numbers in the populations that are served by the different regional offices, but that does not seem to be an argument for not adopting some form of system. After all, that system could be arranged on the new regional basis by the regional outposts. The body does not necessarily have to consider appointments for the whole of England and Wales. That is not what was suggested by the amendment.

I was pleased to hear the Minister say that the Government will look closely at the recommendations of the Nolan Committee on this subject. Judging from the committee's questioning of the chief executive of the National Health Service, my suspicion is that its recommendations may come closer to some of the suggestions in our amendments than to the Government's present proposals.

As I said earlier, the amendments are exploratory. They were designed to explore some of the different ideas for improving the democratic accountability of health authorities. However, the Minister's response has made me feel that perhaps we should return to the subject on Report. I shall examine carefully what the Minister has said, but for the moment I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Gardner of Parkes moved Amendment No. 20:

Page 19, line 43, after ("Authority)") insert ("at least one of whom shall be a health professional working in primary care").

The noble Baroness said: I rise to move Amendment No. 20 because I think it important that the new health authorities, as constituted, should have a clear recognition of the role played in the health service by primary care. I believe that those involved in delivering primary care form the basis of the health service. Although we have acknowledged that in central London people tend to visit accident and emergency departments as a first port of call, that is not the pattern throughout the country. Usually, someone will visit first their GP, the local community pharmacist, dentist, midwife, practice nurse or a health visitor who may be sent in by the local council. All of those people are involved in delivering primary care and are normally a patient's first contact with the health service.

The work done by those involved in primary care is close to the patient and the community and is of enormous value to the health service. That is the level at which decisions are made as to who needs more complicated or specialised treatment, who should be referred on, and to where. I fear that people working in primary care are being overlooked in the Bill because they are not specifically mentioned on the face of the Bill.

The Royal College of General Practitioners asked me to use the term "a medical practitioner in primary care" in this amendment. The reason that I did not do that,

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although agreeing to move the amendment, was that I did not think that we should be too specific by mentioning a "medical practitioner". However, I acknowledge that most patients would view their general practitioner as their first port of call. Indeed, general practitioners are undertaking more and more work. Many more treatments are now given within practices and standards have improved greatly. Years ago in the area where I practised as a dentist, the local GP did not have a car because he said that people lived in such a confined area that he could walk around it more readily than he could drive. That was true because the living conditions in the area were terrible. That GP was very much at the centre of the community, although the practice was primitive. I am pleased to note the way in which practices have changed over the years and that the standard of primary care provision is now so high.

Those involved in primary care feel that they are being ignored in the reorganisation and that their role is not receiving the recognition that it deserves. They feel that the only way in which they can be confident of having a proper degree of input is to be specifically mentioned on the face of the Bill in the provisions relating to membership of the authorities.

As I have said, I believe that it would be wrong to specify any particular branch of primary care because to do so would be to define that profession, and that profession only, whereas many professions are involved. I believe that the Minister referred the other day to the fact that something like 20 different professions are involved in primary care. Under the terms of my amendment, a member of any one of those professions could be chosen. The amendment would not restrict the Secretary of State to any particular branch of primary care when making appointments. However, the provisions would be some recognition of that marvellously hardworking and progressive part of the health service. That is important because the primary care service is ever-growing. I beg to move.

Lord Rea: I fully support the noble Baroness, Lady Gardner of Parkes, in her amendment. Once again, I apologise to her if in speaking to her last amendment I seemed to suggest a hierarchy among the professions working in the family health services authorities. That is not my view. We are certainly all in the same boat together on this. I thank the noble Baroness for putting the case for the general practitioner. It means that I do not have to do that. The noble Baroness did it very well, and it is better coming from someone who is not a general practitioner. Perhaps I may point out, however, that, although I changed from visiting patients on foot to visiting them by car, the wheel has now gone full circle because you cannot park. I find that visiting patients by pushbike is the quickest way to get around. That is the same means by which I come to your Lordships' House.

There are anxieties among GPs, dentists, pharmacists and opticians about the new arrangements. Unlike professionals in hospitals, they are independent contractors and wish to remain so, and the Government have agreed that their independent contractor status shall continue. The system has worked well—even though it

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has its critics, including myself, with regard to certain aspects of the independent contractor system, but that is another story.

The new health authorities will, by merging with FHSAs, regain a dual role in primary care—both as purchasers and providers, thus functioning in that respect rather like the old district health authorities prior to the 1990 Act. The FHSAs and their predecessors, the executive committees and the family practitioner committees, have had to perform the balancing act of looking after some of the interests of the professions contracted to work for the NHS in the community while at the same time administering their contracts and, among other things, operating the complaints procedures against them. In other words, they have in a sense been both poacher and gamekeeper. In most cases, they have been remarkably successful in their dual role and are regarded as friends by most of the professionals involved.

However, when merged with the larger and financially more powerful district health authorities to form the new combined health authorities, there are worries, first, that that carefully built-up relationship will suffer and, secondly (despite the Government's very welcome aim of building a primary care-led service) that the costly needs of the hospital service will dominate, even though it is now held at arm's length through the purchaser-provider split, and even though hospitals are now semi-independent NHS trusts.

Logically, it is right that primary and secondary care should be purchased by the same health authority—many of us have been suggesting that for years—but safeguards are needed to reassure primary care providers that their needs, and particularly those of their patients and communities, are not to be submerged. The amendment is one way in which that reassurance could be given, at least partially.

I should like to see more details on the face of the Bill of how the new combined health authority will be structured and regulated. Failing that, I should like to ask the Minister whether regulations governing those arrangements will be laid before this place so that we can scrutinise them. It would be preferable if that were done before Report. At this stage I ask the Minister to accept this modest amendment. But I give notice that we shall probably return to the topic on report. Conversations about it in the meantime would be very welcome.

4.30 p.m.

Baroness Cumberlege: We very much share the commitment to primary care of my noble friend Lady Gardner of Parkes and the noble Lord, Lord Rea. As the Committee will be aware, the Government's intention is to have eventually a primary care-led NHS. But we do not believe that the best way to achieve that is by restricting non-executive membership of health authorities to particular groups. That runs contrary to our aim of opening non-executive appointments to as wide a range of people as possible.

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We want the new health authorities to be compact and streamlined. There will be a maximum of seven non-executive members, although the normal number will be five. We could not hope to reserve a place for each organisation and group with an interest.

Of course, those working in primary care have a great deal to contribute. I am sure that many HAs will have non-executive members with experience in these areas. GPs, nurses, dentists and pharmacists will be welcome to apply provided there is no conflict of interest. Indeed, I hope that many of them will apply. But to reserve a place for a representative of each of the interested groups, even if it were possible, would not be enough.

Since we are moving towards a primary care-led NHS, the new HAs will be very different kinds of authority from the old DHAs and FHSAs. They will have a major new role in supporting and developing primary care. Every person working for HAs, from the chief executive downwards, will need to understand and support primary care provision. They will need to ensure that primary care practitioners contribute to the development of the HA's strategy. So they will need to involve fundholding and non-fundholding GPs and a wide range of other professionals working in primary care.

We do not believe that it would be possible for a single member to provide that broad spectrum of advice. We have discussed in detail under a previous amendment the Government's proposal to secure broad professional involvement—by requiring health authorities to make arrangements for receiving advice from a wide range of professionals.

We believe that that is the best way of securing advice, expertise and involvement of the range of health care professionals in the decision making processes of the new health authorities. I am grateful to my noble friend for reminding us that that must include primary care. I hope she will be able to withdraw her amendment.

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