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Lord Carter: My Lords, my noble friend has explained the purposes of these two amendments extremely well. However, it is important to emphasise from this Front Bench that we feel there must be a clear recognition in the Bill of the role that is played in the health service by primary care. We know all about the GP being the gate-keeper and so on and we feel that wording on these lines—or indeed on the lines of Amendment No. 15 which is grouped with this amendment and concerns a report on the functions of the family health services authorities—would help to underline the crucial importance of primary care in the operation of the health service. It is often thought when one refers to the health service that it is a hospital service but I believe that the hospital budget accounts for only about 15 per cent. of the whole. The words I have referred to may not be perfect but something along those lines would at least underline and, as my noble friend said, would remind those concerned of the crucial importance of primary care in considering the functions of the new arrangements. I hope that if the Minister cannot accept the amendment she will at least be able to confirm the crucial importance of the whole of the primary care service.

Baroness Cumberlege: My Lords, while respecting greatly the distinguished medical career of the noble Lord, Lord Rea, in family doctor services, I think that he will surely recognise that the Government's aim in establishing the new health authorities is to create a single authority at local level with responsibilities across the full range of health care. This aim has been widely supported by many of your Lordships. We believe that the new authorities will deliver a better service to patients by removing artificial boundaries between primary and secondary care. Unified health authorities will be able to develop a single comprehensive health strategy for the people in their area. We expect them to secure a more sensitive balance than was possible in the past between prevention and treatment, and between primary, community and hospital-based care.

Against that background, I am not at all sure that it makes sense for the Secretary of State to report in isolation on certain functions, simply because in the past they were carried out by family health services authorities. The Secretary of State and the NHS Executive already publish a wide range of reports and, of course, health authorities, like DHAs now, will be expected to publish annual reports on their activities.

I recognise, as the noble Lord, Lord Carter, has said, that there are people who are concerned that former FHSA functions may be overshadowed in the new authorities and I am very happy to make it absolutely clear that we will not allow that to happen. The close working which already exits between some authorities has demonstrated that there need be no loss of focus on primary care in the new health authorities. Rather, the skills and knowledge of both DHAs and FHSAs are being brought together to provide a better service. I can assure your Lordships that administration of primary

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care will be a core function of health authorities, with many specific functions placed on them in primary legislation and supported by regulations. So any health authority which neglected these functions would be failing in its statutory duties.

As has already been said by the noble Lord, Lord Rea, the department issued guidance to the NHS recently on The Creation of the New Health Authorities. Your Lordships may be reassured by some of the statements in the guidance about the role of an effective health authority. For example, the guidance says that essential elements of their role include:


    "developing a strategy in collaboration with GPs, providers, local people and other agencies ... to meet national and local priorities ... developing primary care and forging constructive partnerships with all primary care professionals ... administering and managing arrangements with local GPs, dentists, ophthalmic practitioners and pharmacists".

The performance of the new authorities will be measured by how well they carry out functions like these, not just by how effectively they purchase hospital care. I hope that your Lordships accept that the Government are committed to a more primary care-led NHS and that these amendments are not necessary.

Lord Rea: My Lords, perhaps I may ask the Minister how much force the guidance that she and I have quoted has on the conduct of health authorities and what sanctions the Government have if guidance is not followed.

Baroness Cumberlege: My Lords, some of the specific functions, not the actual guidance, are placed upon health authorities through primary legislation and are supported by regulation. If an authority were to fail in those it would be contravening that legislation and failing in its statutory duty. Certainly, the department and management executive would come down very heavily on that authority.

We have found guidance to be very effective. One aspect that impresses me about the National Health Service is that when it is asked to do something it does its utmost to achieve it. One sees that not only in terms of broad strategy but in the detail of the care that is provided. There is every reason to believe that conviction exists in the health service that guidance is there to be carried out.

Lord Rea: My Lords, what the noble Baroness says has pleased me greatly. It was in order to get such a statement that I put down the amendment. I believe that many workers in primary care will be very relieved to read in the pages of Hansard what she said. I thank the Minister very much for her statement. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

5.45 p.m.

Lord Rea moved Amendment No. 8:


Page 6, line 40, at end insert:
("( ) The Secretary of State shall give directions with respect to the exercise of responsibilities exercised prior to the passing of the Health Authorities Act 1995 by Regional Health Authorities in

24 Apr 1995 : Column 745

respect of the holding of contracts of registrars and senior registrars so as to require that those responsibilities should continue to be exercised on a regional basis.").

The noble Lord said: My Lords, this amendment allows us to continue the discussion we had in Committee. I refer to Amendment No. 15 and the proceedings at cols. 1601 to 1604. The National Health Executive document Options for the Future Management of Postgraduate Medical and Dental Education was published on the same day and briefly discussed in Committee. At that time the noble Baroness said:


    "It is our intention that the training programmes of registrars and senior registrars, and in the future those doctors in the proposed new unified training grade, will be managed at regional level by the postgraduate medical deans."

That was a relief. Later, she said:


    "It will not be necessary for the doctors' employment contracts also to be held at regional level to safeguard the doctors' training interests. It would not be right for them to be held by the regional offices as part of the Civil Service."—[Official Report, 28/3/95; col. 1603.]

That is possibly but not necessarily so. Mine is not the only voice to express doubt about that statement. The Committee of Vice-Chancellors and Principals said:


    "The CVCP would prefer to see the management of PGMDE contracted to the universities which are well used to the strict accountability requirements placed on them through the Higher and Further Education Act."

This amendment will accommodate that preference. The current contracts of junior doctors are overseen by the regional postgraduate deans who are jointly appointed by the universities and the regional health authorities. They can insist that the educational standards of junior doctors are protected. The CVCP and Royal colleges are unhappy that employment contracts will be held, as the Government suggest, at trust level, even if a lead or neutral trust continues to hold the main contract when a training programme involves rotation from one trust or health authority to another. I pointed out in Committee that it was difficult to insist on protected educational time in the face of heavy clinical demands. It would be more likely to be protected if a doctor's contract was with a body not directly concerned with service provision.

In Committee the Government put down several amendments to secure continuity of employment if junior doctors moved across trusts or health authorities during their rotation. However, those amendments were not moved. It is reasonable to ask why not. If the Government reject this amendment, the amendments, which the Government did not move, will be necessary to protect the jobs of junior doctors. If those amendments were withdrawn for a technical reason, surely it should be explained. Depending on the reply of the noble Baroness, we will have to consider whether or not those amendments, or something like them, should be introduced by this side. Of course, this will not be necessary if the noble Baroness accepts our amendment

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to keep the contracts of junior hospital doctors under one jurisdiction—the universities—through the current regional arrangements. I beg to move.

Baroness Cumberlege: My Lords, as I made clear when we discussed this in Committee, there are two important issues in relation to the contracts of registrars and senior registrars whose contracts are currently held by RHAs. First, their employment contracts need to be held elsewhere when RHAs go. Secondly, the continuity and quality of training programmes needs to be properly protected. It may be helpful if I deal first with the question of employment contracts. The Government tabled amendments to employment legislation in Committee which were relevant to these staff, among others. We did not move the amendments because we had not yet completed consultation on related issues set out in the department's discussion document on the future management of postgraduate medical and dental education. In particular, we are concerned to ensure that the new arrangements do not disadvantage doctors by breaking their continuity of employment so as to deprive them of rights under employment legislation. We are considering the means by which such protection can best be secured. Should further amendments prove necessary to achieve that, it would be our intention to table them at Third Reading.

It would not be right for the contracts of junior doctors to be held by the regional offices as part of the Civil Service. The Government have made clear that they would prefer junior doctors' employment contracts to be held by the employer, usually an NHS trust. This is consistent with the treatment of other NHS medical and non-medical staff. It is consistent with the principle that personnel issues are generally best managed at local employer level and with trust freedoms to determine the quality and type of resources they employ. Devolving contracts to employers is still a matter for discussion with the various professional bodies representing these staff.

This brings me to the second issue. I am aware that particular concern has been expressed that to transfer contracts to NHS trusts may cause problems in maintaining the required level and standards of training. A number of proposals arising from discussions with postgraduate deans were set out in the discussion document issued recently by Dr. Winyard, the medical director of the NHS Executive. The closing date for comments is today. In particular, the document suggests that there should be a network of training agreements between trainee doctors, deans and trusts. There would also be a system of service-level contracts between deans and trusts to ensure that the right environment was provided for a high standard of training delivered in a cost-effective way. Training agreements might cover matters such as the agreed balance between service and training; the level and type of specialist training to be provided; educational plans, inlcuding rotational arrangements and study leave; and arrangements for assement.

Service level contracts between deans and trusts have already been introduced in many parts of the NHS. They are a good way of ensuring that trusts continue to

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provide high quality postgraduate medical education. The safeguard they provide is reinforced by the dean's financial control over a very significant proportion of the resources involved—including 50 per cent. of the basic salary costs of full-time junior doctors. That amounts to between £300 million and £400 million nationally. I should make clear that neither training agreements nor service level contracts would require any provisions in this Bill.

We are committed to high quality medical education and training, which underpins our objective of providing high quality health care to patients. The interests of the profession, universities and postgraduate deans will be taken fully into account in developing the detailed framework for medical education and training. We will ensure that the staff concerned are treated fairly, and that continuity and quality of training is maintained.

In the light of those comments I hope that the noble Lord will withdraw his amendment.


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