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Lord Warner: I rise to oppose Amendments Nos. 3, 6 and 12 because, taken together, I believe that they are actually rather dangerous. Indeed, they would enable a smallish group of GPs to prevent the progression from primary care group to primary care trust, irrespective of whether most of the local health and social care professionals in the community in that particular area wanted to make such a progression. The good Benthamite principle of the greatest good for the greatest numbers is a very sound one and one upon which we should reject the amendments.

I should also like to remind noble Lords opposite that when the previous government sought to merge family health service authorities with district health authorities, a good number of GPs were opposed to such a move. I do not recall a great deal of enthusiasm for consulting local GPs on that move. Indeed, the will of Parliament was regarded as sufficient at that time.

Baroness Carnegy of Lour: We do not want to play political football with this matter. I hope that the noble Lord will not address those on the Benches opposite him as if they are always wanting one thing while he wants another. That is not what we are about when we are examining a Bill, and this is one that we want to work.

Does the noble Lord really believe that you could proceed to form a trust with more than half of the GPs in the group being against operating within such a trust? The noble Lord, Lord Rea, was anxious about that and, therefore, thought that it was a pity to give them the

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chance to ballot on such a move. Does the noble Lord really feel it would not operate successfully?--because he knows about these things.

Lord Warner: The amendment does not put forward that particular proposition. This is all about health professionals at the local level working together on a co-operative basis. It takes a particular group of health professionals at that local level and almost encourages them to stand out against change if they choose to do so. In my view, that would not be a good contribution to the welfare of local people when we are talking about health professionals and social care professionals working together in the interests of their communities.

I made some remarks about the Benches opposite. I should point out that the amendment was moved by the Front Bench opposite as part of a group. Therefore, I believe one is entitled to respond on the basis that the party opposite is actually supporting the amendments. I was merely reminding Members of the Committee opposite of the changes which they introduced when they were in government. There was no consultation and no right of veto as far as concerns GPs when the FHSAs were actually merged with district health authorities.

Lord Clement-Jones: Thus far in the debate a clear distinction has been made between, if you like, the balloting proposals in the first three amendments of the group and the proposal contained in Amendment No. 16, which--to use a word employed by the noble Lord, Lord Rea--is much more inclusive. It is certainly not our intention to have an unnecessary and artificial block on progress into PCTs. We are trying to avoid a situation which is theoretically possible. If one looks at the guidance notes, they state:

    "It is envisaged that proposals to establish a Primary Care Trust will be generated locally. The views of Primary Care Groups, NHS trusts and local communities will be taken into account in considering such a proposal".
That does not give the PCG the primary role. In a sense, if one is going to undertake all the consultation that is proposed, it seems rather fruitless to find at the end of the day that the PCG is not favourably disposed to moving towards a PCT. That is why we on these Benches propose Amendment No. 16. We seek to make sure that the sine qua non of the whole process is the PCG itself, which includes not only GPs but also professions allied to medicine such as nurses, community nurses and so on. Therefore it is a much more inclusive proposal. What we want to avoid is the theoretical possibility that GPs and other health professionals could be delivered, bound and gagged, into the new PCT system. We think that would be highly undesirable. The foundation of proceeding to a PCT must be to obtain the consent of the PCG. Those are our motives. They are entirely distinct from those which underlie the other three amendments in the group. We hope that the Government will look favourably on this provision as a mechanism for making sure that there is full consent and that all parties moving into PCTs are part of a constructive process.

Lord Walton of Detchant: Having heard the discussion, while I can understand and sympathise with

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some of the principles underlying Amendments Nos. 3, 6 and 12, I find it difficult to support those amendments. However, I believe that Amendment No. 16, to which the noble Lord, Lord Clement-Jones, has just referred, is one of considerable importance. I now pose the following question to the Minister. In her remarks a few moments ago the noble Baroness, Lady Carnegy, referred to wide consultation. That is an issue which I believe is mentioned in subsection (5) of this clause, to which I believe Amendment No. 17 refers. There are a number of important issues to which I should like to draw the attention of the Committee at a later stage. May I take it that it would be more relevant to discuss issues such as the interests of the universities and of other bodies when we reach Amendment No. 17?

Baroness Fookes: As I understand it, the principle underlying all these amendments, different though they may be, is that there should be agreement to participate in a primary care trust. It is absolutely vital that all those involved should be agreeable to this, and it should not be forced upon them. I am concerned that if the matter is left to consultation--which is a somewhat vague phrase--that could lead to something being imposed which is not welcome to the participants. I am rather taken with Amendment No. 6 because it provides for a secret ballot with a majority in favour of the proposal. I concede that perhaps it does not include the interests of others directly involved, but I think the principle of a secret ballot--perhaps involving all the people who will form the trust--is a wise and sensible proposal, rather than leaving the matter to the rather vague notion of consultation.

Lord Skelmersdale: Before the noble Lord, Lord Warner, spoke, I was about gently to chide my noble friend for being too prescriptive in his series of three amendments, Amendments Nos. 3, 6, and 12. As the noble Baroness, Lady McFarlane, and others have pointed out, there are many more people involved in the acceptance of all of these provisions than just GPs. I most certainly go along with that. I am not quite sure though why Amendment No. 16 is in this group, because I could support that straightaway without the slightest problem. The Secretary of State would make a grave error indeed if having slowly brought the PCGs through the various stages, he then enforced a trust upon them. I believe that would result in total and absolute chaos. I cannot go along with that.

5.15 p.m.

Baroness Hayman: This has been a useful debate on this set of amendments. As the noble Lord, Lord Walton, said, I think it is a precursor for the debate that we shall have as regards some of the groups that we need to ensure are consulted. It has raised an issue that we shall deal with--to which the noble Lord, Lord Skelmersdale, has just referred--namely, exactly how prescriptive one is on the face of the Bill in an area where there are a large number of different groups and interests who need to be consulted, and where the list in one geographical area and circumstance may not apply to another geographical area and circumstance. By

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listing everything, one runs the risk either of having legislation that goes on for pages and pages and pages, or leaving out important bodies that may need to be consulted. I refer to local circumstances in this regard. However, that is a general issue to which we can return. I shall deal with the specific amendment of the noble Lord, Lord Clement-Jones, in a moment because that is much more precise.

Lord Clement-Jones: I wonder whether the noble Baroness can answer a question. What she seems to be saying is that the whole consultation process has a large agenda and PCGs are simply part of that. But does she accept that the requirement for the consent of a PCG comprises something other than purely consulting with the wider community, the voluntary sector, carers and so on, all of which we shall debate when we reach the later amendments?

Baroness Hayman: The noble Lord is quite right to chide me on the relationship between a PCG and progression to PCT status. I shall certainly discuss that in a moment. I was just trying to deal with the more general issue which I believe will concern us at various stages in the passage of the Bill.

Perhaps it would be helpful to respond to the noble Baroness, Lady Carnegy. It is sometimes genuinely difficult to disentangle the role that GPs will play as commissioners of services, as providers of services as part of a level four PCT, and their services as general practitioners in the traditional sense and as independent contractors. I make it clear that in their role as general practitioners providing general medical services, the status of independent contractor will not be affected at all by primary care trusts. We recognise that it is the bedrock of general practice and that it is a major force for improving primary care. It is not the intention of the Government or of this legislation that it should be affected by the creation of PCGs or PCTs.

I turn to the amendments in the group. As has been acknowledged, the first three deal particularly with general practitioners in relation to the progression to primary care trust status. We have made it clear all along that GPs and community nurses have a key role in developing local services and in rebuilding some of the public confidence in the NHS as a public service accountable to patients and open to the public and shaped by their views. We recognise the important part that GPs have to play in the progress of primary care groups to primary care trusts and in developing and shaping the delivery of healthcare to meet the needs of whole populations. However, that needs to involve the whole community.

The Government's aim is for an establishment process that is locally driven and that takes into account all local views. We envisage proposals to establish a PCT being generated locally and any decision whether or not to establish a PCT will take into account the range of local views. Local doctors will, of course, have a view on that, but as has been pointed out by both the doctors who have contributed to the debate, they are not the only group of professionals or group within the

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community who will have a particular interest in the matter. Local PCGs will have a view on the matter--that is the issue which the amendment of the noble Lord, Lord Clement-Jones, addresses--but so too will local NHS trusts providing community services and many others, including (this is important) professional and patient representative groups.

The PCG has a pivotal role in this process, to which I will return in a moment when I deal with Amendment No. 16. It is our assumption that the support of the primary care group would be required by the Secretary of State before he approved a primary care trust. Not all proposals will go forward for consultation. It is proposed that health authorities will select which proposals are to proceed to consultation, and then to consideration by the Secretary of State. The Government intend to provide in directions that the health authority must select proposals made or endorsed by a PCG or NHS trust providing community services locally. So there is a power for ensuring that locally generated proposals from PCGs go ahead.

The issue we are addressing in these amendments is whether there is a veto in either body. But, on the positive and proactive side, there is some assurance that at least one of the local NHS bodies is signed up to a proposal before it triggers formal consultation.

It is argued that these arrangements will provide GPs with a significant opportunity to influence whether or not the PCG initiates proposals and if so, the scope of such proposals, and whether or not to support others put together independently. The amendments proposed put GPs--and this was illustrated in the debate--in a uniquely preferential position. It effectively gives them the right of veto over primary care trusts. That is not the way to go forward. For those reasons I suggest to the Committee that this group of amendments should not be taken forward.

I turn now to the wider proposal that a primary care trust should only be approved if it has the support of the primary care group. It is important to say at the start that it is no part of the Government's agenda to impose primary care trusts on the service. We believe that primary care trusts will bring benefits to patients, NHS professionals and local communities--and we are confident that people will recognise the opportunities they offer and will want them established--but we do not intend rushing headlong into primary care trusts. We want measured change, progression to trust status, driven locally, based on local views. That is why the Secretary of State will be able to establish a trust only after local consultation.

There is clear provision in Clause 2, inserting the new Section 16A(4) and (5), for the Secretary of State to impose consultation requirements in relation to the establishment of primary care trusts. The detailed arrangements for that consultation are rightly matters for secondary legislation. Comparable orders for establishing NHS trusts are set out in the 1990 Act.

The views of primary care groups, local GPs and other professions, as well as those of the wider community and the NHS locally, will be key considerations for the Secretary of State in deciding

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whether to establish a primary care trust. It is our assumption that the support of the relevant primary care group will be required. My honourable friend the Minister of State for Health made this clear to the chairs of primary care groups, health authorities and NHS trusts in a letter to them on the 19th February--which has been referred to by some Members of the Committee--a copy of which has been placed in the Library. We intend to establish PCTs in a way that is sensitive to local views, and primary care groups are key to that.

We believe that the amendment is unnecessary and that if it was inserted in the Bill it would be unnecessarily restrictive. For example, it is possible that if two PCGs join to form one PCT, one PCG with a non-GP majority might oppose, even though the great majority of GPs in both PCG areas want to go ahead. Clearly that is a complex and difficult situation to handle--and one which we would have to be very careful and sensitive about--but to put a restriction on the face of the Bill would be overly restrictive. I hope that the explanation I have given--that we would not envisage circumstances in which proposals would go ahead without the support of PCGs--is such as to reassure the noble Lord, Lord Clement-Jones.

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