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Earl Howe: I am grateful to the Minister for her reply. In the circumstances, I think she has provided as much reassurance as she was able to. I therefore beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 46 to 48 not moved.]

Schedule 1 agreed to.

Clause 3 [Primary Care Trusts: finance]:

[Amendments Nos. 49 and 50 not moved.]

Lord Clement-Jones moved Amendment No. 51:

Page 3, line 45, at end insert--
("( ) For the avoidance of doubt, notwithstanding anything contained in this section, general practitioners shall not be cash-limited in respect of any drug or treatment prescribed by them for their patients which falls within the Part II expenditure of the Primary Care Trust to which they relate.").

The noble Lord said: This is a fairly straightforward issue. It is unashamedly a probing amendment, but it is a matter of considerable importance. We have a situation where doctors at GP level will potentially become the

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rationing instrument of the NHS. This could be a fairly invidious situation if the proposals for cash limiting prescribing costs goes ahead. The same issue was discussed on Second Reading and there were a number of contributors to that debate. If the national institute of clinical excellence is prescribing effectively what is best practice (which GPs and PCTs have to observe) but at the same time the drug budget of GPs is limited, the latter will become the rationers in those circumstances, especially as the year goes on.

If there had been a proposal to cash-limit every GP in the country under the previous government, I am pretty certain that the party opposite would have had something to say about it. I am not clear in my own mind about the motives behind this proposal. I do not find the Explanatory Notes particularly informative. Indeed, the latter seems to bring it in by a side wind (on page 16), as if it were something casually dropped in from April 1999, and so on. So it is a matter of considerable concern. The phrase I used on Second Reading was that GPs risk being caught between the hammer and the anvil. I believe that rationing does take place currently and, if it does so, it should be transparent. If we are not careful, we shall build up problems for ourselves at that level where there is insufficient flexibility.

The position at present, as I understand it, is that non-GP fundholders are not effectively cash limited. However, what can happen is that a health authority may take one of them to task after it has overrun its budget, which is perfectly proper. Indeed, explanations can be sought from GPs in those circumstances. But this is a very different proposition. Quite where the cash limits bite in terms of primary legislation and how it all works is not very transparent, hence the reason for tabling this amendment; namely, to try to flesh out precisely how it all operates. I am sure that the Minister will elucidate the position. I beg to move.

9.30 p.m.

Earl Howe: I rise to express my support for the amendment. The noble Lord, Lord Clement-Jones, is absolutely correct to point out that there is doubt surrounding this matter in that neither the Bill nor the Explanatory Notes seem to indicate clearly whether the drugs budget will be cash limited. I suspect I know the answer because the Government have previously indicated that the NHS will be subject to a cap on the budget available for prescriptions. I would welcome the Minister's comments in that respect. If she says, as Ministers have said before, that no patient will be denied the drugs that they need merely because the primary care trust has run out of cash, then I should like to know how the Government intend to achieve that here.

Baroness Hayman: I hope that I can clarify the situation and explain to the noble Lord why the amendment is unnecessary. Neither the existing legislation nor this Bill provide for the prescribing costs of individual GPs or their practices to be cash limited. We have no plans to introduce cash limiting at this level. What we are trying to do, as the White Paper The New NHS explained, is to ensure that clinical and financial

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responsibility is aligned within health authorities at primary care group level and subsequently at primary care trust level. That will be achieved by bringing together within a unified budget the costs of hospital and community health services, GP infrastructure investment and the drugs and appliances prescribed by GPs and community nurses. That will enable individual clinicians to decide both the most appropriate treatment in individual cases in the light of clinical efficacy and costs and also to look at the whole range of provision that is available in the round rather than in separated budget streams.

Within the overall local cash limit provided by the unified budget, primary care trusts will be able to decide how much they spend on prescribing. Individual practices will have an indicative budget for prescribing, but this will not be a cash limit. It will be a tool to assist primary care trusts in comparing the prescribing activities of their constituent practices. Many times in this Chamber we have drawn the attention of noble Lords to the wide differences that exist in prescribing patterns, and the importance of ensuring best practice in that regard.

I recognise that in moving this amendment the noble Lord may be seeking to prevent the inclusion of overall prescribing costs within the unified budget. However, I suggest that would defeat the purpose of establishing the unified budget and introduce for prescribing a disjunction between clinical and financial responsibilities. It would destroy the integrity of the unified budget and undermine one of the key commitments in the White Paper. For those reasons I cannot support the amendment that has been put forward.

Baroness Gardner of Parkes: The Minister said that there will be no restrictions in this regard at this level. At what level will the restrictions apply? Will she explain to me in simpler English what an indicative budget is? Will she tell us a little more about the unified budget? Her reply was the most unsatisfactory that I have heard all day. She appeared to be trying to imply that there will be no limit on what is spent on the health service, when every one of us knows that no nation in the world can make an absolutely unlimited commitment in this regard. Our health service is free at the point of delivery. I hope the Minister will clarify this matter a little further.

Baroness Carnegy of Lour: When the Minister replies to that question, I hope that she can also answer a question for me. Doctors in Scotland have raised this matter. The funding position in this respect appears to me to be about the same there. They are concerned that if drug costs within a trust rise steeply, the money they will need to develop the infrastructure of their practices--for example, if they wish to develop new computer systems--will not be available. They fear that

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their practice costs--apart from drug costs--will be squeezed. Is it part of the Government's plan to make trusts and GPs do the rationing?

Baroness Hayman: I shall try to achieve greater clarity in my explanation than I obviously did earlier. I was not trying to suggest that there would be no cash limits at all for the health service. Obviously there are cash limits in terms of the budget that is allocated nationally to the health service which then filters down through health authorities and primary care trusts. There will be an overall cash limited unified budget for primary care trusts. That is quite clear. However, beyond that there is the situation--

Lord Clement-Jones: I am sorry to interrupt the Minister but there is a comparison here in a sense with the current situation. As I understand the position, if non-fundholding GPs overspend on their drug budgets, the health authority then passes the request for payment through to the central department which pays it. Is the Minister saying that that flexibility will not be available to PCTs because their unified budget is cash limited at that level, unlike the position with health authorities at present?

Baroness Hayman: As to what would happen if an individual PCT overspends in any one year--which I think is the circumstance to which the noble Lord is referring--there are well-established risk-sharing arrangements which provide temporary financial assistance. Those arrangements are effective and it is our intention that they would continue for PCTs. They would therefore be available to a primary care trust if it overspent on the unified budget. I hope that that solves that problem.

Turning to the cash limited overall figure and how that then filters down in terms of drugs expenditure overall, both within the PCT and at practice level, the indicative budget is the amount which the PCT would expect a practice to spend for prescribing in that year. It is important that we have an indicative amount because that allows the practices to look at the ways in which they are managing issues like drug prescription against which they can make savings which can be ploughed back into the individual practice, as we discussed earlier.

But an indicative amount does not represent a cash limit. Cash will be managed by the PCT as a whole by offsetting any overspend in one area with reductions elsewhere.

Baroness Gardner of Parkes: As I understand it, the indicative budget does not have built-in provision for the prescribing of drugs like Viagra. I am not talking about Viagra for relaxation or pleasure, but I have known practices where it has been prescribed for someone who matches every requirement--diabetes, kidney failure, everything under the sun--and yet other partners in the practice are very concerned because that absolutely unthought of and unknown expense has arisen.

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If the drug was available more widely than just for these few really difficult cases, it would absolutely blow holes through the budget for this year, next year and every other year. What amount will be built into the indicative budget for such miracle drugs, as I suppose one could call them?

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