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Noble Lords: Hear, hear!

Baroness Hayman: That technique has not been used in your Lordships' House since 1985.

Lord Henley: Rubbish, my Lords. It was 1991 or 1990.

Baroness Hayman: My Lords, perhaps we will both go back and look at our precedents--but it has not been done for some years. I hope that it is not a reflection--if I may take up the football metaphor of the noble Lord, Lord Lyell--of the hooligan tendency on the Conservative Back Benches permeating to the Front Bench. It would not be the most sensible way to deal with these particular issues. We welcome detailed scrutiny of the Bill and want to look constructively at any suggestions about how we might better achieve the objectives we have outlined.

In my opening speech I said that we would certainly want to take into account the views of the Delegated Powers and Deregulation Committee and weigh very carefully anything it has to say on the topic. However, in regard to the reasoned amendment and primary care trusts, perhaps I may reiterate that the legislative approach taken in the Bill is well in line with the approach that governments have taken over many years to NHS legislation. Indeed, it is expressly intended to accommodate primary care trusts within the general framework of NHS legislation as it has grown up over the years. We believe that that is the right approach to accommodate primary care trusts within NHS law and that it will enable them to evolve in response to local circumstances, thereby building on their own experience, as we promised they would do. It is very much part of a developmental agenda, which I believe was the thrust of some of the arguments about radical reorganisations not being in the interests of the service. If we want to retain some of that flexibility, there are prices to be paid.

It is for all of us as legislators to debate where the right balance is struck in terms of every detail being put on the face of the Bill. Of course, it is the putting of every detail on the face of primary legislation which has led us into some of the difficulties that the professions have encountered in their concern to be able to amend the legislation that deals with professional self-regulation. Again, we are trying to strike the correct balance between enabling legislation and the right kind of safeguards which need to be there.

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Therefore, this is nothing to do with draconian powers and nothing to do with attempting to obfuscate; it is simply ensuring that we avoid the welter of technical and administrative detail for which legislation is often criticised. We must ensure that flexibility exists to respond quickly to changing circumstances and that we enable detailed administrative arrangements to be readily updated over time within structures and principles set out in parliamentary primary legislation. We must also allow flexible timing to develop, consult on it, and modify secondary legislation over time. In the light of that explanation, I hope that the noble Earl will think carefully about whether it is really the most sensible and the most considered way to proceed to press his amendment to a Division.

I made reference to the complexities in the legislation. The noble Baroness, Lady Carnegy, kindly gave me notice of the specific question she would ask on Part II of the Bill; namely, whether we could provide a Keeling schedule for the Scottish provisions. I should like to take that suggestion back and consider it with the parliamentary draftsman to see whether it is possible. I shall write to the noble Baroness on the matter.

Baroness Carnegy of Lour: My Lords, I am very grateful to the Minister for her agreement to my request. However, can she also agree to our having a draft of such an amendment before the Committee stage? In that way we would know what we are talking about as regards Part II, because it is not self-evident from the Bill.

Baroness Hayman: My Lords, I shall certainly consider both those issues. I am grateful for the noble Baroness's intervention because it has allowed me to clarify the position about the last time such a reasoned amendment was tabled. I suspect that we were both right, but certainly I was right to say that 1985 was the last time that an Official Opposition tabled such a reasoned amendment.

Lord Henley: My Lords, does the Minister agree that that was not the last time that it was used? It is irrelevant whether or not it was used by the Official Opposition. It has been used since then by other Members of this House.

Baroness Hayman: Yes, my Lords. Because minority factions have employed such tactics in the past, and because they are now so decimated, the noble Lord seems to think that it is the sort of guerrilla tactics in which the Official Opposition should take part. However, I move on as I am anxious to deal with some of the specific issues which have been raised.

I shall deal now with one of the fundamental issues which was inherent in the speech made by the noble Lord, Lord McColl. I refer to the accusation that, in some way, there is an ideologically driven change of structure that takes away improvements created in the past. I reject that totally. I believe I said very clearly that, in recognising some of the benefits that have come with fundholding and with collective commissioning

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arrangements, the Government are trying to build on such improvements. But it is absolutely crucial and central to our purpose that we intend to bring those benefits to all parts of the population. We shall not do so in a spirit of levelling down, but in a spirit of ensuring quality across the board. It is not part of an ideological compulsion but absolutely a matter of principle that we do not believe that the mechanisms of the market are the most appropriate way to ensure equality of access to high quality care in a complex and much cherished public service like the NHS. That is central to what we believe.

I took note of some of the remarks made by the noble Earl, Lord Howe, when he said that he mourned the demise of GP fundholding. For example, he said that it would no longer be possible to shop around for a hospital where the care is better and that hospitals would not be on their mettle in case another hospital captured their business. That is not the way to drive up standards within the NHS. We firmly believe that issues of co-operation and collaboration are what actually deliver in terms of quality for patients and in terms of cost-effectiveness. It is on the basis of ensuring that the population as a whole can benefit from high quality services that we are taking this legislation forward.

I should like to deal briefly with some of the issues raised about primary care trusts. I believe that there has been a real welcome for the way in which these will put doctors and nurses in the driving seat of community health services. I take the opportunity to confirm that nurses are already able to chair primary care groups and that some have been appointed to do so in St. Helens and Knowsley and in south Cambridgeshire. Moreover, every PCG must have at least one nurse on its governing board. I know that there is interest in the arrangements; indeed, there has been wide consultation on the way forward. My honourable friend the Minister for Health hopes to have more to say soon in that respect. It will be important to balance the need for strong professional influence and involvement with the proper requirement for public accountability and local involvement in any public body responsible for large sums of public money. Getting those arrangements right and getting the balance right are issues to which my noble friend Lady Pitkeathley, and other noble Lords, referred.

I turn now to some of the other issues raised. One of them was mentioned most potently by my noble friend Lord Winston when he talked about PCTs. He expressed a concern that, in putting this particular responsibility and authority at primary care level, it would in some way diminish the role of secondary care and, indeed, of tertiary care. I make no apology--I do not think my noble friend would expect me to do so--for the emphasis that we are placing on the perspective of the patient and the community, and the GP and the community nurse, as the persons nearest to the patient and the community and therefore best placed to articulate their needs and aspirations as regards the National Health Service. However, that does not in any way diminish the recognition that what we need are high quality services at secondary and tertiary level. We recognise the crucial role of universities and medical research. We are talking about a continuum of care. My

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noble friend talked about the importance, as regards cancer treatment, of ensuring that specialists are available.

I think we all know from the experience of implementing Calman-Hine that we need a continuum of care. However good the tertiary services are, if that vital first link in primary care and at GP level is not made and the patient is not appropriately referred, the system is as nothing to that patient. We should not pit one part of the service against another part. We should realise that we need to give appropriate recognition to all those parts. That is a difficult task. It is one of the reasons why we seek to involve in health improvement programmes clinicians at all levels, at primary and secondary care level, and also the voluntary groups and the patient groups and those in the community.

Several detailed points were made about the provisions in Part II of the Bill in relation to Scotland. My noble friend Lord Ewing of Kirkford spoke--as ever on health matters--with great authority and knowledge. He said clearly that fundholding was never popular in Scotland--I believe that was echoed by the noble Earl, Lord Mar and Kellie--and that the Government are therefore right to build on the consensus that the benefits of primary care-centred services should be universally available. As my noble friend pointed out, primary care trusts in Scotland have been established and will be operational by 1st April. However, they cannot adopt the full range of powers without the Bill, as my noble friend Lord Ewing indicated. That is why it is important that we legislate as soon as possible. There has been much public discussion of the Scottish reforms--the noble Baroness, Lady Carnegy of Lour, referred to this matter--and since the publication of the White Paper Designed to Care the proposals have been generally welcomed. Most of them have been put in place under the existing legislation and this Bill deals with those few matters which require a change in the law.

I refer to devolution and the general point raised by the noble Lord, Lord Mackay of Ardbrecknish, who is not present at the moment. We have been careful to legislate for Scotland only where that is necessary and only where there is a clear consensus. For example, we are not legislating on joint working between health and local government as that is a matter which could rightly be dealt with by the Scottish Parliament.

I turn now to the important issue of professional self-regulation which has attracted perhaps some of the most stringent comments from noble Lords. I was not in the Chamber when my noble friend Lord Desai made his speech but I have heard reports of it. It is important that we do not view professional self-regulation as separate from the rest of the quality agenda and as something that can be dealt with separately. It is very much part of the quality agenda and part of our agenda to ensure consistency of care within the NHS. That is why I believe it is right to include it within the Bill.

We all understand that the noble Baroness, Lady Cumberlege, had to leave your Lordships' House. She said that professional self-regulation was at heart about trust between professionals and patients. She referred to a recent survey which revealed how highly

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trusted doctors and nurses are. My own cursory reading of that survey suggests that they are now even more highly trusted than clergymen and that the only people who are less trusted than government Ministers are journalists. I stopped reading at that point and tried to comfort myself with the thought that one can at least aspire to high standards even if some people do not think you have attained them.

I listened to the exposition of the Bill given by the noble Earl, Lord Howe. I believe that he has misunderstood what is contained within it. I make it absolutely clear that there is no intention or desire to end professional self-regulation. The powers within the Bill have been referred to as sweeping. However, we have tried to put on the face of the Bill checks and balances to ensure that there is full debate before change occurs inside and outside Parliament. Clause 48(6) provides for affirmative procedures. We could not abolish the GMC by order, as has been suggested. That is specifically excluded by paragraph 7 of Schedule 3 which states that an order,

    "may not abolish the regulatory body of any profession to which section 47(1)(a) applies".

It is important to clarify these points and to give some reassurance in terms of the drafting of the Bill. I think that would be in everyone's interests. It is also important to be clear about our purposes. We want to work with the professions, not against them. As the noble Lord, Lord Walton, said, we have a common endeavour to modernise and strengthen the existing arrangements for professional self-regulation. I acknowledge the efforts that the professions themselves are making in this area. The noble Lord will perhaps be interested to know that the Chief Medical Officer will attend the GMC conference on revalidation and take part in those proceedings.

We do not wish to dismantle the framework of professional self-regulation. We do not wish to react hysterically--as I think the noble Lord, Lord McColl, suggested--to the real problems and concerns that have arisen concerning particular cases. However, it is in no one's interest to diminish the high esteem in which professional self-regulation is currently held. If we want to strengthen that, we have to find the appropriate mechanisms to do so. I believe that the noble Lord, Lord Colwyn, and my noble friend Lord Morris both mentioned some of the problems inherent in a primary legislation framework which seeks to do this, just as some of the problems of a secondary legislation framework have been mentioned in the debate tonight. We have to strike the right balance. My noble friend Lord Ewing and the noble Baroness, Lady Fookes, emphasised the fact that orders may not be amended by Parliament. That is absolutely right and is all the more reason for making sure that there is full consultation on any draft order and for making sure that it is right before it ever comes before Parliament. Those are some of the safeguards that we have tried to adopt.

However, I repeat once more that we seek to do something which I firmly believe is in the interests of the professions themselves as well as in the interests of patients. If there are ways in which we can improve the Bill so that it better meets the objectives that are shared

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between the Government and the professions, and offers reassurance on points of concern, we shall want to consider that most carefully and constructively.

I wish to mention briefly the PPRS provisions to which reference has been made. I restate that the Government recognise what has been achieved over the years of the PPRS and the voluntary agreement. However, I think it is equally recognised--my noble friend Lord Ewing referred to this and, in fact, I would not expect any of your Lordships to fail to acknowledge it--that a situation where some companies decide simply and unilaterally not to take part in the scheme and simply and unilaterally decide to raise prices that are outwith the terms that have been agreed with the industry as a whole and where there is no power to ensure compliance is not a satisfactory one.

Again, we need to look at these provisions in detail but we remain committed to reaching a voluntary agreement with the industry. We recognise the strength of a successful pharmaceutical industry in the United Kingdom. We show our support for that in a number of ways. We recognise too that the research and development on which these industries are based are in the interests of patients as well as of the country as a whole. We want to find a resolution to this issue that is actually fair to the NHS and to its purchasing responsibilities and also fair to what is a very important industry.

I am very conscious that I have not dealt with all the points that have been raised. I think we shall have interesting debates over the next few weeks. There have been criticisms that the Bill goes too far and is draconian and criticisms that it does not go far enough in terms of strengthening the links between local government and the health service. It is important that in all the mechanisms we are dealing with through this legislation we look at some of the principles behind it--the principles of improving quality and of having partnership not only between different parts of the NHS but also between the NHS, the local authorities and the voluntary groups. We should look forward, not to framing the legislation alone, but to doing an enormous number of other things that we need to do with the resources that are going into the health service. We want to see improved, more accessible and more responsive care across the board so that resources are invested in front-line staff whose contribution to the NHS is so critical. I commend the Bill to the House.

8.32 p.m.

Earl Howe: My Lords, this has been a very interesting debate. I have listened with care to the contributions made by your Lordships and in particular to the speech of the noble Baroness. I accept entirely that in a Bill of this kind there is a need to delegate order-making powers to Ministers for the sake of flexibility and administrative convenience on what might be called routine issues. I would never seek to argue otherwise, but what I feel has emerged from the contributions of a number of your Lordships is that a Bill of this importance really ought to include a

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framework at least--and it is a framework Bill--for each of the major provisions within it, in order to give each of them some substance.

The noble Lord, Lord Ewing of Kirkwood, pointed out that one of the weaknesses of affirmative resolutions is that they cannot be amended. I quite agree with him. That is one very good reason why I believe we should have at least the essential features on the face of the Bill. Only if they are on the face of the Bill will we have an opportunity to amend them if we wish to do so. As it is, the Bill is silent on even the definition of primary care trusts. I really do not think it is sufficient to say that each primary care trust will be different and that we have to accept that there will be a "suck it and see" approach to setting them up. I am quite sure that each primary care trust will be different, but equally I cannot accept that none of them will have any principal features in common. I am not asking for "small print" on the face of the Bill but I am asking for principal headings so that we can all be certain of what we are talking about.

The Minister has not accepted my point--I confess that I did not hold out much hope that she would--but I tabled my amendment, which I believe is perfectly in order, and we have had a debate about it. I would just say to the noble Baroness that I do not believe it would in any way infringe the established conventions of the House if I were to ask your Lordships to agree to my amendment. However, the point about primary care trusts has been made, and made emphatically; and it has commanded considerable support from all sides of the House. I have reached the view that a Division on the issue would be superfluous.

However, I doubt very much that the fears of doctors will have been allayed by what the Minister has said this evening. The answers we get in Committee really must be better and fuller ones. Further to that, I anticipate that our debates in Committee will be considerably lengthier than they would otherwise have been by virtue of the Government's refusal to concede any part of the point I have made. Therefore, with my thanks to all noble Lords who have supported me and with the promise that we shall return to these matters in Committee, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

On Question, Bill read a second time, and committed to a Committee of the Whole House.

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