Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

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.'''.

Mr John Maxton (Glasgow, Cathcart, Labour)

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.

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

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.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

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?

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

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.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

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.

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

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.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

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.

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

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.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

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?

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

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.

Dr Peter Brand (Isle of Wight, Liberal Democrat)

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?

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

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.

Dr Peter Brand (Isle of Wight, Liberal Democrat)

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.

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

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.

Dr Peter Brand (Isle of Wight, Liberal Democrat)

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.

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

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.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

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?

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

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.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

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?

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

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.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

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.

Mr John Maxton (Glasgow, Cathcart, Labour)

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.

Dr Peter Brand (Isle of Wight, Liberal Democrat)

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.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

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?

Dr Peter Brand (Isle of Wight, Liberal Democrat)

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.

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

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.

Dr Peter Brand (Isle of Wight, Liberal Democrat)

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.

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

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.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

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.

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

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.

Dr Peter Brand (Isle of Wight, Liberal Democrat)

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.

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

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.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

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.

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

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.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

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?

Mr John Denham (Minister of State, Department of Health; Southampton, Itchen, Labour)

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.