Clause 24 - Declaration of financial interests, gifts, etc

Health and Social Care Bill – in a Public Bill Committee at 3:30 pm on 25 January 2001.

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Photo of Philip Hammond Philip Hammond Shadow Spokesperson (Health) 3:30, 25 January 2001

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

Photo of Mr John Maxton Mr John Maxton Labour, Glasgow Cathcart

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

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

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

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

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

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

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

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

Photo of Philip Hammond Philip Hammond Shadow Spokesperson (Health)

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

refuse to all patients except those of low intrinsic value.

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

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

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

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

Photo of Dr Peter Brand Dr Peter Brand Liberal Democrat, Isle of Wight

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

Photo of Philip Hammond Philip Hammond Shadow Spokesperson (Health)

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

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

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

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

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

Photo of Dr Peter Brand Dr Peter Brand Liberal Democrat, Isle of Wight 3:45, 25 January 2001

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

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

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

Photo of John Denham John Denham Minister of State (Department of Health)

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

Photo of Philip Hammond Philip Hammond Shadow Spokesperson (Health)

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

Photo of John Denham John Denham Minister of State (Department of Health)

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

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

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

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

Photo of Philip Hammond Philip Hammond Shadow Spokesperson (Health)

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

Photo of John Denham John Denham Minister of State (Department of Health)

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

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

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

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

Photo of Mr Hilton Dawson Mr Hilton Dawson Labour, Lancaster and Wyre 4:00, 25 January 2001

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

Photo of Dr Peter Brand Dr Peter Brand Liberal Democrat, Isle of Wight

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

Photo of Philip Hammond Philip Hammond Shadow Spokesperson (Health)

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

Photo of Adrian Bailey Adrian Bailey Labour/Co-operative, West Bromwich West

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

Photo of Philip Hammond Philip Hammond Shadow Spokesperson (Health)

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

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

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

Photo of Mr Hilton Dawson Mr Hilton Dawson Labour, Lancaster and Wyre

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

Photo of Philip Hammond Philip Hammond Shadow Spokesperson (Health)

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

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

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

Photo of Mr Hilton Dawson Mr Hilton Dawson Labour, Lancaster and Wyre

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

Photo of Philip Hammond Philip Hammond Shadow Spokesperson (Health)

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

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

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

Amendment, by leave, withdrawn.

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

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

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

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

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

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

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

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