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Baroness Gardner of Parkes: Could I ask the Minister for a little clarification on what she has said? First, she says that the aim is to reduce bureaucracy-- I am quite convinced that this proposal will not do that--and she is also looking for savings in financial terms. The noble Baroness said that practices would be able to keep 50 per cent. of any money that they saved. Would she confirm that that will be irrespective of whether every practice saves more than expected and will there be no ceiling at all on how much practices can save? Further, will practices be able to save, for example, by not prescribing in the same budget something like beta interfon--because that is just too expensive and certain GPs and their partners even now object to prescribing something very expensive because it affects the budget? Will GPs be able to prescribe quite freely or will they be losing their incentive if they prescribe these expensive treatments?

Baroness Hayman: The issue about GP prescribing and how we ensure equal access for patients to a variety of treatments is a much wider issue, which I am sure we will come to later. However, through the National Institute of Clinical Excellence, the national service framework and then through the clinical governance arrangements we are making sure that the best quality advice is going out to all those who are providing health services so that they can be publicly accountable through their clinical governance and in the course of clinical governance for the quality of the service which will include access to drugs, for example, to which the noble Baroness referred.

As far as concerns the incentives for efficiency gains, practices will be entitled, as I said, to retain 50 per cent. of all savings they achieve against indicative budgets, but those savings are to be capped at £45,000, and they must be made through efficiency and not through reduction in services. I hope that is helpful.

Earl Howe: This has been a useful debate and I am grateful to the noble Baroness for answering the questions that I put to her. I would only say that if it had been my intention to wreck this Bill I would have given the Committee notice that I intended to resist Clause 1 as part of the Bill, and I would not dream of doing such a thing. With those comments, and reserving the right to bring this matter back at a later stage, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 2 [Primary care trusts]:

Earl Howe moved Amendment No. 3:

Page 1, line 14, after ("may") insert (", only after a request from the doctors on the medical list of the Health Authority who would be covered by the specified area,").

The noble Earl said: This amendment addresses an issue which is of great concern to GPs and other health professionals: namely, the fear that when a proposal is made to establish a PCT, that proposal could go out to

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consultation and be approved without any prior backing from those who are most affected by it, in other words, the PCGs. Unless the PCGs support the establishment of a PCT and unless the collective view of the PCGs is formally canvassed in advance of the consultation, then it is almost impossible to envisage how a PCT could successfully come into being. It would also be hard to justify spending valuable NHS resources in putting the proposals out for full consultation.

Last Friday's circular from the Department of Health emphasised that progression to trust status would be locally driven and based on local views, but I believe we need to ask what that means. I do not think it is enough to say, as the circular goes on to do--and I am quoting here--

    "It is our assumption that the support of relevant primary groups would be required".
I am not really sure what that means. The PCGs need to be actively in favour before the Secretary of State goes out to consultation, let alone takes a decision to give the green light to the PCT. Anything else would look very much like coercion, and we have had quite enough of that already. I beg to move.

Baroness Carnegy of Lour: We seem to have two groups of amendments about consultation--am I right? I am not sure that they cover exactly the same ground, but I do not understand why there should be two groups. I noticed in the department's letter to the chairmen of health authorities, primary care groups and NHS trusts--and I was grateful to the Minister for sending a copy of that, because it was extremely helpful--that the department gives four criteria for the Government's arrangements for primary care trusts that need to be satisfied. The criteria are that they will have to put primary care professionals in the driving seat, that they will need to provide public accountability, support local public involvement and ensure probity regarding public funds and conflicts of interest.

The question for all concerned in agreeing to proceed with a trust seems to me that they will have to decide that what the Bill proposes, in terms of accountability, public consultation and funding arrangements and indeed in conflicts of interest, will in fact enable primary health care professionals to be in the driving seat, whether or not they will stay there when all these arrangements are put into play.

The move from primary care groups to trusts--the groups having been committed to health authorities and the trusts being self-standing--will be an enormous change and the relationship of GPs and others to the centre will change very much. It is a huge change and it seems to me extremely important that everybody concerned is happy about it. It is extraordinary that the Bill treats the matter of consultation is such a cursory way. Clause 2(4) says:

    "If any consultation requirements apply, they must be complied with before a PCT order is made",
and swiftly sent through Parliament to set the whole thing in place. The Royal College of Nursing is very

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concerned about this, and rightly so. It wants to know what time will be allowed for consultation. However, I believe that we will deal with timing when we come to the next group of amendments, so the Minister may not wish to reply now in that respect. The universities are extremely concerned, especially those with medical schools and hospitals attached to them. I know one of them intimately and I am aware of the nature of the concerns. It seems to me that consultation of the sort suggested by my noble friend, or perhaps that proposed in the next group of amendments, is absolutely crucial.

In passing, there is one matter about which I am not clear. The reason for this may be my own thick head, but I am still not clear whether the Government are convinced that GPs who are independent contractors will maintain the freedom that is legally theirs right through the story of a trust to what I believe is the fourth stage. If the Minister could reiterate precisely why they are convinced, I would be happier.

This is not a party political discussion at all; we are trying to clarify the position and assess how we can get the system to work best for all those working in the health service. There are great questions about it and we really do need good answers from the Government.

5 p.m.

Lord Rea: On the face of it, it would seem that this is quite an eminently reasonable amendment. However, the noble Earl seems to forget that general practitioners are not the only people who will play a part in the primary care groups. As someone who has spent most of his professional life working as a GP, I believe that the move from primary care group to primary care trust may be thought to be beneficial by many people who are working in the PCG or indeed in the health authority. There may be a few GPs who are not too keen to move on, but it would be for the benefit of the people living in the PCG area to do so. I am sure that many GPs in every case will want to move on to PCTs, but there is just a possibility that, in some cases, a majority of them want to stay put and not move forward. I believe that it would be wrong simply to have a ballot of GPs. Indeed, I might be more inclined to back the amendment if everyone concerned in the primary care group was balloted. I do not think that the Government should necessarily accept any rigid formula here.

Baroness Thomas of Walliswood: I rise briefly to oppose the amendments tabled in the name of the noble Earl, Lord Howe, and to speak to Amendment No. 16, which has been included in this group. The noble Lord, Lord Rea, has really made my main case for me; namely, that there are a large number of other health care professionals who should be involved in this process. I think it is a mistake to give individual doctors--or perhaps I should say GPs--such a pre-eminent role in determining whether or not you even begin to consider the formation or the institution of a PCT and whether or not it goes ahead.

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Amendment No. 16 follows more closely the circular in that it tries to put on the face of the Bill the necessity of having the agreement of,

    "the Primary Care Group or Groups",
in the area which will form the PCT. Interestingly enough, it is our amendment in this grouping which has the support of the BMA.

Baroness McFarlane of Llandaff: Several Members of the Committee have already spoken about the inadvisability of naming just one profession. Although we accept the importance of the role of general practitioners, they are not the only professionals in the primary health care team. In fact, the Government--and the Minister again, today--have made explicit commitments to include community nurses in the driving seat of the reforms. Therefore, in their present form, it would be difficult to support Amendments Nos. 6 and 12. I believe that any requirements for consultation should be inclusive of all these professions in order to be effective.

We support Amendment No. 16. It is important not only to provide for the matters itemised therein but also to provide for the human resources element in which the professions work. That would include a human resource strategy for the whole of the National Health Service, including issues such as family-friendly employment and the issue of violence at work.

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