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Lord Skelmersdale: Well, my Lords, surprise, surprise. The Minister again has not really answered my point, which was whether we will know exactly what is intended in sufficient time so that we can consider it. If not, that is a very good reason for affirmative regulations rather than negative regulations. I shall read what the Minister said to me in conjunction with what he said to the noble Lord, Lord Clement-Jones. It is to be hoped that I shall make sense of it and that I shall not have to return to this matter on Report. At the moment, I very much doubt it. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 170 agreed to.

4.30 a.m.

Clause 171 [General medical services contracts]:

Baroness Noakes moved Amendment No. 446:



"( ) Regulations under subsection (1) shall reflect the principle of patient choice."

The noble Baroness said: In moving Amendment No. 446, I shall speak also to Amendments Nos. 451, 452 and 453 in this group, which are about the impact of the patient's perspective on GMS contracts. Amendment No. 446 adds a new subsection to Section 28R of the NHS Act 1977, as inserted by Clause 171 of the Bill. The new subsection states that regulations under Section 28R—about the services to be provided under general medical services contracts—must reflect the principle of patient choice.

As Members of the Committee will know, patient choice has been the cornerstone of our policies for the NHS for many years. We have been pleased to see the gradual conversion to choice within the Government. We were particularly pleased that the Explanatory Notes at paragraph 358 state that patient choice should be reflected in the GMS contract.

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The amendment goes further than paragraph (d) subsection (2) of Section 28U because that refers to the rights of patients to choose from whom they are to receive services. That is welcome, but patient choice is about more than just "from whom", it is also about "when", "what" and "how".

While we welcome the acknowledgement in paragraph 358 of the Explanatory Notes that patient choice is important, we do not understand why that choice is confined to the management of patients who recover from illnesses. Paragraph 358 draws a distinction between those patients and patients who are terminally or chronically ill. Apparently, patient choice is not relevant to those patients. That distinction does not appear to be made by the limited paragraph (d) of Section 28U(2), to which I referred a moment ago. Will the Minister confirm that patient choice will be available to the terminally ill or to those suffering from a chronic disease?

Amendments Nos. 451, 452 and 453 are about the important issue of doctors' rights to accept or reject patients. They all amend subsection (3) of Section 28U of the 1977 Act, inserted by Clause 171. Amendment No. 451 has the effect that regulations under Section 28U must deal with the issues of doctors accepting or rejecting patients. The amendment has the effect that the regulations must not only deal with the circumstances, but also deal with the manner in which doctors may act. Amendment No. 452 states that the regulations must cover when a doctor may terminate his responsibility for a patient, but also when he may not.

We fully recognise that there will be circumstances when a doctor must have the right to remove a patient from a list. Violence is the most obvious example, even though here there are difficult issues—for example, in relation to the family of a violent patient. There is much evidence that there are significant concerns about how removal from a list operates in practice. The National Association of Citizens Advice Bureaux says that it regularly receives reports that clients have been struck off lists without a reason being given. It says that these are often patients with serious long-term medical conditions.

I have recently received a worrying letter from a patient with motor neurone disease, with a wife with her own health problems, because they were both removed summarily from the list of their GP and no other local GPs will accept them. The message is that difficult and long-term conditions are not what GPs want on their lists.

I am aware that there is guidance from the Royal College of General Practitioners that a person's condition should not justify removal and that patients should be given a reason. But the complaints go on. So much hope is pinned on the regulations under the Bill. I understand that it is intended that transparent processes will be involved. Will the Minister say what those will be?

I hope that the Minister will also say something about the regulations under this section? When will they be available in draft? The National Association of

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Citizens Advice Bureaux is particularly concerned that new regulations will be drawn up without reference to the groups representing patient interests. Will the Minister say what consultation arrangements will be made? I beg to move.

Lord Clement-Jones: I rise to speak to Amendments Nos. 450 and 454. The tenor of both amendments is very similar and straightforward: they seek to improve the provisions of the Bill in dealing with disputes over matters such as a GP declining to take on a person as a patient or terminating responsibility for him. I have attempted to ensure that there would be a proper system for the adjudication of such disputes. Amendment No. 454 is rather fuller than Amendment No. 450, but essentially it seeks the same end. There should be an appeal and adjudication procedure so that it would not be possible simply for a patient to be struck off a GP's list; rather, there would be a proper process to go through.

We have seen enough cases involving rather arbitrary decisions about patients on GP lists to know that it is vital to put in place this kind of system. I look forward to the Minister's assurance that some kind of procedure is to be introduced.

Lord Warner: These amendments deal with some extremely important issues around patient registration and choice. Amendment No. 446 would ensure that regulations prescribing essential services would include a reference to the principle of patient choice. On a technicality, I am not entirely sure what the noble Baroness intended by inserting the amendment into new Section 28R rather than Section 28U. On a second technicality, I am not sure that it makes sense to single out choice as the sole condition on the face of the Bill. In delivering services a range of other factors are extremely important, such as the quality of clinical care provided, clinical governance and so forth.

However, on the issue of principle raised by the amendment, I can confirm that the Government are fully in support of delivering better choice in primary care. That is precisely why we are engaged in a major consultation exercise, focusing on offering choice to patients and users of health and social care services, including decisions about "where" and "when" care is received, as well as "what" and "how" someone wishes to be treated and manage their condition. Task groups were formed to look at eight specific areas or themes, one of which is primary care, being chaired by Delyth Morgan.

I can assure the noble Baroness that patient choice will be equally available to all types of patient. That is also why the new contract supports better choice in a number of ways that, given the hour, I shall not elaborate on.

Amendment No. 452 would require regulations to specify the manner in which patients are accepted on to, refused acceptance on to, or removed from a list. We intend that the regulations will make clear a responsibility not to discriminate against patients in the process of registering or deregistering them. And

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they will require that a reason is given in writing as to why patients are removed by practices from the practice list. Introducing a requirement that sets out the manner in which these processes work is at this stage overly bureaucratic and prescriptive.

Amendment No. 453 would introduce a requirement for practices to keep patients on their lists. The relationship between the patient and the practice is close and personal. If that relationship breaks down on either side, in our experience the breakdown is usually irreconcilable. We do not believe it is wise to introduce a requirement that practices may not deregister patients, nor is it a balanced one given that patients can choose to register elsewhere. The critical issue is whether, in doing so, they are acting reasonably, and this will be addressed by the requirement to set out reasons for deregistration, and not to discriminate on a range of grounds such as race or age.

These arguments apply equally in relation to Amendment No. 450 and the second part of Amendment No. 454, while an appeals process would add further bureaucracy. If patients are unhappy with the way they have been treated, be that in relation to non-acceptance or removal, they should raise their concerns with the primary care trust. This is the case now and should continue to be the case in the future.

It is important to note that when patients are removed from lists they are still entitled to register with a practice, even in the rare case of all practice lists being closed. It will be a requirement for PCTs to ensure that this happens and they have the power to do so, either by provision of services by the PCT or by allocating patients subject to the new process which involves a patient representative.

Amendment No. 451 proposes changing "may" to "must". The Delegated Powers and Regulatory Reform Committee did not make a recommendation on this issue but brought it to the attention of the House and, indeed, to my attention. The Government are committed to making these regulations as part of the implementation of the new GMS contract. I will be bringing forward a government amendment on this section on Report and, as part of that, will be including the change proposed in Amendment No. 451.

Finally, on the first part of Amendment No. 454, which would require regulations to be made to give reasons for patients being refused inclusion on a list, I am sympathetic. This must be right in principle. It is inconsistent to have a requirement to give reasons at the end of the process for deregistration but not at the beginning for refusing to register someone in the event that the practice list is open. Clearly if the practice list is closed due to capacity constraints, that is the reason.

The most appropriate route for progressing this would be the contract regulations rather than the face

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of the Bill. The department is in discussions with the BMA about the policy underlying those regulations and I can confirm that I will be in a position to set out the outcome of those discussions on Report. The noble Lord may wish to withdraw the amendment in the light of this assurance.


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