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

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

Mr John Maxton (Glasgow, Cathcart, Labour)

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

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

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.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

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.

Dr Peter Brand (Isle of Wight, Liberal Democrat)

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.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

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)?

Mr Desmond Swayne (New Forest West, Conservative)

Offa's dyke.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

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.

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

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.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

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.

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

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.

Dr Peter Brand (Isle of Wight, Liberal Democrat)

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?

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

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.

Dr Peter Brand (Isle of Wight, Liberal Democrat)

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?

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

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

Dr Peter Brand (Isle of Wight, Liberal Democrat)

If the Minister will allow me—

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

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—

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

It is eroding.

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

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.

Dr Peter Brand (Isle of Wight, Liberal Democrat)

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.

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

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—

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

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.

Dr Peter Brand (Isle of Wight, Liberal Democrat)

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.

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

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.

Mr Philip Hammond (Runnymede & Weybridge, Conservative)

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.

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

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—

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

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

Mr John Maxton (Glasgow, Cathcart, Labour)

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

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

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.]

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

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

Mr John Maxton (Glasgow, Cathcart, Labour)

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

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

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.