Health and Social Care Bill

Public Bill Committee, 25 January 2001.

Standing Committee E

Health and Social Care Bill

John Denham (Labour, Southampton, Itchen)

On a point of order, Mr. Maxton. Further to my point of order on Tuesday morning, it might help the members of the Committee if I brought them up to date with discussions taking place through the usual channels regarding our sittings. It is intended that at or immediately before our rising at 11.25 am we should move to a meeting of the Programming Sub-Committee, at which it will be proposed that the Committee sit, if necessary, up to 7 pm this evening, and to set out the possibility of meeting at 4.30 pm on Monday. Those are the possible arrangements to deal with the extra amendments that we will discuss. If the Committee makes better progress, the arrangements will not be necessary. Clause 19 Abolition of NHS Tribunal

Clause 19 - Abolition of NHS Tribunal

John Denham (Labour, Southampton, Itchen)

Clause 19 sets out the arrangements for the abolition of the NHS tribunal, which is an integral feature of the proposals in the NHS plan to modernise the way in which poorly performing primary care practitioners are dealt with. We want to make the system more effective, quicker and fairer, not only for patients, but for practitioners.

I hope that you will bear with me, Mr. Maxton, if I put clause 19 in context by referring, at least in passing, to clauses 22 to 28, which are relevant. Taken together, the clauses update the provisions for managing health authority practitioner lists. Clauses 22, 25 and 27, which we will debate subsequently, deal with lists and cover doctors, dentists, pharmacists and optometrists. They relate to non-principals as well as principals, and to practitioners who operate under parts I or II of the National Health Service Act 1977. Clause 22 deals with part II principals by amending the existing powers on admission to health authority medical, dental, ophthalmic, pharmaceutical and dispensing doctor lists. Clause 25 extends the concept of health authority lists to non-principals, and clause 27 extends it to doctors and dentists who are part I practitioners.

I mention those three clauses to try to avoid some repetition. Between them, they apply the same principles and procedures to each list, with any variations simply being those needed by the circumstances of particular groups. Although the clauses may seem similar in structure, that is the design and purpose as the issues that underlie them are the same.

The lists will underpin health authority systems for managing primary care services and for improving quality. The clauses will improve the arrangements by: giving health authorities powers to suspend or remove practitioners from their lists; extending the arrangements into the new provisions for service delivery, such as personal medical services, under part I of the 1977 Act; giving health authorities powers to remove practitioners from their lists on grounds of unsuitability, as well as when they are prejudicial to the efficiency of the service or because of fraud; and giving practitioners rights of appeal to the Family Health Services Appeal Authority against decisions by their health authority to remove them from its list. The clauses also reconstitute the Family Health Services Appeal Authority so that it is fully independent of the Secretary of State, and by including provisions to ensure that the new system operates quickly and effectively to address any risks to patients or to the service and to deliver proportionate and fair outcomes to practitioners.

We will have the opportunity to discuss the detail of the arrangements as we consider each clause, but those clauses are very much part and parcel of the series of measures that we are discussing on clause 19, to which I shall now return.

Only a small number of practitioners are referred to the NHS tribunal. However, there have been some problems with the tribunal's operations. It has been in existence since 1911, and has been responsible for the suspension and removal of poorly performing practitioners from health authority lists, but the system is now outdated.

Philip Hammond (Conservative, Runnymede and Weybridge)

Does the Minister remember saying that

the tribunal has operated effectively, with the broad confidence of the national health service and the professions, during that period.—[Official Report, Standing Committee A, 20 May 1999; c. 881.]

What has changed since 20 May 1999?

John Denham (Labour, Southampton, Itchen)

At that time, I had been in my post for only about six months. Since then, we have had the opportunity to consider more closely several cases going through the pipeline in which general practitioners' performance has been found wanting, perhaps in the criminal courts or by the General Medical Council. I have had to ask myself why those cases had not been referred to the NHS tribunal or why it had apparently failed to act. My conclusion is that a significant number of health authorities have lost confidence in the arrangement and take the view that the tribunal's procedures are unable to deal quickly enough with practitioners who pose a danger to patients. That has led to a situation in which health authorities are reluctant to instigate proceedings, so the tribunal's case load is light, averaging as few as eight cases in recent years.

Philip Hammond (Conservative, Runnymede and Weybridge)

Surely the Minister is not suggesting that his predecessor as Minister of State at the Department of Health—now the Secretary of State for Health—overlooked such important matters when he was in the post. He would surely have had the forward-looking qualities needed to see precisely the problems that the Minister has identified.

John Denham (Labour, Southampton, Itchen)

Mr right hon. Friend the Secretary of State for Health gives way to no right hon. or hon. Member, or to any member of the Government, in his determination to improve quality in health provision. He has led the way in campaigning for improvements, from the development of the first-class service that set out our quality agenda, to his consistent pressure for effective reforms of the regulatory system,

As each year goes by, more information becomes available, giving Ministers greater opportunities to study individual cases. As a Government, we now believe that the obstacles to making the NHS tribunal work quickly and effectively for patients, and fairly for GPs, are so great as to make us try to find a better system. It causes me no embarrassment at all to say that I no longer take the same position that I set out with as Minister of State in 1999. As I have said, since then I have had the chance to consider some cases, not all of which are yet entirely in the public domain, that have convinced me that we need a better system.

Health authorities are sometimes reluctant to refer cases to the tribunal because they perceive its processes as slow and bureaucratic. It would be wrong to cite individuals or health authorities, but in two recent cases the first action against a practitioner was the commencement of criminal proceedings, rather than action by the health authority to seek the suspension or disqualification of the doctors concerned. In both cases, the health authority did not refer to the tribunal because it considered that quicker action would result from letting the criminal case proceed. That is not good enough.

We must give health authorities the right tools for the job if we expect them in future—as we do—to monitor practitioners' performance and standards of behaviour and to take action quickly when necessary. As I caught your eye earlier, Mr. Maxton, I will not go into detail of the later clauses again, but we intend to have a system for suspending or removing practitioners that is faster, more effective and fairer to practitioners and their patients. We propose to confer on health authorities new powers akin to those of employers to suspend and remove practitioners from their lists. That will remove the need for the NHS tribunal.

The NHS Confederation, representing NHS managers, has welcomed clause 19. There has been no public opposition to the abolition of the NHS tribunal from the General Practitioners Committee of the British Medical Association. We must of course not overlook the rights of practitioners. Future clauses will deal with rights of appeal against a decision to remove, or contingently remove, a practitioner from a list. A need will arise, consequent on the clause, for a properly constituted and independent Family Health Services Appeal Authority. Clause 28 provides for that.

Philip Hammond (Conservative, Runnymede and Weybridge)

Despite some effort, clause 19 defied amendment, which is why we are now debating clause stand part. The best argument against treating the matter in hand as an open and shut issue came from the Minister in Standing Committee A on 20 May 1999. When we discussed circumstances that could lead to the disqualification of practitioners, my hon. Friend the Member for Lichfield (Mr. Fabricant) and I raised several concerns about practitioners being deprived of their livelihoods. We asked for reassurances about the nature of the process that they would undergo.

The Minister has told the Committee this morning that the NHS tribunal will be abolished, that instead health authorities will take its role, and that appeals will be referred to the Family Health Services Appeal Authority. I am sure that the Minister will correct me if my paraphrase is wrong. The problem is that the Minister is adding nothing, but only removing a part of the current process. He told Standing Committee A, in response to an intervention by another hon. Member:

Concerns were expressed about whether we might be seeing the evolution of the tribunal into an arbitrary kangaroo court sitting in judgment over general practitioners. I had been trying to say that a case would reach the tribunal only after, for instance, internal health authority disciplinary arrangements had begun, or following measures to support and bring up to standard poorly performing doctors.—[Official Report, Standing Committee A, 20 May 1999; c. 882.]

The Minister argued that the present safeguard is the initial informal involvement of health authorities in difficult situations, with referral to the tribunal happening only later. In answer to a question from me about the nature of the tribunal and the guarantees and safeguards, the Minister said—and perhaps the reason that I am repeating these points is that I have a long memory—

I honestly think that the hon. Gentleman is making a ridiculous meal out of this. Given the track record of the tribunal and its status as an independent body—the Secretary of State has no influence over its quasi-legal, quasi-judicial hearings—as well as the seriousness of the offences that it has heard, I cannot foresee any circumstances in which it could be used in the way that the hon. Gentleman suggests. —[Official Report, Standing Committee A, 20 May 1999; c. 890.]

That was a response to concerns about the human rights implications of people being deprived of their livelihoods by a tribunal decision.

The Minister now proposes that health authorities should take the decision, subject, of course, to an appeal to the FHSAA. Health authorities are not quasi-legal, quasi-judicial hearings, over which the Secretary of State has no influence. The Secretary of State has great influence: indeed, he has power to direct health authorities. They cannot be regarded as impartial bodies. The Minister's proposal would remove from the process any quasi-judicial function at first instance. I accept that there will be a quasi-judicial body, the FHSAA, as an appeal mechanism. However, in the first instance, such matters will be dealt with by a non-independent, non-quasi-judicial body. That is important because previously the Minister outlined a mechanism of cases going first to the health authority as an informal, non-judicial body, then to the tribunal and finally to appeal. Now, we have just two steps: cases will go first to the health authority and then—and only if there is an appeal—quasi-judicial involvement.

Section 47 of the 1977 Act, which was inserted into that Act by the Health Act 1999, provides for a health authority to ask the tribunal to review a conditional disqualification. There are several provisions of that nature, but I will take that one as an example. Section 47 states,

If any health authority request a review of a conditional disqualification on the ground that

—and then lists a number of grounds—

the tribunal shall review the conditional disqualification.

What will happen now? Will the health authority request itself to review a conditional disqualification that it has made? That is not a sound process. Has the Government thought through the consequences of abolishing the tribunal? Can the Minister tell us how the mechanism will work when health authorities are effectively subsuming their roles and those of the tribunal under the existing system? Will the Minister confirm whether it is the case that sections 46 to 49 of the 1977 Act are to be repealed by schedule 5? Will clause 19 be necessary because, if sections 46 to 49 are repealed, the national health service tribunal will no longer exist or be referred to in the extant legislation? Clause 63 and schedule 5 will have the same effect. The principal of parliamentary drafting is economy and on that basis clause 19 may be redundant.

Can the Minister tell us what the position is in Scotland? The legislation includes reference to the NHS tribunal in Scotland; is that tribunal different from the one we are discussing; is it constituted under a different Act, but has the same name? Will that tribunal continue to function? Will it be affected by the Bill? Can the Minister assure the Committee that he dealt in his opening remarks with all the current functions of the NHS tribunal and how they will be handled in future? Can he also assure us that the NHS tribunal has no functions other than the ones he has referred to in relation to the qualification and disqualification of medical practitioners? If there are any other functions, can he tell us who will be responsible for them and how they will be handled?

John Denham (Labour, Southampton, Itchen)

I shall address those points hopefully in order.

I have already dealt with the way in which Government thinking has moved on since the debates in July 1999. As far as I can recall, the assurances given on how the 1999 legislation would operate were correct at the time and remain correct in respect of the legislation. We now propose further changes to the legal framework, which I explained this morning.

Some feel that in politics the worst thing that Ministers can do is to change their thinking on an issue. Such people attach the highest premium to sticking to a position. However, I believe that if a Minister gains a new insight or a new understanding of where problems may lie, it is perfectly proper for him to bring it to bear on future policy. That is what we doing now.

I am not sure whether it is appropriate to go into detail during a clause stand part debate on how the new procedures will operate, especially as we shall be discussing that in relation to other clauses. I have signed the declaration that, in my judgment, the measures in the Bill are compatible with human rights requirements. Although, under our proposals, the ability to suspend or disqualify will pass to the health authority, it will not have escaped the notice of the hon. Member for Runnymede and Weybridge (Mr. Hammond) that we are reconstituting the Family Health Services Appeal Authority so that it is no longer a body of the Secretary of State; otherwise, it would not have had the independence necessary to meet the requirements of the Human Rights Act 1998.

I believe that we are taking the necessary measures to ensure the proper procedures. For instance, we shall be discussing in later clauses whether suspension would affect the human rights of practitioners, and I am sure that we shall consider maintenance of income in such circumstances. We have studied what is necessary to make the Bill compatible with human rights legislation.

Philip Hammond (Conservative, Runnymede and Weybridge)

I accept what the Minister says, which is why the final court of appeal will be quasi-judicial. I want to focus on what might be called the court of first instance. Will the health authority's informal role, which the Minister outlined during our debates on the 1999 Act, be clearly and distinctly separate from its formal role in disqualifying practitioners? Will a formal hearing procedure have to take place, and will that be quasi-judicial—will a burden of proof be required at that stage, or will the whole process be informal until the point when an appeal is lodged to the FHSAA?

John Denham (Labour, Southampton, Itchen)

The hon. Gentleman will be aware that future clauses provide for the ability to make regulations on how the health authority should conduct that process. For example, the Bill makes it clear that we shall set out the criteria that health authorities must take into account when considering whether to suspend or disqualify a practitioner. That implies that a process has to be followed, and that the health authority would have to demonstrate that it had done so in order to comply with the legislation. The process will include written notification and the opportunity for a hearing. There will not be a slide from general performance management into taking practitioners off the list; there will always be a point at which the practitioner will know that the process is taking place. It is worth re-emphasising that the provision is part of a wider picture and that it should give health authorities better informal powers.

A few weeks ago, we announced the formation of the National Clinical Assessment Authority, a body to which health authorities could informally refer GPs if they had doubts about their performance or assessment. Since July 1999, we have moved to strengthen the early intervention powers available to health authorities if they were concerned about doctors' practices.

The hon. Gentleman asked other specific questions. The Bill does not abolish the NHS tribunal for Scotland; the NHS tribunal will continue to operate there. It is a matter for the Scottish Parliament. We shall be discussing later the arrangements between England, Wales and Scotland, to ensure that practitioners who are not on the list in one country are not on the list in the others.

I hope that I have answered all the points raised by the hon. Member for Runnymede and Weybridge, if only briefly.

Question put and agreed to.

Clause 19 ordered to stand part of the Bill.

Clause 20 - Payments relating to past performance

Philip Hammond (Conservative, Runnymede and Weybridge)

I beg to move amendment No. 178, in page 14, line 6, leave out from `shall' to end of line 7 and add:

`be substituted with—

(4) The remuneration to be paid under the arrangements mentioned in subsection (1) above to a practitioner who provides general medical services shall, at least in part be dependent upon the quality and outcome of the services provided and shall not ordinarily consist wholly or mainly of a fixed salary.'.

The clause is four lines long instead of one, so it lent itself to amendment. It is designed to repeal the requirement that general medical services remuneration should not consist wholly or mainly of a fixed salary paid to the practitioner.

When the 1977 Act was written, or when this provision was inserted, the assumption was that the basis of such remuneration would be capitation—that practitioners would be paid a sum per person on their list. The Government's policy is clearly to move away from capitation payments, and broadly speaking we would support that policy. It can provide a perverse incentive to practitioners to get the largest list they possibly can in order to maximise remuneration. A high number of patients on a practitioner's list does not necessarily correlate with a high quality of care provided by that practitioner. There might be prima facie reasons for assuming that the larger the practitioner's list, the lower the quality of the care that he is able to provide.

We understand the Government's desire to allow practitioners to be remunerated by reference to quality and outcomes, rather than simply by reference to the number of patients on their list. However, the clause is not necessary to achieve that objective. I refer the Committee to the explanatory notes, which state:

Clause 20 ends the requirement under 29(4) of the 1977 Act that the majority of remuneration of GPs should have reference to the number of patients the GP has undertaken to provide services under General Medical Services.

That is not what section 29(4) of the 1977 Act states. This is not the first time that I have found the explanatory notes to be misleading, so that a member of the Committee who does not have time to read the base legislation may be misled.

Section 29(4) of the 1977 Act states:

The remuneration...shall not...consist wholly or mainly of a fixed salary

that does not relate to capitation. It does not state that the remuneration cannot be calculated with reference to some other criteria such as quality or outcomes. The notes are misleading, and might lead somebody to believe that clause 20 was required in order to allow the Government to introduce remuneration based wholly or mainly on quality of outcomes into the GMS contract. That is not the case. It is already possible to introduce remuneration based on such criteria.

The amendment specifically includes a reference to quality and outcomes. It requires consideration to be given to those factors as a basis of remuneration. To allow remuneration to be based either wholly on capitation, or wholly on a fixed salary, would be a step backwards. Everything that the Government have said suggests that they want to move away from capitation-based payments to ensure that quality of patient experience and outcomes are the principle criteria in determining the remuneration of a practitioner. Clause 20 would allow practitioners to be paid a fixed salary. It removes from the 1977 Act the prohibition on fixed salaries without reference to capitation, which is neither positive nor helpful and flies in the face of the Government's stated objectives.

I am unsure what is in the Government's mind. Members of the Committee will be familiar with the distinction between personal medical services and general medical services. Under personal medical services, practitioners are paid a salary, while under general medical services, they are remunerated in a variety of ways, though with capitation as a significant element of the package.

During the debates on the Health Act 1999, which introduced personal medical services, the Minister assured the Committee that personal medical services would co-exist alongside general medical services. They would not replace them and there would be no pressure to move from GMS to PMS. Despite the assurances, some GPs are—or will be—under pressure to move from GMS to PMS, particularly single-handed practitioners, and that flies in the face of the assurances given in 1999.

The clause—and its ramifications—suggests that the Government, in addition to a full-frontal assault on GMS—to persuade, entice and cajole practitioners into PMS—are working a flanking movement. They are undermining the principals of GMS by giving themselves the power to make a fixed salary the basis of a GMS service contract, which would give it most if not all the characteristics of a PMS contract. Perhaps the Minister can explain what the distinction between GMS and PMS will be? Perhaps he will give an assurance that, even if the clause is passed without the benefit of the amendment, there will still be a distinctive GMS system.

If the Government have a benign reason, such as the one that they gave in ``The NHS Plan'' and other documents, for wanting to re-negotiate the GMS to make it more quality sensitive, they will have no difficulty accepting the amendment. The Minister should either accept the amendment or admit that the Government have a plan to out-flank GMS with a fixed salary system that will make it almost indistinguishable from PMS.

John Maxton (Labour, Glasgow Cathcart)

Before I call the Minister, perhaps it would be for the convenience of the Committee if I said that I have changed the provisional selection to include the debate on clause stand part in the debate on the amendment.

John Denham (Labour, Southampton, Itchen)

I am pleased by the widespread acceptance that the GMS contract based primarily on head counts, has had its day. That is the view outside the Committee and is generally the view of the hon. Member for Runnymede and Weybridge. The way forward is to move towards contracts that recognise the quality of service that GPs provide and reward them appropriately. The measure will not abolish the link between pay and patient numbers: it will merely remove the legal requirement for the majority of GPs' pay to be linked to patient numbers. As has been pointed out, in extreme cases, a direct link between list size and pay can lead to a perverse incentive, particularly for hard-pressed GPs.

Philip Hammond (Conservative, Runnymede and Weybridge)

I must ask the Minister to correct what he said. Despite what the explanatory notes state, my interpretation of section 29(4) of the 1977 Act is not that it requires the majority of remuneration to be linked to capitation, but that it requires it not to be a fixed salary that is not linked to capitation. That is different. My reading of the section is that it would permit the Government to use a criterion other than capitation for the majority of remuneration. That would include outcomes and quality. That is why the clause is not needed to enable the Government to do what they intend.

John Denham (Labour, Southampton, Itchen)

My advice and understanding are that the practical interpretation of section 29(4) is that more than 50 per cent. of GPs' interests must be calculated on the basis of the number of patients on a list. I shall seek advice about that again, after the Committee, and if my interpretation is wrong I shall write to the hon. Gentleman to correct what I have said. I believe that what I have said is the general understanding, and it is what we are attempting to deal with, to bring about greater flexibility in the development of the GP contract in future.

The fixed salary is the fixed basic income of the GP rather than specific additional payments. I should make that clear, because I suppose that it is possible for more than 50 per cent. of total income to come from other sources. We are concerned with the basic income of a GP. Immunisation service payments would fall outside the calculations that I am describing, for example. We want to work with the British Medical Association to modernise GP contracts. We are going about that now and the clause would remove a constraint.

The hon. Member for Runnymede and Weybridge raised two issues in addition to the interpretation of the 1977 Act. The first was whether the Bill should include a new requirement with respect to outcomes and quality. The second was whether the clause leads to blurring, changing or redefining of the boundary between PMS and GMS or perhaps whether there is a relationship between that boundary and salaried or independent contractor status.

I have thought long and hard about amendment. No. 178. We certainly want a future contract to reflect quality and outcomes much more clearly than the national contract does now. I am not convinced, however, that it is necessarily helpful for the Bill to replace a constraint that has been and will be problematic with a different constraint. The difficulty is illustrated by the amendment, which could allow the quality consideration to be attached to the merest fraction of the payments made to GPs operating under the Red Book arrangement. We accept the spirit of the relevant part of the amendment and have acted accordingly in the NHS plan. There is a consensus on the need for more emphasis on quality and outcomes.

In response to the hon. Gentleman's request for me to clarify as well as I can the difference between PMS and GMS, I remind the Committee that PMS is a voluntary contract entered into by GPs at local level. About 22 per cent. of GPs indicated their desire to go onto PMS contracts from 1 April 2001.

Philip Hammond (Conservative, Runnymede and Weybridge)

As the Minister has made that comment, would he reiterate for the record what I think he said in 1999, that PMS will remain voluntary and that GPs, whether single-handed or otherwise, will not to be subjected to pressure to enter into PMS arrangements in future?

John Denham (Labour, Southampton, Itchen)

GPs are not being pressured into PMS arrangements, although I need to be clear that we said in ``The NHS Plan'' that our preference is for single-handed GPs to have a different national contract that would overcome their apparent problems of clinical isolation. Should that not be the case, we would seek to move that group of GPs onto a national PMS contract. That is important and the hon. Gentleman is right to ask me to reiterate.

Philip Hammond (Conservative, Runnymede and Weybridge)

Just to clarify, is the Minister saying that he hopes to be able to negotiate a new type of GMS contract for single-handed practitioners, but if he is unable to negotiate that to his satisfaction, he will consider imposing a PMS contract on single-handed practitioners? Negotiations that take place under the threat of imposed unilateral action are not usually fair or reasonable.

John Denham (Labour, Southampton, Itchen)

The hon. Gentleman is entitled to his view, but our intention is to negotiate an appropriate national contract that can help overcome recognised problems faced by single-handed GPS. The hon. Member for Woodspring (Dr. Fox) has set out the need to address some of the problems of physical isolation that are faced by single-handed GPs. There is not a huge difference on this issue across the Committee. The essential difference between PMS and GMS contracts is the same as that between the locally-agreed contract which GPs enter voluntarily and the national contract that is for the majority a matter of choice, but is the default national contract under which GPs operate. The clause was not intended to change that basic difference between the national Red Book contract and the local PMS contract, nor is there any intent behind the clause, or in wider Government policy, to force people from independent contractor status into a salaried status. That is important and it is now widely accepted.

There is often confusion, and a belief that PMS means a move to salaried doctor status. It is worth saying on record again that the vast majority of GPs with PMS contracts are independent contractor status GPs. They have not switched to salaried status: they have changed the nature of their independent contract. I do not see why there should be significant changes other than those that are taking place at grass roots where it appears that a rising number of younger GPs are opting for salaried status. It is too early to tell, however, whether they see that as a permanent arrangement or something for the first years of their practice, taking on the greater obligations of independent contractor status later. From the people I have talked to, it appears that salaried status is seen as transitional. However, essentially that is something permitted by the greater variety of employment opportunities available to GPs.

Peter Brand (Liberal Democrat, Isle of Wight)

The Minister said that PMS was a voluntary arrangement and clearly that is the case in respect of the move from GMS to PMS. Could the Minister reassure us that the reverse move is also possible? Once people have accepted PMS, if there were to be a disagreement with the commissioning body, under PMS the same health authority would also have the power to block the institution of a GMS contract.

John Denham (Labour, Southampton, Itchen)

Yes. I do not have chapter and verse at my fingertips, but my understanding is that PMS GPs have a preferred status in their ability to switch to GMS that would not be available to another GP who wanted to work on a GMS basis. I assure the hon. Gentleman that nothing in the measures that we are taking will change that status, which, as I recall, derives from the National Health Service (Primary Care) Act 1997.

Doug Naysmith (Labour/Co-operative, Bristol North West)

Will my hon. Friend the Minister confirm that it will still be possible for single-handed practitioners to remain under GMS conditions of service, provided that all the problems of isolation and the necessities of keeping up with clinical development are dealt with?

John Denham (Labour, Southampton, Itchen)

We would like to negotiate a new national contract with a greater emphasis on quality that could therefore address such issues. We can never say at this stage whether negotiations will be successful, but the NHS plan makes it clear that we would like to tackle such concerns through a quality-based national contract. That is what we shall seek to do with the profession and its representatives.

Philip Hammond (Conservative, Runnymede and Weybridge)

I want to focus on one point. I am not sure that the Government have made or would want to make a case for paying fixed salaries. The case for paying GPs by reference to the quality of outcomes, the experience of their patients and the quality of service provided does not need making, as it is self-evidently sensible. The Minister rather glibly glossed over my concern about the need for the clause at all. I re-assert the fact that section 29(4) of the 1977 Act does not prevent the Government from negotiating a GMS contract in which the majority of the payment would refer to quality of outcome, patient experience, clinical indicators and anything, in fact, other than a fixed salary amount. The only reason for the clause would be if the Government intended to pay GPs the majority of their remuneration—50 per cent. plus of it—by a fixed salary. I have not understood from the Minister's remarks whether that is his intention.

The Minister said that the amendment could allow for only 1 per cent. of GPs' remuneration to be linked to quality, while 99 per cent. was linked to something else. That is true, but the amendment makes it clear that no more than half the remuneration would have to be based on a fixed salary. It uses the same language as the 1977 Act, which the Minister has interpreted as meaning no more than half. The amendment would provide that only less than half of the remuneration could be through fixed salary, and that at least some of the remuneration must refer to the quality and outcome of services provided. That is a clearer presentation of what the Minister seems to be saying that he wants to do.

By rejecting the amendment, the Minister leaves us with the suspicion that he intends more than 50 per cent. of remuneration being paid by way of a fixed salary and, by extrapolation, less than 50 per cent. being related to quality or other parameters that we all might consider to be sensible and useful. Will he clarify his intention? Why can he not accept the amendment? The mere fact that it does not require a minimum percentage to be linked to quality does not invalidate there being a reference to quality and outcome in the Bill. The clause, unamended, would allow payments to be made without reference to the quality or outcome of the services provided. If the Bill is to give effect to the Government's stated intentions, it should include a reference to quality.

John Denham (Labour, Southampton, Itchen)

I have considered that last point carefully. It is a matter of judgment for the Committee, but my view, on balance, is that quality need not be included. The Government's wish to have a contract that gives appropriate rewards for quality is shared by the profession. That is not in doubt. We have found in previous legislation that including such factors imposes constraints; it is a matter of judgment whether one should impose a further constraint, but I believe that it is unnecessary.

The hon. Gentleman is in something of a tangle with his interpretation of clause 20 and the 1977 Act. The effective interpretation of the 1977 Act has been that doctors are paid a fixed amount each year, including a sum that is based on capitation and must be more than 50 per cent. of the total remuneration. That is a restriction. The contract is to be renegotiated. I do not know whether a payment related to quality might replace it. It is conceivable that, as with some PMS contracts, a certain part of the payment should relate to maintaining a certain size of list, but one that is not related to capitation. A number of variations are possible.

Rightly or wrongly, I take reassurance from the fact that my officials have met with the General Practitioners Committee of the BMA and discussed the clause in some detail, as they have done the rest of the Bill. The GPC understands what we propose, and does not share the hon. Gentleman's concern. It is true that they would like a provision on quality to be included in the Bill, which I entirely understand. However, it has not raised with my officials the matter of remuneration being

wholly or mainly of a fixed salary.

Philip Hammond (Conservative, Runnymede and Weybridge)

I do not wish to flatter him unduly, but the Minister says that the GPC has not raised those concerns with him. If he turns his mind back a couple of years, he may remember that, on more than one occasion, he got the better of the GPC in negotiations. The fact that the GPC has not expressed concerns about what the Minister intends to do does not mean that we should not probe the matter carefully. By nature, doctors tend to be trusting, and they will expect Ministers to be open and honest. I do not think that there is any misunderstanding over clause 4.

I seek a clear statement from the Minister. If he is looking to replace capitation-based remuneration with fixed remuneration, he needs to repeal section 29(4) of the 1977 Act. If he proposes that GPs should have more than 50 per cent. of their remuneration by way of a fixed salary, without reference to capitation or anything else, he needs clause 20. My understanding, from the general tone of the Government's approach to GP remuneration, was that he intends that more than 50 per cent. of GPs' remuneration should be related to the quality of the service that they provide and the outcomes that they deliver. If, therefore, the most significant part of their remuneration will be dependent on the quality of service that they deliver, he does not need clause 20.

Nothing in section 29(4) of the 1977 Act would prevent the Minister from paying a general practitioner 49 per cent. of his total remuneration as a fixed sum, by reference to nothing, and the other 51 per cent. by reference to something like quality of outcome or patients' experiences of the services delivered. Will the renegotiated GMS contract provide for the payment of a fixed salary, without reference to capitation, which constitutes more than 50 per cent. of the total remuneration? If so, the Government are missing an opportunity to do something that their propaganda suggested they would do, which is to place quality patient experience and outcomes at the top of the agenda.

John Denham (Labour, Southampton, Itchen)

In a sense, capitation payments are fixed. They are not fixed in absolute terms, because they depend on the number of people on the practitioner's list, but they are fixed in that they must be more than 50 per cent. of the total. We are trying to remove that obstacle. The provision effectively requires a GP who has twice the number of people registered on his or her list as another GP to be paid twice as much. We are trying to escape the hook of a direct link to capitation. In the future, it is likely that remuneration will be linked less directly to the number of patients on the list. In some PMS contracts, the GP is required to maintain a list of a certain size, but the contract emphasises the quality of services provided to those on the list. It is conceivable that we may wish to cap that type of contract.

In this discussion, where there is no real difference between our objectives and those of the profession, it seems pointless to try to specify what elements might or might not constitute precisely 50 per cent. of the future remuneration. When we come to negotiate, it is likely that the number of patients will be a relevant factor, but we are trying to get rid of the provision that has effectively tied us to a capitation system.

Peter Brand (Liberal Democrat, Isle of Wight)

It is true that before quality can be delivered, a basic practice must be assembled, so there is still a need for a basic practice allowance of some sort. I support what the Government are trying to do, and that is not necessarily because I am so trusting. I have spent my clinical professional life with drug addicts—people who are pathological liars.

Philip Hammond (Conservative, Runnymede and Weybridge)

Like politicians.

Peter Brand (Liberal Democrat, Isle of Wight)

I have been anticipated. Medical negotiators can certainly cope with the average politician.

John Denham (Labour, Southampton, Itchen)

We know that, but what we want to know is what the hon. Gentleman did before he became a Member of Parliament.

We have reached the stage in the debate where I have set out my view of the legislation and the purposes that lie behind the clause, and the hon. Gentleman has set out his views. I fear that we will simply go over the same ground again and again.

Philip Hammond (Conservative, Runnymede and Weybridge)

I fail to be convinced by the Minister's argument. My interpretation of section 29(4) of the 1977 Act is that it would allow for a fixed salary, without reference to capitation, equivalent to 49 per cent. of the total remuneration to be paid. I see nothing in clause 20 that would stop a further amount, linked to capitation, being paid, and a further amount beyond that, linked to the fulfilment of other criteria.

The Minister is clearly basing his remarks on the advice that he has been given. I will go away and talk to people who are better able to dissect these things than I am. I do not pretend to be a lawyer. One of the problems under which we labour in this place is that we are expected to provide interpretations and advice for which people outside the House would expect to be paid a great deal more per hour than Members of Parliament or civil servants are. However, I hope that the Minister will think again if I come back to him, before the Bill is considered on Report, with an opinion that gives credence to what I am saying. We are simply seeking to look behind what he is trying to do and find out whether he has an agenda that requires the measure. Such an agenda might give some cause for concern, whereas his stated agenda, which we do not believe requires the clause, does not. We accept that that agenda is being discussed with the profession. Our only concern is to unmask any actual or potential hidden agenda for the future.

The Committee can move on now, but I hope to revisit the issue with the Minister later. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 20 ordered to stand part of the Bill.

Clause 21 - out of hours medical services

Desmond Swayne (Conservative, New Forest West)

I beg to move amendment No. 168, in page 14, line 21, leave out `another' and insert `any other'.

John Maxton (Labour, Glasgow Cathcart)

With this it will be convenient to take amendment No. 169, in page 14, line 26, at end insert

`, including requirements as to the provision of information on services provided to the principal'.

Desmond Swayne (Conservative, New Forest West)

In view of what the Minister has told us about the disagreeable consequences of reconvening the dreaded Programming Sub-Committee, it may be for the convenience and relief of the Committee if I kept my remarks as focused as possible. That will be my endeavour.

Amendment No. 168 attempts to remedy the lack of clarity in the clause. What was meant was not entirely clear to us. The explanatory notes state:

The body to be regulated is any body or organisation providing out-of-hours cover to GPs that will have to be accredited by a Health Authority.

Does that mean that the body will have to be accredited by any health authority, not necessarily by every health authority, to which it provides an out-of-hours service? That is our understanding of what the clause means, so we are trying to make it more explicit. After all, we are here to help. The spirit of the amendment follows Oliver Cromwell when he said that no real reform could be achieved unless the whole law was reduced to the bigness of a pocket book, intelligible to all men.

Having said that, and believing that the clause has precisely that meaning, I understand the attractions of its having an interpretation under which a provider would have to be accredited and be on the list of every health authority to which it provided a service. If a complaint were to arise against such a provider, the health authority that received the complaint might be unable to seek redress by taking proceedings against that provider, with a view to removing it from its list. The health authority would have to initiate those proceedings with another health authority that had the provider on its list.

It may be administratively convenient for a provider to be on every health authority's list to which it makes provision. However, that administrative convenience must be set against the huge bureaucratic burden that would be placed on the provider of having to register to be accredited by every health authority to which it provided a service. We tabled the amendment in the understanding that the clause means that once a provider has secured access to the system by gaining accreditation from a health authority, that body can provide those services to all health authorities. We seek to make that explicit in the Bill.

Amendment No. 169 is intended to make one of our principal concerns explicit. We fear that access to NHS services may be becoming fragmented. That concern for continuity of care is not restricted to Conservative Members, but is also a concern among medical professionals. In an article in Doctor on 21 January 2000, Dr. Gillam, the Luton general practitioner who is also a director of the primary care programme at the King's Fund, commented that NHS Direct was part of what he saw as an agenda of fragmenting access to the national health service and that it could destroy continuity of care.

That fear has been echoed in a survey of doctors published in GP Magazine on 25 February 2000, which revealed that 81 per cent. of doctors questioned felt that continuity of care was being jeopardised by NHS Direct and walk-in centres. That concern for continuity of care was expressed in the independent report that was commissioned by the Department of Health ``Raising New Standards for Patients—New Partnerships in Out-of-Hours Care.'' I draw the Committee's attention specifically to recommendation 4 of that report, which states that

all providers should report all out-of-hours consultations to GPs by 9.00 am the next normal working day.

Clearly, the authors of the report share the concern that there should be continuity of care and that that information should be provided. However, even that was only an interim measure and very much a second best, because the ideal solution is the provision of electronic systems. The electronic health record will provide a three-way exchange of data between NHS Direct, the out-of-hours providers and general practitioners. It would assist us if the Minister could say precisely what stage has been reached in the provision of the electronic record and what prospect there is of its delivery in the medium term.

I have a wider concern about the clause, which is not germane to these two rather focused amendments. I am inclined to leave that matter to a stand part debate, but if you decide that there will not be a stand part debate, Mr. Maxton, I shall seek to catch your eye a second time.

John Denham (Labour, Southampton, Itchen)

The hon. Member for New Forest, West (Mr. Swayne) has raised some useful points and I hope that I can deal clearly with our policy intentions. We shall address these matters in regulations made under the clause, but what we intend to do on health authority accreditation goes some way towards meeting the hon. Gentleman's concerns, although not entirely.

If a GP co-op provides out-of-hours services covering two or three health authority areas, it is obviously sensible for the health authorities to agree that one health authority should take responsibility for accrediting the service for all of the others, to avoid repetition of a bureaucratic process, and regulations will provide for that. However, we do not think it appropriate that an out-of-hours provider who is on the list of one health authority should automatically have that accreditation accepted by all other health authorities. The reason is that some out-of-hours providers are very large--some are large commercial organisations. Although legally they are single bodies, they have a fairly loose federal structure, and the quality of service can vary from one part of the country to another, even though the umbrella organisation is the same.

Thus we feel it necessary to allow a health authority, if it wishes, to choose to accredit the organisation that offers the service to patients in its area. We believe that to be the right compromise. Under these arrangements, part of a large organisation—I do not want to single out the commercial deputising organisations—would not receive an automatic right to accreditation everywhere simply because it offered a perfectly satisfactory service in one place, as quality of service varies.

Philip Hammond (Conservative, Runnymede and Weybridge)

I understand what the Minister says, but as the clause is phrased, it is the person providing the service—that is, the company—that is being accredited. The health authority would therefore be unable to determine who was providing the services. It could be a national company based in London that provided services all over the country.

John Denham (Labour, Southampton, Itchen)

The health authority would be able to look at the arrangements being implemented in that particular area—for example, to satisfy itself that the information technology requirements or the arrangements for clinical audit were in place for patients in its area.

Peter Brand (Liberal Democrat, Isle of Wight)

Has the Minister considered an alternative way of tackling this problem? If approval in one health authority qualified a large company to practise in any other, it could lose that approval in all health authorities if its performance was unsatisfactory in any one of them. In some franchising operations, those who trade on well-known national images may not be diligent in ensuring that that national package is being delivered locally. That would make the larger organisations more accountable.

John Denham (Labour, Southampton, Itchen)

The hon. Gentleman is right about accountability. Our solution allows the individual health authority to carry out the accreditation process itself. That will provide a stronger safeguard than the health authority having to accept the accreditation of other authorities and being able to object only once problems came to light. I think that we are at one on the level of accountability required.

We entirely accept the principle behind amendment No. 169, but it should be dealt with in regulations. It is important that a patient's GP or a person providing personal medical services has full and up-to-date information when one of his patients has been seen out-of-hours—information on who saw the patient, the diagnosis, what was prescribed and so on. The out-of-hours review recognised that. The Government intend to specify that out-of-hours service providers must supply full clinical details of consultations to practices by the start of the next working day. We will make regulations to ensure that GMS principals and other providers of primary care receive the necessary information.

Philip Hammond (Conservative, Runnymede and Weybridge)

If the Minister is committed to ensuring continuity of care and that information is passed back to the principal practitioner, what arrangements will he put in place to ensure that the details of a patient's walk-in consultation is reported back to his GP?

John Denham (Labour, Southampton, Itchen)

It is a consistent part of the walk-in centre programme to develop and improve those links. That relates to the electronic patient record, which the hon. Member for New Forest, West mentioned. Paragraph 4.21 of the NHS plan states that there should be

access to electronic personal medical records for patients by 2004.

By that time, we expect that

75 per cent. of hospitals and 50 per cent. of primary and community trusts will have implemented electronic patient record systems.

That is the extent of the progress that the Government hope to have made by 2004.

In the interim, it is not sufficient for walk-in centres to wait for electronic patient records to come along at some time in the future. Depending on the local infrastructure, local protocols are being developed with primary care groups to use electronic communications, fax or telephone, as appropriate.

Philip Hammond (Conservative, Runnymede and Weybridge)

What would happen if a patient walked into a walk-in centre and refused to disclose his identity? My understanding is that the patient would receive a consultation like any other patient, although it would not be possible to report back, whether or not there is an electronic data system. That would be a serious disruption to continuity of care. If the Minister is concerned about the issue in relation to out-of-hours treatment, is he not also concerned about the proliferation of walk-in centres leading to patients being able to opt part of their medical history out of their records? That is happening in some walk-in centres.

John Denham (Labour, Southampton, Itchen)

Every effort is made not only to encourage patients to identify themselves at walk-in centres, but proactively to encourage patients who are not registered with a GP to do so. I am not entirely sure whether the hon. Gentleman was suggesting that those who, for whatever reason, do not want to disclose their medical histories should be turned away from NHS treatment. However, we are working hard to ensure that continuity of care is maintained. That is a key objective in our development of this new and convenient method of access to the NHS.

Peter Brand (Liberal Democrat, Isle of Wight)

I am sure that we have a long way to go on information exchange, as a recent Which report pointed out. Would the Minister answer the question asked by the hon. Member for Runnymede and Weybridge slightly differently? If a patient registers normally at a walk-in centre but specifies that certain aspects of the consultation should not be shared, does that patient have the right to have those details withheld? The answer to that question will clearly be relevant to later debates.

John Denham (Labour, Southampton, Itchen)

I should like to take advice on that, as that is slightly outside the scope of the amendments, which are about out-of-hours services provided by GPs or walk-in centres if they are part of an accredited system of out-of-hours services. I am not entirely sure of the precise legal rights that patients may have, in any part of the NHS, not to disclose their full medical history if they prefer not to do so. I would like to be sure before saying how that would apply to walk-in centres or out-of-hours services.

Peter Brand (Liberal Democrat, Isle of Wight)

It would help if that advice was made available in time for our later debates. It is not uncommon for a patient to share all sorts of information, and a core of information certainly needs to be shared, but a patient may not want to share certain aspects of a consultation. For instance, a pregnant under-age girl may not want a family friend who happens to be the GP to have that information shared. It is important, when we reach the information-sharing provisions, that we recognise that there are real ethical problems as well as administrative problems.

John Denham (Labour, Southampton, Itchen)

I am grateful to the hon. Gentleman for that early indication. I hope that the Committee accepts that it is better for me not to risk misleading the Committee on those legal issues, but I shall ensure that we can return to them in due course.

Philip Hammond (Conservative, Runnymede and Weybridge)

I am grateful to the Minister for his indulgence in allowing me to make one final point in this rally.

He asked a few moments ago whether I thought that patients should not be seen at walk-in centres if they did not want to disclose their identities. I was not suggesting that; I was asking the Minister to acknowledge an inconsistency. We all believe that, in principle, continuity of care is a positive thing, and the amendment seeks to achieve that for out-of-hours services. Does the Minister accept that, by creating walk-in centres, with all their convenience, the Government have for the first time allowed patients access to the NHS free at the point of use without that consultation having to be entered in their medical records?

For the first time in the family practitioner service, we will allow patients selectively to edit their on-going definitive medical history. As in the example given by the hon. Member for Isle of Wight (Dr. Brand), patients already do that to ensure that information that may be embarrassing or inconvenient or that may affect their insurance ratings is excluded from their medical history.

John Denham (Labour, Southampton, Itchen)

I am not sure that that is the case. For example, those who go to accident and emergency departments and do not reveal their real identity are not turned away. There are many ways in which patients can do that. It is generally undesirable, although the hon. Gentleman mentioned circumstances in which it might be necessary. For example, in the tradition of genito-urinary medicine clinics, confidentiality is respected. It has always been possible to gain access to the NHS without identifying oneself. Perhaps we can return to that matter later.

Desmond Swayne (Conservative, New Forest West)

My hon. Friend the Member for Runnymede and Weybridge has drawn our attention to a key point that goes to the heart of our concern about the fragmentation of access to the NHS.

Hilton Dawson (Labour, Lancaster and Wyre)

Does the hon. Gentleman recognise that in drawing attention to what he calls fragmentation, he overlooks the excellence of NHS Direct? He should note the comments of Mrs. Jean Jones of Pickthorn close, Lancaster, who spoke of the tremendous benefit that she derived from NHS Direct on new year's day 2001. It gave her excellent, comforting, reassuring advice when medical services were not available to her husband.

Desmond Swayne (Conservative, New Forest West)

I could detain the Committee for some time, Mr. Maxton, but you have informed me in a note that there will be a stand part debate, so I shall confine myself to the narrow subject of the amendment on out-of-hours access. I am reassured to learn from the Minister that what we would like included in the Bill, by way of amendment No. 169, will be dealt with in regulations.

I am not entirely sure that I understood the compromise that the Minister was outlining with respect to amendment No. 168. Am I right in thinking that he was suggesting a regional structure?

John Denham (Labour, Southampton, Itchen)

To use an example from my locality, Southampton and South West Hampshire health authority might decide to accept the judgment of Portsmouth and South East Hampshire health authority in accrediting a service that was offered across both health authority areas. However, there would not be a requirement on the Southampton and South West Hampshire health authority to accept another health authority's judgment. That allows for cases in which it is thought that the quality of service might vary between areas.

Desmond Swayne (Conservative, New Forest West)

I now understand the Minister. That leaves us with reservations about the bureaucratic hurdles that a provider might have to negotiate if the health authorities were not minded to accept one another's accreditations. However, seeing the clock, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

John Maxton (Labour, Glasgow Cathcart)

Order. I wonder whether it would be for the convenience of the Committee if I mentioned that while, as Chairman, I am reasonably tolerant of amendments if they help the debate, in the previous debate my tolerance was stretched a little.

Question proposed, That the clause stand part of the Bill.

Mr. Swayne: We welcome the principle of the clause. It is appropriate and desirable that a high standard of out-of-hours care should be available throughout the country. I am sure that all hon. Members will be aware of the need for that from their postbags and constituency case work. The health service ombudsman has drawn attention to existing problems.

Some concerns remain, however. The first is that the clause has resource implications for the administration and scrutiny of the accreditation process. What is the Minister's estimate of the effort and cost that health authorities will have to face with the new duty?

I received a brief from the Royal College of Nursing that detailed a concern pertinent to the clause, although it also affects a number of others. It sought assurances that the new accreditation conditions will not exclude nurse-led practices under the new personal medical services dispensation. Some nurse-led practices employ GPs, but the RCN fears that, because nurses cannot act as principals, they will be excluded from acquiring accreditation under the clause. Will the Minister deal with that concern?

We understand that, by 2004, a single phone call to NHS Direct will be a one-stop gateway for out-of-hours access to health care, with NHS Direct passing on the calls to the GP or the out-of-hours provider. Our concern is that that should not be the only gateway; it should be a one-stop shop or gateway but not the only one.

The independent report ``Raising New Standards for Patients -New Partnerships in Out-of-Hours Care'' proposes, in recommendation 7:

Service level agreements incorporating all the Quality Standards should be established, between NHS Direct and all providers of out-of-hours services.

We are concerned that these regulations will be used to push all out-of-hours providers into accepting NHS Direct as the only gateway to their services.

Simon Burns (Conservative, West Chelmsford)

Has my hon. Friend ever rung NHS Direct? Unlike the hon. Member for Lancaster and Wyre (Mr. Dawson), I phoned on new year's day 2001 to get some advice on a child's health but, after 25 minutes of waiting to get through, I had to give up.

Desmond Swayne (Conservative, New Forest West)

I have only rung NHS Direct when I have been prompted to do so by constituents who have complained to me about the service. I always use pharmacists rather than the assistance that can be had over the phone from medical professionals, for precisely the reasons to which my hon. Friend drew attention.

We fear that these regulations will push us towards a situation in which someone wanting to access any out-of-hours provision must do so via NHS Direct.

Philip Hammond (Conservative, Runnymede and Weybridge)

Although my hon. Friend has not stated this explicitly, he knows well that pilots are being considered in which access to the 999 ambulance service is also obtained via NHS Direct. The experience of my hon. Friend the Member for West Chelmsford (Mr. Burns) could be alarming in that context.

Desmond Swayne (Conservative, New Forest West)

I am aware of that, and the prospect is most alarming. We have the same concern with those pilots as we have with these regulations: that they will be used as a means of enforcing the provider to allow access to his service only through NHS Direct.

Lorna Fitzsimons (Labour, Rochdale)

Whatever the experiences of the hon. Gentleman and his colleagues, will he also accept that I am deluged with complaints about surgeries that leave inadequate answer phone messages? In some cases, the contact number for an emergency doctor is cut off halfway through, and no information is given about when the surgery will next be open or about any service alternatives. That leaves the person no choice but to go to an accident and emergency department or to contact NHS Direct.

We are lucky enough in my area to be able to access NHS Direct. It is a safeguard for many people who find themselves in the same situation as the hon. Member for West Chelmsford when he had to phone to get advice about a sick child. I have used the service and found it invaluable when the ordinary surgery has let me down.

Desmond Swayne (Conservative, New Forest West)

I should be interested to know how long the hon. Lady waited to get through. She draws attention to a legitimate concern in saying that there needs to be a safety valve. The problems that she has highlighted should be rectified by the regulations that we have discussed, so that a high quality standard of provision is assured. Our fear is that NHS Direct will become the only means by which out-of-hours services can be accessed. We do not believe that it is proper to move to such a situation until the case for NHS Direct has become much sounder than it is at the moment. The jury is still out.

My hon. Friends have already drawn attention to the problems that many people perceive with NHS Direct. Only last year, the conference of the British Medical Association voted that the £80 million currently being spent on NHS Direct would be better spent on renovating their surgeries [Laughter.] I can understand there being a measure of self-interest among general practitioners, but those are the very people who must have confidence in that service. It would be improper of us to use these regulations to require them to make their out-of-hours services available only through NHS Direct before there is sufficient confidence in NHS Direct to bear the weight of that requirement.

Hilton Dawson (Labour, Lancaster and Wyre)

Does the hon. Gentleman accept that the experience of the present pilot project for NHS Direct is that, despite some initial scepticism from GPs, the project has been successful and has developed largely because of the co-operative attitudes of GPs and the medical profession?

Desmond Swayne (Conservative, New Forest West)

Experiences differ as, no doubt, the National Audit Office report will tell us. However, at the moment the jury is very much out. A snapshot survey of 500 calls to NHS Direct from 5 to 11 January last year showed that 33 per cent. of patients were advised to take care of themselves, 23 per cent. were told to go to their GP immediately, 18 per cent. were advised to see their GP as a routine visit and 6 per cent. were told to go to their hospital accident and emergency department, of which 2 per cent. were to be as emergencies. In addition, 18 per cent. were told to seek advice from another health professional or to get more information. Most of the calls involved young children and young women, with a low rate for older adults.

The survey showed that almost half those who ring NHS Direct go to their GP as well. A call to the service costs the NHS £8. A visit to the GP costs £10.55, and one to an accident and emergency department £42. When a patient talks to NHS Direct and then goes to the doctor—as so many do—it costs a total of £18.55, so we are increasing the cost to the national health service by sending so many of the people who have rung NHS Direct to their doctors. They may as well have gone straight to the doctor and saved the additional cost.

Adrian Bailey (Labour/Co-operative, West Bromwich West)

Does the hon. Gentleman acknowledge that many people phone NHS Direct for advice about whether they should go to the GP? When the advice is that there is no need to go to the GP, there is a potential saving to the NHS that should be incorporated in the figures.

Desmond Swayne (Conservative, New Forest West)

The answer to the hon. Gentleman is that very few of those who ring NHS Direct are saved that trouble, because so many subsequently visit their GP.

Philip Hammond (Conservative, Runnymede and Weybridge)

Labour Members are jumping up and down like Jack-in-the-boxes to extol the virtues of NHS Direct. The fact is that the Government have rolled out the programme without a robust evaluation of its success and cost effectiveness. Now, our best hope is that the National Audit Office will undertake a full investigation into NHS Direct and its cost effectiveness, and only after that will sensible decisions about its role be taken. Until then, neither Labour Members nor anyone else can make an effective evaluation of the part that NHS Direct plays in our health system.

Desmond Swayne (Conservative, New Forest West)

My hon. Friend is right and we are awaiting that investigation. It would not be acceptable if the regulations could create a situation in which the only out-of-hours access to the NHS was via NHS Direct, given that we are doubtful about the robustness of that organisation to deliver the service. My hon. Friend's point that there has been no evaluation of NHS Direct is accurate, although the figures that I quoted come from Sheffield university's evaluation of NHS Direct's first-wave sites, contained in the second interim report to the Department of Health, produced in February last year.

Philip Hammond (Conservative, Runnymede and Weybridge)

It was not robust.

Desmond Swayne (Conservative, New Forest West)

It may not have been robust, but it nevertheless drew attention to a significant number of problems. My hon. Friend is correct that we must await a more thorough examination. The medical profession is deeply concerned about the way in which NHS Direct has been rolled out without any proper evaluation hitherto. It is time that that evaluation was made. We should not accept regulations that create a situation in which all out-of-hours access is through NHS Direct when so many questions still pertain to that organisation.

Peter Brand (Liberal Democrat, Isle of Wight)

I do not want discussion on the clause to focus solely on NHS Direct. However, it is clearly an evolving service that is having problems during its evolution. Not only has it found it difficult to cope with capacity, but there have also been significant problems with the computer programmes on which the advice is based. It can take a long time to get hold of someone, and the assessment process by an NHS Direct assessor is very time consuming. Sometimes advice is also a little too direct. One of my wife's patients told her that NHS Direct had told the mother that the child had to be seen by a doctor within an hour. It is not the role of NHS Direct to dictate how a patient should be seen, or at least I do not believe that it should be. Those issues must be resolved in time.

I worry that NHS Direct is a free service to GPs. In effect, GPs are being bribed into using NHS Direct because they are pragmatic people who will use a free service. However, it is not a free good and we must recognise that public money is spent on that service. Let us hope that it works out well.

My concern about the clause is that a health authority may be reluctant to sanction any other other-of-hours services as out-of-hours first-line-of-call access is free through NHS Direct. Would arrangements made by individual contractors—to have internal rotas, for example—also have to be approved by the health authority, or could those contractors retain their individual 24-hours-a-day responsibility? I was in a single-handed practice for about 15 years, and I was on call every night apart from Thursday, through a rota with colleagues. That worked well, except that one of my colleagues, who was not terribly reliable, put a message on the answer phone saying, ``If there are any problems, ring me at home''.

Such methods are no longer acceptable to most practitioners, and would not be to me now, because patients' attitudes have changed. That is perhaps part of increasing consumerism, which the Government have fuelled by raising patients' expectations that there should be access to just about anything, 24 hours a day. That issue needs to be addressed, but not in this debate.

Philip Hammond (Conservative, Runnymede and Weybridge)

The hon. Gentleman pursues an interesting line and might further ask the Minister whether the purpose of the clause is to approve providers of out-of-hours services, or whether the regulations under it are to be used to define the routes of access to those services by making it a condition of approval that a person's service is accessed in a certain way. That would run some of the risks that the hon. Gentleman has outlined.

Peter Brand (Liberal Democrat, Isle of Wight)

I am grateful for that intervention, which clarifies what I was intending to say. The clause gives the Secretary of State the power, through regulations, to determine how access is provided, irrespective of local traditions or of what has worked in the past.

I do not oppose the clause, because I am a realist and I know that the world has moved on during the past 20 years. However, I would like an assurance from the Minister that the clause gives neither the Secretary of State nor health authorities powers of direction that could become unreasonable, such as the power to direct not in the interests of patient care but in the interests of administrative convenience, or even the power to shuffle responsibilities among different budgets.

John Denham (Labour, Southampton, Itchen)

I shall start on that final point. The clear intention of the clause is to enable the setting of standards that providers will have to meet. The focus is on those standards; that should be a considerable reassurance to the Committee. Those standards will have to be met by all accredited providers, however their services may be organised. I do not find it acceptable to require a higher standard from one provider than from another. For example, the out-of-hours review proposed that 1 per cent. of clinical records should be continuously audited by a sampling method that would measure the standard of record keeping for each provider of out-of-hours services. We would not want the out-of-hours services of some patients to be subject to that regime, but not those of others. The out-of-hours review suggested the imposition of standards on aspects of telephone access, such as the percentage of calls engaged or abandoned and the time taken to answer, and on the way in which the triage system operates.

Such standards should be available to patients in all parts of the country, irrespective of the way in which the service is provided. Our focus is on those standards. The out-of-hours review suggests measures that are directly related to patient services and patient outcomes rather than to particular organisational models. For example, time limits for home visits in the case of an emergency should be subject to quality standards.

It is important that record keeping and auditing should be of a consistent standard throughout the country, however the provider organises its service.

Philip Hammond (Conservative, Runnymede and Weybridge)

Is the Minister saying that he will not use the regulations under the clause to define certain methods of access only to out-of-hours providers?

John Denham (Labour, Southampton, Itchen)

We have no intention of using the regulations to require every patient to follow a particular procedure—as they are currently drafted, I am unsure whether we could use them in that way. However, I believe that patients will find it convenient to have to ring only one number to access advice and out-of-hours services. That service is already offered to between 2 and 3 million patients in England, as a result of the integration of NHS Direct with GP co-ops. Therefore, it is not just a fanciful concept. It already exists in large areas of west London, where the Harmoni co-op is integrated with NHS Direct. An increasing number of co-ops are integrating their services with NHS Direct. The situation will further improve as the latest triage software becomes available to the whole of NHS Direct and is integrated with out-of-hours services.

An existing telephone line may be retained because, for example, a co-op may wish to offer that service to its patients; but I believe that most patients will prefer to have to remember only one number to access a wide range of services.

I assume that the Committee has not discussed in detail the principle of accreditation because it generally welcomes the proposals that underlie the clause, and that are described, in particular, in the out-of-hours review. Therefore, although I could discuss the clause in more detail, it might be satisfactory to deal only with the issues raised in the debate.

I am unsure whether the hon. Member for New Forest, West was objecting to the concept of NHS Direct or to the idea that there should be accreditation and standards. I assume that he accepts the idea but does not like NHS Direct.

When we began to develop NHS Direct, the official Opposition used to jump up and down and say, ``We thought of it first.'' Now, just as its success is becoming apparent, they seem to have changed their tune. That is typical of their political judgment at the moment.

Philip Hammond (Conservative, Runnymede and Weybridge)

The Minister has rattled my cage. I reassert that my party thought of NHS Direct first; I think that our pilot scheme was in Wiltshire. We have consistently said that NHS Direct could play an important role in the overall delivery of health care services, but it must be properly evaluated before it is rolled out. Our objection is that the Government rolled out the pilot schemes nationwide without any robust study of the value for money and cost-effectiveness provided by the service. As the NHS budget is limited, that is an irresponsible way to proceed.

John Denham (Labour, Southampton, Itchen)

I disagree. NHS Direct—which is clearly linked with the provision of out-of-hours services—is subject to continuous evaluation, and that evaluation is published. NHS Direct is also subject to a degree of clinical governance that is not practised in every part of the NHS. That is one of the great strengths of NHS Direct. Consultations are tape recorded, although the information contained on those recordings is confidential. Therefore, if a patient complains that he or she was told to do X, that can be checked. That would not be the case in almost any other consultation that may take place elsewhere in the health service, and it has enabled previous allegations to be substantiated.

I want progress to be made with out-of-hours services, so that it becomes possible in every part of the country to access accredited out-of-hours services by ringing the NHS Direct number. At present, millions of patients already have that service. Other GP co-operatives would like to work with NHS Direct because they recognise the advantage of having NHS Direct provide a triage service. People working in other parts of the service want to see how it works in practice. That is why the implementation of the out-of-hours review is based on the development of exemplar projects over the coming years.

Those projects will demonstrate to GPs who may be uncertain about which course to take that the service is a cost-effective, patient-friendly and doctor-friendly way of proceeding. That will enable those services to achieve the necessary standards of accreditation and to offer a better service to patients. When we responded to the out-of-hours review, I made it clear that we wanted to proceed on that basis. By working with those who want to move in this direction at an early stage, we will be able to demonstrate to those who have doubts that this is the right direction.

Desmond Swayne (Conservative, New Forest West)

The Minister asked if I was opposed in principle to accreditation. In my opening remarks, I sought to make it absolutely clear that we are in favour of that. We support the principle behind the clause. Our concern is that the regulations might be used to enforce access to all out-of-hours services via NHS Direct, which we do not believe is yet sufficiently robust to bear that burden.

John Denham (Labour, Southampton, Itchen)

I have dealt briefly with the strategy that we would prefer to follow in order to convince people, and I believe that we will achieve our objective.

The resolution of practitioners at the BMA last year about investing £80 million in their premises provoked some amusement. At our last sitting, we discussed the investment of £8,000 million in the premises of GPs, so clearly we are meeting that aspiration of the medical profession.

Regarding nurse-led practices, the responsibility for out-of-hours provision clearly lies with the GP, as does the rest of the service. However, there is no bar to nurse-led practices—PMS practices—becoming accredited providers, provided that they meet the standards set out in the regulations.

Peter Brand (Liberal Democrat, Isle of Wight)

The Minister did not respond to my specific question about whether rotas for GPs who intend to retain 24-hour responsibility will be caught by the regulatory mechanism.

John Denham (Labour, Southampton, Itchen)

I had intended to answer the hon. Gentleman's question. It does not matter whether the service is provided by rotas. If it is an out-of-hours service, it has to be accredited under the regulations. The quality of the service offered to the patient must be consistent.

Peter Brand (Liberal Democrat, Isle of Wight)

If a husband and wife team look after a practice population 90 per cent. of the time, will they have to apply for accreditation in order to have an arrangement about who gets up at night?

John Denham (Labour, Southampton, Itchen)

The issue is whether someone delegates responsibility to another provider. If that is unclear, I will write to the hon. Gentleman.

We must ensure that we have consistent standards across the service. That should be a part of any arrangements that are put into place. There will be some challenges to the traditional provider or practice, but if there is no delegation—the individual is offering a 24-hour service as stated in his or her contract—there will be no accreditation requirement.

Question put and agreed to.

Clause 21 ordered to stand part of the Bill.

Further consideration adjourned.—[Mr. Jamieson.]

Adjourned accordingly at twenty-four minutes past Eleven o'clock till this day at half-past Two o'clock.

Standing Committee E

Health and Social Care Bill

John Denham (Labour, Southampton, Itchen)

I beg to move,

That the Programming Order of the Committee of 18th January be amended—

(1) in paragraph (1), at the end, by inserting the words `(save on the afternoon of Thursday 25th January, when the Committee may sit until Seven o'clock)'; and

(2) in the Table, by leaving out the entry in the third column in respect of the 5th sitting and inserting instead '7 p.m.'

The resolution does not deal with a possible sitting on Monday afternoon, but if we do not make sufficient progress this afternoon we might need to convene the Programming Sub-Committee later.

Question put and agreed to.

Clause 22 - Unsuitability for inclusion in medical, dental,ophthalmic and pharmaceutical etc. lists

John Denham (Labour, Southampton, Itchen)

I beg to move amendment No. 116, in page 15, line 6, at end insert—

`( ) In section 29A (medical lists), after subsection (4) there shall be inserted—

``(4A) Regulations may make provision in relation to the supply to a Health Authority, by a medical practitioner who is included in their medical list (or, as respects paragraph (a), by arrangement with him) of—(a) information of a prescribed description; and

(b) a criminal conviction certificate under section 112 of the Police Act 1997 or a criminal record certificate under section 113 of that Act.'''.

John Maxton (Labour, Glasgow Cathcart)

With this we may discuss the following: Government amendments Nos. 117 to 120.

Amendment No. 170, in page 15, leave out lines 29 and 30.

Government amendment No. 121.

Amendment No. 171, in page 16, leave out lines 1 and 2.

Government amendment No. 122.

Amendment No. 172, in page 16, leave out lines 16 and 17.

Government amendments Nos. 123 to 126.

Amendment No. 173, in page 16, line 29, leave out from `inclusion' to end of line 31.

Amendment No. 174 page 16, line 35, at end add—

`(7) In sections 29B, 36, 39, 42 and 43 the expression ``grounds of unsuitability'' shall mean, in relation to such person, grounds that enable the Health Authority (or on appeal the FHSAA) to be satisfied that it is—

(a) necessary in the public interest or for the protection of members of the public; or

(b) in the interest of the person concerned

that such person is not included in the respective list and, elsewhere in this Act the word ``unsuitability'' shall be construed accordingly.'.

Government amendments Nos. 127 to 133.

John Denham (Labour, Southampton, Itchen)

This is a lengthy group of amendments, so before speaking to the clause in general terms, I shall discuss the amendments themselves.

Clause 22 forms a key part of our package of measures to improve the quality of delivery of primary care services—a subject on which I touched in our discussions on Clause 19. Clauses 25 and 27 also deal with lists, and taken together clauses 22, 25 and 27 cover doctors, dentists, pharmacists and optometrists. They cover non-principals as well as principals, and practitioners under part I or part II of the National Health Service Act 1977. Between them, the clauses apply the same principles and procedures to each list, and any variations are those required by the circumstances of the particular group. Clause 22 deals with part II principals by amending the existing powers.

Clause 22 will also deliver more consistency to the provisions applying to each practitioner group. That is important, because although each practitioner group has distinct and different roles, in each case potential risks to patient safety can arise through the possibility of inappropriate or unscrupulous behaviour by a practitioner who is unsuitable for the role.

It might come as a surprise to some to learn that health authorities do not already have such powers. They have the power to refuse admission in some circumstances, but it has become clear that the powers are currently drawn too narrowly to be applied uniformly across the four practitioner groups. I should make it clear that, as now, the process of entry to the health authority list will be wholly separate from the processes through which a general practice selects new partners.

On the issue of unsuitability, to which Opposition amendments Nos. 170 to 174 relate, the clause will extend the grounds on which a health authority may refuse admission to its relevant practitioner list. Health authorities are already required to hold lists of all principal practitioners providing medical, dental, optical and pharmaceutical services. The new provisions will strengthen the power of health authorities to control the provision of family health services in their area. Crucially, they will allow health authorities to refuse a practitioner's entry to a list on the grounds of unsuitability or fraud. Unsuitability is capable of wide interpretation, so we will set out in regulations the criteria that health authorities must consider in reaching decisions on those grounds.

We intend that a health authority be able to consider a wide range of issues relating to the applicant, or, where relevant, to directors or other persons controlling a body corporate. They include criminal convictions, the adverse findings of a licensing or regulatory body, personal references, qualifications and previous career history—in other words, issues similar to those that any employer considers before engaging someone. We intend that barring from the list should be automatic where someone has been convicted for murder, is not on the relevant professional list—not quite as serious a matter, but a none the less suitable ground—or is subject to a national disqualification. In other cases, the decision would be at the health authority's discretion.

Before refusing a person's application on the grounds of unsuitability, we would expect a health authority always to consider criteria such as: the nature of any criminal offence or professional regulatory investigation; the length of time since any offence was committed or since the conviction or investigation; whether there are other offences to be considered; the penalty imposed on conviction or the outcome of the investigation; the relevance of the offence or investigation to his provision of family health services; the likely risk to patients or impact on the national health service or on confidence in it; and whether he has been refused admission to, removed from or suspended from other health authority lists, and the facts involved in such cases.

We intend to set those criteria in regulations. The list will not be exhaustive, in order to allow health authorities to apply other criteria that are relevant to each case. It will be for the authority to decide how much weight to attach to the criteria in the regulations and to other relevant factors.

Philip Hammond (Conservative, Runnymede and Weybridge)

The Minister is racing through his brief. The import of his comments seems to be that different health authorities could reach different decisions based on the same regulations. Does he really intend that a practitioner who applies in one health authority area and is rejected should then be able, quite properly, to apply in another area and be accepted?

John Denham (Labour, Southampton, Itchen)

If a practitioner applied in one health authority area and was rejected, and no national disqualification was in force, he could then apply to a different health authority, which, under the clause, would have to take proper account of the fact that he had been rejected by the other authority. We do not seek to establish a system that leads to wide variations in performance, but it is possible that there may be grounds for refusal on a specifically local basis that would not apply in another area.

Philip Hammond (Conservative, Runnymede and Weybridge)

I am a little surprised by the direction of the Minister's comments. I point out to him the obvious danger involved. In a previous sitting, we discussed disparities in the general practitioner population in different parts of the country. Are not two distinct classes of health authority inevitable—those in popular areas, which are able with more care to pick and choose GPs for inclusion, and those that are desperately struggling to get enough doctors and not able to apply such choosy criteria? That may be the perverse outcome of the Minister's proposals.

John Denham (Labour, Southampton, Itchen)

It would be a perverse outcome. That is partly why the individual practitioner has the right to appeal to the Family Health Services Appeal Authority and the health authority has the right to submit to the FHSAA that a disqualification relating to a person whom it did not want on its list should apply nationally. Moreover, it is reasonable to expect health authorities to take seriously the decision of another health authority—including those outside England, in Wales or Scotland. I stress to the Committee that the health authority is legally required to take into account any previous refusals and the other factors that I mentioned if no national disqualification is in place.

I do not believe that a health authority would be able consistently to apply a higher standard because it was in a more sought-after area. At any hint of that happening, the practitioners affected would apply to the FHSSA, which would examine the case purely on the grounds of suitability. It would not take into account the popularity of the area where the GP hoped to be on the health authority list.

Philip Hammond (Conservative, Runnymede and Weybridge)

Does the structure of the clause mean that the Government have effectively given up on organisations such as the General Medical Council, the General Dental Council and the General Optical Council? Although the Minister has discussed mandatory grounds for unsuitability, he could cover those grounds if the likes of the General Medical Council are working properly by stipulating that nobody may be included on a health authority list unless they are also on the list of the appropriate body. If he has confidence in the ability of those bodies to function in future, it would be better to make the mandatory criteria relate to inclusion on their lists, and leave the health authorities with what he refers to as discretionary criteria.

John Denham (Labour, Southampton, Itchen)

The difficulty is that it is possible to have a category of practitioner, for example a doctor, who is allowed to practise with or without restrictions by his professional body, but whom the NHS, as an employer or contractor, would not wish to have working for it. There are many professions in which the professional body allows individuals to practise, but that does not oblige an employer to give them jobs. It is possible to conceive circumstances in which somebody who was allowed, on professional grounds, to practise as a health professional by his regulatory body might not be seen as suitable to work in the NHS because other aspects of his conduct fell outside those grounds. However, it is possible that that person would be offered a job in the private health sector. This system gives greater protection by allowing the NHS to take its own decisions.

There is a need, in practice, for the health service to be able to move quickly in response to problems that become apparent, without being dependent on the action of a third party. We are watching the discussions in the General Medical Council with interest. The council already has a president who is committed to tackling the backlog of cases on disciplinary action that have built up, and we look to that to be successful. Wide-ranging discussions are taking place on the reform of the General Medical Council, but it is inherently unsatisfactory for the NHS, as a provider of health services in Britain, to depend on the action of another body in order to deal with a disciplinary or other problem that could threaten patients. We look to the professional bodies to perform to the highest possible standards, but that does not obviate the need for these measures.

Philip Hammond (Conservative, Runnymede and Weybridge)

I am surprised that the Minister has given that explanation. When we considered the Care Standards Act 2000, I thought that the Government had grasped that they have a responsibility for maintaining standards across both the private and the public sector. However, he is now arguing, ``A doctor might not be good enough for the NHS, but he could still work in the private sector.'' Can he give an example of a situation where a doctor might properly and legitimately be expected to be competent to practise in the private sector, but not good enough for the NHS? How can the Government properly discharge their responsibility to maintain standards across both sectors, but allow that doctor to practise in the private sector?

John Denham (Labour, Southampton, Itchen)

The NHS might not wish to employ somebody who has a record of fraud against it. A different employer might take a different view about whether that person should be employed. Depending on the circumstances of the fraud, neither opinion would relate directly to his clinical competence as a doctor or other health professional. I hope that the hon. Gentleman accepts the validity of that distinction.

Peter Brand (Liberal Democrat, Isle of Wight)

It is helpful to be able to ask the Minister questions as he goes along.

I appreciate that the Minister would want the list to be more NHS-specific than the General Medical Council's list, but I do not see why it should involve any local variation. I understand that once a person is on the supplementary list of one authority, they automatically appear on the lists of others. Why should not principals be in the same position?

John Denham (Labour, Southampton, Itchen)

That is likely to apply in the vast majority of cases. The FHSAA has the power to say on application that a person should not be on a list anywhere, and a health authority will know if they have been turned down somewhere else and will take that into account. It is conceivable that in certain circumstances the FHSAA would not consider the reasons for a person's disqualification from a local list to be sufficient grounds for a national disqualification. However, that is unlikely to lead to huge inconsistencies in treatment of individuals or of differing standards between one health authority and another.

Peter Brand (Liberal Democrat, Isle of Wight)

It may not lead to inconsistencies in treatment, but it will certainly lead to a burden of administration and bureaucracy. A great delay will be built into the system by which someone moves from one health authority to another. If they have the approval of one health authority, they should be eligible to apply for jobs elsewhere without going through a bureaucratic process.

John Denham (Labour, Southampton, Itchen)

We had the option of replacing the current system of health authority lists. At the moment, someone who moves from one practice to another moves from one list to another—that transfer process already exists. Having considered the creation of a single national list for all GPs, we decided instead to build on the current system of health authority lists, while applying a more satisfactory test. That is the best way forward. No obvious body is capable of holding a single national list of GPs, and we would have had to create one for the purposes of the Bill.

Peter Brand (Liberal Democrat, Isle of Wight)

I am aware of the current system, but the Bill introduces something new in that suspension from one list will mean suspension from all other lists. The negative powers should be balanced against the positive powers.

John Denham (Labour, Southampton, Itchen)

In practice, being on one list does not confer an automatic right to move to another one. However, if a practitioner who had not been subject to disqualification applied to move from the list of health authority A to that of health authority B, it would be extremely difficult—unless some new material fact came to light about their past practice or record—for health authority B to refuse them admittance to its list without immediately facing an appeal to the FHSAA. Although that is short of an absolute legal right to move from one list to another, a little consideration of how the system will operate suggests that it would be difficult to introduce hugely arbitrary variations.

I turn to amendments Nos. 170 to 174 tabled by the hon. Member for Woodspring (Dr. Fox). The Bill introduces the concept of unsuitability. Although that is a broad term, I have illustrated the way in which we would require health authorities to consider action under the clause.

Amendments Nos. 170 to 174 take a different approach by seeking to include a definition of unsuitability. In preparing the Bill, we considered carefully whether to follow that approach by including a definition or setting parameters. We decided not to do so for a number of reasons, although there is an important qualification that I shall discuss in due course. There is a risk that, in time, any definition could prove over-prescriptive, and health authority powers could thereby be too narrowly or inflexibly drawn. As a result, cases could arise where, in everyone's view, action was necessary but could not be taken.

The issue of suitability extends beyond establishing whether a practitioner is qualified, or whether the health authority can prove that the practitioner would be a direct danger to his patients. All available information should be examined, and a decision on suitability for the job should be reached using criteria familiar to any employer. Health authorities should examine the available information and consider whether the practitioner in question has the qualities and attributes suitable to deliver medical, dental, ophthalmic or pharmaceutical services to our population.

There is considerable precedent for reliance on a broad term that is undefined in primary legislation. For example, employment rights legislation gives individuals under threat of redundancy the right reasonably to refuse their employer's offer of alternative employment if the post in question is not suitable. That legislation leaves ''suitability'' undefined, but over the years courts and tribunals have developed a body of case law. In practice, we envisage that the Family Health Services Appeal Authority will play a similar role.

Philip Hammond (Conservative, Runnymede and Weybridge)

I am sure that the Minister realises that we did not invent on a rainy Thursday evening the definition of unsuitability that amendment No. 174 would insert—it was taken from the Medical Act 1983. Does the Minister consider that definition too narrowly drafted, and does he plan to change it?

John Denham (Labour, Southampton, Itchen)

If only the hon. Gentleman had listened when I said that there was one important qualification that I would discuss in due course. In fact, I am coming to it just about now.

Although we are discussing clause 22, it is important to distinguish between the different roles of various clauses, such as those on refusing or permitting admittance to the list, removal from the list—which we shall discuss later—and suspension from it. In my view, the grounds for refusing admission to, or removing someone from, the list need to be sufficiently broad to capture all cases that might arise. Suspension, however, is a different process. Given its nature, suspension should be a neutral act. It is undertaken when serious allegations have not been proven, or while further investigations take place.

It is relevant to recognise that the wording of amendment No. 174 is drawn from a particular part of the Medical Act 1983. That wording is the test that should be applied by the GMC's interim orders committee, under which interim suspension orders can be made. I think it a good idea to import that wording into the clause dealing with suspensions. It sets a helpful precedent, and has attractions in defining the circumstances in which suspension might be appropriate. The wording captures both the notion of a risk to the patient, and that of a wider risk to the NHS or the public good.

I should like to signal now that when we discuss clause 26 we shall propose to adopt the wording of the amendment as the basis for a Government amendment to be tabled on Report, which will set out the circumstances in which a health authority may suspend a practitioner. That will leave this clause with a similar architecture of health authority powers to those in the Medical Act 1983. The test on suspension would be the wording used by the hon. Gentleman in his amendment.

The test for disqualification, removal and refusal to admit to a list will be a broader power. When the professional conduct committee of the General Medical Council decides whether to disqualify a practitioner, the grounds for serious professional misconduct are broader than those used for suspension. I hope that the hon. Gentleman will accept that we have recognised the force of his argument—if not in relation to clause 22, then certainly in relation to the suspension powers in clause 26. We shall table an amendment on Report to reflect that.

I now turn to the Government amendments. Amendment No. 116 introduces provisions to underpin the application process for medical lists. It provides for regulations setting out information that a doctor on the medical list must provide. We intend that those regulations will largely replicate health authority procedures. They will include matters such as medical and vocational qualifications, career history, declarations on criminal convictions and adverse regulatory body judgments, and references, which is all information that any good employer would require from someone seeking work. Being clear that we will make that check will deter dishonesty.

Amendment No. 117 addresses consistency. The Bill already provides for health authorities to refuse applications to join supplementary and services lists in certain circumstances. There would be no logic in providing grounds by which a person could be refused admission to the supplementary and services lists that did not equally apply to decisions by health authorities on admission to their existing medical list. The amendment clearly and unambiguously provides the means of introducing that.

The amendment also provides grounds on which a health authority could defer an application—for example, where it was known that the applicant was facing a criminal charge that would be likely to make him unsuitable to provide general medical services were he found guilty. Furthermore, the amendment allows regulations to be made to allow the Secretary of State to prescribe circumstances where a person cannot be admitted by a health authority to its medical list—for example, where the person had been convicted of murder or sentenced to more than six months' imprisonment.

Philip Hammond (Conservative, Runnymede and Weybridge)

The Minister has just given a precise example of what the regulations might say. Are we to infer from that that the Department of Health has draft regulations prepared? If so, would it be possible for members of the Committee to see them?

John Denham (Labour, Southampton, Itchen)

To the best of my knowledge, we do not have a full set of draft regulations. However, there are issues that I shall refer to that have been discussed by the Government and the British Medical Association. Although those discussions are, as yet, unfinished, we have indicated our intentions. The hon. Gentleman will be aware that the specific point that I just mentioned is already incorporated in the test as part of the regulations introduced in the wake of the initial conviction of Harold Shipman. We discussed that matter in the House, and the provision merely reflects that for the sake of consistency in the regulations. Government amendments Nos. 119 to 126 make similar provisions for the lists for other professions.

Finally, Government amendments Nos. 127 to 133 make minor consequential changes to the numbering of certain new provisions introduced by clause 24, to which we shall come in due course.

Philip Hammond (Conservative, Runnymede and Weybridge)

I suspect that we have now had most of the debate on the amendment through interventions on the Minister's speech, but I would like to make one or two additional points.

It is incumbent on the Minister to explain why the Government have tabled so many amendments at this stage—at total of about 90 over the next few clauses. We understand that they have arisen from consultation and discussion with the representative bodies. We have no problem with that process having taken place, just as we—I can speak only for the official Opposition—have no problem with the amendments themselves. However, it is extraordinary that the Government apparently find it impossible to have sensible discussions with the people who know how these things work before publishing the Bill. Why do the Government consider it appropriate to publish a Bill without, one presumes, any real consultation with the bodies that they acknowledge need to be consulted, to consult them after it is published and then to table 90 amendments to three or four clauses? That does not seem the most sensible or efficient way to proceed. Indeed, it is slightly disconcerting in a Bill that makes provision to consult those very organisations before issuing regulations. Perhaps the Minister could give us some of the deep background to that peculiar train of events.

We recognise the driving force behind the clause. I suspect that the groundswell of feeling that such a measure was necessary started before the Shipman case, but that case has added impetus to the idea that we must deal with unsuitability. However, the Minister is getting himself into difficulty by confusing unsuitability in the sense of medics who must not be allowed to deal with patients with a much more amorphous concept of unsuitability based on a feeling that one would not want to employ a certain chap because he is not quite the ticket. The Minister's conflation of those separate notions is dangerous. Health authorities will be able to decide whether to include people on their list and might reject one chap on a Monday because he is a pathological serial killer and another on a Tuesday because he has been divorced twice or has something in his history that does not make him the most appropriate employee. There is a qualitative difference between such cases. Our definition of unsuitability would deal with that by allowing exclusion from the list only on grounds of real unsuitability—someone being a menace to themselves or to the public.

The Minister seems to be saying that there is a serious level of unsuitability and if someone falls into that category he or she must be debarred across the country. That is obviously right and proper. However, there is a lesser level of unsuitability, which would mean that someone might be unsuitable in Cheshire but suitable in Cornwall. We accept that there may be differences between the decisions of different health authorities, but such a system could have a slightly alarming outcome because—although the Minister denied it when I raised the matter with him earlier— it seems self-evident that in some parts of the country more people wish to practice as general practitioners than there are vacancies, while in other parts of the country there is a desperate need to get general practitioners into service. Such regions will typically be the most deprived parts of the country: inner city, run-down areas where health authorities are crying out for GPs. Frankly, it beggars belief that health authorities that are desperate for practitioners will not apply standards that are easier to meet than health authorities that have plenty of doctors and have no problem in providing a service whether or not they admit a given person to the list. Whether or not the Minister intends it—I feel certain he does not—so long as there is a shortage of GPs, the clause as it stands will serve only to heighten the inequalities in provision of service, instead of reducing them, which is the Government's stated objective.

I found it disturbing to hear the Minister repeatedly talking about employment practices and defining unsuitability to include factors that an employer might take into account when employing somebody. Returning to the discussion before lunch, we are seeking to be clear in our minds that the Minister is not attempting to undermine general medical services. GMS is not employment; it is not an employer-employee relationship, but a contractor-contracting relationship and precisely for that reason it is not appropriate to use the criteria that an employer would consider when he is employing someone.

I suppose that I should be pleased that the Minister has decided that amendment No. 174 have some applicability, however it is a shame that we tabled it in respect of the wrong clause. I understand the logic of his argument, but I think he is potentially making a serious mistake in confusing the two degrees of unsuitability—unsuitability because someone is dangerous either to himself or to patients and unsuitability because someone is not up to the standard that the health authority might like. We would have much preferred the two issues to be addressed separately.

If the Minister has confidence in the future of the General Medical Council and believes that the current programme of reform will be successful in restoring public confidence in that body, it would be right and proper for dangerous unsuitability to be dealt with by reference to whether a person is on the GMC's list. The Minister told us that it is necessary sometimes for the NHS to be able to move quickly in the case of a practitioner who is deemed unsuitable in order to suspend him from practice. It is equally important that the GMC is able to act quickly. Our objective should be not to put in place a separate mechanism subject to the Human Rights Act 1998 and to proper quasi-judicial practices within the NHS because we simply accept that the GMC will always be too slow, but to make the GMC process acceptable rather than duplicating the whole thing.

I accept the Minister's argument that there may occasionally be NHS reasons for not employing someone that would not be give the GMC reasons to exclude that person from the medical list. However, I cannot envisage—and the Minister could not give us any examples—circumstances where those NHS reasons would apply in one health authority area but not in another. We ought to take a general view that when Ministers bring Bills to Committees, giving themselves new powers, they ought at least to be able to present to the Committee an example of when such a power might be required. For the Minister to say that he cannot think of a single example of when a variation between one health authority and another might be justified invites us to question whether there is a need to allow such a discrepancy to arise.

John Maxton (Labour, Glasgow Cathcart)

Before I call the hon. Member for Isle of Wight, I should point out that the selection list marked ``3 Revised'', which was distributed before this sitting, is incorrect. We are using the selection list that was distributed before this morning's sitting marked ``3''. The cut-off time is now 7 o'clock and not 5 o'clock.

Peter Brand (Liberal Democrat, Isle of Wight)

Medical lists are maintained by health authorities but it is unusual not to get on a medical list if one is suitably qualified, has suitable prescribed experience, is registered with the GMC and has insurance. Those are the criteria. The Bill introduces another qualification—suitability for the job. If we are going to introduce that, I find it surprising that the criteria will not be set out in regulation or applied nationally. That can be done be through health authorities, as agents of the Secretary of State, but I should have thought that if one health authority approves, that approval should be automatic for all others. I can see real difficulties through delay, for instance. If one applies for a partnership in a practice that covers two or three health authorities, by the time one has gone through the two or three processes to determine suitability, the job may have gone. The Government are missing an opportunity to streamline the approval system as they are streamlining the disqualification or the suspension system, which I fully support.

As the hon. Member for Runnymede and Weybridge (Mr. Hammond) said, suitability has been a matter for the applicant's prospective partners. They should be the best judges of whether a suitably qualified and registered person is right for that locality. That job is done by the health authority for single-handed practices, and I would assume that it is done by the health authority or the agency running a personal medical service project, if it is to be delivered through a directly employed practitioner. We are creating an extra barrier for people who may not fit the idealised picture of the family doctor. They may not get approval in the health authority area except through an appeal mechanism, by which time the vacancy may well have gone. It is likely to ghettoise people into the less attractive areas.

The other issue that the Minister has not addressed is whether there will be approval of a list and whether it will vary with the type of practice that is being considered. One of the powers that the Minister does not have is the ability to deal with a practitioner who falls out with his partners and establishes a single-handed list. There are apparently no powers in the Bill to prevent. Consequently, people who are excluded from a partnership because their mental health is unstable, or they have problems with alcohol or drugs, although not serious enough to warrant formal notification to the authorities, are made even more vulnerable.

Philip Hammond (Conservative, Runnymede and Weybridge)

The hon. Gentleman emphasised the fact that suitability as a partner in the practice should be a decision for the other partners. Does he agree that that abrogation of that power to the health authority looks suspiciously like yet another attack on the independent status of GMS contractors?

Peter Brand (Liberal Democrat, Isle of Wight)

That is why I am worried about the effect that clause—even with the amendments—may have on the way in which practitioners are distributed around the country. I want everyone to have an equal opportunity to apply for partnerships in all parts of the country. Creating the artificial device of having suitability determined by a health authority, rather than by the people who have to work with the partner that they are appointing, cuts right across the concept of partnership and independent contractor status. In the case of directly-employed doctors, the health authority would be acting as an employer so suitability criteria are applicable.

On another minor issue, can I check with the Secretary of State that clause 22 and the subsequent clauses apply only to medical, dental and ophthalmic practitioners? If so, where does that leave practices that are led by nurses? Are we likely to see a situation where an unsuitable person may be in charge of a practice, but cannot be removed from a list or any arrangement of that sort? I have never quite understood the accountability relationship between a nurse-led or lay-led practice employing doctors. Who is the responsible person in that instance?

In the Care Standards Bill we made it quite clear that the employing body, for instance a cosmetic surgery clinic, had a responsibility for what happened in that clinic and it was not only the doctors who were accountable. I cannot see how the Bill addresses that issue.

John Denham (Labour, Southampton, Itchen)

I shall endeavour to deal with as many of those points as possible. The hon. Member for Runnymede and Weybridge asked, quite reasonably, was why the Government found it necessary to table so many amendments so late in the proceedings. As I said the other day, it is regrettable.

The essential issue that influenced the drafting of the Bill has been some ambiguity in the extent to which it was necessary to take primary legislative powers in order to establish the lists that are under discussion. We decided—rightly, I think— that it would be clearer and more secure to take primary legislative powers, and that is what we have done. However, the timing has meant that some amendments, particularly those that seek to ensure consistency across the different categories, were tabled later than I would have wished.

The process means that there has been considerable discussion on various elements of the lists, the criteria and so on with the BMA and other relevant bodies, pre-dating the final drafting of the legislation—although I do not want to give the impression that all those negotiations and discussions are complete.

A number of issues have been raised including whether the provision will lead to greater inequality. I do not believe that it will. I think it will be clear that all health authorities have to act with natural justice and in a fair and proper manner in order to meet the definition in the Bill in respect of suitability for inclusion on the list. The appeals authority is there to back that up.

It is greatly to the advantage to primary care services for health authorities to know—much more unambiguously than in the past— that they have a direct responsibility for maintaining standards and for taking responsibility for whether practitioners are on their lists. I believe that some of the problems that arose in the past stemmed from a feeling in health authorities that although they maintained lists, those lists applied only to some of the practitioners and it was never quite clear who was responsible for the rest. They felt that perhaps the GMC ought to sort it out, and that the NHS tribunal involved quite a complex process. The lack of front-line responsibility for the quality of doctors and other health professionals working in a health authority area is a significant weakness. This Bill represents an important step forward.

The hon. Member for Runnymede and Weybridge quite fairly said that it was a bit poor for Ministers to put a measure before the Committee without being able to think of a single worked example to illustrate it. However, he will understand my caution with worked examples because there is always a residual fear that in 10 or 15 years' time a High Court judge will look back through the Committee Hansard , pull out an example and say, ``That is the precise definition of what the law was meant to say because it is what the Minister said on the day''.

So there is a natural nervousness in doing this, and I will heavily preface what I am about to say as a purely illustrative example of what might happen. Let us suppose that a GP ran into difficulties in one local area because, as the owner of a nursing home, it became apparent that his referral practices were unduly influenced by his financial interests in the nursing home. It is possible that, after proper investigation, that led to his subvention and disqualification from a health authority list. It might be that the appeal authority, while considering that that was a perfectly reasonable decision for the health authority to take in that particular case, felt that there were some local peculiarities in respect of that health authority, that GP and that set up, which would not necessarily lead to a national disqualification. It is therefore possible that another health authority, in an area where the individual concerned had no financial interests, would take a different view. I have to be careful about saying whether that sequence of events would happen or whether that is precisely the right example, but it serves to illustrate how it is possible for the system to operate in that way.

Peter Brand (Liberal Democrat, Isle of Wight)

I fully accept the Minister's reminder that we are not here to judge a particular case, but his hypothetical example suggested a reason not to have someone on a local list, and there have got to be jolly good reasons to do that. If the reasons are good—if there were corrupt practices, which are against the regulations as they are at the moment—they should be grounds for a national disqualification. I really cannot accept the Minister's example.

John Denham (Labour, Southampton, Itchen)

It would probably not do us much good to pursue the hypothetical example to its final conclusion, but it is sufficient to illustrate the possibility. There are unlikely to be a huge number of inconsistent decisions, for all the reasons that I set out earlier, but I have given a possible. It is far more likely that where someone is judged unsuitable to be on a list, and that decision is upheld by the appeal authority, either it is likely to be applied across the country, or health authorities will look into the background and apply decisions in a consistent way.

Philip Hammond (Conservative, Runnymede and Weybridge)

The Minister touched briefly on the question of inequality of distribution, and said he did not believe it would happen. However, I do not think that he gave any reason for that. It seemed to me that the argument that I set out was persuasive, superficially at least, and I was looking forward to hearing him demolish it, but he has not done so.

John Denham (Labour, Southampton, Itchen)

The fact that all health authorities will be clear that they are seen as having a much more front-line responsibility for the quality of services than they felt that they had in the past will mean that they are unlikely to lower their standards and say that they are willing to put up with a dodgier quality of doctor than elsewhere. That shift of outlook and responsibility is an important element of the new system, and it does provides protection against the circumstances to which the hon. Gentleman referred.

The hon. Member for the Isle of Wight (Dr. Brand) asked specifically about nurse-led practices. He probably had in mind a practice where a nurse holds the contract for a PMS practice with the local health authority but employs the general practitioners. It is the general practitioners in that practice who would be on the list that we are discussing. There is no provision in the Bill for creating a list of nurses or other health practitioners outside the four professions currently covered by the part II provisions in the 1977 Act. It is certainly the case that the doctors in a PMS practice, even if it is nurse-led, are subject to the same need to be on a list, and the same scrutiny powers as any others. I hope that the hon. Gentleman is reassured on that point.

Peter Brand (Liberal Democrat, Isle of Wight)

The Minister has explained the issue clearly, but I am not reassured. Should there not be some way within the powers of the Bill to make the employer accountable in the same way as the employee? It is quite clear that the employer can affect the way that services are delivered by his or her employee, in the same way as we discussed in relation to the Care Standards Act 2000.

John Denham (Labour, Southampton, Itchen)

I will reflect on that point. I believe that the powers in the Bill are sufficient and that the nature of the PMS contract with the health authority would enable other deficiencies in the running of a practice to be addressed. I have not seen the need to specifically address a new category. One category in the Bill that we have identified is commercial corporate bodies—dental corporations—that are dealt with in a later clause. I will reflect on the points made by the hon. Member for Isle of Wight, but I am satisfied by what I have so far seen that the protections are adequate.

Philip Hammond (Conservative, Runnymede and Weybridge)

If I understand the exchange that has just occurred, the Minister is saying that in cases whereby the practitioner is the principal, he must be on the health authority's list. If the nurse is an employee, she would presumably be required to be on the supplementary list.

John Denham (Labour, Southampton, Itchen)

No. All doctors have to be on a list. If they are principals, they will be on the list of principals, and if they are non-principals, assistants or locums, they will be on the relevant list. Whether they are the principal in a PMS practice or whether they are a salaried doctor or whatever their employment status within the PMS practice, they will be on the relevant PMS list. There is not a list for nurses working in primary care. We have not taken the legislation further than those groups or professions that are currently covered by part II of the Bill.

Philip Hammond (Conservative, Runnymede and Weybridge)

At the risk of getting ahead of ourselves, perhaps it would help if I clarified the issue. In relation to the supplementary list, the Bill states

persons approved...for the purpose of assisting in the provision of general medical services.

Does that mean that ``assisting'' must be defined narrowly, and would not include, for example, practice nurses, who, in the everyday sense of the word, are ``assisting'' in the provision of services?

John Denham (Labour, Southampton, Itchen)

I believe that that is right. I will ensure that we cover it adequately when we get to that point. We need a specific rather than a colloquial definition.

Amendment agreed to.

Amendments made: No. 117, in page 15, line 8, leave out from beginning to end of line 18 and insert—

`(a) after subsection (2), there shall be inserted—

``(2A) The regulations may also make provision in relation to—

(a) grounds on which a Health Authority may, or must, refuse to nominate or approve a medical practitioner for appointment to fill a vacancy (including his unsuitability for inclusion in their medical list, and grounds corresponding to the condition referred to in section 49F(3) below);

(b) information which must be supplied to a Health Authority by a medical practitioner seeking such nomination or approval (or by arrangement with him);

(c) the supply to a Health Authority by such a medical practitioner of a certificate of the kind referred to in section 29A(4A)(b) above; and

(d) the disclosure by a Health Authority, to prescribed persons or persons of prescribed descriptions, of information of a prescribed description about such medical practitioners, and refusals by the Health Authority to nominate or approve them.'';

(b) in subsection (3), after paragraph (a) there shall be inserted—

``(aa) grounds on which a Health Authority may defer a decision whether or not to nominate or approve a medical practitioner for appointment to fill a vacancy;''; and

(c) after subsection (3) there shall be inserted—

``(3A) If regulations made by virtue of subsection (2A)(a) provide that a Health Authority may refuse to nominate or approve a medical practitioner for appointment to fill a vacancy, they must provide for an appeal (by way of redetermination) to the FHSAA against the Health Authority's decision.'''

No. 118, in page 15, line 21, leave out `(5)' and insert `(7)'.

No. 119, in page 15, line 21, leave out `and' and insert—

`( ) after subsection (1) there shall be inserted—

``(1A) The regulations may include provision as to—

(a) information which must be supplied to a Health Authority by, or by arrangement with, a dental practitioner or dental corporation included or seeking inclusion in a list referred to in subsection (1)(a); and

(b) the supply to a Health Authority—

(i) by a dental practitioner who is included, or seeking inclusion, in such a list, or

(ii) by a director of a dental corporation included, or seeking inclusion, in such a list,

of a criminal conviction certificate under section 112 of the Police Act 1997 or a criminal record certificate under section 113 of that Act.''; and'.

No. 120, in page 15, line 24, leave out from `provision' to end of line 34 and insert

`in relation to grounds on which a Health Authority may, or must, refuse to include a dental practitioner or a dental corporation in a list referred to in subsection (1)(a) (including his, or its, unsuitability for inclusion in such a list, and grounds corresponding to the condition referred to in section 49F(3) below).

(5) Those regulations may make provision in relation to criteria to be applied in making decisions under the regulations.

(6) If those regulations provide that a Health Authority may refuse to include a dental practitioner or dental corporation in such a list, they must also provide for an appeal (by way of redetermination) to the FHSAA against the Health Authority's decision.

(7) Regulations may provide for grounds on which a Health Authority may defer a decision whether or not to grant an application for inclusion in a list referred to in subsection (1)(a).

(8) Regulations may make provision as to the disclosure by a Health Authority, to prescribed persons or persons of prescribed descriptions, of information of a prescribed description about dental practitioners and dental corporations seeking inclusion in such a list, and refusals by the Health Authority to include them.'.

No. 121, in page 15, line 40, leave out from `provision' to end of line 7 on page 16 and insert

`in relation to— (a) grounds on which a Health Authority may, or must, refuse to include a medical practitioner or an ophthalmic optician in a list referred to in subsection (1)(a) (including the unsuitability of the applicant for inclusion in such a list, and grounds corresponding to the condition referred to in section 49F(3) below);

(b) information which must be supplied to a Health Authority by a person included or seeking inclusion in such a list (or by arrangement with him);

(c) the supply to a Health Authority by an individual—

(i) who is included, or seeking inclusion, in such a list, or

(ii) who is a director of a body corporate included, or seeking inclusion, in such a list,

of a criminal conviction certificate under section 112 of the Police Act 1997 or a criminal record certificate under section 113 of that Act;

(d) grounds on which a Health Authority may defer a decision whether or not to include a person in such a list;

(e) the disclosure by a Health Authority, to prescribed persons or persons of prescribed descriptions, of information of a prescribed description about applicants for inclusion in such a list, and refusals by the Health Authority to include them; and

(f) criteria to be applied in making decisions under the regulations.

(3) If regulations made by virtue of subsection (2)(a) provide that a Health Authority may refuse to include a person in such a list, they must also provide for an appeal (by way of redetermination) to the FHSAA against the Health Authority's decision.'''.

No. 122, in page 16, line 12, leave out from beginning to `and' in line 17 and insert—

```(f) as to other grounds on which a Health Authority may, or must, refuse to grant an application (including the unsuitability of the applicant for inclusion in such a list, and grounds corresponding to the condition referred to in section 49F(3) below);

(g) as to information which must be supplied to a Health Authority by a person included, or seeking inclusion, in such a list (or by arrangement with him);

(h) for the supply to a Health Authority by an individual—

(i) who is included, or seeking inclusion, in such a list, or

(ii) who is a director of a body corporate included, or seeking inclusion, in such a list,

of a criminal conviction certificate under section 112 of the Police Act 1997 or a criminal record certificate under section 113 of that Act;

(i) for grounds on which a Health Authority may defer a decision whether or not to grant an application;

(j) for the disclosure by a Health Authority, to prescribed persons or persons of prescribed descriptions, of information of a prescribed description about applicants for inclusion in such a list, and refusals by the Health Authority to grant such applications;

(k) as to criteria to be applied in making decisions under the regulations (other than decisions required by virtue of paragraph (d)).'','.

No. 123, in page 16, line 19, leave out from `regulations' to end of line 23 and insert

`made by virtue of subsection (3)(f) provide that a Health Authority may refuse to grant an application, they must also provide for an appeal (by way of redetermination) to the FHSAA against the Health Authority's decision.'''.

No. 124, in page 16, line 25, leave out `(2A)' and insert `(2B)'.

No. 125, in page 16, line 26, leave out `(2AA)' and insert `(2BA)'.

No. 126, in page 16, line 27, leave out from beginning to end of line 35 and insert—

`(a) as to grounds on which a Health Authority may, or must, refuse to grant an application for inclusion in a list of medical practitioners referred to in subsection (2A) (including his unsuitability for inclusion in such a list, and grounds corresponding to the condition referred to in section 49F(3) below);

(b) as to information which must be supplied to a Health Authority by a medical practitioner included, or seeking inclusion, in such a list (or by arrangement with him);

(c) for the supply to a Health Authority by a medical practitioner who is included, or seeking inclusion, in such a list of a criminal conviction certificate under section 112 of the Police Act 1997 or a criminal record certificate under section 113 of that Act;

(d) for grounds on which a Health Authority may defer a decision whether or not to grant an application for inclusion in such a list;

(e) for the disclosure by a Health Authority, to prescribed persons or persons of prescribed descriptions, of information of a prescribed description about applicants for inclusion in such a list, and refusals by the Health Authority to grant such applications;

(f) as to criteria to be applied in making decisions under the regulations.

(2BB) If regulations made by virtue of subsection (2BA)(a) provide that a Health Authority may refuse to grant an application for inclusion in such a list, they must also provide for an appeal (by way of redetermination) to the FHSAA against the Health Authority's decision.'''.—[Mr.Denham.]

Clause 22, as amended, ordered to stand part of the Bill.

Clause 23 - Dental Corporations

Desmond Swayne (Conservative, New Forest West)

Were we still labouring under the ancien regime and had we decided, under the procedures that until 6 December governed these Committees, properly to scrutinise the Bill and subject clause 23 to a thorough examination, this would be a stretching process.

Yesterday, I sought a briefing from the British Dental Association, which replied to me in an e-mail message, saying that it

does not object to the amendment—

by which it means the clause—

to allow dental corporate bodies/companies to provide General Dental Services and to contract with Health Authorities for services. Some questions remain about the practical application of this, particularly in relation to discipline within the GDS Regulations, and these will be discussed with the Department of Health.

The Minister will no doubt look forward to those discussions, because they will be had with him, rather than in Committee. However, I have a couple of questions about the clause. Why is there no provision for ophthalmology or pharmacies similar to the arrangements that we are making for corporate bodies in respect of dentists?

Peter Brand (Liberal Democrat, Isle of Wight)

Or doctors.

Desmond Swayne (Conservative, New Forest West)

The hon. Gentleman is correct. I was prompted to ask that question by a representation that I received from Lloyds Pharmacy, which is worried about clause 26 and the provisions for disqualifying practitioners. It says:

While we welcome any measure which enables individual misconduct to be dealt with effectively, we are concerned that this Clause could enable entire pharmacies or chains of pharmacies to be prevented from operating as a result of the misconduct of an individual pharmacist. Our concern hinges on what the Government means by ``person'' in the Clause.

It is referring to clause 26 and goes on to say:

If a ``person'' is defined as being a single individual only, the Clause has our full support.

If a ``person'' is defined as being a corporate body, it seems to us this could mean that, should a single employee misbehave (ie an individual pharmacist within the corporate pharmacy ``person''), an entire company could end up being removed from a Health Authority's list.

That would be highly inequitable. That confusion could be avoided if there were a provision for pharmacists and ophthalmologists similar to that in clause 23.

John Denham (Labour, Southampton, Itchen)

Clause 23 deals with dental corporations. Most dental practices are owned by individual dentists or partnerships, but a limited number are owned by corporate bodies that employ the dentists. Boots has recently acquired a corporate body, and the largest, Integrated Dental Holdings Ltd., has a multi-million pound turnover.

Experience shows that limited liability status helps such bodies to raise capital for investment in building and equipping new dental surgeries, so we want to encourage their growth while ensuring that patients have the same protection that we provide for patients of practices directly owned by dentists.

It may not be commonly known that the number of corporate bodies is currently limited by restrictions in the Dentists Act 1984. Some trading is possible, and new bodies have recently entered the field by buying shell companies, which have ceased to trade. The restriction dates back to the Dentists Act 1921, when the number of corporate bodies was frozen because of concerns that clinical and ethical requirements might be overridden by commercial interests. However, there have been major improvements in the safeguards provided by company law and, with the introduction of the NHS, by the disciplinary controls that we are discussing and enhancing today.

We have positive experience of the widespread involvement of corporate bodies in providing pharmaceutical and optical services for NHS patients. The hon. Member for New Forest, West asked why there was a provision about dental corporate bodies and not others. It is because there is an existing provision for the ophthalmic profession, and there are pharmaceutical regulations that list corporate bodies, but dental corporate bodies are not covered. The proposal corrects that anomaly.

Peter Brand (Liberal Democrat, Isle of Wight)

For completeness, will bodies providing medical services under PMS be mentioned?

John Denham (Labour, Southampton, Itchen)

The contracts that are held for PMS are not analogous to those held by the commercial trading organisations referred to in respect of pharmacies, opticians and dentistry. I am not sure that it is the same issue.

Peter Brand (Liberal Democrat, Isle of Wight)

There is a move towards one-stop shops, especially within large chemist chains, which provide ophthalmic, dental and medical services in walk-in clinics. Thus there must be parallel arrangements for corporate bodies that may want to move into that market.

John Denham (Labour, Southampton, Itchen)

I am not convinced that that is so. People provide PMS either under a GMS contract or a PMS contract under the National Health Service (Primary Care) Act 1997. The arrangements that are allowed for the provision of medical services are fully and adequately covered.

The hon. Gentleman may be suggesting that some time in the future there will be a rise of corporate medical organisations contracting commercially to the NHS, but that is not the case now, nor is it on the horizon. It is not something that the Bill will encourage.

Philip Hammond (Conservative, Runnymede and Weybridge)

Will the hon. Gentleman give way?

John Denham (Labour, Southampton, Itchen)

No, as I want to make some progress.

We plan to remove the restriction in the Dentists Act 1921 through enabling powers included in the Regulatory Reform Bill currently before Parliament. The extensive consultations and parliamentary scrutiny proposed in that Bill mean that it will be the end of the year before the change comes into effect.

First, however, we must guarantee NHS patients the same protection whoever treats them. The clause will protect patients who receive dental care from corporate bodies by enabling health authorities to contract with a corporate body for the provision of general dental services in the same way as they contract with individual general dental practitioners. As a result, health authorities will be able to remove from their lists all dental providers, including corporate bodies and/or the dentists they employ, if there is evidence that they are unsuitable. For example, directors of a corporate body who are not dentists may be involved in fraudulent abuses of the fee regulations or they may fail to provide adequately equipped surgery premises. In such cases, the health authority could remove the company from its list. I hope to table amendments on Report that will prevent the same directors reappearing as a new company and going on to the list. I hope that that will allay the hon. Gentleman's concerns.

Any response should be proportionate. The failure of a dentist in a corporate body to provide an adequate service in one part of the country should not usually lead to the entire organisation being shut down or deemed unsuitable, and the measure's appeal provisions will prevent that. However, if there were wrongdoing at the top, that option would be borne in mind.

Question put and agreed to.

Clause 23 ordered to stand part of the Bill.

Clause 24 - Declaration of financial interests, gifts, etc

Philip Hammond (Conservative, Runnymede and Weybridge)

I beg to move amendment No. 184, in page 17, line 29, after `gifts', insert `above a specified value'.

John Maxton (Labour, Glasgow Cathcart)

With this it will be convenient to discuss the following amendments: No. 175, in page 17, line 30, at end insert

`or to be received, including any bequests in favour of the practitioner by patients'.

No. 181, in page 17, line 30, at end insert—

`(5AA) Any regulations under (5A) above which specify a value above which gifts must be declared, shall specify such value by reference to the limits from time to time set by the Ministerial Code for such declarations by Ministers of the Crown.'.

No. 176, in page 17, line 39, at end insert

`or to be received, including any bequests in favour of the practitioner by patients'.

No. 177, in page 17, line 39, at end insert—

`(1AA) Any regulations under (1A) above which specify a value above which gifts must be declared, shall specify such value by reference to the limits from time to time set by the Ministerial Code for such declarations by Ministers of the Crown.'.

Philip Hammond (Conservative, Runnymede and Weybridge)

I do not know whether other hon. Members have noticed the wonderful howler in paragraph 105 of the explanatory notes, which talks about doctors normally being obliged to

refuse to all patients except those of low intrinsic value.

In the run-up to the general election, I am already working on how selectively to quote that and turn it into a Government definition of a patient of low intrinsic value.

The five amendments would insert a de minimis concept into the arrangements, so that they would refer to gifts within a certain value, eliminating a bureaucratic structure for gifts of minimal value.

First, the amendments would ensure that expected future benefits were declarable. All members of the Committee will be familiar with that concept. The rules on declaration of interests in the House include declarations of any expectation that the Member might have of a future financial benefit. Especially given the concerns raised by the Harold Shipman case, the expectation of future financial benefit is a material consideration, so we have made specific reference to bequests.

Secondly, the amendment, as tabled, may not do the trick. However, I hope that the Minister will accept the suggestion that practitioners who are aware that they are beneficiaries of a patient's will should register that fact. It may be argued that many doctors are genuinely unaware that they are beneficiaries of people's wills. I find the idea slightly strange, but I am told that it is not uncommon for people to make general practitioners beneficiaries of their wills. However, when practitioners are involved in persuading the patient to draw up a will or in helping to redraft the will, they will have knowledge of it and that should be required to be registered.

Peter Brand (Liberal Democrat, Isle of Wight)

I am sure that the hon. Gentleman would not be surprised to learn that medical practitioners are often promised future benefits in wills that never arrive. I have problems with the hon. Gentleman's concept because to publish the fact of expectations will put unreasonable pressure on patients, who will feel that they are obliged to fulfil their perhaps rash idea, which they may have had at some soft moment.

Philip Hammond (Conservative, Runnymede and Weybridge)

I understand the hon. Gentleman's point. However, in view of the events that have occurred, the fact of expectation is material and relevant. If a general practitioner stands to benefit financially from the demise of a patient, that fact should be brought to the notice of a responsible body—the health authority, in this case—if not placed within the public domain. It is a relevant fact that should be recorded somewhere. However, we will hear what the Minister says about that amendment before we continue our debate.

The third purpose behind the amendments is to set the value threshold by reference not to a specific monetary amount but to the threshold for declaration of gifts by Ministers of the Crown. That seems entirely equitable and reasonable. That threshold is £125. No doubt the Minister would argue—and I would not disagree with him—that Ministers of the Crown would not be likely to be influenced by receiving a gift, certainly not a gift with a monetary value of less than £125, and are mature enough to be able to accept small gifts without it distorting their powers of judgment.

One is entitled to ask why medical practitioners are not assumed to be similarly discriminatory and able to receive small gifts without being unduly or inappropriately influenced by them. The case in logic for linking the monetary threshold to the monetary threshold that is applied to politicians is unanswerable. It would be grossly insulting to doctors to suggest that they are of a different calibre when it comes to making moral judgments about financial gifts or incentives that they are offered.

I emphasise that the amendment does not require the threshold to be set at the same level as for Ministers of the Crown, but merely by reference to it. It could be twice the level for Ministers of the Crown or half the level. The amendment would also have the singular advantage that, as the ministerial code levels were adjusted over time, there would be an automatic updating to take account of inflation and/or society's changing perception of the corruptibility or otherwise of those in positions of office. I think that has benefits.

I acknowledge that this group of amendments is not technically perfect. Indeed, due to nothing other than laziness on my part, they address only general medical services and general dental services; I could not bear the thought of writing out the same amendments twice again in order to cover ophthalmic and pharmaceutical services. I hope the Minister will take them as pointing in that direction. We would like to hear his views, and if he believes the amendments have any merit, we could perhaps return to them at a later stage in the Bill's progress and make sure that they are technically perfected.

Peter Brand (Liberal Democrat, Isle of Wight)

I support the spirit behind these amendments. The issue of gifts to practitioners is extremely difficult. It is churlish to turn down a gift, especially when people have made a special effort. In the appropriate season, we are frequently given a brace of pheasant. We particularly appreciate it when it comes from the wife of the gamekeeper, because she prepares them for the oven. I am afraid that the nobs who shower me pheasant, do so literally—it is difficult to know when they were shot, but that is good for anatomical skills.

However, there is a real difficulty with the issue of gifts having a reasonable value, because people appreciate gifts, and that works both ways. We have a large orchard and have large bowls of apples in the waiting room. I am not trying to keep people away by giving them an apple, and nor am I trying to bribe them to come. It is an interaction between communities and the people who serve them. It is important for there to be a monetary value, and for us to distinguish between gifts that are of personal benefit and gifts to the practice, which predominantly benefit other patients or other staff. I cannot see anything in this clause that helps to deal with that particular issue.

I know that there are rules and regulations for trusts. People often want to express their gratitude for the hard work done in a hospital, and a box of chocolates for the nurses is appropriate, as is a donation to the league of friends. I hope that, when the regulations are drawn up, the Minister will bear in mind the fact that independent contractor have a particular difficulty. Anything that is bought out of gifts they do not have to buy themselves. That could be interpreted as extra moneys going towards practice facilities that are of direct benefit to the practitioner, so perhaps they should be spent on extras, such as sound systems and extra chairs.

John Denham (Labour, Southampton, Itchen)

Although I have no fundamental objection to amendment No. 184, it is unnecessary because we intend that regulations should specify a value for gifts. I will leave it to the hon. Member for Runnymede and Weybridge to decide whether he wishes to press me on the point, but I hope that he will be satisfied with that assurance.

Philip Hammond (Conservative, Runnymede and Weybridge)

The Minister will know that the pharmaceutical industry's voluntary code sets a limit of £5 on gifts to general practitioners. What monetary value does he have in mind?

John Denham (Labour, Southampton, Itchen)

Those matters are for discussion with the profession, but it is well known that the figure of £25 has been bandied about in discussions with the BMA over recent months. The figure has not been finalised, but it gives an idea of the order of magnitude involved. We will need to return to parliamentary counsel on the issue. I would prefer not to bring forward an amendment on that on Report, but I have no fundamental objection to the notion of a specified value.

I agree that a comparison of the proposal with the ministerial code of conduct appears at first sight to suggest that it costs five times as much to buy a Minister as it does to buy a general practitioner. I would not want to argue that that is an example of market forces at work. It is obviously not a relevant comparison. I shall make a few points about the position of Ministers and hon. Members. My understanding of the ministerial code of conduct is that we are required simply to refuse gifts that might give rise to concerns about their effect on our impartiality, and that we must give back or buy gifts with a value of more than £140. Members of Parliament must declare any gift of more than £125 in the Register of Members' Interests, which is open to the public. There is an important difference between a register that any member of the public can look at, and a register such as we propose for GPs, which we have never suggested should be open to the public.

A more relevant comparison would be with the guidelines for employees in the NHS—although I acknowledge that there is some difference in the position of those working in hospitals and that of general practitioners. We have sought to achieve the right balance and to have a broadly consistent approach. We have just published guidance on commercial sponsorship within NHS hospitals. Sponsorship was defined as funding from an external source, including funding of all or part of the costs of members of staff, NHS research staff, training, pharmaceuticals, equipment, meeting rooms, costs associated with meetings, meals, gifts, hospitality, hotel and transport costs, provision of free services, buildings or premises. It includes among its requirements the declaration of gifts and other forms of sponsorship valued at more than £25, while the proposal that we are discussing requires that gifts from pharmaceutical companies should be declared. The BMA strongly supported that guidance, stating that the vast majority of GPs would be more than willing to comply with it.

Our guidance on commercial sponsorship does not replace the guidance issued to the NHS under the previous Administration: ``Standards of Business for NHS Staff''. That document addressed the difficult issue of gifts from patients, and made it clear that NHS staff, including doctors, should decline all gifts from patients other than those of low intrinsic value. I agree with the hon. Member for Isle of Wight that in the vast majority of cases—with the exception of small gifts such as a box of chocolates or flowers—staff routinely encourage patients to make donations to a league of friends or a local appeal, which is what grateful patients often do.

Philip Hammond (Conservative, Runnymede and Weybridge)

The Minister fails to distinguish between a personal gift to a member of staff and a gift made for the benefit of the hospital or, if is it to the GP, for use in the practice. Does the Minister accept that there is a relevant distinction between a bottle of whisky and a box of sphygmometer cuffs?

John Denham (Labour, Southampton, Itchen)

Yes, of course. I do not know what the position is for NHS staff if patients personally present them with a gift of hospital equipment, because that usually goes through a different route. However, it is important to note that the emphasis of these provisions is on declaration within the organisation rather than refusal of a gift. What we will end up with as a result of these regulations is a system of disclosure akin to that for NHS staff. Declarations of financial interests will have to be made, and that is right. It will be known whether a GP owns a private nursing home to which he refers patients, whether he has an interest in a pharmacy, or whether pharmacists and opticians have similar possible conflicts or overlaps of interest. The move is toward an appropriate consistency.

What attitude should we take towards gifts from patients to GPs? If we took an approach that was wholly consistent with the position of staff employed in the NHS, we would have to require that all gifts should be refused unless they were of low intrinsic value. Although it is hard to define, the relationship between a general practitioner and his patients over a long period is often somewhat different. That is why we are requiring declaration of gifts over a certain value, rather than taking the harder line of requiring GPs to refuse gifts, as would be the case in a hospital situation.

Very often the relationship between GP and patient is highly positive, but it can also be a potentially problematic relationship between a powerful GP and a vulnerable patient. Having this information available is a useful safeguard, so that if grounds for concerns arose, the pattern could be examined.

The hon. Member for Runnymede and Weybridge asked me about his amendment on bequests. I understand his point, and I certainly see why the information might be of advantage. However, I have identified a host of quite considerable practical difficulties in running such a system. I make no promise about introducing further measures, but I shall give the issue further consideration. I accept that such information could be useful, but I would not want to introduce a system that could not work in practice, or that could be discredited.

Hilton Dawson (Labour, Lancaster and Wyre)

I believe that GPs should be treated exactly the same as other professionals working in the NHS and in other care fields. Although it is nice to think of the ruddy, rural GP receiving a brace of pheasants from his patients now and then, we are trying to modernise the NHS. Everyone is aware of the vulnerability of patients, and of the relationships that can develop between people who are being looked after and their carers. I do not see why GPs should be in a different category. I have nothing against GPs: I value their professionalism as much as that of anyone else in the health service or in the social care field. If we want consistency, it should not be appropriate for patients to give those who care for them any more than the normal tokens of politeness and decency. We should ponder on that.

Peter Brand (Liberal Democrat, Isle of Wight)

I am happy to respond to the hon. Member for Lancaster and Wyre (Mr. Dawson), whose opinions I normally value a great deal. There is an enormous difference between being a general practitioner, who has to live in the community that he serves, and a doctor, who has to work in an institution or hospital. I have known most of my patients for more than 20 years, and the gifts do not all go in one direction. If Mrs. Salmon does not bring us some smoked salmon on Christmas eve, we might go hungry because we had planned on having it; but she may join us instead for a meal on boxing day. How can we resolve that difficulty? Not only is she a very good friend, she has been my patient for 25 years. It can be difficult, because the gifts are not given for a particular episode of care. I hope that such relationships will continue, although I suspect that they are getting fewer. I now get more bottles of sherry than I used to receive of whisky.

Philip Hammond (Conservative, Runnymede and Weybridge)

The miserable puritanism of the hon. Member for Lancaster and Wyre does not appeal to me. I hope that the Minister agrees that it should be possible to modernise the NHS without losing the human touches that characterise it. Relationships between those who work in an organisation and those who use it exist also between doctors and their patients.

Adrian Bailey (Labour/Co-operative, West Bromwich West)

In view of the hon. Gentleman's opinion of my hon. Friend's miserable puritanism, I take it that he disagrees with his party's leader that the Government should be purer than pure?

Philip Hammond (Conservative, Runnymede and Weybridge)

That is slightly—[Interruption.] As my hon. Friends said, Labour Members might wish to steer clear of such subjects.

Although he has not enjoyed the pleasure of our Committee discourses before, the hon. Member for Lancaster and Wyre will not have been shocked or surprised by my comments—any more than I have been shocked or surprised by some of the things that he has said about me. The trick is to keep the insults in order, as I am sure the hon. Gentleman would agree.

I am grateful to the Minister for undertaking to look into the matter of bequests. I realise that it will not be easy, but that potential route of abuse has been shockingly highlighted by recent events. I urge the Minister to reconsider a link between the ministerial code and the threshold for declaring the value of gifts. I wonder whether we need to distinguish between gifts for personal use and those that are given for the benefit of service. For example, an item given to a hospital that is intended to be kept on the ward and used would not have to be medical equipment. I accept that patients do not arrive bearing boxes of medical supplies in gratitude for their treatment, but they sometimes buy relatively expensive pieces of equipment. It is not uncommon for patients to want to give something to the hospital; someone whose child has been treated in a paediatric ward may want to give some toys or curtains to brighten up the place. It would be a miserable NHS if it was not considered appropriate to accept such small tokens, not for the personal use of any member of staff, but for the general benefit of staff and patients.

Hilton Dawson (Labour, Lancaster and Wyre)

I enjoyed the hon. Gentleman's good humour, but I was not arguing that small gifts and the odd kindnesses of ordinary human relationships should be removed from the equation. I had in mind bequests and the substantial amounts that people sometimes give.

Philip Hammond (Conservative, Runnymede and Weybridge)

I am grateful for that clarification. There are probably three categories: one is minor, insubstantial personal gifts and another more major gifts and financial interests of a personal nature. The Minister touched on a GP's interest in a pharmacy. I must admit that I was surprised—that is putting it mildly—when I discovered that the General Medical Council allows general practitioners to have interests in pharmacies that may dispense the scrips that they issue. That is a highly relevant financial interest and the health authority should know about it in order to be able to monitor the doctor's prescribing activity and ensure that it is not irregular.

The third category of gift is that not intended for the personal use of the recipient. That would clearly not include a pheasant, but it might include a small piece of equipment or something to brighten up the surgery. I accept that there is a difficult line to tread in the case of GMS, because without such a gift the practitioner might have to dig into his own pocket to buy the equipment. However, it seems to me and to many in the pharmaceutical industry that there should be a distinction between something of benefit to the practitioner and something that will be used in the practice to the mutual benefit of both parties. Its use in the practice will benefit patients and practitioners, but it also benefits the pharmaceutical company whose name it bears, by providing advertising.

Yesterday, I encountered an example of what I am describing. Let me own up; I was given a copy of a medical textbook by a pharmaceutical company. The cover value is $25. I was told that the company would like regularly to be able to give those books to general practitioners—not for them to take home and squirrel away on their book shelves, but because they would be useful in the practice. However, under the pharmaceutical industry's current voluntary code of conduct, it is not permissible to give a medical textbook with a value of $25 to be kept and used in the practice, and perhaps referred to by the practice nurse. That strikes me as slightly bonkers. I hope that the regulations will exclude gifts of that nature, which are intended to benefit the practice rather than the practitioner.

Hilton Dawson (Labour, Lancaster and Wyre)

There is another distinction to be made, between pharmaceutical companies, which are well able to look after themselves, and patients.

Philip Hammond (Conservative, Runnymede and Weybridge)

The hon. Gentleman is right. The clause points in two directions: first, towards preventing what I hope are rare instances of manipulation and exploitation of parents, of the kind that we have heard about recently; and secondly, in the direction of the widespread practice of giving small items in the normal course of business not as gifts but as advertising material. The question is of achieving the right balance.

I sense that we have moved into clause stand part territory, so in anticipation that there may not be a further debate on the clause, I want to mention that generally we support the idea that gifts should be declared. However, that should not be an unnecessarily bureaucratic process designed to catch gifts of very small value or items for use in the practice rather than for the personal benefit of the practitioner. I understand the difficulties in GMS of making that distinction, but I hope that the Minister will manage to do so when making the regulations.

In the light of the Minister's remarks, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Amendments made: No. 127, in page 17, line 36, leave out `subsection (1)' and insert `the subsection (1A) inserted by section 22'.

No. 128, in page 17, line 37, leave out `(1A)' and insert `(1B)'.

No. 129, in page 17, line 40, leave out `(1B)' and insert `(1C)'.

No. 130, in page 17, line 40, leave out `(1A)' and insert `(1B)'.

No. 131, in Clause 24, page 18, line 11, leave out `(g)' and insert `(k)'.

No. 132, in, page 18, line 13, leave out `(h)' and insert `(l)'.

No. 133, in page 18, line 17, leave out `(3)(h)' and insert `(3)(l)'.—[Mr. Denham.]

Clause 24, as amended, ordered to stand part of the Bill.

Clause 25 - Supplementary lists

John Denham (Labour, Southampton, Itchen)

I beg to move amendment No. 98, in page 19, line 1, leave out from beginning to end of line 3.

John Maxton (Labour, Glasgow Cathcart)

With this it will be convenient to take Government amendments Nos. 99, 160 and 109 to 112.

John Denham (Labour, Southampton, Itchen)

This clause is about the regulation of practitioners who assist in the provision of primary care services, such as deputies, assistants and locums. They are an essential and sometimes unrecognised part of the primary care work force. It is estimated, for example, that they undertake 20 million consultations each year in general practice. They cover temporary vacancies arising from, for example, sickness, holidays or study leave. However, despite their crucial role, they are largely unsupported and unregulated. A locum can lead an isolated professional life. We want to attend to that gap by integrating them into the range of developing NHS support mechanisms. The list system will enable that.

I do not want to repeat earlier debates about the list system. Many of the same points that were covered earlier with respect to changes to the main list of GP principals apply also to the present topic. However, I need to make a few quick points. The list, together with provisions for the accreditation of out-of hours-providers, will ensure that GP co-operatives and deputising services, as well as mainstream practices, as it were, will have to employ doctors who are on health authority lists. It may interest the Committee to know that any general practice qualified doctor who works as a locum will be granted access to the NHS pension scheme on admission to the appropriate health authority list. It is our intention, subject to parliamentary approval of the regulations, to backdate the entry to the pension scheme to April 2001. We are discussing with the British Medical Association how that might be done.

Amendments Nos. 99, 110, 112 and 160 would provide for a new power of the Secretary of State to make regulations to prevent a person from withdrawing from a health authority principal, supplementary or services list during any period in which he or she was under investigation that might result in removal or suspension from the list. Some unnecessary provisions are also being removed. When considering an application to join a list, the health authority would be obliged to consider the facts underlying any previous decisions by other health authorities to remove the individual from a list. The fact of a previous incident would not, as we have discussed, automatically disqualify a person from admission to a list—unless a national disqualification had been imposed—but the health authority would be entitled to consider it as sufficient grounds for refusing an application.

Of course it would sometimes be advantageous for individuals voluntarily to withdraw from a list if they were under investigation or suspension, or had received notice of an intention to remove them—to avoid a health authority-imposed removal, which could rightly disadvantage them in attempts to gain a place on another list. Avoidance of enforced removal would mean that the individual would have nothing to declare to another health authority. That would be an unsatisfactory and inconsistent state of affairs.

Amendments Nos. 98, 109 and 111 deal with the fact that in the interests of limiting bureaucracy we do not want to force people who are on a health authority supplementary list to reapply periodically. If there are circumstances that warrant a removal based on elapsed time, for example, because a doctor has not worked as a deputy or assistant for a significant period, they can be prescribed in the regulations that will define the circumstances in which a health authority may remove a person from the list. The provisions are, therefore, unnecessary. I hope that that provides an adequate explanation of the amendment and a brief introduction to the purpose of the clause.

Philip Hammond (Conservative, Runnymede and Weybridge)

In principle, we do not have any problems with the Government amendments. We accept that there is a need to ensure that locum GPs and non-principal GPs are properly covered by all the rules and regulations and are subject to the same kind of scrutiny as principal GPs. When I read the clause, I suspected that the phrase

persons approved by the Health Authority for the purpose of assisting in the provision of general medical services

might have a precise, technical meaning. However, that meaning is not explicit in the Bill. The lady who makes the tea for the nurse who assists the doctor who delivers the general medical services could be regarded as

assisting in the provision of general medical services.

Can the Minister tell me where to find definition of who is and who is not a person

assisting in the provision of general medical services

given that cursory glance through the amended 1977 Act has not furnished me with that information? For the moment, I will take it that, as stated, it is clear that the measure applies only to doctors and not to any other employee or any other person who assists in the provision of general medical services.

The hon. Member for Isle of Wight and my hon. Friend the Member for New Forest, West (Mr. Swayne) both mentioned nurse-led practices, but the issue extends further than that. More and more of the services that comprise GMS and are provided to patients in the general practitioner's surgery are and will continue to be provided by nurses or persons other than qualified medical practitioners. The Government are encouraging that trend and I expect them to continue to do so, because it makes sensible use of scarce manpower, but it raises the question of why nurses are not to be regulated in a way similar to that in which GPs are to be regulated.

There is no doubt that in some places nurses provide services that in other places are provided by employee or principal doctors. Some patients will be treated in a given way by a person who has to be on a list, and others going into a similar surgery in another place will be treated in the same way but by a nurse, who does not have to be on any list. The Minister may be unable to deal with that problem immediately, but he will probably agree that, as the barriers between what medical practitioners and other practitioners do are broken down, there will be a need to do so.

Peter Brand (Liberal Democrat, Isle of Wight)

Returning to an earlier discussion, the hon. Gentleman's point illustrates that, under PMS, the employer must be held accountable. Under GMS, a practice nurse would be accountable for her actions to whoever has the contract—the partner responsible. However, in the circumstances described by the hon. Gentleman, would be no accountability to the practitioners listed under the clause. In fact, there would be no accountability at all.

Philip Hammond (Conservative, Runnymede and Weybridge)

I think that I understand the hon. Gentleman's point. A bizarre situation could arise. Take two people who are, in effect, doing the same job in different practices. One of them is an employee GP in a practice that does not have a large nursing input; the other is a nurse in a forward-looking practice in which nurses perform many of the roles that traditionally have been performed by doctors. The former would have to apply to be put on an approved list by the health authority before he was allowed to do the job, despite having medical qualifications. The latter, despite not having medical qualifications, would not be required to seek any approval to be subject to the procedure for possibly having to provide certificates under the Police Act 1997. The distinction does not seem logical, and it certainly does not seem logical that the medically qualified person has to jump over the hurdles while the non-medically qualified person does not. I hope that the Minister will ponder on that apparent inconsistency and comment on it.

I also want to test the Minister on short-term locum roles. If a person is on a principal list somewhere and performs a short-term role as a locum elsewhere, will he be required to register again on the supplementary list, or will his inclusion on the principal list be sufficient to give him cover? I am simply trying to think of situations in which the proposals might become cumbersome and unnecessarily bureaucratic. If I have understood the clause correctly, its provisions allow someone, once he has registered with any health authority, to practise as a locum or a person assisting in provision of services in any other health authority area, albeit not across the border between England and Wales. Is there any logical reason for creating that Berlin wall, in the phrase of the former Secretary of State, the right hon. Member for Holborn and St. Pancras (Mr. Dobson)?

Desmond Swayne (Conservative, New Forest West)

Offa's dyke.

Philip Hammond (Conservative, Runnymede and Weybridge)

That does not quite have the ring of the Berlin wall; I have never heard of anyone tearing down Offa's dyke in recent years. I shall not speculate on that but merely ask the Minister why there is no ability to transfer across the border. I hope that there is a practical reason, and that it is not owing to some post-devolution political correctness.

The Government amendments are so extensive that, inevitably, one refers to the clause as a whole when speaking to them. I would like to be sure that we are not sanctioning a development that could be used to undermine further the independent contractor status of GMS providers by, for example, requiring their adherence to certain terms and conditions of service. I would like the Minister to assure us that the provisions are designed solely to ensure that people providing assistance are appropriately qualified and are not dodgy characters. I would also like an assurance that the regulations will not create conditionality about being on the supplementary list that will mean greater involvement of the health authority in contractual relationships between the principal and the employee.

There is a clear need for such provisions, but a light touch is required to provide a clear set of regulations that do not leave too much room for local discretion and that apply clear criteria across the country. I have to believe that that is the Minister's intention, given that the Bill will allow people registered in the list in one place to practise in another. I look forward to hearing his remarks.

John Denham (Labour, Southampton, Itchen)

The hon. Gentleman raised some interesting questions, which were essentially about whether, as roles develop in primary care, there should be equivalent lists for nurses. It is important to recognise that, at the current point in the evolution of the NHS, individual roles are changing. Nurses are now carrying out procedures, taking responsibility for various treatments and giving advice in surgeries that would previously have been done by GPs. However, formal responsibility for patients and for their care in GMS still rests with the GP. Analogous situations exist in pharmacy. It is professional responsibility that is important, along with the contractual relationship that exists under GMS to provide those services.

Normal professional regulations are still in place in respect of practice nurses, and although it is legally possible for a patient to be on a GP's list, it is not legally possible to be a nurse's patient, even though it may be the nurse who gives the treatment. That is how the law is structured. It was an interesting speculation, but we are dealing with the responsibilities of practitioners towards their patients. A slightly different situation pertains in PMS, but a nurse-led practice has a different form of accountability because of the PMS contract between the employer or contract holder and the health authority.

Philip Hammond (Conservative, Runnymede and Weybridge)

The Minister sayd that the difference between doctors and nurses is that contractual responsibility under GMS lies with the doctor. Surely the contractual responsibility lies with the principal practitioner and the employee practitioner is in the same contractual relationship to GMS as the nurse employed by the practice—or even the therapist employed by the practice, as many now do.

John Denham (Labour, Southampton, Itchen)

It is true that the principal who holds the list is responsible for the patients. It should be recognised that the locum doctor who steps in for a fortnight while the principal is on holiday is being asked to fulfil the principal's role in a way that the practice nurse is not; that is how the work is normally delegated. There is great concern about the weakness of the checks on locum doctors that I have not heard expressed about the role of practice nurses. We are trying to deal with a genuine problem. One of the advantages of having a list of locums is that it does not take from principal GPs the responsibility to assure themselves of the suitability of a locum, but provides a framework within which the appraisal of locums can take place.

Peter Brand (Liberal Democrat, Isle of Wight)

I should be grateful if the Minister could solve a conundrum. If someone who wants to work as a locum for a PMS project have to be on a list, or does an individual contractual arrangement have to be entered into every time someone wants to work for a PMS set up?

John Denham (Labour, Southampton, Itchen)

Those who want to work as a locum will be required to appear on either a PMS list or a supplementary list. Under the Bill's provisions, it will not be possible for anyone to provide NHS services unless they are on the appropriate list. That brings me to the point raised by the hon. Member for Runnymede and Weybridge about principals on the medical list seeking to act as locums. The Bill provides that a principal on the medical list would be able to act as a locum in another health authority.

Peter Brand (Liberal Democrat, Isle of Wight)

I should like to return to the PMS question, about which I am still unclear. I presume that, in a nurse-led PMS contract, the doctor employed by a nurse would have to be accountable by being on a list, but that the nurse employed by a practice nurse would not. There is no accountability between the practice nurse and practice doctor, so the practice doctor cannot have any responsibility for the actions of the practice nurse under the PMS scheme. Does that not leave the practice doctor vulnerable and the practice nurse controlled only through her employer?

John Denham (Labour, Southampton, Itchen)

The doctor still has to exercise his professional responsibilities under those circumstances. I may be missing the hon. Gentleman's point—

Peter Brand (Liberal Democrat, Isle of Wight)

If the Minister will allow me—

John Denham (Labour, Southampton, Itchen)

If the hon. Gentleman will let me get two words out before he leaps to his feet, it may be best if he made another speech on the subject. To be perfectly honest, we have been through the matter several times already and I am struggling to understand the hon. Gentleman's difficulties. I would prefer a clearer exposition that I have heard so far in the hon. Gentleman's brief interventions.

The hon. Member for Runnymede and Weybridge sought an assurance, as he always does, that we are not proposing some Machiavellian back-door way of doing away with independent contractor status—

Philip Hammond (Conservative, Runnymede and Weybridge)

It is eroding.

John Denham (Labour, Southampton, Itchen)

No, it is about establishing a better framework for ensuring that doctors, particularly locums, are properly regulated and supported. The list means that for the first time we can develop a proper system of appraisal for locum doctors akin to the system that applies to GPs. That has never existed before and amounts to one of the greatest single gains from our proposals.

Peter Brand (Liberal Democrat, Isle of Wight)

The Liberal Democrats welcome the idea of bringing locums out from the cold and into a regulatory framework, but let me have a final go at explaining my difficulty with developments under PMS. When a PMS project is led by a person who is not on a list—it could be any employer—the doctor will have to work to directions, so it is the employer who determines the patterns of work. The employer will decide what activity is to be performed by doctors and what by nurses. If the doctor has no control over how the work is shared out within the PMS project, people who are not on any list will be carrying out duties usually done under the supervision or control of people who are on a list, such as principals. The professional doctor may have no control over activities for which he may be held accountable by a controlling authority. I am sorry if that is complex, but surely the Minister can understand that explanation, however inadequate, of my real anxieties.

John Denham (Labour, Southampton, Itchen)

I am struggling a little. The hon. Gentleman is presenting a caricature of nurse-led PMS contracts and conjuring up an anti-nurse-led PMS contract vision of dictatorial nurses forcing GPs not to follow their usual professional responsibilities—

Dr Brand rose—

John Denham (Labour, Southampton, Itchen)

Let me pursue this line of argument. Consistent with the hon. Gentleman's argument, it would be impossible for hospital doctors to carry out their responsibilities because they are employed by another organisation. I do not accept that. Under PMS, irrespective of whether doctors are the contract holder with the health authority, they are responsible for their patients. Nothing overrules that. We are simply ensuring that all PMS doctors are on a list. At present, unless they are principals, they are not.

Peter Brand (Liberal Democrat, Isle of Wight)

I hear the Minister's explanation, but hospital doctors are not on a supplementary list. They are accountable to their employing authority, the hospital, as are other practitioners within the team. I do not have an anti-nurse-led PMS worry, but a worry about PMS itself. That is why I developed the point about corporations running PMS services. Either accountability stops with the practitioner on the definitive or supplementary list, or the employer must become more directly accountable—in the same way as practitioners. The solution is to put either practitioners or the employing authority on a list.

John Denham (Labour, Southampton, Itchen)

The hon. Gentleman is completely missing the point. Previously, he asked whether commercial companies would be allowed to provide a service in the same way as corporate dental bodies. I said no, that is not happening, but it does not follow that there is no accountability. The health authority has a contract with a nurse-led practice, which provides the line of accountability. It is a different issue from ensuring that all the health service practitioners covered in part II are on a list.

Philip Hammond (Conservative, Runnymede and Weybridge)

First, the Minister did not deal with the split between England and Wales. Secondly, throughout his remarks he referred to locums. I assume that the hon. Gentleman uses the term as a short hand because GP registrars and anyone either training or employed in general practice as a doctor will also be covered by the regulations. It irritates GP registrars enormously when patients refer to them wrongly as locums.

John Denham (Labour, Southampton, Itchen)

The hon. Gentleman is right. I have used the term as a short hand for a larger group of non-principals. The term ``assistant'' is defined in the GMS regulations, where other definitions are also set out. The Welsh Assembly passes Welsh regulations made under the 1977 Act, so the lists are different.

Amendment agreed to.

Sitting suspended.

On resuming—

John Denham (Labour, Southampton, Itchen)

I beg to move amendment No. 134, in page 19, line 8, leave out `by health Authorities'.

John Maxton (Labour, Glasgow Cathcart)

With this we will consider Government amendment Nos. 163 and 166.

John Denham (Labour, Southampton, Itchen)

I can assure the Committee that this and the remaining Government amendments to the clause are essentially technical and consequential.

Amendment agreed to.

Amendment made: No. 99, in page 19, line 20, at end insert—

`( ) circumstances in which a person included in a supplementary list may not withdraw from it,'.—[Mr. Denham.]

John Denham (Labour, Southampton, Itchen)

I beg to move amendment No. 135, in page 19, line 33, leave out `49K(1)' and insert `49K'.

John Maxton (Labour, Glasgow Cathcart)

With this we will take Government amendments Nos. 136, 100 to 103, 147, 105 to 108, 164, 165 and 167.

John Denham (Labour, Southampton, Itchen)

These are simply technical and drafting amendments.

Amendment agreed to.

Amendment made, No. 136, in page 19, line 49, leave out `8A' and insert `8ZA'—[Mr. Denham.]

Clause 25, as amended, ordered to stand part of the Bill.

Clause 26 - Suspension and disqualification of practitioners

John Denham (Labour, Southampton, Itchen)

I beg to move amendment No. 137, in page 21, line 2, leave out `49M' and insert `49MA'.

John Maxton (Labour, Glasgow Cathcart)

With this it will be convenient to take Government amendment No. 162.

John Denham (Labour, Southampton, Itchen)

The provisions of amendment No. 162 will prevent a practitioner who has been disqualified from a health board list by an NHS tribunal in Scotland or Northern Ireland from being included on any list in England or Wales. Specifically, it enables the Secretary of State to make provisions in regulations to recognise the decisions of Scottish and Northern Irish tribunals in England and Wales. It is essential to ensure that there are robust arrangements across the UK so that practitioners removed from lists in one area of the country do not appear in another area. Contractors who are unfit to practice in Scotland or Northern Ireland are likely to be unfit to practice in England or Wales. Indeed the FHSAA will not be able to overturn or review a decision of a Scottish or Northern Irish tribunal. I am sure that everyone will agree that this is an important provision to ensure patient safety. Amendment 137 makes a consequential change to the numerical reference in the clause to reflect the addition of the new section.

Desmond Swayne (Conservative, New Forest West)

I could have dealt with this point in an intervention, but I failed to catch the Minister's eye. I was wondering about the degree of discretion that the amendment appears to give the Secretary of State. I refer specifically to the phrase in parentheses and ``whether or not exactly'' the two things may correspond to what has happened in a health board in Scotland, for example, as against the circumstances in England. Can the Minister give an example to bring that to life so that we can understand precisely what is meant?

John Denham (Labour, Southampton, Itchen)

I believe, and I will certainly write to the hon. Gentleman if I am wrong, that because the tests that we are introducing on suitability, efficiency and fraud into the English legislation do not mirror directly the tests applied by the NHS tribunals in Scotland and Wales, which currently have the test of efficiency, they do not map on to each other directly. It will be necessary to allow one to be translated into the other to achieve the same effect.

Amendment agreed to.

John Denham (Labour, Southampton, Itchen)

I beg to move amendment No. 138, in page 21, line 23, leave out from `they' to `with' in line 26 and insert

`so decide, they must impose such conditions as they may decide on his inclusion in the list'.

John Maxton (Labour, Glasgow Cathcart)

With this it will be convenient to take Government amendments Nos. 139 to 141 and 150.

John Denham (Labour, Southampton, Itchen)

This group of technical amendments clarifies the provisions of the Bill in relation to the health authority's power to make a contingent removal from its main practitioner list when dealing with inefficiency or fraud. The most substantial changes are made by amendments Nos. 138 and 139, but they essentially clarify the policy intention rather than change direction or add a new function. Amendment No. 138 makes it clear that if a health authority makes a contingent removal it must apply conditions on the practitioner with a view to removing any prejudice to the efficiency of the NHS or preventing further fraud. Essentially, if one limits a person's scope to practise because of a particular problem, one must limit it in a way that deals with the problem.

Amendment No. 139 clarifies that where a practitioner fails to meet any such conditions, a health authority can vary them, apply new ones, or remove the practitioner from the list. Amendment No. 150 is a consequential drafting amendment. Amendments Nos. 140 and 141 are technical amendments to ensure clarity of the powers in the clause. I hope that that is sufficient for the Committee.

Philip Hammond (Conservative, Runnymede and Weybridge)

I have a brief question. The Minister used the word ``contingently''. This may not be the place to ask, but could he tell me the difference between ``contingently'' and ``conditionally''? It seems a rather nice distinction.

John Denham (Labour, Southampton, Itchen)

I have a helpful note from my officials somewhere in my notes explaining that difference, but I will have to rely on my memory. Conditional has the sense that a practitioner should fulfil certain conditions, whereas contingent essentially means that he should not do certain things. I think that that is the underlying difference. Clearly it does not make sense to say that it will be conditional on someone who has been found guilty of fraud not to handle money. That would be an odd use of the English language; instead, it would be contingent on them not handling money. That is the difference in the English language. I bow to the superior wisdom of parliamentary counsel that this is the correct way of doing it.

Philip Hammond (Conservative, Runnymede and Weybridge)

For the record, the Minister did that without the benefit of any notes, and we are all terribly impressed, but why did parliamentary counsel not have a look at the dictionary when drafting the original Bill?

Amendment agreed to.

Amendments made: No. 139, in page 21, line 30, at end insert—

`(3A) If the Health Authority determine that the practitioner has failed to comply with a condition, they may decide to—

(a) vary the conditions, or impose different conditions, or

(b) remove him from their list.'.

No. 140, in page 21, line 31, after `may' insert `decide to'.

No.141, in page 21, line 38, after `49G' insert

`(other than in circumstances falling within paragraph (b))'.

No.102, in page 21, line 40, leave out `Council' and insert `body'.—[Mr. John Denham.]

John Denham (Labour, Southampton, Itchen)

I beg to move amendment No.142, in page 22, line 5, after `case' insert—`(a)''.

John Maxton (Labour, Glasgow Cathcart)

With this it will be convenient to take Government amendment Nos. 143 and 144.

John Denham (Labour, Southampton, Itchen)

The provisions in new section 49H in the Act provide that a health authority may suspend a practitioner while it decides whether he should be removed or contingently removed from a list. In such cases the health authority must specify the period. If the period has expired, amendment No. 143 enables the health authority to continue the suspension for a further specified period.

We do not propose the suspension of family health service contractors to continue indefinitely. We have no desire to recreate in the family health services some of the problems that have been encountered, for example, with the suspension of consultants in hospital services, which we are as Government anxious to deal with. It is in everyone's interest to ensure that the period of suspension is kept to a minimum, but there are cases in which it will be necessary to extend an initial period of suspension while further enquiries are made or a regulatory body considers the case.

Contractors need to be protected from the uncertainty of indefinite suspension. Amendment No. 144 clarifies that if a health authority imposes an initial period of suspension which is running out and then imposes a further period of suspension, the total period of suspension, including the initial period, may not normally exceed the six months set out in the Bill. If a health authority wishes to continue a suspension beyond six months it will be required to make representations to the appeal authority, just as it would have done had it made an initial suspension for a six-month period

Amendment agreed to.

Amendments made: No. 143, in page 22, line 7, at end insert

(b) if that period has expired, they may impose a further suspension, for a period which they must specify.'.

No.144, in page 22, line 9, after `case)' insert `,

including in both cases the period of any further suspension imposed under subsection(4)(b),'.

No.103 in page 22, line 28, leave out `(4)' and insert `(6)'.—[Mr. Denham.]

John Denham (Labour, Southampton, Itchen)

I beg to move amendment No. 145 in page 22, line 37, after `and' insert `(except in prescribed cases.)'.

John Maxton (Labour, Glasgow Cathcart)

With this it will be convenient to take Government amendments Nos. 146, 148, 104 and 149.

The rest of the debate is in Hansard.