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Lord Hunt of Kings Heath: I am grateful to the noble Earl, Lord Howe. He has raised some practical issues, which it is important to clarify. It is accepted practice that when engaging a deputy or an assistant, the principal practitioner is responsible for ensuring that the person engaged is suitably experienced and

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qualified to undertake the tasks for which he is engaged. In applying to join a health authority supplementary list, a person's suitability and qualifications will be tested against a number of criteria. As the Committee would expect, those are factual issues such as the person's registration with the appropriate professional body, a criminal record check and a check on necessary qualifications. But I must stress that it is not a check on clinical performance or whether the person will be a good addition to the practice team. In the end, it will be for the principal practitioner to test those matters.

Not only is the test limited to factual issues, they are issues which are tested once on application. As a person moves between geographical locations, he may remain on the list for a number of years. So reliance on tests carried out on admission, even if they were widened to take account of clinical performance, might become unreliable.

I believe that the supplementary lists will ease some of the burdens of employment but they cannot take away all the responsibilities which rest with a practitioner engaging in the system.

We very much share the noble Earl's aim in relation to the second proposed subsection but we believe that the amendment is unnecessary. A decision by any health authority applies only to lists maintained by that health authority, whether it be a principal, supplementary or services list. Such a decision does not prevent an application to another health authority. We should expect the second health authority to consider the circumstances of the original removal in reaching its decision. But the second authority would be free to reach its own decision. So a national disqualification--that is, one which applies to all health authorities--can be applied only by the FHSAA. I believe that that meets the noble Earl's concern.

The third proposed subsection is very much a practical issue. I am sure that the noble Earl is right to say that many of those registered on a supplementary list will move from position to position across health authority boundaries--the point the noble Earl made. It would not be in anyone's interest to be unable to take up a position for which he was otherwise suitable because of some bureaucratic delay in the NHS or elsewhere. We recognise that and want to make the process as straightforward as possible. To work as an assistant in one GMS, a doctor will have to register on only one health authority list. That will qualify him to work across health authority boundaries in England. We believe that that better addresses the needs of a person who needs to move quickly to fill a position. However, it ensures that we continue to protect the public by ensuring that a person is properly registered on the supplementary list before he begins to treat patients.

We recognise also that some of the health authority checks before admitting a person to the list rely on third parties. For example, if a person declares an overseas regulatory body to the health authority but through no fault of that individual, the health

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authority has difficulty in obtaining confirmation, we shall seek to provide provisions which allow the person to be placed on the list while the confirmation is being actively sought. The individual would, however, still need to be on a supplementary list to provide family health services and we intend that the regulations will provide for that.

4.15 p.m.

Earl Howe: I am grateful to the Minister for that helpful reply, particularly as regards the second and third parts of my amendment. His answer on the first part took me rather by surprise. What he said was extremely interesting and certainly expanded my understanding of what is intended here. I shall read very carefully what he said and perhaps return to this matter at a later stage. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Hunt of Kings Heath moved Amendment No. 183:

    Page 27, line 40, at end insert--

"( ) The imposition of such conditions must be with a view to--
(a) preventing any prejudice to the efficiency of the services to which the supplementary list relates; or
(b) preventing any acts or omissions of the type described in section 49F(3)(a) below."

The noble Lord said: This is another set of amendments which concerns consistency in the administration by health authorities of their main, supplementary and service lists. It should mean that health authorities will have a robust system in relation to conditional inclusion to protect the interests of patients and of the NHS.

It is important that each health authority administers each of its lists in a similar way to ensure that there are no loopholes. In that way, patients will be assured that their interests are being safeguarded. Clause 28 provides for conditional inclusion in the main lists. This clause also contains express provisions at subsection 43ZA(2) limiting the circumstances in which those provisions can be used to considerations, as I said in an earlier debate, which involve fraud or matters which are prejudicial to the efficiency of the service.

Amendment Nos. 183, 203 and 209 make the same express provision in relation to the supplementary and service lists. I beg to move.

On Question, amendment agreed to.

Lord Hunt of Kings Heath moved Amendment No. 184:

    Page 27, line 43, at end insert--

"( ) If the regulations provide under subsection (3)(e) or (4) that a Health Authority may suspend or remove a person from a supplementary list, they must include provision--
(a) requiring him to be given notice of any allegation against him;
(b) giving him the opportunity of putting his case at a hearing before the Health Authority make any decision as to his suspension or removal; and

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(c) requiring him to be given notice of the Health Authority's decision and the reasons for it and of any right of appeal under subsection (6) or (7)."

On Question, amendment agreed to.

Earl Howe moved Amendment No. 185:

    Page 28, line 28, at end insert--

"(10) Before making regulations under this section, the Secretary of State must consult such bodies as he may recognise as representing persons who, in his opinion, are likely to be included in supplementary lists.""

The noble Earl said: Clause 31 seeks to make regulations for the publication of lists of professionals who can assist in the provision of community health services.

While the clause details the regulations for supplementary lists, it makes no specific mention of which professionals are to be included. Perhaps I may raise one specific example which is that of practice nurses. It is now universally accepted that we do not have enough GPs in the country to satisfy the demands of the NHS Plan, a deficit made more apparent by the publication of the national service framework for coronary heart disease.

A sensible solution would be for doctors to delegate responsibility for chronic disease management to practice nurses through a protocol. To my mind, that is a perfect example of,

    "assisting in the provision of general medical services".

Unfortunately, there is no accepted definition of a practice nurse nor is there a recognised qualification, although that has never prevented a large number of excellent nurses from working efficiently in general practice. The post of nurse practitioner is often quoted but there, too, there is no definition.

In this particular example, if the Secretary of State consulted the Royal College of Nursing, then he could save the health authorities considerable time and, dare I say, raise still further his stature in community services by helping to clarify exactly what is meant by practice nursing and who should be qualified to undertake it. I beg to move.

Lord Hunt of Kings Heath: I am happy to pay tribute to the role of practice nurses. It has been very pleasing to see how their professionalism has developed. Perhaps the noble Earl will clarify for me that his amendment deals with whether nurses can be placed on these lists.

Earl Howe: That was by way of an example. The purpose of the amendment is to require the Secretary of State to consult the relevant professional representative body, the problem being that the clause makes no specific mention of which professionals will be included. I was really probing the Government as to whether, for example, practice nurses might be included in the regulations.

Lord Hunt of Kings Heath: I am grateful to the noble Earl. The position is that practice nurses do come within the ambit of this clause but at the moment, we have no proposals to list nurses or nurse practitioners.

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As regards the specific issue of consultation, the noble Earl will know that I am very reluctant to be drawn to lists or to be too specific. But I assure the noble Earl that we should be committed to very detailed consultation with the appropriate bodies. I have made that clear throughout the passage of the Bill.

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