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There are a number of national health service staff whose contracts of employment are presently held by regional health authorities because they are undertaking training programmes that require them to move regularly between different NHS employers. While the contracts are held by RHAs, the staff can move between employers without losing any of the employment rights that depend upon staff serving a period of continuous employment—for example, protection against unfair dismissal and the right to return to work after maternity leave.
It is clear that, when RHAs no longer exist, new arrangements must be made for such staff. Junior doctors and dentists in the registrar and senior registrar grades are the largest groups affected; others include clinical psychology trainees, finance and general management trainees, and some pharmacy and scientist training grades. Staff in the training grades must move regularly between employers in order to gain a high standard of professional training, so we need to ensure that there are no obstacles that would discourage them from so moving.
That is what the amendments are designed to achieve. The provisions in schedule 2 ensure protection of continuity for staff who move from RHAs to other NHS bodies next April. Without the amendments, however, continuity of employment of trainees would be broken on any subsequent moves between NHS employers.
Does the Parliamentary Under-Secretary recognise that many employees within the NHS who support the proposals are concerned that most NHS employees at local trust level are being taken on as temporary employees? Why are the Government not seeking to give those people permanent jobs? Should not the Under-Secretary be moving a further amendment?
The amendment deals with protections which now exist and how those apply to regional health authorities. We want the House to agree with the Lords that those protections should continue to exist. The detailed arrangements for devolving contracts to employers are still a matter for discussion with the various professional bodies representing staff. I believe that the amendments offer NHS staff significant reassurances.
We all took note of the Under-Secretary's remark that the business of Government must continue, and he has been sent here to ensure that it does. I am not sure what that implies for his future, but I wish him luck; he will no doubt make a further announcement later.
The matter before us today is slightly at variance with comments which have been made to the House, particularly in Committee. The issue under consideration is the contracts of NHS employees, the largest single group of whom are junior doctors. The question of which body should hold the contracts of junior doctors exercised our minds in Committee.
I asked the Under-Secretary on 26 January where the contracts would be held, and he replied:
Junior doctors' contracts and vocational training are under discussion with the relevant professional organisations. We must reach a conclusion about the role of the regional offices or district health authorities in those matters. However, those issues must be discussed with the profession."—[Official Report, Standing Committee A, 26 January 1995; c. 58.]
Implicit in what the Under-Secretary said is that there would be a role for either the regional office of the Department of Health or the newly created district health authority.
As there was some uncertainty as to what that meant in practice, I intervened on 31 January on the Minister for Health to ask:
Is it the Government's intention to hold the contracts for junior doctors at regional level?
The Minister replied:
I can assure the hon. Gentleman that that is the case; it makes sense in current circumstances to do so. As he asked me that strategic question, I can state that it would not be necessary for the type of organisations suggested in amendment to perform that function."—[Official Report, Standing Committee A, 31 January 1995; c. 84.]
In Committee, Labour tabled a probing amendment dealing with who was to hold the contracts for, among others, junior doctors.
What the Under-Secretary is telling us is at variance with those assurances in Committee. He correctly says that the employment contracts of certain groups of NHS staff are held by regional health authorities, which, the House will recall, are to be abolished by this Bill, so the contracts must be held elsewhere. The advantage of having contracts held by regional health authorities is that the employees could occupy successive posts with different NHS employers as part of a structured training programme, without breaking the continuity of their employment for the purposes of employment protection legislation.
I have no quarrel with the Minister's stated objective of ensuring that there is no discontinuity in employment. The largest group of employees involved are the medical and dental registrars—the backbone of secondary services in the NHS—and senior registrars, who move around a number of hospitals as part of their specialist training. A number of other groups—most notably the clinical psychology trainees and general management and finance trainees—are also affected.
The Lords amendments will make provision for those groups of staff to enjoy continuity of employment even if they are employed by trust bodies or by a consortium of trust bodies. Many Labour Members feared that that was the Government's intention, and probed them on the matter in Committee. We were assured that this was not the Government's intention, yet we are now dealing with Lords amendments that suggest that it is.
The British Medical Association, as one would expect, is concerned about the amendments. The association does not think that it is right that the contracts of junior doctors should be held at trust level. It believes, as we believe, that the training of junior doctors requires strategic administration at regional level, and that devolution to individual trusts will make it far more difficult to achieve the right number of trained doctors and to get a broad mix of specialty rotation for each doctor under training.
We believe—we explored the matter at some length in Committee—that the new arrangements will increase bureaucracy, although it is a stated purpose of the Bill that bureaucracy will be reduced, not increased. Each consortium of trusts or individual trusts will have to draw up their own contracts for their own junior doctors.
The Government's proposals will bring about distortions in their internal market. Doctors in training are a national, or at least a regional, resource, and their contracts should be at higher than trust level. Having the contracts above trust level would prevent local problems in the purchaser-provider relationship—problems that we believe will distort the requirement for trained doctors.
In addition, it is not clear to me how the arrangements for training rotation will work in practice. The Government are committed to achieving the Calman report's objective of improving the quality of training. Many junior doctors are appointed to posts that are rotational within the duration of the contract. They progress through a series of posts and through a number of hospitals in the region to maximise their experience of different aspects of their speciality. A typical rotation post lasts for six months.
I am quarrelling not with the arrangements, but with the fiendishly difficult practice of making the arrangements work when the contract of employment is held by an individual trust whereas the employment is carried out across a range of different trusts. Presumably the juniors will have to apply for different posts at six-month intervals. There is no guarantee that they can obtain particular posts in aspects in which they require experience.
The Government have not thought the matter through properly. If their idea is that there should be a consortium of trusts holding the contracts, there will inevitably be an increase in bureaucracy, because there will be a need for professional personnel managers and professional training staff to monitor the training programme and to hold the contracts of the individual doctors. It is more economically efficient to do that at regional level, as is the case in England at present.
I am worried that the proposed structure will not protect the educational content of the posts. I have little confidence that the educational part of the junior doctors' training will be retained if they are trust employees. The trusts have to respond to day-to-day commercial pressures, and they are bound to put those commercial pressures above the broader interests of training the doctors.
There is also a threat to the national pay and conditions of staff who will be covered by the arrangements. If their contracts are held locally, the terms and conditions, although this has not yet been stated by the Government, stand to be negotiated locally and not nationally. It is perfectly obvious that the arrangements could be the thin end of the wedge. At best, they facilitate the break-up of the national pay bargaining structure. That cannot be right.
I took careful note of what the Minister of State said about a core of national terms of service for juniors. He said that they would serve
as a reference point for their employers to establish fair and locally workable contractual arrangements to provide a degree of flexibility".
The BMA is wholly opposed to local pay for doctors—so is the parliamentary Labour party. Amendments that look innocuous are nothing of the kind, but specifically reverse assurances that hon. Members were given, and which they believed in good faith, in Committee. I therefore urge the House to vote the amendments down.
The occupation of the Government Back Benches reminds one irresistibly of the story of Sleeping Beauty. One wonders which prince will awaken the hon. Member for Lancaster (Dame E. Kellett-Bowman) on Thursday, although I must confess that she has competition from Old Father Time behind me.
The Labour Front-Bench spokesman, the hon. Member for Newcastle upon Tyne, East (Mr. Brown), has raised an important issue, because it relates to the training of doctors. I speak as a lay member of the General Medical Council, which has an important responsibility for scrutinising and approving the training of junior doctors, and for their registration after they have been trained.
I hope that the Minister will agree that he owes the House a little more explanation as to how the Government intend to ensure that doctors in training posts are not treated merely as a spare pair of hands. The Calman report made it clear that the Government's objective is to improve the quality of doctors' training. Simply putting doctors in the employment of trusts, where their work may well be demand-led from crisis to crisis, will not be sufficient training, and is unlikely to gain the approval of the postgraduate deans and others who approve the rotational training of junior doctors.
In anaesthetics, for example, a doctor may have a three-year contract, moving to a different hospital every six months to secure his or her full training. Without being told more by the Minister, it is difficult to understand how the Government intend to ensure that that training is harmonised under the regulations proposed following the amendments. There is little confidence that the educational element will be protected if trusts are the employers, when immediate needs could plainly dominate the working week.
The British Medical Association has proposed the establishment of a small special health authority to oversee the training of junior doctors and other doctors undergoing training for one reason or another. The establishment of such health authorities on a regional basis for that purpose would ensure a clear line of accountability, a clearly identifiable purchaser of medical—[Interruption.] The hon. Member should not interrupt when she has not been listening to most of the debate. Would she like me to give way?
I can assure the hon. Lady that she drifted away during the Minister's speech and consolidated her repose well into the beginning of mine, but I am very glad that she is now listening sufficiently intently to become ever so slightly incandescent.
The BMA's proposals for small special health authorities based regionally would be a useful innovation. They would assume responsibility for all doctors in training within the region, which would establish a clear line of accountability and introduce market principles, in that such an authority would be clearly identifiable as the purchaser of medical education and training within the current structure of NHS management.
Whether or not that is the right solution, we have not yet heard from the Minister how that important integrity of rotational training is to be maintained. I hope that he will be able to give the House a better explanation in a moment.
With the leave of the House, Madam Deputy Speaker, I remind the House that the amendments are about continuity of employment and protection of employment rights under new employers, following the proposed end of regional health authorities.
The hon. Member for Newcastle upon Tyne, East (Mr. Brown) should not make too much of a slip of the tongue in Committee by my hon. Friend the Minister of State, because my hon. Friend has made it clear since, in a speech to the annual conference of the British Association of Medical Managers, that junior doctors' contracts will be held by NHS trusts, with deans of postgraduate medicine overseeing junior doctors' educational needs.
I am the last person in the world to make too much of a slip of the tongue, but I remind the Under-Secretary what was said in Committee. I asked the Minister:
Is it the Government's intention to hold the contracts for junior doctors at regional level?
The Minister now says that the Government's response is, "No, they will be held at trust level." That is a perfectly straight answer to a straight question. He must accept that the answer that I was given at the time was not a slip of the tongue. It was:
I can assure the hon. Gentleman that that is the case; it makes sense in current circumstances to do so."—[Official Report, Standing Committee A, 31 January 1995; c. 84.]
—that is, to hold them at regional level. The Minister cannot characterise that as a slip of the tongue.
I am sorry that the Committee was momentarily misled. On examination, it is clear that it would be difficult for the regions to hold all those contracts of employment without asking all doctors to become civil servants, which we would both agree would be unwise.
On the point made by the hon. and learned Member for Montgomery (Mr. Carlile), I see no reason why postgraduate deans and trusts should not co-operate to ensure a proper rotation of doctors. After all, many of those doctors will end up working for trusts. There is no reason to suppose that trusts would wish to require postgraduate deans to short-change junior doctors on their training. Given that provision in the health service is now taken care of by trusts, it seems eminently natural that trusts should employ junior doctors.
What the Minister says makes perfect sense, but if a postgraduate dean took the view that the way in which a junior doctor was employed was not consistent with good training, how would such a dispute be resolved under the arrangements that the Government have in mind? So far, we have not heard the answer.
We must allow that all those involved will, with good will, come to arrangements that are in the best interests of medical training. I have no reason to suppose that those arrangements would be unsatisfactory.
The hon. Member for Newcastle upon Tyne, East talked about consortia of trusts. A number of combinations are possible, but the most likely would be lead trusts for particular specialties, which would hold those contracts in each region; so people in those trusts would deal with postgraduate deans on matters concerning postgraduate education.
People outside this House would be surprised to hear us suggest that junior doctors should be employed by anyone other than hospitals. To set up some alternative procedure—a special health authority—would be a bureaucratic and expensive option, which is exactly what the Bill seeks to put behind us.
May I return to the nub of the matter? The amendments seek to protect the employment rights of junior doctors after the end of regions. For that reason, I commend them to the House.
Question put, That this House doth agree with the Lords in the said amendment:—
|Division No. 175]||[3.58 pm|
|Ainsworth, Peter (East Surrey)||Ancram, Michael|
|Aitken, Rt Hon Jonathan||Arbuthnot, James|
|Alison, Rt Hon Michael (Selby)||Arnold, Jacques (Gravesham)|
|Amess, David||Arnold, Sir Thomas (Hazel Grv)|
|Atkins, Rt Hon Robert||Gummer, Rt Hon John Selwyn|
|Atkinson, Peter (Hexham)||Hague, William|
|Baldry, Tony||Hamilton, Rt Hon Sir Archibald|
|Banks, Matthew (Southport)||Hamilton, Neil (Tatton)|
|Batiste, Spencer||Hanley, Rt Hon Jeremy|
|Beresford, Sir Paul||Hannam, Sir John|
|Biffen, Rt Hon John||Hargreaves, Andrew|
|Bonsor, Sir Nicholas||Haselhurst, Sir Alan|
|Booth, Hartley||Hawkins, Nick|
|Boswell, Tim||Hawksley, Warren|
|Bottomley, Peter (Eltham)||Heald, Oliver|
|Bottomley, Rt Hon Virginia||Heath, Rt Hon Sir Edward|
|Bowis, John||Heathcoat-Amory, David|
|Boyson, Rt Hon Sir Rhodes||Hendry, Charles|
|Brandreth, Gyles||Heseltine, Rt Hon Michael|
|Brazier, Julian||Higgins, Rt Hon Sir Terence|
|Bright, Sir Graham||Hill, James (Southampton Test)|
|Brooke, Rt Hon Peter||Hogg, Rt Hon Douglas (G'tham)|
|Browning, Mrs Angela||Horam, John|
|Budgen, Nicholas||Hordern, Rt Hon Sir Peter|
|Burns, Simon||Howard, Rt Hon Michael|
|Burt, Alistair||Howarth, Alan (Strat'rd-on-A)|
|Butler, Peter||Howell, Rt Hon David (G'dford)|
|Butterfill, John||Hughes, Robert G (Harrow W)|
|Carlisle, Sir Kenneth (Lincoln)||Jenkin, Bernard|
|Carrington, Matthew||Johnson Smith, Sir Geoffrey|
|Cash, William||Jones, Gwilym (Cardiff N)|
|Channon, Rt Hon Paul||Jones, Robert B (W Hertfdshr)|
|Chapman, Sydney||Jopling, Rt Hon Michael|
|Churchill, Mr||Kellett-Bowman, Dame Elaine|
|Clappison, James||Key, Robert|
|Clark, Dr Michael (Rochford)||Kirkhope, Timothy|
|Clifton-Brown, Geoffrey||Knapman, Roger|
|Colvin, Michael||Knight, Mrs Angela (Erewash)|
|Congdon, David||Knight, Greg (Derby N)|
|Conway, Derek||Knight, Dame Jill (Bir'm E'st'n)|
|Coombs, Simon (Swindon)||Knox, Sir David|
|Cope, Rt Hon Sir John||Lait, Mrs Jacqui|
|Cormack, Sir Patrick||Lamont, Rt Hon Norman|
|Couchman, James||Lang, Rt Hon Ian|
|Cran, James||Legg, Barry|
|Curry, David (Skipton & Ripon)||Leigh, Edward|
|Day, Stephen||Lennox-Boyd, Sir Mark|
|Deva, Nirj Joseph||Lester, Jim (Broxtowe)|
|Dicks, Terry||Lidington, David|
|Dover, Den||Lilley, Rt Hon Peter|
|Duncan, Alan||Luff, Peter|
|Duncan-Smith, Iain||Lyell, Rt Hon Sir Nicholas|
|Dykes, Hugh||MacGregor, Rt Hon John|
|Elletson, Harold||MacKay, Andrew|
|Emery, Rt Hon Sir Peter||Maclean, Rt Hon David|
|Evans, David (Welwyn Hatfield)||McLoughlin, Patrick|
|Evans, Jonathan (Brecon)||McNair-Wilson, Sir Patrick|
|Evans, Nigel (Ribble Valley)||Madel, Sir David|
|Evans, Roger (Monmouth)||Maitland, Lady Olga|
|Evennett, David||Malone, Gerald|
|Faber, David||Mans, Keith|
|Field, Barry (Isle of Wight)||Marland, Paul|
|Forman, Nigel||Marlow, Tony|
|Forsyth, Rt Hon Michael (Stirling)||Martin, David (Portsmouth S)|
|Forth, Eric||Mawhinney, Rt Hon Dr Brian|
|Fox, Sir Marcus (Shipley)||Merchant, Piers|
|Freeman, Rt Hon Roger||Mitchell, Andrew (Gedling)|
|French, Douglas||Mitchell, Sir David (NW Hants)|
|Gale, Roger||Moate, Sir Roger|
|Gallie, Phil||Monro, Sir Hector|
|Gardiner, Sir George||Montgomery, Sir Fergus|
|Garel-Jones, Rt Hon Tristan||Needham, Rt Hon Richard|
|Garnier, Edward||Neubert, Sir Michael|
|Gill, Christopher||Newton, Rt Hon Tony|
|Gillan, Cheryl||Nicholls, Patrick|
|Goodson-Wickes, Dr Charles||Nicholson, Emma (Devon West)|
|Gorman, Mrs Teresa||Norris, Steve|
|Grant, Sir A (SW Cambs)||Onslow, Rt Hon Sir Cranley|
|Greenway, John (Ryedale)||Ottaway, Richard|
|Griffiths, Peter (Portsmouth, N)||Page, Richard|
|Patnick, Sir Irvine||Stern, Michael|
|Peacock, Mrs Elizabeth||Stewart, Allan|
|Pickles, Eric||Streeter, Gary|
|Porter, David (Waveney)||Sumberg, David|
|Portillo, Rt Hon Michael||Sykes, John|
|Richards, Rod||Tapsell, Sir Peter|
|Rifkind, Rt Hon Malcolm||Taylor, Ian (Esher)|
|Robathan, Andrew||Taylor, John M (Solihull)|
|Roberts, Rt Hon Sir Wyn||Taylor, Sir Teddy (Southend, E)|
|Robertson, Raymond (Ab'd'n S)||Thomason, Roy|
|Roe, Mrs Marion (Broxbourne)||Thompson, Patrick (Norwich N)|
|Rowe, Andrew (Mid Kent)||Thurnham, Peter|
|Rumbold, Rt Hon Dame Angela||Townsend, Cyril D (Bexl'yh'th)|
|Sackville, Tom||Tracey, Richard|
|Scott, Rt Hon Sir Nicholas||Trend, Michael|
|Shaw, David (Dover)||Twinn, Dr Ian|
|Shephard, Rt Hon Gillian||Walker, Bill (N Tayside)|
|Shepherd, Colin (Hereford)||Waller, Gary|
|Shepherd, Richard (Aldridge)||Waterson, Nigel|
|Shersby, Sir Michael||Watts John|
|Soames, Nicholas||Whitney, Ray|
|Spencer, Sir Derek||Whittingdale, John|
|Spicer, Sir James (W Dorset)||Widdecombe, Ann|
|Spicer, Michael (S Worcs)||Willetts, David|
|Spink, Dr Robert||Wood, Timothy|
|Spring, Richard||Yeo, Tim|
|Sproat, Iain||Young, Rt Hon Sir George|
|Squire, Robin (Hornchurch)|
|Stanley, Rt Hon Sir John||Tellers for the Ayes:|
|Steen, Anthony||Mr. Michael Bates and|
|Stephen, Michael||Dr. Liam Fox.|
|Ainger, Nick||Davies, Rt Hon Denzil (Llanelli)|
|Ainsworth, Robert (Cov'try NE)||Davies, Ron (Caerphilly)|
|Allen, Graham||Denham, John|
|Austin-Walker, John||Dewar, Donald|
|Barnes, Harry||Dixon, Don|
|Barron, Kevin||Dobson, Frank|
|Battle, John||Donohoe, Brian H|
|Beckett, Rt Hon Margaret||Dunwoody, Mrs Gwyneth|
|Benn, Rt Hon Tony||Eagle, Ms Angela|
|Bennett, Andrew F||Eastham, Ken|
|Bermingham, Gerald||Etherington, Bill|
|Berry, Roger||Evans, John (St Helens N)|
|Blair, Rt Hon Tony||Fatchett, Derek|
|Bradley, Keith||Faulds, Andrew|
|Bray, Dr Jeremy||Field, Frank (Birkenhead)|
|Brown, Gordon (Dunfermline E)||Fisher, Mark|
|Brown, N (N'c'tle upon Tyne E)||Flynn, Paul|
|Burden, Richard||Foster, Rt Hon Derek|
|Byers, Stephen||Foster, Don (Bath)|
|Campbell, Mrs Anne (C'bridge)||Foulkes, George|
|Campbell, Ronnie (Blyth V)||Fraser, John|
|Campbell-Savours, D N||Fyfe, Maria|
|Canavan, Dennis||Gapes, Mike|
|Carlile, Alexander (Montgomery)||George, Bruce|
|Chidgey, David||Gerrard, Neil|
|Church, Judith||Godman, Dr Norman A|
|Clark, Dr David (South Shields)||Golding, Mrs Llin|
|Clarke, Eric (Midlothian)||Gordon, Mildred|
|Clarke, Tom (Monklands W)||Griffiths, Nigel (Edinburgh S)|
|Clwyd, Mrs Ann||Griffiths, Win (Bridgend)|
|Coffey, Ann||Grocott, Bruce|
|Cohen, Harry||Gunnell, John|
|Cook, Frank (Stockton N)||Hain, Peter|
|Cook, Robin (Livingston)||Hanson, David|
|Corbett, Robin||Harman, Ms Harriet|
|Corbyn, Jeremy||Harvey, Nick|
|Corston, Jean||Hattersley, Rt Hon Roy|
|Cousins, Jim||Henderson, Doug|
|Cunningham, Jim (Covy SE)||Heppell, John|
|Cunningham, Rt Hon Dr John||Hill, Keith (Streatham)|
|Dalyell, Tam||Hogg, Norman (Cumbernauld)|
|Home Robertson, John||O'Brien, Mike (N W'kshire)|
|Hoon, Geoffrey||O'Brien, William (Nomanton)|
|Howells, Dr. Kim (Pontypridd)||O'Hara, Edward|
|Hoyle, Doug||Olner, Bill|
|Hughes, Kevin (Doncaster N)||Orme, Rt Hon Stanley|
|Hughes, Robert (Aberdeen N)||Pendry, Tom|
|Hughes, Simon (Southwark)||Pike, Peter L|
|Hutton,John||Powell, Ray (Ogmore)|
|Illsley, Eric||Prentice, Bridget (Lew'm E)|
|Ingram, Adam||Primarolo, Dawn|
|Jackson, Glenda (H'stead)||Quin, Ms Joyce|
|Jackson, Helen (Shef'ld, H)||Radice, Giles|
|Jamieson, David||Reid, Dr John|
|Jones, Jon Owen (Cardiff C)||Rendel, David|
|Jowell, Tessa||Robertson, George (Hamilton)|
|Kennedy, Jane (Lpool Brdgn)||Roche, Mrs Barbara|
|Khabra, Piara S||Rooker, Jeff|
|Lestor, Joan (Eccles)||Rowlands, Ted|
|Lewis, Terry||Ruddock, Joan|
|Liddell, Mrs Helen||Sedgemore, Brian|
|Lloyd, Tony (Stretford)||Sheldon, Rt Hon Robert|
|McCartney, Ian||Short, Clare|
|McFall, John||Skinner, Dennis|
|Mackinlay, Andrew||Smith, Chris (Isl'ton S & F'sbury)|
|McLeish, Henry||Squire, Rachel (Dunfernline W)|
|Maclennan, Robert||Steel, Rt Hon Sir David|
|McMaster, Gordon||Stevenson, George|
|MacShane, Denis||Strang, Dr. Gavin|
|McWilliam, John||Straw, Jack|
|Madden, Max||Sutcliffe, Gerry|
|Maddock, Diana||Taylor, Mrs Ann (Dewsbury)|
|Mahon, Alice||Taylor, Matthew (Truro)|
|Mandelson, Peter||Timms, Stephen|
|Marshall, David (Shettleston)||Tipping, Paddy|
|Marshall, Jim (Leicester, S)||Touhig, Don|
|Michael, Alun||Turner, Dennis|
|Michie, Bill (Sheffield Heeley)||Vaz, Keith|
|Milburn, Alan||Wareing, Robert N|
|Miller, Andrew||Williams, Rt Hon Alan (Sw'n W)|
|Morgan, Rhodri||Williams, Alan W (Carmarthen)|
|Morris, Rt Hon Alfred (Wy'nshawe)||Wright, Dr Tony|
|Morris, Estelle (B'ham Yardley)|
|Morris, Rt Hon John (Aberavon)||Tellers for the Noes:|
|Mudie, George||Mr. Joe Benton and|
|Murphy, Paul||Mr. Jim Dowd.|