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Baroness Northover: We share the Government's aim of an equitable distribution of GPs to ensure that patients have equal access to doctors. However, we are also very concerned about the abolition of the Medical Practices Committee without the continuation of its functions of national oversight, data collection and control. I shall put on record some of the views of the noble Lord, Lord Rea, who would have liked to contribute to the debate, but has unfortunately had to go home because of illness. He has passed me a note of what he intended to say.
The noble Lord would have spoken in support of the amendments, which are aimed at averting the danger of a less than even spread of GPs. He points out that if individual health authorities are allowed to fill or create new GP vacancies without national co-ordination, we are likely to get ourselves into a worse situation than we have been in up to now. He argues that the MPC has not had sufficient incentive at its disposal to attract adequate numbers of GPs to deprived areas. I agree with much of what he has said.
How will the Government's new system work in practice? What powers might the Secretary of State have to ensure an equitable distribution of GPs? In the absence of such safeguards, I commend the amendments.
We shall debate the Medical Practices Committee later. Our proposals detract not a jot from the hard work that the MPC has undertaken over the years. I have worked for many years with the current chair of the committee and I have enormous respect for her. As the noble Earl, Lord Howe, said, the MPC's role is to determine, on referral from a health authority, whether a vacancy for a GP should be declared. He rightly pointed out that it cannot direct a GP to practise in an under-doctored area, although it can prevent more vacancies being declared in over-doctored areas.
After many years the MPC has had some success, but it has not been as successful as one would want in ensuring a much fairer distribution of GPs throughout the National Health Service. I am convinced that the mechanism that we have adopted will allow local health authorities to take the lead role through the leverage that they will be given. The local medical services and the other techniques that can be used will
I assure noble Lords that health authorities are not going to be left floating on their own to engage in a brutal market force approach to ensuring a better distribution of GPs. In the first place, as part of the process that they have to undertake, they will have to agree with regional offices of the NHS Executive the need for the number of GPs in their area and to agree with the regional office target increases. There will be what are described as "regional envelopes" for the number of GPs, so that we can match--I very much take the point raised by the noble Earl, Lord Howe in this respect--the distribution of numbers of GPs to both the increase in GPs who come through as a result of the NHS Plan and the overall increase in medical training and the need for a better distribution of GPs. That will be linked into national workforce planning arrangements, which I shall shortly describe more generally.
The substantive point that I want to make is that health authorities will be given much greater freedom to be proactive in this area, but that will be within a sensible performance management framework through regional offices, allowing for targets to be agreed between the health authority and the regional office and allowing the Department of Health to have some workforce planning arrangements at national level. I believe that that will give us the best of both worlds: a framework for the NHS and greater freedom for the health authorities.
I oppose the specific amendments that have been tabled because I believe that they would limit the Secretary of State's power. He could only take into account Part II expenditure with a view to ensuring that each health authority has an appropriate number of medical practitioners. These amendments ignore the need to look at the whole primary care workforce when considering GP distribution. I suggest that they also continue to separate GP services from the rest of the NHS although workforce planning is moving in the direction of integration.
The amendments would also require the Secretary of State to say how many GPs he thinks there should be in each health authority. I believe that that amounts to over-centralisation. It seems to me that the determination of the need for GPs should form part of the local strategic planning role of the health authority, which is very much underpinned by the changes in the funding formula.
The other point that I make in relation to the amendments is that a further effect of them would be that the only non-cash-limited expenditure which could be taken into account would be that on general medical services. I said earlier that, although our present focus is on general medical services, we want to ensure that in future we shall be able to cover other contractor professions, including, for example, dentistry.
I turn to Amendments Nos. 12 and 15. I have said that we want to devolve responsibility for GP distribution to health authorities, but not in isolation. We believe that health authorities must consider GP numbers as part of their whole NHS workforce planning strategy. But we do not believe that a framework is needed to oversee national GP distribution, which I suspect would almost recreate the Medical Practices Committee.
We are setting up a new national workforce development board, which will start its work in April. It will oversee the workforce development of all NHS clinical staff, including GPs and their staff at national level. Alongside that, the Medical Education Standards Board will also keep under review the impact of training requirements on the distribution of GP trainees and principals. Through the national workforce development board, we shall establish an integrated structure of national workforce planning.
I turn to Amendment No. 225. I believe that a medical practice advisory body would amount to over-centralisation and would, as I have already said, tend to recreate the Medical Practices Committee in another guise. I believe that the overall framework that we have set--a funding formula with the right financial incentives, a leadership role for health authorities within a performance management framework, and a national workforce mechanism at national level--will give us the right balance between a central framework and local determination.
Earl Howe: We shall see. I hope that the noble Lord is right in his predictions. I am grateful to him for explaining very clearly the full set of mechanisms that will be in place to deliver what I am sure he wants to see; namely, a more equitable distribution of GPs. However, I still have worries that the significant expertise built up in the MPC will be dissipated.
Lord Hunt of Kings Heath: Perhaps I may respond to that. I am the first to admit that the expertise of the MPC has been valuable, but it is worth pointing out that all the data on which it relies come from individual health authorities, which have to make cases to the MPC. The health authorities have a great deal of expertise in putting together information and making cases to the MPC, and I am sure that that is a good foundation on which health authorities can take forward this work.
Earl Howe: That is true. Nevertheless, the skill lies in the interpretation of the data. I do not believe that the tools of analysis developed by the MPC over the years are readily available and to hand in most health authorities, as they will need to be to enable the health authorities to approach the kind of fine tuning required. In the mean time, this has been a useful debate and I beg leave to withdraw the amendment.
Lord Clement-Jones: I do not want to extend the debate unduly. We have had a fair canter around the course and the Minister has tried to explain a thicket of very difficult language in the existing Act and in the proposed Clause 1. Certainly, as a lawyer who is used to reading legislation, I find the 1977 Part IV provisions very difficult to understand. I am also ashamed to say that the Government Resources and Accounts Act 2000 had passed me by. I did not realise what it was all about until very recently, when the provisions of the Explanatory Notes made clear why it was so relevant.
This is not only a debate about transparency or the future of the MPC; it is also about the merits of Clause 1. I listened very carefully to what the noble Baroness, Lady Cumberlege, said. I believe that she could give tutorials in resource allocation, although she said that they are "shrouded in mystery". They continue to have a shroud around them.
I believe that the essence of the clause is that it is directed at under-doctoring. The way in which it tries to do so is to allow a different method of dealing with total resources by permitting non-cash-limited expenditure to be offset against cash-limited expenditure. However, I am baffled. If we are trying to get more GPs into deprived areas, why are we adopting this extraordinarily complicated method of doing so? Is it not simply a rather sophisticated way of introducing overall cash limiting? The noble Earl, Lord Howe, used the expression "back-door" cash limiting. I wonder what the ultimate agenda is in that sense.
I understand what the Minister said. The clause is designed to achieve a fairer system. But why is the BMA so opposed to the proposal? One would have thought that a new system, both of resource allocation and of assessing the needs of deprived areas, could have been concocted and used in conjunction with the medical profession. Why have we chosen this rather unilateral way of doing it?
The Minister said that it cannot be subjective, but, frankly, the Wednesbury unreasonableness test, which relates to judicial review, is hardly the most fine instrument of control on government policy, as some of the former Ministers in this House will be only too well aware. Therefore, I do not believe that an adequate level of objectivity is in place, and the result could be overall reductions. We heard what the Minister had to say. Reference was made to overall reductions in the budgets in total. If one added together the GMS budgets and unified budgets, that would be the power available.
Therefore, in a sense, does not this proposal represent a move towards overall cash-limited expenditure? Could it not be used for all sorts of other purposes, quite apart from those stated by the Minister? In addition, as a number of Members of the Committee asked, will it involve a transfer of funding?
My final point is that a great deal hangs on the formula in Clause 1. I find it somewhat inexplicable that the MPC could not have been reformed rather than abolished. Perhaps it needs to be less powerful or perhaps it could have been advisory. However, so much now hangs on that formula. I heard what the Minister said about the national workforce planning framework. Nevertheless, without the MPC, that formula will be very important. It is extremely opaque and, if I were a health authority manager, I would find it somewhat baffling. I would need a great deal more explanation than I believe we have heard today.
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