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Lord Colwyn: I am grateful to the Minister for that answer. I am not an expert on pensions. I shall examine with the British Dental Association what the noble Baroness has said and possibly return to the matter. At this stage, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 169 agreed to.

Clause 170 [Provision of primary medical services]:

Lord Clement-Jones moved Amendment No. 444:

The noble Lord said: Clause 170 deals with the provision of primary medical services. Amendment No. 444 is designed to alter the situation currently contained in Clause 170. There are three kinds of primary medical services: essential, additional and enhanced. GPs have preferred provider status for essential and additional services but not for enhanced services. Enhanced services are, for example, some minor surgery, perhaps minor injury services, services for violent patients, flu immunisation, child immunisation, sexual health services and of course services such as out-of-hours services.

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The clause makes radical changes to current arrangements. Under current arrangements GPs provide most of these services. Under the new arrangements contained in Clause 170, those services would now be able to be purchased by the PCO. In England that means the primary care trust itself. Indeed, it may be able to purchase services, such as out-of-hours services, from commercial deputising services. That may include non-NHS provision of services such as physiotherapy.

There has been some attempt to explain the new arrangements by both the Government and negotiators, such as the BMA, but it is not entirely clear why these arrangements should have been put into place and why it is necessary for these services to be provided in the way that they are. I notice that the Minister states in the letter that some of us have received that it is an essential part of the new system of primary care that has been negotiated with the General Practitioners Committee and the NHS Confederation. I should be interested to hear from the Minister why that should be so. Why is it so essential? Why have enhanced services been split off in that way from the other services to be provided? What benefits will that provide to patients in those primary care trusts? I beg to move.

Lord Warner: New Section 16CC is a fundamental part of the new system of primary care that has been negotiated by the General Practitioners Committee and the NHS Confederation. It allows PCTs to contract with a range of providers to secure primary services for people in their area. The majority of contracts for primary medical services will be between PCTs and GP practices—through either a GMS contract or a Section 28C contract.

However, it is essential that we give PCTs as much flexibility as possible to ensure that patients can access the full range of services. That is especially true where practices opt out of providing out-of-hours care or other additional services. PCTs will be under a duty to ensure that services are maintained for the patients affected. PCTs will be able to provide services themselves or, where appropriate, commission services from a range of other providers. For example, in the case of out-of-hours services, that would include NHS Direct, GP co-operatives, practice partnerships, paramedics, other GP practices or deputising services, including organisations such as Primecare.

The amendment would remove that flexibility. Let us consider an area where, at present, GPs delegate out-of-hours services to a commercial deputising service. Under the new contract, some GPs may well opt out of having primary responsibility. Suppose that the PCT wanted to recommission the service directly from the current commercial provider. Without that power, it could not do so.

We are also committed to expanding capacity in primary care. In some areas in which there has been a shortage of doctors for many years, the private sector may well be the best route to provide additional capacity to deliver NHS care. However,

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we remain committed to the contract agreement with the profession that makes clear that existing primary and general medical service practices will have preferred provider status for the new essential services. Again, the amendment would rule that out.

I hope that I have clarified matters for the noble Lord and that he will feel able not to pursue his amendment.

Lord Clement-Jones: I thank the Minister for his reply, although he has not clarified the matter to any great extent. Many ordinary patients will be baffled by his statement that many GPs will opt out of primary responsibility. That is a crucial aspect of the clause. It sits oddly with the Minister's statement that he is committed to expanding capacity. That seems strange, yet he relies on the fact that there is a contractual agreement over which we have no power. In those circumstances, I want to test the opinion of the Committee.

4.14 a.m.

On Question, Whether the said amendment (No. 444) shall be agreed to?

Their Lordships divided: Contents, 8; Not-Contents, 39.

Division No. 5


Barker, B. [Teller]
Blatch, B.
Clement-Jones, L. [Teller]
Colwyn, L.
Howe, E.
Noakes, B.
Roper, L.
Skelmersdale, L.


Acton, L.
Amos, B. (Lord President)
Andrews, B.
Archer of Sandwell, L.
Bach, L.
Bassam of Brighton, L.
Brett, L.
Brooke of Alverthorpe, L.
Burlison, L.
Campbell-Savours, L.
Carter, L.
Chandos, V.
Crawley, B.
Davies of Coity, L.
Davies of Oldham, L. [Teller]
Dean of Thornton-le-Fylde, B.
Desai, L.
Evans of Temple Guiting, L.
Farrington of Ribbleton, B.
Golding, B.
Gordon of Strathblane, L.
Grocott, L. [Teller]
Hollis of Heigham, B.
Hoyle, L.
Hunt of Kings Heath, L.
Jones, L.
Jordan, L.
McIntosh of Haringey, L.
McIntosh of Hudnall, B.
MacKenzie of Culkein, L.
Mitchell, L.
Pendry, L.
Plant of Highfield, L.
Sawyer, L.
Simon, V.
Warner, L.
Warwick of Undercliffe, B.
Whitty, L.
Woolmer of Leeds, L.

Resolved in the negative, and amendment disagreed to accordingly.

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4.23 a.m.

Lord Roper: We have now spent more time since 10 p.m. considering this Bill in Committee than we did in the whole of the time after Starred Questions until 10 p.m. Will the Government Chief Whip accept that

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there is now a need for further consultations about progress on the Bill? Otherwise, it will be difficult to maintain the co-operation between the usual channels. That co-operation has taken this Bill a long way forward tonight, but further progress may become increasingly difficult.

Lord Grocott: I suggest that we have a discussion in the normal way. Meanwhile, we should proceed with the next amendment.

Lord Skelmersdale moved Amendment No. 445:

    Page 87, line 9, at end insert—

"( ) Regulations under subsection (5) may not be made unless a draft of the regulations has been laid before and approved by a resolution of each House of Parliament."

The noble Lord said: As the noble Lord, Lord Clement-Jones, has failed to get satisfaction on what exactly the Government intend on Clauses 170 and 171, it falls to me to have another crack. Subsection (5) of Clause 170 provides a regulatory power to clarify what should or should not be considered as primary medical services for which PCTs and LHBs have the duty to secure provision. For example, it could be used if necessary to maintain a consistent national level of primary medical services that must be provided across all PCTs. Only a few minutes ago, in answer to the noble Lord, Lord Clement-Jones, the Minister said that it is essential that we allow as much flexibility as possible. I do not see how those two statements fit together.

Moving on to Clause 171, on general medical services contracts, we find that subsection (1) inserts six new sections into the 1977 Act providing for the new GMS contracts that replace the current arrangements under Part II of that Act. The point that concerns me is the first provision, new Section 28Q, which gives power for PCTs and LHBs to enter into GMS contracts. A GMS contract is a contract for primary medical services, but it may also include services—this is the point I think made by the noble Lord, Lord Clement-Jones—that are not primary medical services, for example, in heart services that are on the boundaries of primary and secondary care, such as certain more specialised services in areas such as drug and alcohol misuse, sexual health or depression and so on.

Therefore, I am, as I said, somewhat confused. Is the Minister thinking of professions supplementary to medicine as well or, in part, instead? Will we know before the regulations come to be laid, which is the point of Amendments Nos. 445 and 447? If we are not to know in good time, then I propose that we make the regulations affirmative. I beg to move.

Lord Warner: In general terms, we believe that custom and practice will be sufficient to determine the scope of primary medical services. We do not believe that it is wise or helpful for service development to develop a fixed legal definition that could ossify service

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provision and militate against achieving better integration between primary and acute sectors.

Primary care is a developing field. In recent years we have seen the development of walk-in centres, diagnostic and treatment centres and an increase in the number of GPs with special interests. Medical knowledge is increasing and there is a shift of care from hospitals to the community. It would be impossible to keep an up-to-date definition of primary medical services. So we envisage that the power will be used, for example, only where it is felt necessary to ensure that a particular service is considered within the scope of primary medical services in the event of doubt.

The Lords Select Committee on Delegated Powers and Regulatory Reform has considered the powers carefully. It did not consider it appropriate that they should be made subject to affirmative procedure. The powers are in keeping with existing equivalent powers and the level of scrutiny is appropriate. I see no reason to disagree with its judgment on this issue. We do not support these amendments.

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